Version May 2024
| To obtain emergency consultation with a medical toxicologist, in the United States, call 1-800-222-1222 for the nearest regional poison control center. Contact information for poison control centers around the world is available at the WHO website and in the UpToDate topic on regional poison control centers (society guideline links). |
| Clinical syndromes |
| Acute toxicity |
| Generally manifests in minutes to hours |
| Evidence of cholinergic excess |
| SLUDGE = Salivation, Lacrimation, Urination, Defecation, Gastric Emptying |
| BBB = Bradycardia, Bronchorrhea, Bronchospasm |
| Respiratory insufficiency can result from muscle weakness, decreased central drive, increased secretions, and bronchospasm |
| Intermediate syndrome |
| Occurs 24-96 hours after exposure |
| Bulbar, respiratory, and proximal muscle weakness are prominent features |
| Generally resolves in 1-3 weeks |
| Organophosphorus Agent-Induced Delayed Peripheral Neuropathy (OPIDN) |
| Usually occurs several weeks after exposure |
| Primarily motor involvement |
| May resolve spontaneously, but can result in permanent neurologic dysfunction |
| Diagnostic evaluation of acute toxicity |
| Atropine challenge if diagnosis is in doubt (1 mg IV in adults, 0.01 to 0.02 mg/kg in children) |
| Absence of anticholinergic signs (tachycardia, mydriasis, decreased bowel sounds, dry skin) strongly suggests poisoning with organophosphate or carbamate |
| Draw blood sample for measurement of RBC acetylcholinesterase activity to confirm diagnosis |
| Treatment of acute toxicity |
| Deliver 100% oxygen via facemask; early intubation often required; avoid succinylcholine |
| Decontamination if ingestion within 1 hour give single dose activated charcoal, adult 50 g (1 g/kg in children) unless airway not protected or other contraindication. Aggressive dermal and ocular irrigation as needed. Bag/discard clothing. |
| Atropine 2 to 5 mg IV/IM/IO bolus (0.05 mg/kg IV in children) |
| Escalate (double) dose every 3-5 minutes until bronchial secretions and wheezing stop |
| TACHYCARDIA AND MYDRIASIS ARE NOT CONTRAINDICATIONS TO ATROPINE USE |
| Hundreds of milligrams may be needed over several days in severe poisonings |
| Inhaled ipratropium 0.5 mg with parenteral atropine may be helpful for bronchospasm; may repeat |
| Pralidoxime (2-PAM) 2 g (25 mg/kg in children) IV over 30 minutes; may repeat after 30 minutes or give continuous infusion if severe |
| Continuous infusion at 8 mg/kg/hour in adults (10 mg/kg/hour in children) |
| If no IV access, give pralidoxime 600 mg IM (15 mg/kg in children <40 kg). Rapidly repeat as needed to total of 1800 mg or 45 mg/kg in children. |
| Pralidoxime is given with atropine |
| Benzodiazepine therapy |
| Diazepam 10 mg IV (0.1 to 0.2 mg/kg in children), repeat as necessary if seizures occur. Do not give phenytoin. |
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