Template:Cholinergic Toxicity Treatment - Revision history

Danbot: Fix cite errors: convert named refs to inline refs to prevent conflicts with transcluding pages that define same named refs

2026-03-21T01:08:26Z

Fix cite errors: convert named refs to inline refs to prevent conflicts with transcluding pages that define same named refs

Danbot: Fix cite errors: add content to named refs (medscape, bmj, wfsa, pralidoxime_statpearls, prognosis) that were self-closing without definitions

2026-03-21T00:59:46Z

Fix cite errors: add content to named refs (medscape, bmj, wfsa, pralidoxime_statpearls, prognosis) that were self-closing without definitions

Danbot: Convert adult pralidoxime dose to MedicationDose template

2026-03-20T22:39:18Z

Convert adult pralidoxime dose to MedicationDose template

← Older revision		Revision as of 22:39, 20 March 2026
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	*'''Must give atropine BEFORE pralidoxime''' to prevent worsening of muscarinic symptoms		*'''Must give atropine BEFORE pralidoxime''' to prevent worsening of muscarinic symptoms
	*'''Must be given before aging occurs''' (see [[#Aging and Oxime Window\|aging table above]])		*'''Must be given before aging occurs''' (see [[#Aging and Oxime Window\|aging table above]])
	*~~Adult~~ dose~~: '''~~1-2 g IV over 15-30 ~~minutes'''~~, ~~may repeat in 1 hour; or '''30 mg/kg bolus~~ then 8-10 mg/kg/hr ~~continuous~~ infusion~~'''<ref name~~=~~"medscape"/>~~		*{{MedicationDose\|drug=Pralidoxime\|dose=1-2 g IV over 15-30 min, then 8-10 mg/kg/hr infusion (or repeat bolus in 1 hr)\|route=IV\|context=Cholinergic toxicity (oxime reactivator)\|indication={{PAGENAME}}\|population=Adult}}
	*Pediatric: {{MedicationDose\|drug=Pralidoxime\|dose=20-50 mg/kg IV, then 5-10 mg/kg/hr infusion\|route=IV\|context=Cholinergic toxicity (oxime reactivator)\|indication={{PAGENAME}}\|population=Pediatric}}		*Pediatric: {{MedicationDose\|drug=Pralidoxime\|dose=20-50 mg/kg IV, then 5-10 mg/kg/hr infusion\|route=IV\|context=Cholinergic toxicity (oxime reactivator)\|indication={{PAGENAME}}\|population=Pediatric}}
	*Continue until clinical improvement or patient is off ventilator		*Continue until clinical improvement or patient is off ventilator

Danbot: Add MedicationDose templates for atropine and pralidoxime in cholinergic toxicity

2026-03-20T22:38:24Z

Add MedicationDose templates for atropine and pralidoxime in cholinergic toxicity

← Older revision		Revision as of 22:38, 20 March 2026
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	*'''First-line antidote''' — muscarinic antagonist; treats bronchorrhea, bronchospasm, bradycardia, and secretions<ref name="medscape"/>		*'''First-line antidote''' — muscarinic antagonist; treats bronchorrhea, bronchospasm, bradycardia, and secretions<ref name="medscape"/>
	*'''Does NOT reverse nicotinic symptoms''' (weakness, fasciculations, paralysis)		*'''Does NOT reverse nicotinic symptoms''' (weakness, fasciculations, paralysis)
	*Starting dose: ~~'''~~1-2 mg IV~~'''~~ (~~pediatric~~: 0.02-0.05 mg/kg~~, minimum~~ 0.1 mg)		*Starting dose: {{MedicationDose\|drug=Atropine\|dose=1-2 mg IV (double q5min until atropinization)\|route=IV\|context=Cholinergic toxicity antidote (muscarinic)\|indication={{PAGENAME}}\|population=Adult\|notes=May need 100+ mg in first 24h; endpoint is drying of secretions}}
			*Pediatric: {{MedicationDose\|drug=Atropine\|dose=0.02-0.05 mg/kg IV (min 0.1 mg), double q5min\|route=IV\|context=Cholinergic toxicity antidote (muscarinic)\|indication={{PAGENAME}}\|population=Pediatric}}
	*'''Doubling protocol''': If inadequate response after 5 minutes, double the dose (1 → 2 → 4 → 8 → 16 mg...) until atropinization is achieved<ref name="medscape"/>		*'''Doubling protocol''': If inadequate response after 5 minutes, double the dose (1 → 2 → 4 → 8 → 16 mg...) until atropinization is achieved<ref name="medscape"/>
	*Massive doses may be required — total doses of 100+ mg in the first 24 hours have been reported<ref name="bmj"/>		*Massive doses may be required — total doses of 100+ mg in the first 24 hours have been reported<ref name="bmj"/>
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	*'''Must be given before aging occurs''' (see [[#Aging and Oxime Window\|aging table above]])		*'''Must be given before aging occurs''' (see [[#Aging and Oxime Window\|aging table above]])
	*Adult dose: '''1-2 g IV over 15-30 minutes''', may repeat in 1 hour; or '''30 mg/kg bolus then 8-10 mg/kg/hr continuous infusion'''<ref name="medscape"/>		*Adult dose: '''1-2 g IV over 15-30 minutes''', may repeat in 1 hour; or '''30 mg/kg bolus then 8-10 mg/kg/hr continuous infusion'''<ref name="medscape"/>
	*Pediatric dose: 20-50 mg/kg IV, then 5-10 mg/kg/hr infusion		*Pediatric: {{MedicationDose\|drug=Pralidoxime\|dose=20-50 mg/kg IV, then 5-10 mg/kg/hr infusion\|route=IV\|context=Cholinergic toxicity (oxime reactivator)\|indication={{PAGENAME}}\|population=Pediatric}}
	*Continue until clinical improvement or patient is off ventilator		*Continue until clinical improvement or patient is off ventilator
	*'''Controversies''':		*'''Controversies''':

Ostermayer: /* Antidotes */

2026-02-28T23:44:12Z

Antidotes

← Older revision		Revision as of 23:44, 28 February 2026
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	==Antidotes==		==Antidotes==
	===[[Atropine]]===		===[[Atropine]]===
	*~~Competitively blocks~~ muscarinic ~~sites (does nothing for nicotinic-related muscle paralysis)~~		*'''First-line antidote''' — muscarinic antagonist; treats bronchorrhea, bronchospasm, bradycardia, and secretions<ref name="medscape"/>
	*May require massive dosage (hundreds of milligrams)		*'''Does NOT reverse nicotinic symptoms''' (weakness, fasciculations, paralysis)
	*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>~~		*Starting dose: '''1-2 mg IV''' (pediatric: 0.02-0.05 mg/kg, minimum 0.1 mg)
	*~~Adult~~: ~~Initial bolus of~~ 2~~-6mg~~ IV~~; titrate by doubling dose q5-30m until tracheobronchial secretions controlled~~		*'''Doubling protocol''': If inadequate response after 5 minutes, double the dose (1 → 2 → 4 → 8 → 16 mg...) until atropinization is achieved<ref name="medscape"/>
	**Once secretions controlled → start IV gtt 0.02-0.08 mg/kg~~/hr~~		*Massive doses may be required — total doses of 100+ mg in the first 24 hours have been reported<ref name="bmj"/>
	**Child: 0.~~05-0~~.~~1mg/kg (at least 0~~.~~1mg~~) ~~IV; repeat bolus q2-30m~~ until ~~tracheobronchial secretions controlled~~		*'''Endpoints of adequate atropinization''' (goal of therapy):
	**Once secretions controlled → start IV gtt 0.025 mg/~~kg/hr~~		**Drying of bronchial secretions ('''most important endpoint''')
	*~~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~~>		**Heart rate >80 bpm
			**Systolic BP >80 mmHg
			*'''Do NOT target''': Fully dilated pupils, absent bowel sounds, or HR >150 — these indicate atropine toxicity<ref name="wfsa"/>
			*After initial atropinization: Consider atropine infusion (10-20% of loading dose per hour) to maintain effect
			*'''Optimize oxygenation before giving atropine''' to reduce risk of dysrhythmias (though in resource-limited settings, do not withhold atropine waiting for oxygen)<ref name="bmj"/>


	===[[Pralidoxime]]===		===[[Pralidoxime]]===
	*AKA 2-PAM		*AKA 2-PAM
	*~~For Organophosphate poisoning only -~~ reactivates AChE ~~by removing phosphate group~~ → ~~oxime-OP complex then excreted by kidneys.~~		*Oxime that reactivates phosphorylated AChE → primarily reverses '''nicotinic''' symptoms (weakness, fasciculations, respiratory muscle paralysis)<ref name="pralidoxime_statpearls"/>
	**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~~>		*'''Must give atropine BEFORE pralidoxime''' to prevent worsening of muscarinic symptoms
	**~~Pralidoxime can actually bind~~ and ~~inhibit AChE once all AChE enzymes have aged, and can make the toxicity worse~~		*'''Must be given before aging occurs''' (see [[#Aging and Oxime Window\|aging table above]])
	**Window to aging ~~depends on the agent, and is a matter of debate, but pralidoxime within 1-2 hours of exposure is the goal~~		*Adult dose: '''1-2 g IV over 15-30 minutes''', may repeat in 1 hour; or '''30 mg/kg bolus then 8-10 mg/kg/hr continuous infusion'''<ref name="medscape"/>
	*Dosing<ref name="CDC"></ref>		*Pediatric dose: 20-50 mg/kg IV, then 5-10 mg/kg/hr infusion
	**Adult: 1-~~2gm~~ IV over 15-~~30min;~~ repeat in 1 hour ~~if needed '''~~or''' 50 mg/hr infusion.		*Continue until clinical improvement or patient is off ventilator
	**Child: 20-~~40mg~~/kg IV ~~over 20min; repeat in 1 hour if needed~~ '''or''' 10-~~20 mg~~/kg/~~hr infusion.~~		*'''Controversies''':
			**Evidence for benefit of pralidoxime is inconsistent; several meta-analyses have not shown clear mortality benefit when added to atropine<ref name="prognosis"/>
			**However, per AHA 2023 guidelines and expert consensus, oximes should still be given for significant OP poisoning, particularly when fasciculations, weakness, or paralysis are present<ref name="medscape"/>
			**Efficacy depends on timing (before aging), dose, and the specific OP compound involved
			*'''Caution''': Administer slowly — rapid IV push can cause hypertensive crisis, cardiac arrest

Elcatracho: /* Supportive Care */

2021-02-01T19:05:49Z

Supportive Care

← Older revision		Revision as of 19:05, 1 February 2021
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	**Use nondepolarizing agent ([[Rocuronium]] or [[Vecuronium]])		**Use nondepolarizing agent ([[Rocuronium]] or [[Vecuronium]])
	**Succinylcholine is absolutely contraindicated		**Succinylcholine is absolutely contraindicated
			*[[Benzodiazepines]] for seizures

	===Antidotes===		===Antidotes===

Elcatracho: /* Atropine */

2021-01-15T06:30:09Z

Atropine

← Older revision		Revision as of 06:30, 15 January 2021
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	**Child: 0.05-0.1mg/kg (at least 0.1mg) IV; repeat bolus q2-30m until tracheobronchial secretions controlled		**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		**Once secretions controlled → start IV gtt 0.025 mg/kg/hr
	*No max dose, ~~reports of~~ 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>		*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]]===		===[[Pralidoxime]]===

Elcatracho: /* Atropine */

2021-01-15T06:29:37Z

Atropine

← Older revision		Revision as of 06:29, 15 January 2021
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	**Child: 0.05-0.1mg/kg (at least 0.1mg) IV; repeat bolus q2-30m until tracheobronchial secretions controlled		**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		**Once secretions controlled → start IV gtt 0.025 mg/kg/hr
			*No max dose, reports of 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]]===		===[[Pralidoxime]]===
	*AKA 2-PAM		*AKA 2-PAM

Kxl328: /* Supportive Care */

2018-10-07T02:45:43Z

Supportive Care

← Older revision		Revision as of 02:45, 7 October 2018
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	*Aggressive airway management is of utmost importance.		*Aggressive airway management is of utmost importance.
	**Intubation often needed due to significant respiratory secretions / bronchospasm.		**Intubation often needed due to significant respiratory secretions / bronchospasm.
	**Use nondepolarizing agent ([[Rocuronium]] or [[Vecuronium]]).		**Use nondepolarizing agent ([[Rocuronium]] or [[Vecuronium]])
			**Succinylcholine is absolutely contraindicated

	===Antidotes===		===Antidotes===

Kxl328: /* Pralidoxime */

2018-10-05T20:19:58Z

Pralidoxime

← Older revision		Revision as of 20:19, 5 October 2018
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	*AKA 2-PAM		*AKA 2-PAM
	*For Organophosphate poisoning only - reactivates AChE by removing phosphate group → oxime-OP complex then excreted by kidneys.		*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.		**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>		*Dosing<ref name="CDC"></ref>
	**Adult: 1-2gm IV over 15-30min; repeat in 1 hour if needed '''or''' 50 mg/hr infusion.		**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.		**Child: 20-40mg/kg IV over 20min; repeat in 1 hour if needed '''or''' 10-20 mg/kg/hr infusion.

← Older revision		Revision as of 01:08, 21 March 2026
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	==Antidotes==		==Antidotes==
	===[[Atropine]]===		===[[Atropine]]===
	*'''First-line antidote''' — muscarinic antagonist; treats bronchorrhea, bronchospasm, bradycardia, and secretions<ref ~~name="medscape"~~>Eddleston M, Buckley NA, Eyer P, Dawson AH. Management of acute organophosphorus pesticide poisoning. Lancet. 2008;371(9612):597-607. doi:10.1016/S0140-6736(07)61202-1</ref>		*'''First-line antidote''' — muscarinic antagonist; treats bronchorrhea, bronchospasm, bradycardia, and secretions<ref>Eddleston M, Buckley NA, Eyer P, Dawson AH. Management of acute organophosphorus pesticide poisoning. Lancet. 2008;371(9612):597-607. doi:10.1016/S0140-6736(07)61202-1</ref>
	*'''Does NOT reverse nicotinic symptoms''' (weakness, fasciculations, paralysis)		*'''Does NOT reverse nicotinic symptoms''' (weakness, fasciculations, paralysis)
	*Starting dose: {{MedicationDose\|drug=Atropine\|dose=1-2 mg IV (double q5min until atropinization)\|route=IV\|context=Cholinergic toxicity antidote (muscarinic)\|indication={{PAGENAME}}\|population=Adult\|notes=May need 100+ mg in first 24h; endpoint is drying of secretions}}		*Starting dose: {{MedicationDose\|drug=Atropine\|dose=1-2 mg IV (double q5min until atropinization)\|route=IV\|context=Cholinergic toxicity antidote (muscarinic)\|indication={{PAGENAME}}\|population=Adult\|notes=May need 100+ mg in first 24h; endpoint is drying of secretions}}
	*Pediatric: {{MedicationDose\|drug=Atropine\|dose=0.02-0.05 mg/kg IV (min 0.1 mg), double q5min\|route=IV\|context=Cholinergic toxicity antidote (muscarinic)\|indication={{PAGENAME}}\|population=Pediatric}}		*Pediatric: {{MedicationDose\|drug=Atropine\|dose=0.02-0.05 mg/kg IV (min 0.1 mg), double q5min\|route=IV\|context=Cholinergic toxicity antidote (muscarinic)\|indication={{PAGENAME}}\|population=Pediatric}}
	*'''Doubling protocol''': If inadequate response after 5 minutes, double the dose (1 → 2 → 4 → 8 → 16 mg...) until atropinization is achieved<ref ~~name="medscape"~~/>		*'''Doubling protocol''': If inadequate response after 5 minutes, double the dose (1 → 2 → 4 → 8 → 16 mg...) until atropinization is achieved<ref>Eddleston M, Buckley NA, Eyer P, Dawson AH. Management of acute organophosphorus pesticide poisoning. Lancet. 2008;371(9612):597-607. doi:10.1016/S0140-6736(07)61202-1</ref>
	*Massive doses may be required — total doses of 100+ mg in the first 24 hours have been reported<ref ~~name="bmj"~~>Eddleston M, Chowdhury FR. Pharmacological treatment of organophosphorus insecticide poisoning: the old and the (possible) new. Br J Clin Pharmacol. 2016;81(3):462-470. doi:10.1111/bcp.12784</ref>		*Massive doses may be required — total doses of 100+ mg in the first 24 hours have been reported<ref>Eddleston M, Chowdhury FR. Pharmacological treatment of organophosphorus insecticide poisoning: the old and the (possible) new. Br J Clin Pharmacol. 2016;81(3):462-470. doi:10.1111/bcp.12784</ref>
	*'''Endpoints of adequate atropinization''' (goal of therapy):		*'''Endpoints of adequate atropinization''' (goal of therapy):
	**Drying of bronchial secretions ('''most important endpoint''')		**Drying of bronchial secretions ('''most important endpoint''')
	**Heart rate >80 bpm		**Heart rate >80 bpm
	**Systolic BP >80 mmHg		**Systolic BP >80 mmHg
	*'''Do NOT target''': Fully dilated pupils, absent bowel sounds, or HR >150 — these indicate atropine toxicity<ref ~~name="wfsa"~~>Mitra RL, Mohan S. Anaesthesia and organophosphorus poisoning. World Federation of Societies of Anaesthesiologists. Anaesthesia Tutorial of the Week. 2011.</ref>		*'''Do NOT target''': Fully dilated pupils, absent bowel sounds, or HR >150 — these indicate atropine toxicity<ref>Mitra RL, Mohan S. Anaesthesia and organophosphorus poisoning. World Federation of Societies of Anaesthesiologists. Anaesthesia Tutorial of the Week. 2011.</ref>
	*After initial atropinization: Consider atropine infusion (10-20% of loading dose per hour) to maintain effect		*After initial atropinization: Consider atropine infusion (10-20% of loading dose per hour) to maintain effect
	*'''Optimize oxygenation before giving atropine''' to reduce risk of dysrhythmias (though in resource-limited settings, do not withhold atropine waiting for oxygen)<ref ~~name="bmj"~~/>		*'''Optimize oxygenation before giving atropine''' to reduce risk of dysrhythmias (though in resource-limited settings, do not withhold atropine waiting for oxygen)<ref>Eddleston M, Chowdhury FR. Pharmacological treatment of organophosphorus insecticide poisoning: the old and the (possible) new. Br J Clin Pharmacol. 2016;81(3):462-470. doi:10.1111/bcp.12784</ref>


	===[[Pralidoxime]]===		===[[Pralidoxime]]===
	*AKA 2-PAM		*AKA 2-PAM
	*Oxime that reactivates phosphorylated AChE → primarily reverses '''nicotinic''' symptoms (weakness, fasciculations, respiratory muscle paralysis)<ref ~~name="pralidoxime_statpearls"~~>Bhatt MH, Bhatt S. Pralidoxime. [Updated 2023 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024.</ref>		*Oxime that reactivates phosphorylated AChE → primarily reverses '''nicotinic''' symptoms (weakness, fasciculations, respiratory muscle paralysis)<ref>Bhatt MH, Bhatt S. Pralidoxime. [Updated 2023 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024.</ref>
	*'''Must give atropine BEFORE pralidoxime''' to prevent worsening of muscarinic symptoms		*'''Must give atropine BEFORE pralidoxime''' to prevent worsening of muscarinic symptoms
	*'''Must be given before aging occurs''' (see [[#Aging and Oxime Window\|aging table above]])		*'''Must be given before aging occurs''' (see [[#Aging and Oxime Window\|aging table above]])
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	*Continue until clinical improvement or patient is off ventilator		*Continue until clinical improvement or patient is off ventilator
	*'''Controversies''':		*'''Controversies''':
	**Evidence for benefit of pralidoxime is inconsistent; several meta-analyses have not shown clear mortality benefit when added to atropine<ref ~~name="prognosis"~~>Peter JV, Sudarsan TI, Moran JL. Clinical features of organophosphate poisoning: A review of different classification systems and approaches. Indian J Crit Care Med. 2014;18(11):735-745. doi:10.4103/0972-5229.144017</ref>		**Evidence for benefit of pralidoxime is inconsistent; several meta-analyses have not shown clear mortality benefit when added to atropine<ref>Peter JV, Sudarsan TI, Moran JL. Clinical features of organophosphate poisoning: A review of different classification systems and approaches. Indian J Crit Care Med. 2014;18(11):735-745. doi:10.4103/0972-5229.144017</ref>
	**However, per AHA 2023 guidelines and expert consensus, oximes should still be given for significant OP poisoning, particularly when fasciculations, weakness, or paralysis are present<ref ~~name="medscape"~~/>		**However, per AHA 2023 guidelines and expert consensus, oximes should still be given for significant OP poisoning, particularly when fasciculations, weakness, or paralysis are present<ref>Eddleston M, Buckley NA, Eyer P, Dawson AH. Management of acute organophosphorus pesticide poisoning. Lancet. 2008;371(9612):597-607. doi:10.1016/S0140-6736(07)61202-1</ref>
	**Efficacy depends on timing (before aging), dose, and the specific OP compound involved		**Efficacy depends on timing (before aging), dose, and the specific OP compound involved
	*'''Caution''': Administer slowly — rapid IV push can cause hypertensive crisis, cardiac arrest		*'''Caution''': Administer slowly — rapid IV push can cause hypertensive crisis, cardiac arrest

← Older revision		Revision as of 00:59, 21 March 2026
Line 25:		Line 25:
	==Antidotes==		==Antidotes==
	===[[Atropine]]===		===[[Atropine]]===
	*'''First-line antidote''' — muscarinic antagonist; treats bronchorrhea, bronchospasm, bradycardia, and secretions<ref name="medscape"/>		*'''First-line antidote''' — muscarinic antagonist; treats bronchorrhea, bronchospasm, bradycardia, and secretions<ref name="medscape">Eddleston M, Buckley NA, Eyer P, Dawson AH. Management of acute organophosphorus pesticide poisoning. Lancet. 2008;371(9612):597-607. doi:10.1016/S0140-6736(07)61202-1</ref>
	*'''Does NOT reverse nicotinic symptoms''' (weakness, fasciculations, paralysis)		*'''Does NOT reverse nicotinic symptoms''' (weakness, fasciculations, paralysis)
	*Starting dose: {{MedicationDose\|drug=Atropine\|dose=1-2 mg IV (double q5min until atropinization)\|route=IV\|context=Cholinergic toxicity antidote (muscarinic)\|indication={{PAGENAME}}\|population=Adult\|notes=May need 100+ mg in first 24h; endpoint is drying of secretions}}		*Starting dose: {{MedicationDose\|drug=Atropine\|dose=1-2 mg IV (double q5min until atropinization)\|route=IV\|context=Cholinergic toxicity antidote (muscarinic)\|indication={{PAGENAME}}\|population=Adult\|notes=May need 100+ mg in first 24h; endpoint is drying of secretions}}
	*Pediatric: {{MedicationDose\|drug=Atropine\|dose=0.02-0.05 mg/kg IV (min 0.1 mg), double q5min\|route=IV\|context=Cholinergic toxicity antidote (muscarinic)\|indication={{PAGENAME}}\|population=Pediatric}}		*Pediatric: {{MedicationDose\|drug=Atropine\|dose=0.02-0.05 mg/kg IV (min 0.1 mg), double q5min\|route=IV\|context=Cholinergic toxicity antidote (muscarinic)\|indication={{PAGENAME}}\|population=Pediatric}}
	*'''Doubling protocol''': If inadequate response after 5 minutes, double the dose (1 → 2 → 4 → 8 → 16 mg...) until atropinization is achieved<ref name="medscape"/>		*'''Doubling protocol''': If inadequate response after 5 minutes, double the dose (1 → 2 → 4 → 8 → 16 mg...) until atropinization is achieved<ref name="medscape"/>
	*Massive doses may be required — total doses of 100+ mg in the first 24 hours have been reported<ref name="bmj"/>		*Massive doses may be required — total doses of 100+ mg in the first 24 hours have been reported<ref name="bmj">Eddleston M, Chowdhury FR. Pharmacological treatment of organophosphorus insecticide poisoning: the old and the (possible) new. Br J Clin Pharmacol. 2016;81(3):462-470. doi:10.1111/bcp.12784</ref>
	*'''Endpoints of adequate atropinization''' (goal of therapy):		*'''Endpoints of adequate atropinization''' (goal of therapy):
	**Drying of bronchial secretions ('''most important endpoint''')		**Drying of bronchial secretions ('''most important endpoint''')
	**Heart rate >80 bpm		**Heart rate >80 bpm
	**Systolic BP >80 mmHg		**Systolic BP >80 mmHg
	*'''Do NOT target''': Fully dilated pupils, absent bowel sounds, or HR >150 — these indicate atropine toxicity<ref name="wfsa"/>		*'''Do NOT target''': Fully dilated pupils, absent bowel sounds, or HR >150 — these indicate atropine toxicity<ref name="wfsa">Mitra RL, Mohan S. Anaesthesia and organophosphorus poisoning. World Federation of Societies of Anaesthesiologists. Anaesthesia Tutorial of the Week. 2011.</ref>
	*After initial atropinization: Consider atropine infusion (10-20% of loading dose per hour) to maintain effect		*After initial atropinization: Consider atropine infusion (10-20% of loading dose per hour) to maintain effect
	*'''Optimize oxygenation before giving atropine''' to reduce risk of dysrhythmias (though in resource-limited settings, do not withhold atropine waiting for oxygen)<ref name="bmj"/>		*'''Optimize oxygenation before giving atropine''' to reduce risk of dysrhythmias (though in resource-limited settings, do not withhold atropine waiting for oxygen)<ref name="bmj"/>
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	===[[Pralidoxime]]===		===[[Pralidoxime]]===
	*AKA 2-PAM		*AKA 2-PAM
	*Oxime that reactivates phosphorylated AChE → primarily reverses '''nicotinic''' symptoms (weakness, fasciculations, respiratory muscle paralysis)<ref name="pralidoxime_statpearls"/>		*Oxime that reactivates phosphorylated AChE → primarily reverses '''nicotinic''' symptoms (weakness, fasciculations, respiratory muscle paralysis)<ref name="pralidoxime_statpearls">Bhatt MH, Bhatt S. Pralidoxime. [Updated 2023 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024.</ref>
	*'''Must give atropine BEFORE pralidoxime''' to prevent worsening of muscarinic symptoms		*'''Must give atropine BEFORE pralidoxime''' to prevent worsening of muscarinic symptoms
	*'''Must be given before aging occurs''' (see [[#Aging and Oxime Window\|aging table above]])		*'''Must be given before aging occurs''' (see [[#Aging and Oxime Window\|aging table above]])
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	*Continue until clinical improvement or patient is off ventilator		*Continue until clinical improvement or patient is off ventilator
	*'''Controversies''':		*'''Controversies''':
	**Evidence for benefit of pralidoxime is inconsistent; several meta-analyses have not shown clear mortality benefit when added to atropine<ref name="prognosis"/>		**Evidence for benefit of pralidoxime is inconsistent; several meta-analyses have not shown clear mortality benefit when added to atropine<ref name="prognosis">Peter JV, Sudarsan TI, Moran JL. Clinical features of organophosphate poisoning: A review of different classification systems and approaches. Indian J Crit Care Med. 2014;18(11):735-745. doi:10.4103/0972-5229.144017</ref>
	**However, per AHA 2023 guidelines and expert consensus, oximes should still be given for significant OP poisoning, particularly when fasciculations, weakness, or paralysis are present<ref name="medscape"/>		**However, per AHA 2023 guidelines and expert consensus, oximes should still be given for significant OP poisoning, particularly when fasciculations, weakness, or paralysis are present<ref name="medscape"/>
	**Efficacy depends on timing (before aging), dose, and the specific OP compound involved		**Efficacy depends on timing (before aging), dose, and the specific OP compound involved
	*'''Caution''': Administer slowly — rapid IV push can cause hypertensive crisis, cardiac arrest		*'''Caution''': Administer slowly — rapid IV push can cause hypertensive crisis, cardiac arrest