Ver el código de «Template:Cholinergic Toxicity Treatment»

===Decontamination===
*Providers should wear appropriate PPE during decontamination.
**Neoprene or nitrile gloves and gown (latex and vinyl are ineffective)
*Dispose of all clothes in biohazard container
*Wash patient with soap and water

===Supportive Care===
*IVF, O2, Monitor
*Aggressive airway management is of utmost importance.
**Intubation often needed due to significant  respiratory secretions / bronchospasm.
**Use nondepolarizing agent ([[Rocuronium]] or [[Vecuronium]])
**Succinylcholine is absolutely contraindicated
*[[Benzodiazepines]] for seizures

===Antidotes===
*Dosing with atropine and pralidoxime are time dependent and provides ability to reverse symptoms while awaiting agent metabolism
*For exposure to nerve agents, manufactured IM autoinjectors are available for rapid administration:
**Mark 1
***Contains 2 separate cartridges: atropine 2 mg + 2-PAM 600 mg
***Being phased out with newer kits
**DuoDote
***Single autoinjector containing both medications
***Same doses as Mark 1: atropine 2 mg + 2-PAM 600 mg

==Antidotes==
===[[Atropine]]===
*Competitively blocks muscarinic sites (does nothing for nicotinic-related muscle paralysis)
*May require massive dosage (hundreds of milligrams)
*Dosing<ref name="CDC">Agency for Toxic Substances and Disease Registry, Case Studies in Environmental Medicine, Cholinesterase Inhibitors: Including Pesticides and Chemical Warfare Nerve Agents. Centers for Disease Control (CDC). [http://www.atsdr.cdc.gov/csem/cholinesterase/docs/cholinesterase.pdf PDF] Accessed 06/21/15</ref> 
*Adult: Initial bolus of 2-6mg IV; titrate by doubling dose q5-30m until tracheobronchial secretions controlled
**Once secretions controlled → start IV gtt 0.02-0.08 mg/kg/hr
**Child: 0.05-0.1mg/kg (at least 0.1mg) IV; repeat bolus q2-30m until tracheobronchial secretions controlled
**Once secretions controlled → start IV gtt 0.025 mg/kg/hr
*No max dose, doses >400mg have been reported<ref>Hopmann G, Wanke H. Höchstdosierte Atropinbehandlung bei schwerer Alkylphosphatvergiftung [Maximum dose atropin treatment in severe organophosphate poisoning (author's transl)]. Dtsch Med Wochenschr. 1974;99(42):2106-2108. doi:10.1055/s-0028-1108097</ref>

===[[Pralidoxime]]===
*AKA 2-PAM
*For Organophosphate poisoning only - reactivates AChE by removing phosphate group → oxime-OP complex then excreted by kidneys.
**This must be done before "aging" occurs - conformational change that makes OP bond to AChE irreversible<ref>Eddleston M, Szinicz L, Eyer P, Buckley, N (2002) Oximes in Acute Organophosphate Pesticide Poisoning: a Systematic Review of Clinical Trials. QJM. 95(5): 275–283.</ref>
**Pralidoxime can actually bind and inhibit AChE once all AChE enzymes have aged, and can make the toxicity worse
**Window to aging depends on the agent, and is a matter of debate, but pralidoxime within 1-2 hours of exposure is the goal
*Dosing<ref name="CDC"></ref>
**Adult: 1-2gm IV over 15-30min; repeat in 1 hour if needed '''or''' 50 mg/hr infusion.
**Child: 20-40mg/kg IV over 20min; repeat in 1 hour if needed '''or''' 10-20 mg/kg/hr infusion.