Cholinergic (SLUDGEM) vs Anticholinergic Poisoning: Toxidrome Recognition and First Aid¶

Ke make ke keiki, kanaka makua, a mea mahiai paha i kekahi laau i ike ole ia, mea kanu, halo, a i ole ia, aole e kali ka poe toxicologists a me na mea kokua pilikia i na hora no ka nana ana i ka hale hana e hoomaka ai i ka lapaau ola: aka, nana lakou i na haumana o ka mea ma'i, ka hou o ka ili, ka puuwai, ka hanu hanu, a me ke kulana noonoo e ike ai i kahi toxidrome (toxic syndrome). ʻElua o nā toxidromes maʻamau a make ma ka Honua he kūʻē i ka physiological e hana ana ma ka ** acetylcholine (ACh) neurotransmitter system**: ʻo ka ** Cholinergic Toxidrome (hoʻomanaʻo ʻia e ka mnemonics SLUDGEM / DUMBELS a me ka Killer B's) , ka mea e hoʻoheheʻe i nā mea hoʻokipa me ka nui o ka acetylcholine, ka hoʻoheheʻe ʻana i ka acetylcholine a me ka hoʻoheheʻe ʻana i ka maʻi. puʻuwai lohi, ʻāwīwī, me nā haumāna pinpoint", e kū'ē i ka Anticholinergic (Antimuscarinic) Toxidrome, ka mea e poloka ai i nā mea hoʻokipa acetylcholine a hana i ka mea maʻi " maloʻo iwi, wela, ʻulaʻula, puʻuwai wikiwiki, delirious, mālama i ka mimi, me nā haumāna ākea ākea". Inā manaʻo ʻoe he tooxidrome paha, e kelepona i kāu helu ulia pōpilikia ma o kā mākou helu pilikia papa kuhikuhi a hoʻopili koke i ka Poison Control, no ka mea, ʻo ka cholinergic poisoning pono e hoʻopau koke i ka ʻili a me atropine + pralidoxime ʻoiai ʻo ka lāʻau ʻawaʻawa anticholinergic e pono ai ka hoʻomaha ikaika, benzodiazepines, a i ʻole physostigmine, me kā mākou alakaʻi no pesticide organophosphate a me ka lāʻau ʻawaʻawa, ka ʻai ʻana i nā mea kanu ʻona, a maʻi serotonin vs. maʻi neuroleptic malignant.

E hana i kēia i kēia manawa¶

1. Hoʻopale iā ʻoe iho mai ka ʻili lua a i ʻole ka hoʻohaumia ʻana i ka mahu FIRST:
2. Ma mua o ka hoʻopā ʻana i ke kanaka e kulu ana, e ʻuhu nui ana, luaʻi, a ʻāwīwī paha ma hope o ka ʻike ʻia ʻana i kahi lāʻau lāʻau lāʻau lāʻau, ʻūhā kīhāpai, a i ʻole wai kemika ʻike ʻole ʻia, e kau i nā mīkina lima nitrile a i ʻole neoprene (ʻaʻole ka latex lahilahi, kahi e komo ai nā organophosphates) a neʻe i ka makani.
3. Mai hana i ka hanu hoʻopakele waha i ka waha ma luna o ka mea maʻi i ʻona ʻia e ka organophosphate a i ʻole ka carbamate pesticides, no ka mea, ʻo ke koena pesticide i loko o ko lākou kohu, ka hou, a me ka luaʻi e ʻona iā ʻoe ma kou waha a me kou ʻili.
4. Kahea koke aku i kāu helu ulia pōpilikia a me ka Poison Control: Kāhea i ka 911 ma ʻAmelika Hui Pū ʻIa a me Kanada (a me US Poison Control ma 1-800-222-1222), 112 ma waena o ka European Union, 999 ma United Kingdom, 000 ma Australia, a i ʻole e ʻike i kā mākou honua. helu pilikia papa kuhikuhi. E haʻi i ka mea hoʻouna inā he "Wet and Drooling with Pinpoint Pupils (Suspected Cholinergic Crisis)" a i ʻole "Bone-Dry, Hot, Flushed, and Delirious with Huge Pupils (Suspected Anticholinergic Overdose)".
5. Hana i ka hoʻokolokolo kino wikiwiki o nā hōʻailona toxidrome ʻehā (Sweat, Pupils, Airway Sounds, and Heart Rate):
6. Hoopa i ka lima (axillae) a me ka lae o ka mea ma'i: ** pulu i ka hou (Cholinergic)** a i ole ** maloo iwi e like me ka pepa one (Anticholinergic)**?
7. E nānā i kā lākou haumāna: ʻO lākou ka ** kuhikuhi i nā kiko 1 mm (Cholinergic)** a i ʻole ** ākea ākea 7 a 8 mm mau pōʻai ʻeleʻele (Anticholinergic)**?
8. E hoʻolohe i ko lākou waha a me ka umauma: ʻO lākou ** ʻūhū, huʻaʻa, a me ka uwē me ka wai (Cholinergic "Killer B's")**, a i ʻole ko lākou waha pulu-maloʻo me nā māmā māmā (Anticholinergic)?
9. Inā "WET" ka mea maʻi (Cholinergic / SLUDGEM Crisis), e hoʻokahua mua i ka Airway Drainage and Skin Decontamination:
10. E ʻōwili i ka mea maʻi i pane ʻole a i ʻole drooling ma ko lākou ʻaoʻao ma ke ** kūlana hoʻōla ** nui loa ka kohu, ka huʻa bronchial, a me ka luaʻi e kahe mai ka waha ma mua o ka luʻu ʻana i ko lākou mau māmā.
11. Inā ʻike ʻia i ka wai pesticide a i ʻole ka hoʻoheheʻe insecticide, e wehe koke i nā lole, nā kāmaʻa, a me nā mea ʻili a holoi pono i ko lākou ʻili a me ka lauoho me ka kopa a me ka wai kahe nui no 15 mau minuke.
12. Inā he pūʻali koa a lapaʻau paha ka mea maʻi Atropine / Pralidoxime auto-injector (DuoDote a ATNAA), e hoʻokomo koke iā ia i loko o ka ʻūhā waena.
13. Inā ʻo ka mea maʻi he "DRY and HOT" (Anticholinergic Delirium), e hana mua i ka Active Cooling, Calm Environment, a me ECG:
14. Ma muli o ka hoʻopaʻa ʻana o ka lāʻau ʻawaʻawa anticholinergic i ka hiki o ke kino i ka hou (anhidrosis) i ka wā e hoʻoulu ai i ka hana ʻiʻo, hiki ke piʻi ka wela nui i ka hyperthermia make. E hoʻoneʻe iā lākou i kahi lumi anuanu, e wehe i nā pākeʻe kaumaha, e hoʻopili i nā lole pulu maloʻo a i ʻole nā ​​ʻeke hau i ʻōwili ʻia i nā kāwele ma ka ʻāʻī, nā ʻāʻī, a me ka ʻāʻī, a e hoʻomaha iā lākou i loko o kahi lumi mālamalama a hiki i ka poʻe lapaʻau me ka 12-lead ECG a me ka benzodiazepines.

Ka lāʻau hoʻoholo: Hoʻokaʻawale i ka Cholinergic vs. Anticholinergic vs. Sympathomimetic Toxidromes¶

flowchart TD
    Start["Hāʻawi ka poʻe maʻi me ka ʻawaʻawa nui, overdose, mea kanu a i ʻole nā ​​haohao ʻai ʻana, a i ʻole ka hōʻike kino."] --> SweatCheck{"Hoopa aku i na Armpits (Axillae), Puuwai, a me Oral Mucosa: Ua PAU anei ka mea ma'i (Hohu/Drooling) a i ole IWI-MALOO?"}

    SweatCheck -->|"WET: Ka wela nui, drooling, a i ʻole nā mea huna bronchial"| PupilWet{"E nānā i nā haumāna, ka puʻuwai puʻuwai, a me ka leo ʻiʻo"}

    PupilWet -->|"Nā Haumāna Pinpoint (Miosis: 1 a i 2 mm) + Slow Pulse (a i ʻole ka tachycardia mua) + Māmā Mākū (Bronchorrhea/Wheezing) + Vomiting/Diarrhea/Urination + Muscle Fasciculations (Twitching) a i ʻole Paralysis"| CholinergicBox["CHOLINERGIC TOXIDROME (SLUDGEM / DUMBBELS): Nā kumu: Organophosphate a i ʻole Carbamate Pesticides, Nerve Agents (Sarin / VX / Novichok), Pyridostigmine / Neostigmine Overdose, Pilocarpine, Inocybe / Clitocybe Mushrooms 1. Wear Nitrile Gloves Wehe i nā lole a holoi i ka ʻili me ke kopa + wai inā pesticide 2. kūlana hoʻihoʻi + hoʻoheheʻe ʻana i ke ea ea + 100% oxygen 3. STAT IV/IM Atropine (1 a 3 mg kanaka makua; pālua i kēlā me kēia 3 a 5 min a hiki i ka maloʻo ʻana o nā māmā) 4. IV Pralidoxime (2-PAM: 15 to 2 g recholine over0. 5. IV Benzodiazepine (Diazepam / Midazolam) no ka hopu"]

    PupilWet -->|"Nā Haumāna Dilated (Mydriasis) + ʻO ka Pulse wikiwiki a me ka BP kiʻekiʻe + ka hou ʻana o ka hou + ka hoʻonāukiuki + nā kani maʻamau o ka ʻōpū."| SympathoBox["SYMPATHOMIMETIC OR SEROTONIN TOXIDROME: Nā kumu: Cocaine, Methamphetamine, MDMA, Ephedrine, Bath Salts (a i ʻole SSRIs inā clonus) 1. Hoʻomaʻamaʻa ikaika + Kaiapuni mālie + IV Benzodiazepines 2. Hōʻalo i nā Beta-Blockers i ka Cocaine Toxicity"]

    SweatCheck -->|"IWI-MALOO: Maloo lima, ili pepa maloo, pulupulu maloo ka waha a me ke alelo"| AntiBox["ANTICHOLINERGIC (ANTIMUSCARINIC) TOXIDROME: Huna e like me ka Hatter, Makapō e like me ka ʻōpeʻa, ʻulaʻula e like me ka Beet, Wela e like me ka Hare, Māloʻo e like me ka Iwi, Piha e like me ka Flask Nā kumu: Diphenhydramine (Benadryl / Tylenol PM / ZzzQuil), Doxylamine, Atropine, Oxybutylaminepressants (Amitriptyline), Jimsonweed (Datura), Deadly Nightshade 1. ʻO ka hoʻomaha hoʻomaha no ka Hyperthermia + Quiet Dim Room 2. Koke 12-Lead ECG: E nānā i ka lōʻihi o QRS (ma luna o 100 ms) a me QTc Interval - Ināʻo QRS ma luna o 100 ms (Sodium-Channel Blockade mai ka Diphenhydramine / 1 STTC mai ka Diphenhydramine / 1 STTC): mEq/kg bolus) 3. Foley Catheter no ka hoʻopau ʻana i ka ʻeha ʻeha Acute Urinary Paʻa 4. IV Benzodiazepines (Lorazepam/Midazolam) A I ʻole ʻO ka Antidote i hoʻopaʻa ʻia: IV Physostigmine (0.5 a i ka 2 mg e hoʻokuʻu mālie ma luna o 5 min WALE inā he antimuscarinic maʻemaʻe me QRS maʻamau ma lalo o 100 ms)"]

ʻO Pathophysiology: Pehea e hoʻomalu ai ka Acetylcholine i ke kino (a me ka mea e hana ai i ka wā e kahe ana vs. nalo)¶

** ʻO Acetylcholine (ACh)** kekahi o nā ʻelele kemika mua o ke kino (nā neurotransmitters). ʻO ka mea maʻamau, hoʻokuʻu ka hopena o ke aʻalolo i kahi puʻupuʻu liʻiliʻi o ka acetylcholine ma waena o ka synapse e hoʻāla ai i kahi receptor target, a i loko o ** microseconds **, ka enzyme hoʻomaʻemaʻe ** acetylcholinesterase (AChE) ** e hoʻokaʻawale i ka mole acetylcholine i ka hapalua (i loko o ka choline inactive a me ka acetate) i hiki i ke aʻalolo a me ka ʻiʻo ke hoʻoponopono hou.

Hoʻohana ʻo Acetylcholine ma waena o ** ʻekolu mau ʻupena hoʻokipa anatomical ʻokoʻa**: 1. Muscarinic Receptors (M1, M2, M3) o ka Parasympathetic Nervous System ("Hoʻomaha a me ka Digest"): - E hoʻomalu i nā ʻeleʻele exocrine a pau (** nā ʻāʻī salivary, nā waimaka, nā ʻāʻī o ka bronchial mucus, nā ʻōpū o ka ʻōpū, a me nā ʻāwīwī eccrine**: e hoʻomaopopo ʻoiai ua hoʻopaʻa ʻia nā ʻōpala hou i ke kaulahao aloha, ʻo kā lākou hoʻololi hope loa ʻo muscarinic acetylcholine), hoʻolōʻihi i ka SA a me AV nodes o ka puʻuwai (ma o ka puʻuwai pilae) ** nā paipu bronchial**, a hoʻopaʻa i ka ** ʻōpū, ʻōpū, a me ka ʻiʻo detrusor o ka ʻōpū** i ka wā e hoʻomaha ai i nā sphincters mimi/anal. 2. Nikotinic Receptors (NM a me NN) ma ka Neuromuscular Junction a me Autonomic Ganglia: - E puhi pololei i kēlā me kēia ʻiʻo iwi ʻiʻo i loko o ke kino (me ka diaphragm a me nā ʻiʻo hanu intercostal) a hoʻāla i nā ganglia sympathetic/adrenal. 3. ** Pūnaehana Nervous Central (Brain) Cholinergic Receptors**: - Hoʻomalu i ka hoʻomanaʻo, ka nānā ʻana, ka ala ala, a me ka hoʻokele kaʻa mālie.

Toxidrome 1: ʻO ka Cholinergic Crisis (Excess Acetylcholine: "Wet, Slow, Twitching, and Pinpoint")¶

1. Nā kumu maʻamau o ka make ʻana o Cholinergic¶

Hiki mai ka pilikia Cholinergic i ka wā e hoʻopaʻa ai ka mea make ** i ka enzyme cleanup acetylcholinesterase (AChE)** (no ka hoʻoulu ʻana i ka acetylcholine ponoʻī o ka mea maʻi i nā pae ʻawaʻawa ma waena o nā muscarinic, nicotinic, a me ka lolo i loaʻa) A i ʻole ke hoʻoulu pololei ʻana i nā mea loaʻa muscarinic:

• Organophosphate (OP) Pesticides a me Insecticides (Ireversible AChE Inhibitors):
• Malathion, parathion, chlorpyrifos, diazinon, dichlorvos, fenthion, a me azinphos-methyl. Hoʻohana ʻia ma ka honua holoʻokoʻa i ka mahiʻai, nā holoholona holoholona, ​​​​a me ka mālama ʻana i nā pest. Hiki iā lākou momo koke ma o ka ʻili kanaka paʻa, ka māmā, a me ka ʻōpū.
• Ka "Aging" Clock: Hoʻopili nā organophosphates i ka pūʻulu serine hydroxyl o acetylcholinesterase. Ma nā hola a hiki i nā lā (e pili ana i ke kemika kikoʻī), ua haki kahi paʻa kemika (dealkylation / "aging"), e hoʻopaʻa mau i ka enzyme i kahi kūlana hiki ʻole ke hoʻihoʻi ʻia kahi hiki ʻole i ka antidote pralidoxime (2-PAM) ke hoʻopakele hou iā ia.
• ** Nā ʻĀpana Nerve Koa (Ultra-Potent Organophosphates)**:
• G-series (Sarin [GB], Soman [GD], Tabun [GA]), V-series (VX), a me A-series (Novichok). ʻO Soman "mau makahiki" a hoʻopaʻa mau i ka acetylcholinesterase i ** 2 minuke wale nō **.
• ** Nā Insecticides Carbamate (Na mea pale AChE hiki ke hoʻohuli)**:
• Aldicarb, carbofuran, carbaryl (Sevin), propoxur, a me methomyl. ʻO nā Carbamates ke kumu o ka pilikia SLUDGEM e hoʻoweliweli i ke ola me nā organophosphates, koe wale ko lākou paʻa i ka acetylcholinesterase ** hydrolyzes manawaleʻa (hoʻohuli) i loko o 24 a 48 hola **, a ʻaʻole maʻalahi lākou e hele i ka pale koko-lolo.
• Laau Laau Laau Laau Lapaau (Myasthenia Gravis, Alzheimer's, Glaucoma, a me na Laau Puhi):
• ʻO ka nui o ka pyridostigmine (Mestinon) a i ʻole neostigmine (lawe ʻia e nā maʻi me myasthenia gravis: ʻO ka lawe nui ʻana i ka Mestinon e hoʻoulu ai i kahi pilikia cholinergic e hoʻonāwaliwali ai i ka ʻiʻo e like me ka myasthenic flare), donepezil (Aricept), rivastigmine, galantamine (nā lāʻau a Alzheimer), pilocarpine (nā kulu maka a i ʻole nā ​​papa maloʻo), a i ʻole bethanechol.
• Muscarine-Loaʻa ʻAiʻAha ʻAhiu:
• ʻO ka ʻai ʻana a me ka ʻai ʻana i ka Inocybe ("Fiber Cap") a i ʻole Clitocybe ("Funnel Cap") ke kumu o ka hoʻomaka wikiwiki (15 a 60 mau minuke) o **mau hōʻailona muscarinic SLUDGE maʻemaʻe ** (ka wela nui, salivation, haehae, luaʻi, maʻi maʻi, bradycardia) *me ka ʻole o ka ʻiʻo nicotinic.

2. Hoʻomaopopo i ka ʻona Cholinergic: Muscarinic (SLUDGEM / DUMBBELS) + Nicotinic (Nā lā o ka pule)¶

Ma muli o ka loaʻa ʻana o ka acetylcholine i ka ** ʻelua i ka muscarinic a me ka nicotinic receptors i ka manawa like, hōʻike ka mea maʻi ʻona i ʻelua pūʻulu like o nā hōʻailona:

A. Nā hōʻailona Muscarinic Parasympathetic (Mnemonics: SLUDGEM a i ʻole DUMBBELS)¶

• S (Salivation): Ka kulu ʻana mai ka waha.
• L (Lacrimation): Haehae mau mai nā maka ( "chromodacryorrhea" ʻulaʻula-ʻulaʻula i kekahi manawa).
• U (Urination): ʻO ka nalo ʻole ʻana o ka hoʻomalu ʻana i ka ʻōpū (ka ʻole ʻana o ka mimi).
• D (Defecation / Diarrhea): ʻO ka maʻi pahū wai a me ka ʻeha nui o ka ʻōpū.
• G (Maʻi ʻAi ʻAʻai): ʻAi ʻino a me ka ʻōpū o ka ʻōpū.
• E (Emesis): Ka luaʻi hou ʻana (honi pinepine ʻia i ka ʻala a i ʻole ka ʻaila hinu/kerosene solvent mai ka mea lawe pesticide).
• M (Miosis / Pinpoint Pupils): Hoʻopaʻa nā haumāna ʻelua a hiki i ka 1 a 2 millimeter pinpoint point ʻaʻole e ākea i ka pōʻeleʻele, hele pū ʻia me ka ʻike maka kokoke a me ka ʻeha lae mai ka ʻiʻo ciliary.
• (I loko o ka DUMBBELS mnemonic, ua hōʻike nā B's ʻekolu i ka ** ʻEkolu "Killer B's"**: Bronchorrhea [ka nui o ka ʻōpū o ka ʻōpū wai], Bronchospasm [nā ala ea wīwī paʻa], a me Bradycardia [ka puʻuwai mālie].)

B. Nā hōʻailona Neuromuscular & Sympathetic Nicotinic (Mnemonic: Nā lā o ka pule: M-T-W-Th-F)¶

Ke hoʻokahe nui ka acetylcholine i nā mea hoʻokipa nicotinic ma nā ʻiʻo iwi, hoʻomaka mua ia i ke kī hou ʻana (ka ʻiʻo ʻana o ka ʻiʻo), a laila depolarize a hoʻopau i ka paʻa hope o ka kaʻa, e hoʻopau ai i ka flaccid paralysis (like me ka overdose o ka lāʻau paralytic succinylcholine): - M (Mydriasis: Occasional Early Exception): Kakaʻikahi, hiki i ke kī ʻana i nā ganglion aloha aloha ke mālama mau i nā haumāna ma mua o ka lanakila ʻana o ka muscarinic pinpoint miosis. - T (Tachycardia & Hypertension: The Early Sympathetic Mask): No ka mea, hoʻoulu pū nā mea hoʻokipa nicotinic i ka adrenal medulla e hoʻolei i ka adrenaline, ** a hiki i ka 20% a hiki i ka 30% o nā maʻi cholinergic ʻona nui i loaʻa mua me ka FAST heart rate (tachycardia) a me ke koko kiʻekiʻe** ma mua o ka hoʻoheheʻe ʻana i bra.dycardia. Mai hoʻokuʻu i ka lāʻau make cholinergic no ka wikiwiki o ka pulse. - W (Nawaliwali): Nawaliwali i ka ʻiʻo maʻamau, nawaliwali ka ʻāʻī (hiki ʻole ke hāpai i ke poʻo mai luna o ka uluna), a me ka nalowale ʻana o nā ʻāʻī hohonu. - Th (Tremors and Muscle Fasciculations): ʻIke ʻia, ʻike ʻia, e like me ka ilo ka nalu ʻana a me ka wili ʻana o nā ʻiʻo ʻiʻo ma lalo o ka ʻili (ʻoi loa ma luna o nā lihilihi, alelo, nā keiki bipi, a me ka umauma). - F (Flaccid Paralysis of the Diaphragm): Hoʻopau i ka ʻiʻo hanu e hiki ai i ka hopu ʻana.

Toxidrome 2: ʻO ka Anticholinergic (Antimuscarinic) Delirium ("Dry, Hot, Red, Blind, Mad, and Full")¶

1. Nā kumu maʻamau o ka lāʻau ʻawaʻawa anticholinergic¶

Hana ʻia ka lāʻau ʻawaʻawa i ka wā e hoʻokūkū ʻia ai ka lāʻau a mea kanu paha ** i ka muscarinic acetylcholine receptors (M1 a hiki i ka M5)** ma ka lolo, ka puʻuwai, ka maka, ka ʻāʻī, ka ʻōpū, a me ka ʻōpū (e hoʻomaopopo ʻo ka "anticholinergic" lāʻau maʻamau ** ʻaʻole ** paʻa i ka nicotinic skeletal muscle receptors, no laila ua paʻa ka mea maʻi**): **antimuscarinic

• Over-the-Counter First-Generation Antihistamines and Sleep Aids (The #1 Household Cause):
• Diphenhydramine (kūʻai ʻia ʻo Benadryl, ZzzQuil, Sominex, Nytol, Unisom, Tylenol PM, Advil PM) a me Doxylamine (Unisom SleepTabs, NyQuil), Dimenhydrinate (Dramamine), Chlorpheniramine, a me Hydroxyzine / Promethazine.
• Diphenhydramine Double-Hazard: I ka nui o ka nui (e laʻa., nā pilikia pāpaʻi kaiaulu a i ʻole ka hoʻohana ʻana i ka manaʻo), ʻaʻole ** wale ka diphenhydramine i nā mea hoʻokipa muscarinic: hoʻopaʻa pū ʻo ia i ** nā kahawai sodium puʻuwai wikiwiki (e like me ka tricyclic antidepressant), e hoʻonui ai i ka ** QRS widening (ma luna o 100 ms tachycardia), ventricular status tachycardia. hopu.
• Laau Laau Laau Antimuscarinic, Psychiatric, a me ka Puhi:
• Tricyclic Antidepressants (TCAs): Amitriptyline, nortriptyline, doxepin, imipramine (e nānā i kā mākou hao hale, aspirin, a me tricyclic overdose alakaʻi).
• Atypical Antipsychotics: Quetiapine (Seroquel), olanzapine (Zyprexa), clozapine, chlorpromazine.
• Overactive Bladder & GI Antispasmodics: Oxybutynin, tolterodine, solifenacin, dicyclomine, hyoscyamine, glycopyrrolate.
• Maʻi Maka Ophthalmic & Motion Sickness Patches: Atropine, homatropine, cyclopentolate, a i ʻole tropicamide kulu maka (inā moni ʻia e kahi kamaliʻi, make ka ʻōmole hoʻokahi), a me scopolamine nā ʻāpana transdermal.
• Nā Hoʻomaha ʻIʻo a me nā Laʻau Antiparkinsonian: Cyclobenzaprine (Flexeril), orphenadrine, benztropine, trihexyphenidyl.
• Nā mea kanu a me nā kī ʻawaʻawa Tropane Alkaloid (Atropine, Scopolamine, a me Hyoscyamine):
• Jimsonweed (Datura stramonium / "Thorn Apple" / "Devil's Trumpet"): ʻO ka poʻe ʻōpio a i ʻole nā ​​mea ʻai meaʻai e ale i nā ʻanoʻano spiky a i ʻole ka wai Datura kī e hoʻomohala i ka delirium anticholinergic i nā lā he nui.
• Deadly Nightshade (Atropa belladonna): Ua like nā hua ʻeleʻele ʻālohilohi e like me nā blueberries a loaʻa nā ʻano kiʻekiʻe o ka atropine.
• Ka pū kani a Anela (Brugmansia), Henbane (Hyoscyamus niger), Mandrake (Mandragora), a me nā kī lāʻau i haumia me nā alkaloids belladonna.

2. Hoʻomaopopo i ka Classic Anticholinergic Rhyme¶

Hoʻomaopopo nā kauka i nā hiʻohiʻona koʻikoʻi ʻeono o ka lāʻau ʻawaʻawa antimuscarinic me ka hoʻohana ʻana i ka mele maʻamau.

1. "Maloo e like me ka Iwi" (Anhidrosis a me Xerostomia: ʻO ka hōʻailona ʻokoʻa #1):
2. No ka mea, ua paa ka muscarinic M3 ma ka hou a me ka salivary gland, ua maloo loa ko ka mea ma'i ** mau lima (axillae), ma'i, lima, a me ka lae, a maloo loa ko lakou alelo a me na papalina o loko.
3. "Wehana e like me ka Hare" (Anhidrotic Hyperthermia):
4. No ka mea, ʻaʻole hiki i ka mea maʻi ke hoʻokuʻu i ka wela i ka wā e hoʻoulu ʻia ai ka wela o ka ʻiʻo i loko, piʻi ka wela o ke kino nui i 38.5 a 41.0 degere Celsius (101.3 a 105.8 degere Fahrenheit) a ʻoi aku paha.
5. "ʻulaʻula e like me ka beet" (Cutaneous Vasodilation / Flushing):
6. ʻO ka pale ʻana i ka hoʻoluʻu hou e hoʻoulu i ka hoʻomāhuahua ʻana o nā capillaries ʻili ma luna o ka maka, ka ʻāʻī, a me ka umauma luna i ka hoʻāʻo ʻana e hoʻomālamalama i ka wela, e hana ana i ka ʻulaʻula ʻulaʻula ʻulaʻula.
7. "Makapō e like me ka ʻōpeʻa" (Mydriasis a me Cycloplegia):
8. ʻO ka pale ʻana i ka ʻiʻo o ka iris sphincter e hiki ai i ka haumāna ke hoʻomāhuahua i loko o nui, 6 a 9 millimeter ʻeleʻele pōʻai (mydriasis) e pane mālie a ʻaʻole loa i ke kukui uila, ʻoiai ʻo ka maʻi maʻi o ka ʻiʻo ciliary lens (cycloplegia) hiki ʻole ke nānā aku i nā mea kokoke a heluhelu i ka kikokikona.
9. "Mad as a Hatter" (Central Antimuscarinic Delirium):
10. ʻO ka pale ʻana i nā mea loaʻa M1 i loko o ka lolo ke kumu o kahi ** hoʻohuehue ʻano ʻokoʻa **:
    • ** ʻO ka haʻi ʻōlelo ʻana i ka "waha pulupulu" e ʻōhumu ʻole ʻia** (e hoʻomaka ana i kahi huaʻōlelo maʻamau a hele i ka ʻōhumu ʻike ʻole).
    • Lilliputian visual and tactile hallucinations: Ke ʻike ʻana i nā pōpoki liʻiliʻi noʻonoʻo, nā ʻāwīwī, nā kaula, a i ʻole nā ​​kānaka ma luna o ka pepa moe a ** e ʻohi mau a ʻohi paha i nā mea i ʻike ʻole ʻia i ka lewa a i ʻole ma ko lākou mau lole ("carphologia" a i ʻole "floccillation")**.
11. "Full as a Flask" and "Tachy as a Flea" (Acute Urinary Retention, Absent Bowel Sounds, and Sinus Tachycardia):
12. ʻO ka pale ʻana i nā pahu vagal M2 ma ka puʻuwai ke kumu ** sinus tachycardia (110 a 160+ bpm)**, ʻo ia ka ** mua loa a paʻakikī loa ** o ka lāʻau make anticholinergic.
13. Hoʻopaʻa ʻia ka ʻōpū a me ka ʻōpū M3 nā mea hoʻokipa M3 e hoʻopaʻa i ka ʻōpū o ka ʻōpū (he mālie a i ʻole nā ​​leo o ka ʻōpū / ileus) a hoʻopaʻa i ka sphincter mimi i ka wā e hoʻopaʻa ai i ka paia o ka ʻōpū, e hōʻeha ai ** ka paʻa ʻana o ka mimi (he ʻōpū ʻeha e paʻa ana i ka 500 a 1,200 mL o ka mimi,** e hana pinepine ai i ka wai maʻi. ʻūhā ma kahi moe a hoʻokomo kahi kahu hānai i kahi catheter Foley.

Papa hoʻohālikelike kumu: Cholinergic vs. Anticholinergic vs. Sympathomimetic Toxidromes¶

(E nānā i ke kānāwai lapaʻau ma luna: Pehea ʻoe e haʻi aku ai i kahi maʻi anticholinergic agitated, tachycardic, dilated-pupil me kahi maʻi Cocaine/Methamphetamine Sympathomimetic? Hoʻopā i ko lākou mau ʻāʻī a hoʻolohe i ko lākou ʻōpū.)

Nā Kūlana Antidote Hospital: Pehea e hoʻohuli ai nā kauka i kēlā me kēia Toxidrome¶

1. Hoʻohuli i ka Cholinergic Crisis: Atropine + Pralidoxime (2-PAM) + Benzodiazepines¶

Ke hiki mai ka mea maʻi organophosphate a i ʻole ka carbamate i loko o ke keʻena pilikia me ka make ʻana i nā mea huna bronchial:

• Antidote 1: Intravenous Atropine (Blocks Muscarinic Receptors: Hoʻomaloʻo i ka "Killer B's"):
• Ka Hoʻomaka mua: Loaʻa i nā mākua 1 mg a 3 mg IV (0.02 a i 0.05 mg/kg i nā keiki).
• Rapid Escalating Doubling Regimen (Eddleston / WHO Protocol): ʻAʻole like me bradycardia maʻamau (kahi 3 mg o ka atropine ka nui o ka nui), hiki i kahi mea maʻi ʻona-organophosphate ke koi iā 50 a 500+ milligrams o ka atropine i nā hola 24 mua. Inā pulu mau ke akemāmā o ka mea maʻi me nā ʻūhū/wheezing ma hope o 3 a 5 mau minuke, ʻo nā kauka PAlua i ka nui atropine mua i kēlā me kēia 3 a 5 mau minuke (2 mg, a laila 4 mg, a laila 8 mg, a laila 16 mg, a laila 32 mg) a hiki i ka ** ʻekolu mau hopena o "Atropinization" ** e hoʻokō ʻia:
  1. Hoʻomaʻemaʻe i ka umauma ma ka auscultation (zero bronchorrhea or wheezing: ka #1 endpoint),
  2. ** ʻOi aku ka nui o ka puʻuwai puʻuwai ma mua o 80 i ka minuke**, a
  3. ** Ke koko systolic ma luna o 80 a 90 mmHg**.
• (Rule: ʻAʻole i hoʻohana ʻia ka nui o ka haumāna ma ke ʻano he hopena no ka hoʻōki ʻana i ka atropine, no ka mea, hoʻomaʻemaʻe ʻo systemic IV atropine i nā māmā ma mua o ka hoʻonui ʻana i nā haumāna kikoʻī, a ʻo atropine he ZERO ka hopena i ka maʻi lolo nicotinic.)
• Antidote 2: Intravenous Pralidoxime / 2-PAM a i ʻole Obidoxime (Hoʻihoʻi hou i ka ikaika o ka ʻiʻo Nicotinic):
• No ka mea, hoʻopaʻa wale ʻo atropine i nā ʻāʻī muscarinic a ʻaʻole hiki ke hoʻoponopono i ka nicotinic diaphragm paralysis, hāʻawi nā kauka i kahi oxime, Pralidoxime chloride (1 a 2 grams IV ma luna o 15 a 30 mau minuke i nā pākeke; 20 a 50 mg/kg i nā keiki, a ukali ʻia e ka hoʻoinu IV mau o 500 mg / hola) mole mai ka acetylcholinesterase enzyme ma mua o ka "ʻelemakule" e hoʻopaʻa mau ai ka palapala paʻa.
• Antidote 3: Nā Benzodiazepine Intravenous (Diazepam a i ʻole Midazolam):
• Hoʻopau i ka hoʻopaʻa cholinergic kikowaena a pale i ka hōʻeha lolo hypoxic/excitotoxic.

2. Hoʻololi i ka pilikia Anticholinergic: Benzodiazepines, Sodium Bicarbonate, a me Physostigmine¶

Ke hōʻea mai ka mea maʻi me ka delirium anticholinergic koʻikoʻi mai ka diphenhydramine, jimsonweed, a i ʻole nā lāʻau lapaʻau i kauoha ʻia:

• ** Kaʻanuʻu 1: E hoʻomaka koke i ka ECG 12-Alakaʻi i ka pale no ka Sodium-Channel Blockade (QRS ma luna o 100 ms) a me ka QT Prolongation**:
• ʻO Diphenhydramine (Benadryl), dimenhydrinate, a me nā antidepressants tricyclic (amitriptyline) e hoʻopaʻa i nā kahawai sodium wikiwiki. Inā ʻoi aku ka nui o ka ** QRS complex ma ka ECG ma mua o 100 milliseconds** (a i ʻole he hawewe R-wave koʻikoʻi ma luna o 3 mm i ke alakaʻi aVR), koi koke nā kauka ** Intravenous Hypertonic Sodium Bicarbonate (1 a 2 mEq/kg IV bolus)** e hōʻemi i ka paʻakikī QRS a pale i nā arrhythmias ventricular fatal.
• ** KaʻAnuʻu 2: ʻO ka hoʻohaʻahaʻa ʻana i ka ʻōpū o ka urinary (Foley Catheter) a me IV Benzodiazepines**:
• ʻO ke kau ʻana i ka catheter urinary e hoʻokahe i ka ʻōpū ʻeha (800+ mL) a me ka hāʻawi ʻana i ka intravenous lorazepam (1 i 2 mg IV) a i ʻole midazolam/diazepam e hōʻoluʻolu palekana i ka hoʻonāukiuki, hoʻohaʻahaʻa i ka wela o ke kino, a pale i ka rhabdomyolysis. (Ka ʻōlelo aʻo: Hōʻalo nā kauka i ka haloperidol a i ʻole droperidol i ka lāʻau ʻawaʻawa anticholinergic no ka mea he mau waiwai anticholinergic intrinsic nā antipsychotics a hoʻolōʻihi i ka wā QT.)
• ** KaʻAnuʻu 3: ʻAi Kūlohelohe Kūikawā: Intravenous Physostigmine (A i ʻole Rivastigmine)**:
• He aha ka Physostigmine: ʻAʻole like me ka neostigmine a i ʻole pyridostigmine (i hoʻopiʻi ʻia nā amine quaternary ʻaʻole hiki ke komo i loko o ka lolo), ʻo ** Physostigmine ** he mea hoʻopaʻa ʻole ʻia ʻo tertiary amine reversible acetylcholinesterase inhibitor e hele wale i ka pale koko-lolo. I loko o 5 a 10 mau minuke o ka infusion intravenous lohi (0.5 mg a 2.0 mg i hoʻoheheʻe ʻia i 10 mL saline a hoʻokomo mālie ʻia ma luna o ** ma lalo o 5 mau minuke ** i nā pākeke; 0.02 mg/kg a hiki i ka 0.5 mg i nā keiki), hoʻonui ka physostigmine i ka acetylcholine i loko o ka lolo a hoʻāla i kahi kamaʻilio ʻoluʻolu, hallucinating.
• Nā kānāwai palekana no ka Physostigmine:
  1. ** ʻAʻole hāʻawi i ka Physostigmine i loko o kahi Tricyclic Antidepressant (TCA) overdose a inā hōʻike ka ECG i kahi QRS ākea ma mua o 100 ms, hoʻolōʻihi PR, a bradycardia **: I ka make ʻana o TCA, hiki i ka physostigmine ke hoʻopaʻa koke i asystolic cardiac arrest.
  2. E hoʻoulu mālie ma luna o 5 mau minuke holoʻokoʻa: ʻO ka hoʻokuke ʻana i ka physostigmine me ka wikiwiki loa ke kumu o ka cholinergic seizures a i ʻole bradycardia; ʻO ka ʻaoʻao moe atropine e huki mau ʻia i loko o kahi syringe ma ka hapalua o ka nui o ka physostigmine e hoʻohuli i nā hopena cholinergic keu.
  3. ** ʻAno ʻano hou i ka wā o ka pōkole o Physostigmine (Rivastigmine)**: E like me ka physostigmine, ʻo ka lāʻau Alzheimer rivastigmine he mea hoʻopaneʻe carbamate acetylcholinesterase i waena o ka mea e ʻaʻa i ka pale koko-lolo. Hoʻohana nui ka poʻe toxicologists i ka ** waha a i ʻole transdermal patch rivastigmine ** no ka pale ʻana i ka rebound anticholinergic delirium (no ka pau ʻana o ka physostigmine intravenous i loko o 60 a 90 mau minuke, ʻoiai ke hoʻokuʻu nei ka ʻōpū ʻawaʻawa i ka diphenhydramine a i ʻole nā ​​hua jimsonweed i ka hoʻokuʻu ʻana i ke kino no 24 a 48 mau hola).

Nā helu ulia pōpilikia āpana a me nā protocols oihana¶

• ** ʻAmelika Hui Pū ʻIa a me Kanada **: E kelepona koke iā 911 no nā kūlana noʻonoʻo i hoʻololi ʻia, hopu ʻia, a i ʻole ka hoʻolaha ʻana i ka pesticide, a kāhea aku i ka Poison Control ma 1-800-222-1222 (US) a i ʻole 1-844-POISON-X (Kanada) e kamaʻilio pololei me kahi kauka lāʻau lapaʻau i hōʻoia ʻia e ka papa. Lawe nā pūʻulu HazMat a me EMS ma mua o ka hale maʻi DuoDote / Mark I nā auto-injectors (2.1 mg atropine + 600 mg pralidoxime chloride) ma lalo o CHEMPACK / CDC / ACMT protocols.
• United Kingdom: Kāhea iā 999 no kahi kaʻa kaʻa ulia pōpilikia (a ʻo Fire/HazMat inā pili kekahi mea hana mahiʻai). Hoʻopili nā keʻena ulia pōpilikia i ka National Poisons Information Service (NPIS / TOXBASE) a me Royal College of Emergency Medicine (RCEM) nā alakaʻi antidote no ka atropine intravenous kiʻekiʻe, pralidoxime mesilate, sodium bicarbonate, a me physostigmine.
• Uni ʻEulopa: Kāhea i ka 112 ma nā mokuʻāina lālā a pau o EU. Hoʻopili nā ʻāpana toxicology o ka hale maʻi ʻAhui ʻEulopa o nā Poisons Centers a me Clinical Toxicologists (EAPCCT) (e hoʻohana ana i ka obidoxime a i ʻole pralidoxime ma ka ʻaoʻao o ka atropine no nā organophosphates, a me ka physostigmine salicylate [Anticholium] no ka maʻi antimuscarinic waena).
• Australia a me New Zealand: E kelepona iā 000 ma Australia a i ʻole 111 ma New Zealand, a e nīnau i ka Poisons Information Center ma 13 11 26 (Australia) a i ʻole 0800 764 766 (New Zealand).
• India a me Asia-Pacific: Kāhea i ka 112 ma India (a i ʻole 108 kaʻa kaʻa), 995 ma Singapore, 119 ma Iapana a me South Korea, a i ʻole 999 ma Hong Kong a me Malaysia. Ma nā ʻāina mahiʻai ʻo ʻAsia-Pākīpika, ka hoʻopau ʻana i ka ʻili wikiwiki a me ka Eddleston rapid-doubling IV atropine regimen ʻo ia ka pōhaku kihi o ka mālama ulia pōpilikia.

Nīnau pinepine¶

He aha ke ala wikiwiki loa ma ka ʻaoʻao o kahi moe e haʻi aku ai i kahi overdose Anticholinergic (e like me Benadryl a i ʻole Jimsonweed) ma waho o ka Cocaine a i ʻole Methamphetamine overdose?¶

I ka nānā mua ʻana, ua like loa nā mea maʻi ʻelua: ʻo nā mea maʻi ʻelua ua hoʻonāukiuki, ʻoluʻolu, wela, ʻulaʻula, tachycardic (ka wikiwiki o ka naʻau), a me nā haumāna ākea ākea (mydriasis). ʻO nā ʻokoʻa ʻelua o ka ʻaoʻao moe wikiwiki loa, ʻo ia ka ʻāʻī a me ka ʻōpū: hoʻopā i nā lima lima o ka mea maʻi (axillae) a hoʻolohe i ko lākou ʻōpū. ʻO ka mea maʻi sympathomimetic (cocaine a i ʻole methamphetamine) he hū, pulu ka lima a me ke kani maʻamau o ka ʻōpū. ʻO ka mea maʻi anticholinergic he "maloʻo e like me ka iwi": maloʻo loa ko lākou ʻāʻī a me ko lākou ʻili e like me ke one, maloʻo ko lākou waha i ka pulupulu, hāmau ko lākou ʻōpū, a ua piha ko lākou ʻōpū i ka paʻa ʻana o ka mimi.

He aha ke ʻano o ka acronym SLUDGEM no ka make ʻana o cholinergic?¶

ʻO SLUDGEM ka mnemonic lāʻau maʻamau no ka muscarinic parasympathetic overload i ʻike ʻia i loko o ka pesticide organophosphate, carbamate insecticide, nerve agent, a i ʻole cholinergic lāʻau ʻawaʻawa: Salivation (drooling), Lacrimation (haehae), Urination (incontinence), Defecation (diarrhea), Gastrointestinal cramping, Emesis (2 mm) Hoʻopaʻa mau nā kauka lapaʻau i ka SLUDGEM me ka "Three Killer B's" (Bronchorrhea [drowning in watery lung secretions], Bronchospasm [severe wheezing], a me Bradycardia [slow heart rate]) no ka mea, ʻo ka Killer B a me ka nicotinic diaphragm paralysis nā kumu maoli o ka make.

No ke aha e hiki ai i ka overdose o Benadryl (diphenhydramine) a i ʻole Tylenol PM ke kumu i ka puʻuwai make a me ka hopu ʻana?¶

ʻAʻole wale ʻo Diphenhydramine he antihistamine a me muscarinic acetylcholine blocker; i ka overdose concentrations, kona kemika hoʻopaʻa 'ana i ka wikiwiki sodium a me nā pāpaʻi ala i loko o ka puʻuwai puʻuwai, 'ano like me ka lethal Tricyclic Antidepressant (TCA) overdose. ʻO ka pale ʻana i nā kahawai sodium puʻuwai e hoʻolōʻihi i ka lawe ʻana i ka uila ma o nā ventricles (hoʻonui i ka paʻakikī QRS ma mua o 100 milliseconds) a hiki ke hoʻoulu i ka tachycardia ventricular koke, Torsades de Pointes, hypotension, a me ke kūlana epilepticus seizures, kahi e hoʻohuli koke nā kauka o ka haukapila me intravenous hypertonic sodium bicarbonate.

No ke aha e hāʻawi mau ai nā kauka i ka nui o ka Atropine i ka lāʻau pesticide ʻoiai ma hope o ka hoʻomāhuahua ʻana o nā haumāna o ka mea maʻi?¶

I loko o ka organophosphate a i ʻole ka carbamate pesticide poisoning, ʻo ka pahuhopu o ka atropine intravenous ʻaʻole ia e hana maʻamau nā haumāna: ʻo ka pahuhopu e hoʻomaloʻo i ka wai wai weliweli e kahe ana i nā māmā (bronchorrhea) a hoʻihoʻi i ka puʻuwai a me ke koko. Ma muli o ka loaʻa ʻana o ka atropine systemic i ka māmā a me ka puʻuwai ma nā ʻano like ʻole ma mua o ka iris o ka maka, ke hoʻōki nei i ka atropine no ka hoʻomāhuahua ʻana o nā haumāna e haʻalele i ka mea maʻi e make i loko o nā huna huna bronchial. Hoʻopālua nā kauka i ka pānaʻi IV atropine i kēlā me kēia 3 a 5 mau minuke a hiki i ka leo akaka a maloʻo ka umauma ma kahi stethoscope.

Pehea e hiki ai i kekahi me Myasthenia Gravis ke haʻi aku inā ʻo ko lākou nāwaliwali hikiwawe he Myasthenic Crisis a i ʻole Cholinergic Crisis mai ka lawe nui ʻana i ka Mestinon (pyridostigmine)?¶

ʻO ka pilikia myasthenic (ʻoi aku ka liʻiliʻi o ka hopena acetylcholine mai ka maʻi lapalapa a i ʻole ka maʻi) a me ka pilikia cholinergic (nui loa ka acetylcholine mai ka lawe nui ʻana o pyridostigmine/Mestinon) ke kumu o ka nāwaliwali ʻana o ka ʻiʻo maʻamau, hāʻule nā ​​lihilihi, paʻakikī ke ale ʻana, a me ka hanu hanu. Eia nō naʻe, ʻo ka pilikia cholinergic ka mea maʻamau e pili ana i nā hōʻailona muscarinic SLUDGEM, e like me ka ʻōpū o ka ʻōpū, ka maʻi paʻi, ka nui o ka saliva a me nā mea huna bronchial, ka wela, ka ʻiʻo ʻana o ka ʻiʻo (fasciculations), ka puʻuwai lohi, a me nā haumāna pinpoint liʻiliʻi. Ma muli o ka hoʻoweliweli ʻana o nā pilikia ʻelua i ka hanu ʻana i loko o nā minuke, mai hoʻāʻo e hoʻāʻo a hoʻoponopono paha i nā kau ma ka home: e kāhea koke iā 911/112/999 i hiki i nā kauka o ka haukapila ke hoʻopaʻa mua i ke alaloa a ʻaʻa i nā lāʻau anticholinesterase me ka palekana i ka ICU.

Ke hāʻawi nei kēia alakaʻi i ka ʻike hoʻonaʻauao pilikia a ʻaʻole ia e pani i ka loiloi lapaʻau ʻoihana a i ʻole ke kūkākūkā ʻana i ka Poison Control. No ka mea, hiki i ka cholinergic a me ka anticholinergic poisonings hiki wawe ke keakea i ke ea, ka hanu hanu, ka hopu, a me ka paa puuwai, ke paipai ikaika nei makou e lawe i ke kokua mua a me ka papa CPR mai ke Kea Ula, St John Ambulance, a i ole ia, a i ole ia, a i ole ia, a i ole ia, a i ole ia, ke a'o 'ia nei.

Nā alakaʻi pili¶

• ʻO ka pesticide organophosphate, ka mea aʻalolo, a me ka lāʻau make
• ʻO ka ʻai ʻana i nā halo hihiu (amatoxin a me muscarine) a me ka ʻai ʻana i nā mea kanu ʻona
• Pākuʻi hao, salicylate (aspirin), a me ka tricyclic antidepressant overdose
• Serotonin syndrome, neuroleptic malignant syndrome, a me nā pilina lāʻau
• ʻO Guillain-Barre syndrome, myasthenic crisis, a me ka piʻi ʻana o ka paralysis triage

Nā kumu a me ke alakaʻi kūhelu¶

• ** Ke Kulanui o ʻAmelika Hui Pū ʻIa o Lapaʻau (ACMT) a me ʻAmelika Hui Pū ʻIa o Poison Control Center (AAPCC, ʻAmelika Hui Pū ʻIa):** Nā Kūlana Hoʻomaʻamaʻa Clinical a me nā Manaʻo Antidote no Cholinergic (Atropine / Pralidoxime) a me Antimuscarinic (Physostigmine / Sodium Bicarbonate) Toxidromes.
• World Health Organization (WHO): Clinical Management of Acute Pesticide Intoxication: Organophosphorus and Carbamate Insecticides a me ka Eddleston Rapid Atropinization Regimen (Lancet).
• Nā Center for the Disease Control and Prevention (CDC) a me ka US Department of Health and Human Services (CHEMPACK / ASPR): Prehospital and Hospital Medical Management Guidelines for Nerve Agents and Organophosphate Pesticides.
• ** Ka lawelawe ʻike ʻana i nā meaʻawaʻawa o ka ʻāina (NPIS / TOXBASE) a me ka Royal College of Emergency Medicine (RCEM, United Kingdom): ** Management of Acute Anticholinergic Syndrome, Diphenhydramine Toxicity, and Organophosphate Poisoning.
• U.S. ʻAi a me nā lāʻau lapaʻau (FDA): Lapaʻau Palekana Palekana no nā pilikia o ka naʻau koʻikoʻi, hopu ʻana, a me ka make mai ka High-Dose Diphenhydramine ("Benadryl Challenge") Overdose.