see also: [[Long QT]] > **Toxidrome:** [[Cholinergic syndrome]] > Antidote:: [[atropine]] > mnemonic:: DUMBBELSS # Cause - farmer exposure - 300,000 deaths per year in asia! - **example agents**: Malathion, Parathion, Fenthion, chlorpyrifos - Dimethoate - Coumaphos - many more # Toxic Mechanism ==Irreversible anticholinesterase inhibition== → too much ACh **muscarinic effects** - DUMBBELS (bradycardia, bronchospasm) **nicotnic effects** - neuromuscular blockade (similar to succinylcholine), HTN **CNS effects** - resp depression, seizures, lethargy, coma > ==Respiratory muscle weakness and bronchorrhea cause early deaths== # Clinical features CVS - bradycardia, HTN CNS - seizures, coma, lethargy MSK - resp muscle paralysis, muscle weakness, cramps, paralysis Pulm - bronchospasm, excessive secretions metabolic - hypokalemia, hyperglycemia, metabolic acidosis noteworthy cholinergic effects - sweating, [[miosis]] (pupil constriction), salvation, other DUMBELLS # Treatment > remove clothing for patient, put in plastic bag > decontaminate with soap and water > gown, gloves for staff - [[atropine#Dose for cholinergic toxicity|Atropine]] to tx muscarinic effects (dry secretions, treat wheeze) - double dose Q5 min (1.2 --> 2.4 --> 4.8) - +/- infusion at 10-20% of the cumulative dose required to achieve adequate atropinization per hour - +/- [[Pralidoxime]] (controversial) for nicotinic effects - knocks organophosphate off - time-dependent # Disposition - admitted patients need 24 hours observation after last dose of atropine # Mnemonic DUMBBELSS for muscarinic effects Diarrhea Urination Miosis Bronchospasm Bradycardia Emesis Lacrimation Sweating Salivation