Treatment of Cholinergic Crisis

Clinical Manifestations

Cholinergic crisis results from excessive acetylcholine accumulation at muscarinic and nicotinic receptors, causing muscarinic effects such as bradycardia, hypotension, bronchorrhea, bronchospasm, excessive secretions, GI hypermotility, and urinary incontinence, as well as nicotinic effects like muscle fasciculations, weakness, and flaccid paralysis, and central nervous system effects including anxiety, seizures, respiratory depression, and coma, according to the American Society of Anesthesiologists 3

The American Heart Association recommends atropine administration, with adult dosing at 2-4 mg IV initially, repeated at 5-10 minute intervals until secretions are inhibited, and pediatric dosing at 0.05-0.1 mg/kg IV, titrated until resolution of cholinergic crisis, with a strength of evidence level of high 2, 4
For anticholinesterase poisoning, the American Academy of Pediatrics recommends atropine doses of 2-5 mg initially, then doubled every 10-20 minutes as needed, with a strength of evidence level of moderate 1

The American Society of Anesthesiologists recommends pralidoxime (2-PAM) administration, with adult dosing at 1000-2000 mg IV over 15-30 minutes, and pediatric dosing at 20-50 mg/kg, with a strength of evidence level of low 4
Benzodiazepines, such as diazepam or midazolam, are recommended for seizure control, with a strength of evidence level of moderate 4

The American Society of Anesthesiologists recommends respiratory support, including securing the airway, providing mechanical ventilation, and frequent airway suctioning, with a strength of evidence level of high 5
Cardiovascular support, including fluid resuscitation and vasopressors, is recommended for hypotension, with a strength of evidence level of moderate 4
Continuous cardiac monitoring is recommended for bradycardia, heart blocks, and arrhythmias, with a strength of evidence level of high 3, 5

Pediatric patients may be more susceptible to nerve agent toxicity due to higher minute ventilation and greater risk of dehydration, according to the American Society of Anesthesiologists, with a strength of evidence level of moderate 4
The American Society of Anesthesiologists recommends avoiding succinylcholine in patients with cholinergic crisis, as it may cause prolonged paralysis, with a strength of evidence level of high 6
Anticholinergic agents like ipratropium bromide may be helpful for bronchospasm, but have inconsistent efficacy, according to the American Academy of Allergy, Asthma, and Immunology, with a strength of evidence level of low 7
Beta-agonists and steroids may help manage severe bronchoconstriction, with a strength of evidence level of moderate 5

Underdosing atropine may occur in severe cholinergic crisis, requiring much larger doses than standard, according to the American Society of Anesthesiologists, with a strength of evidence level of moderate 4
Delayed neuromuscular weakness may occur up to 4 days after acute exposure to anticholinesterase agents and responds poorly to antidotal treatment, with a strength of evidence level of low 6