Medicine:Cholinergic crisis
| Cholinergic crisis | |
|---|---|
| Other names | Cholinergic toxicity, cholinergic poisoning, SLUDGE syndrome |
| Symptoms | Hypersalivation, lacrimation, increased urination and defecation, vomiting, sweating, constricted pupils, spasms |
| Complications | Respiratory failure, flaccid paralysis, death |
| Causes | Excess synaptic levels of acetylcholine |
| Differential diagnosis | Myasthenia gravis |
| Medication | Anticholinergics (atropine, diphenhydramine) |
A cholinergic crisis is an over-stimulation at a neuromuscular junction due to an excess of acetylcholine,[1] as a result of the inactivity of the acetylcholinesterase enzyme, which normally breaks down acetylcholine.
Signs and symptoms
As a result of cholinergic crisis, the muscles stop responding to the high synaptic levels of acetylcholine, leading to flaccid paralysis, respiratory failure, and other signs and symptoms reminiscent of organophosphate poisoning. Cholinergic crisis is sometimes known by the mnemonic "SLUDGE syndrome" (salivation, lacrimation, urination, defecation, gastrointestinal distress, and emesis).[2]
Some of the symptoms of increased cholinergic stimulation include:
- Salivation: stimulation of the salivary glands
- Lacrimation: stimulation of the lacrimal glands (tearing)
- Urination: relaxation of the internal sphincter muscle of urethra, and contraction of the detrusor muscles
- Defecation
- Gastrointestinal distress: smooth muscle tone changes causing gastrointestinal problems, including cramping
- Emesis: vomiting[3]
- Miosis:[4] constriction of the pupils of the eye via stimulation of the pupillary constrictor muscles
- Muscle spasm: stimulation of skeletal muscle (due to nicotinic acetylcholine receptor stimulation)
- Diaphoresis: increased sweating
Causes
Cholinergic crisis can be a consequence of:
- Contamination with – or excessive exposure to – certain chemicals including:
- nerve agents, (e.g., sarin, VX, Novichok agents).
- organophosphorus insecticides (e.g., parathion)
- Ingestion of certain poisonous fungi (particularly the muscarine-containing members of the genera Inocybe and Clitocybe).
- Taking too high a dose of medications such as cholinesterase inhibitors, in patients with myasthenia gravis
- Providing too high a dose of a cholinesterase inhibitor drug in order to reverse surgical muscle paralysis following general anaesthesia.
Nicotine poisoning can also be thought of as a subset of cholinergic crisis, as it also involves excessive parasympathetic stimulation.[5]
Treatment
Some elements of the cholinergic crisis can be reversed with antimuscarinic drugs like atropine or diphenhydramine, but the most dangerous effect — respiratory depression - cannot.[6]
See also
References
- ↑ Current Therapy of Trauma and Surgical Critical Care E-Book. Elsevier Health Sciences. Apr 20, 2015. p. 31. ISBN 9780323079808. https://books.google.com/books?id=vkZ9CAAAQBAJ. Retrieved 2 October 2017.
- ↑ Last Minute Emergency Medicine : A Concise Review for the Specialty Boards. McGraw Hill Professional. 1 January 2007. p. 12. ISBN 978-0-07-150975-6. https://books.google.com/books?id=JAvX7hTta_wC.
- ↑ Lehne's Pharmacology for Nursing Care. Elsevier Health Sciences. 2014-12-02. ISBN 9780323340267. https://books.google.com/books?id=C7_NBQAAQBAJ&q=Killer+Bs+in+cholinergic%2C+bradycardia%2C+bronchorrhea%2C+bronchospasm&pg=PA129.
- ↑ "A Comparative Toxidrome Analysis of Human Organophosphate and Nerve Agent Poisonings Using Social Media". Clinical and Translational Science 10 (3): 225–230. May 2017. doi:10.1111/cts.12435. PMID 28238224.
- ↑ "Nicotinic plant poisoning". Clinical Toxicology 47 (8): 771–81. September 2009. doi:10.1080/15563650903252186. PMID 19778187.
- ↑ Lott, Erica L.; Jones, Elizabeth B. (2024), "Cholinergic Toxicity", StatPearls (Treasure Island (FL): StatPearls Publishing), PMID 30969605, https://www.ncbi.nlm.nih.gov/books/NBK539783/, retrieved 2024-02-01
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