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    Atropine Dosing for Cholinesterase Inhibitor Toxicity

    Doses atropine for cholinesterase inhibitor toxicity (prescribed drugs, nerve gas, insecticides).
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    IMPORTANT

    This dosing tool is intended to assist with calculation, not to provide comprehensive or definitive drug information. Always double-check dosing of any drug and consult a pharmacist when necessary.

    INSTRUCTIONS

    • Use in patients with cholinergic toxicity to determine atropine bolus dose and continuous infusion rate.
    • Not for use in treating isolated bradycardia.
    • Not for use in AtroPen Atropine Auto-Injector dosing.
    • In the United States, the local Poison Control Center can be reached at 1-800-222-1222 to help guide management.
    When to Use
    Pearls/Pitfalls
    Why Use
    • Use for patients with cholinergic toxicity (causative agents are typically organophosphate compounds or carbamate, found in pesticides, or agents used in chemical warfare and terrorist attacks).
    • Many symptoms of cholinergic toxicity are recalled with the “SLUDGE and killer B’s” mnemonic:
      • Salivation.
      • Lacrimation.
      • Urination.
      • Defecation.
      • Gastric Emesis.
      • Bradycardia.
      • Bronchospasm.
      • Bronchorrhea.
    • This dosing guide was created to facilitate early and safe atropinization of the patient exhibiting signs of acute cholinergic toxicity.
    • May be used in patients exposed to either pesticide agents (more common) or agents of chemical warfare/terrorism.
    • Markers of atropinization vary, but the most clinically significant is resolution of bronchorrhea, as assessed by auscultation.
    • Large cumulative doses of atropine may be necessary to treat toxicity. Cases requiring hundreds to thousands of milligrams over the course of treatment have been reported (Hopmann 1974).

    Atropine is a competitive antagonist at muscarinic receptors and can reverse the deleterious or life-threatening symptoms of cholinergic toxicity, particularly bronchospasm and bronchorrhea.

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    Advice

    • Patients suspected of cholinergic toxicity exhibiting signs of neuromuscular dysfunction should also be treated with pralidoxime (2-PAM).
    • Doses of atropine delivered intravenously should be given rapidly and in their entirety—slow administration or subtherapeutic doses have been associated with paradoxical bradycardia.

    Management

    Management of organophosphate / carbamate toxicity includes:

      • Prompt, safe, and thorough decontamination.
      • Early intubation for airway protection in severe cases.
        • Avoid succinylcholine for rapid sequence intubation, given prolonged duration of action in cholinergic poisonings.
      • Early atropinization.
      • Administration of pralidoxime.
      • Administration of benzodiazepines for seizure activity.
      • Admission to a higher level of care for close monitoring.

    Critical Actions

    Patients exposed to organophosphate or carbamate agents should be immediately decontaminated by removing all clothing and abundantly irrigating all exposed areas before initiating treatment.

    Content Contributors
    • Philip DiSalvo, MD
    About the Creator
    Dr. Lewis Goldfrank
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    Content Contributors
    • Philip DiSalvo, MD