Cholinergic (SLUDGEM) vs Anticholinergic Poisoning: Idanimọ Tooxidrome ati Iranlọwọ akọkọ¶

Nigbati ọmọ, agbalagba, tabi oṣiṣẹ ogbin ba jẹ majele nipasẹ oogun ti a ko mọ, ọgbin, olu, tabi sokiri kemikali, awọn onimọ-jinlẹ iṣoogun ati awọn oludahun pajawiri ko duro awọn wakati fun ibojuwo yàrá lati bẹrẹ itọju igbala-aye: dipo, wọn ṣe ayẹwo awọn ọmọ ile-iwe alaisan, lagun awọ ara, oṣuwọn ọkan, awọn aṣiri mimi, ati ipo ọpọlọ lati ṣe idanimọ ** tooxidrome (aisan majele)**. Meji ninu awọn toxidromes ti o wọpọ julọ ati apaniyan lori Earth jẹ awọn ilodisi ti ẹkọ iṣe-iṣe deede ti n ṣiṣẹ lori eto eto neurotransmitter ** acetylcholine (ACh): ** Cholinergic Toxidrome (ti a ranti nipasẹ awọn mnemonics SLUDGEM / DUMBBELS ati Killer B's) , eyiti o jẹ ki iṣan omi awọn olugba pẹlu choline ati apọju alaisan, o lọra-ọkàn, twitching, pẹlu pinpoint akẹẹkọ", dipo awọn ** Anticholinergic (Antimuscarinic) Tooxidrome **, eyi ti ohun amorindun acetylcholine receptors ati ki o mu ki alaisan **"egungun-gbẹ, gbona, flushed, sare-ọkàn, delirious, idaduro ito, pẹlu jakejado digba awọn ọmọ ile-iwe. Ti o ba fura boya toxicdrome, pe nọmba pajawiri ti agbegbe rẹ nipasẹ wa pajawiri awọn nọmba Liana ati Kan si Iṣakoso majele lẹsẹkẹsẹ, bi majele cholinergic nilo imukuro ara ni iyara ati ** atropine + pralidoxime ** lakoko ti majele anticholinergic nilo itutu agbaiye ti nṣiṣe lọwọ, ** benzodiazepines ***, tabi ** physostigmine **, lẹgbẹẹ awọn itọsọna wa fun ipakokoropaeku organophosphate ati majele oluranlowo nafu, olu igbo ati jijẹ ohun ọgbin oloro, ati iṣọn serotonin vs.

Ṣe eyi ni bayi¶

1. ** Daabobo ararẹ lọwọ awọ ara keji tabi idoti oru ni AKỌKỌ ***:
2. Ṣaaju ki o to fọwọkan eniyan ti n rọ, ti n rẹwẹsi, eebi, tabi twitching lẹhin ifihan si ipakokoro ti ogbin, fifa ọgba, tabi omi kemikali ti a ko mọ, **fi nitrile tabi awọn ibọwọ neoprene wọ *** (kii ṣe latex tinrin, eyiti organophosphates wọ inu) ati gbe soke.
3. **Maṣe ṣe mimi lati ẹnu-si-ẹnu lori alaisan ti o ni majele nipasẹ organophosphate tabi awọn ipakokoropaeku carbamate **, bi iyoku ipakokoropaeku ninu itọ wọn, lagun, ati eebi yoo majele fun ọ nipasẹ ẹnu ati awọ ara rẹ.
4. **Pe nọmba pajawiri ti agbegbe rẹ ati Iṣakoso majele lẹsẹkẹsẹ *: Tẹ 911 ni Amẹrika ati Kanada (ati Iṣakoso Majele AMẸRIKA ni ** 1-8-221222 *),12*kọja European Union, 999** ni United Kingdom, 000 ni Australia, tabi wo agbaye wa pajawiri awọn nọmba lia. Sọ fun olufiranṣẹ boya alaisan naa wo “Ọrinrin ati Drooling pẹlu Awọn ọmọ ile-iwe Pinpoint (Aawọ Cholinergic ti a fura)”** tabi **“Egungun-Gbẹ,bona, Flushed, ati Delirious pẹlu Awọn ọmọ ile-iwe nla (Afifura Anticholinergic Overdose)”.
5. **Ṣe idanwo ti ara iyara ti awọn itọka toxicrome ẹgbẹ ibusun mẹrin (Lan, Awọn ọmọ ile-iwe, Awọn ohun oju-ofurufu, ati Oṣuwọn Ọkan) ***:
6. Fi ọwọ kan awọn alaisan armpits (axillae) ati iwaju : Njẹ wọn * ti ṣan ninu lagun (Cholinergic) tabi ** egungun patapata-gbẹ bi iwe iyanrin (Anticholinergic)?
7. Wo awọn ọmọ ile-iwe wọn : Ṣe wọn ** pinpoint 1 mm aami (Cholinergic) tabi ** jakejado-ṣii ​​7 si 8 mm awọn iyika dudu (Anticholinergic)**?
8. Fetí sí ẹnu àti àyà wọn: Ṣé wọ́n ** ń kùn, tí wọ́n ń fọ̀fọ̀, tí wọ́n sì ń mimi pẹ̀lú omi (Cholinergic "Killer B's")**, àbí òwú ẹnu* wọn gbẹ pẹ̀lú ẹ̀dọ̀fóró tó mọ́ (Anticholinergic)**?
9. **Ti alaisan naa ba jẹ “WET” (Cholinergic / SLUDGEM Crisis), ṣaju Imugbẹ oju-ofurufu ati Imukuro Awọ ***:
10. Yi alaisan ti ko ni idahun tabi ti o sọ silẹ si ẹgbẹ wọn ni ** ipo imularada ** nitorina itọ ti o tobi, foomu ti iṣan, ati eebi ti n jade kuro ni ẹnu dipo ki wọn rì awọn ẹdọforo wọn.
11. Ti o ba farahan si ipakokoropaeku olomi tabi sokiri ipakokoropaeku, ** yọ gbogbo aṣọ, bata, ati awọn ohun elo alawọ kuro lẹsẹkẹsẹ ** ki o si fọ awọ ati irun wọn daradara pẹlu ** ọṣẹ ati omi ṣiṣan nla ** fun iṣẹju 15.
12. Ti alaisan naa ba ni ologun tabi iṣoogun Atropine/Pralidoxime auto-injector (DuoDote tabi ATNAA), lọ si aarin itan ni ita lẹsẹkẹsẹ.
13. ** Ti alaisan naa ba jẹ “DRY ati GAN” (Anticholinergic Delirium), ṣaju Itutu Itutu Nṣiṣẹ, Ayika Tunu, ati ECG ***:
14. Nitori majele anticholinergic tii agbara ara lati lagun (anhidrosis) lakoko ti o nfa iṣẹ iṣan agitated, iwọn otutu mojuto le fa sinu hyperthermia apaniyan. Gbe wọn lọ si yara ti o tutu, yọ awọn ibora ti o wuwo, lo awọn aṣọ tutu tutu tabi awọn akopọ yinyin ti a we sinu awọn aṣọ inura si ọrun, awọn apa, ati ikun, ki o si jẹ ki wọn balẹ ni yara ti o tan imọlẹ titi ti awọn alamọja yoo fi de pẹlu ** 12-lead ECG ** ati inu iṣan ** benzodiazepines ***.

Igi ipinnu: Iyatọ Cholinergic la Anticholinergic vs. Sympathomimetic Toxidromes¶

flowchart TD
    Start["Alaisan Ṣe Ifarahan pẹlu Majele Kokoro, Aṣeju iwọn lilo, Ohun ọgbin tabi Jijẹ Olu, tabi Ifihan Kemikali"] --> SweatCheck{"Fọwọkan Armpits (Axillae), àyà, ati Mucosa Oral: Njẹ Alaisan WET (Sweating/Drooling) tabi Egungun-DRY?"}

    SweatCheck -->|"WET: Profuse sweating, drooling, tabi awọn aṣiri ti iṣan"| PupilWet{"Ṣayẹwo Awọn ọmọ ile-iwe, Oṣuwọn ọkan, ati Ohun orin Isan"}

    PupilWet -->|"Awọn ọmọ ile-iwe Pinpoint (Miosis: 1 si 2 mm) + Pulse ti o lọra (tabi tachycardia ibẹrẹ) + Awọn ẹdọforo tutu (Bronchorrhea/Wheezing) + Eebi/Igbẹgbẹ/Itọ + Awọn Imọ iṣan (Twitching) tabi Paralysis"| CholinergicBox["CHOLINERGIC TOXIDROME (SLUDGEM / DUMBBELS): Awọn okunfa: Organophosphate tabi Awọn ipakokoropaeku Carbamate, Awọn Aṣoju Nerve (Sarin/VX/Novichok), Pyridostigmine/Neostigmine Overdose, Pilocarpine, Inocybe/Clitocybe Mushrooms 1. Gvesar Ni; Yọ Aso ati Wẹ Awọ pẹlu Ọṣẹ + Omi ti o ba jẹ Ipakokoropaeku 2. Ipo Imularada + Ifarada Airway Air + 100% Oxygen 3. STAT IV / IM Atropine (1 si 3 mg agbalagba; ilọpo ni gbogbo 3 si 5 min titi ti ẹdọforo yoo gbẹ) 4. IV Pralidoxime (2-PAM: 3 lati tun ṣiṣẹ) acetylcholinesterase 5. IV Benzodiazepine (Diazepam/Midazolam) fun ijagba"]

    PupilWet -->|"Awọn ọmọ ile-iwe Dilated (Mydriasis) + Pulse Yara ati BP giga + lagun ti o gbẹ + Agitation + Awọn ohun ifun deede"| SympathoBox["SYMPATHOMIMETIC TABI SEROTONIN TOXIDROME: Awọn okunfa: Cocaine, Methamphetamine, MDMA, Ephedrine, Bath Iyọ (tabi SSRIs if clonus) 1. Itutu Nṣiṣẹ + Ayika Tutu + IV Benzodiazepines 2. Yẹra fun Beta-Blockers ni Kokoro-Blockers ni Cocaine Toxicity"]

    SweatCheck -->|"EGUNGUN-DIYE: Awọn apa gbigbẹ, awọ iyangbẹ gbẹ, ẹnu ati ahọn ti owu gbẹ"| AntiBox["ANTICHOLINERGIC (ANTIMUSCARINIC) TOXIDROME: Mad bi Hatter, Afoju bi Adan, Pupa bi Beet, Gbona bi Ehoro, Gbẹ bi Egungun, Kikun bi Flask Awọn okunfa: Diphenhydramine (Benadryl / Tylenol PM / ZzzQuil), Doxylamine, Atropine, Oxypolamine, Triniti, Scoxybulamine. (Amitriptyline), Jimsonweed (Datura), Alẹ apaniyan 1. Itutu agbaiye fun Hyperthermia + Yara Dim Quiet 2. Lẹsẹkẹsẹ 12-Lead ECG: Ṣayẹwo Iye akoko QRS (ju 100 ms) ati Aarin QTc - Ti QRS ba ju 100 ms (Sodium-Channel): Blockademine IV si Dimistaphe (Sodium-Channel) 2 mEq/kg bolus) 3. Foley Catheter lati mu irora ti o ni idaduro ito gbigbo 4. IV Benzodiazepines (Lorazepam/Midazolam) OR Antidote ti a fojusi: IV Physostigmine (0.5 si 2 miligiramu o lọra titari lori 5 min NIKAN ti antimuscarinic funfun pẹlu deede QRSs labẹ) 1"]

Pathophysiology: Bawo ni Acetylcholine Ṣe Dari Ara (Ati Ohun ti o ṣẹlẹ Nigbati O Ikun omi vs. Parẹ)¶

** Acetylcholine (ACh)** jẹ ọkan ninu awọn ojiṣẹ kemikali akọkọ ti ara (awọn neurotransmitters). Ni deede, awọn opin nafu tu silẹ kekere ti nwaye ti acetylcholine kọja synapse lati mu olugba ibi-afẹde ṣiṣẹ, ati laarin ** microseconds **, enzymu mimọ ** acetylcholinesterase (AChE) *** pin moleku acetylcholine ni idaji (sinu choline aiṣiṣẹ ati acetate) nitorinaa nafu ati iṣan le tunto.

Acetylcholine n ṣiṣẹ kọja ** awọn nẹtiwọọki olugba anatomical ọtọtọ mẹta ***: 1. ** Awọn olugba Muscarinic (M1, M2, M3) ti Eto aifọkanbalẹ Parasympathetic ("Isinmi ati Daijesti") *: - Ṣakoso gbogbo awọn keekeke ti exocrine ( awọn keekeke salivary, awọn keekeke yiya, awọn keekeke mucus bronchial, acid ikun, ati awọn keekeke lagun eccrine **: ṣe akiyesi pe botilẹjẹpe awọn keekeke lagun ti firanṣẹ si ẹwọn aanu, iyipada kemikali ikẹhin wọn jẹ ** muscarinic acetylcholine ***), fa fifalẹ awọn *SA ati awọn apa AV ti okansp), nipasẹ awọn iṣọn-alọ ọkan. pupillae) ati ** awọn tubes bronchial ***, o si ṣe adehun awọn ** ikun, ifun, ati iṣan apòòtọ detrusor ** lakoko ti o n sinmi awọn ito / furo sphincters. 2. ** Awọn olugba Nicotinic (NM ati NN) ni Ipade Neuromuscular Junction ati Autonomic Ganglia ***: - Ina taara gbogbo ** iṣan egungun atinuwa ninu ara *** (pẹlu ** diaphragm ati awọn iṣan mimi intercostal ***) ati muu ṣiṣẹ ibanujẹ / adrenal ganglia. 3. ** Eto aifọkanbalẹ aarin (Ọpọlọ) Awọn olugba Cholinergic ***: - Iranti ijọba, akiyesi, wakefulness, ati iṣakoso moto tunu.

Tooxidrome 1: Idaamu Cholinergic (Acetylcholine ti o pọ ju: “Ọrinrin, O lọra, Twitching, ati Pinpoint”)¶

1. Awọn okunfa ti o wọpọ ti Cholinergic Poisoning¶

Aawọ cholinergic ṣẹlẹ boya nigbati majele kan ** ṣe idiwọ henensiamu afọmọ acetylcholinesterase (AChE) *** (nfa acetylcholine ti alaisan lati ṣajọpọ awọn ipele majele kọja muscarinic, nicotinic, ati awọn olugba ọpọlọ) TABI nigbati kemikali taara ba mu awọn olugba muscarinic ṣiṣẹ:

• **Organophosphate (OP) Awọn ipakokoropaeku ati Awọn ipakokoro (Awọn inhibitors AChE Aiyipada) ***:
• Malathion, parathion, chlorpyrifos, diazinon, dichlorvos, fenthion, ati azinphos-methyl. Ti a lo ni agbaye ni iṣẹ-ogbin, awọn ohun-ọsin ẹran, ati iṣakoso kokoro. Wọn * yara fa ni taara nipasẹ awọ ara eniyan ti ko tọ ***, ẹdọforo, ati ikun.
• ** Aago "Ogbo" *: Organophosphates so mọ ẹgbẹ serine hydroxyl ti acetylcholinesterase. Lori awọn wakati si awọn ọjọ (da lori kemikali kan pato), asopọ kemikali kan ya kuro ( dealkylation / "ti ogbo" **), tiipa henensiamu patapata sinu ipo ti ko le yipada nibiti paapaa oogun oogun ** pralidoxime (2-PAM) *** ko le gba a silẹ mọ.
• ** Awọn Aṣoju Nerve Ologun (Organophosphates Alagbara) ***:
• ** G-jara (Sarin [GB], Soman [GD], Tabun [GA]), ** V-jara (VX), ati ** A-jara (Novichok)**. Soman "awọn ọjọ ori" ati tiipa acetylcholinesterase patapata ni ** iṣẹju 2 kan **.
• ** Awọn ipakokoro Carbamate (Awọn inhibitors AChE Yipada) ***:
• Aldicarb, carbofuran, carbaryl (Sevin), propoxur, ati methemyl. Awọn Carbamates fa idamu SLUDGEM ti o ni idẹruba igbesi-aye gangan bi organophosphates, ayafi ti asopọ wọn si acetylcholinesterase ** awọn hydrolyzes lairotẹlẹ (yiyipada) laarin awọn wakati 24 si 48 **, ati pe wọn kọja idena-ọpọlọ ẹjẹ ni imurasilẹ.
• ** Awọn oogun Cholinergic Oogun (Myasthenia Gravis, Alzheimer's, Glaucoma, ati Awọn oogun Atọpa) ***:
• Iwọn apọju ti pyridostigmine (Mestinon) tabi neostigmine (ti a mu nipasẹ awọn alaisan pẹlu myasthenia gravis: gbigbe pupọ Mestinon nfa ** aawọ cholinergic kan ** ti o fa ailera iṣan ti o nfarawe igbunaya myasthenic), **donepezil (Aricept), rivastigmine, galantamine ** (Awọn oogun Alzheimer), ** pilocarpine ** (oju oju tabi awọn tabulẹti ẹnu gbẹ), tabi bethanechol.
• **Muscarine ti o ni awọn olu igbẹ ninu **:
• Foraging ati jijẹ * Inocybe * ("Fiber Cap") tabi * Clitocybe * ("Funnel Cap") olu fa ibẹrẹ ni kiakia (iṣẹju 15 si 60) ti awọn aami aisan SLUDGE muscarinic muscarin funfun ** (profuse sweating, salivation, tearing, ìgbagbogbo, gbuuru, bradycardia) * laisi* paralysis iṣan nicotinic.

2. Ti o mọ Majele Cholinergic: Muscarinic (SLUDGEM / DUMBBELS) + Nicotinic (Awọn Ọjọ Ọsẹ)¶

Nitori apọju acetylcholine deba ** mejeeji *** muscarinic ati awọn olugba nicotinic nigbakanna, alaisan ti o ni majele fihan awọn ami aisan meji ti o jọra:

A. Awọn ami Parasympathetic Muscarinic (Mnemonics: SLUDGEM tabi DUMBBELS)¶

• S (Salivation): Sisun omi tutu lati ẹnu.
• ** L (Lacrimation) ***: Tesiwaju yiya lati oju (nigbakugba "chromodacryorrhea" pupa-brown)).
• U (Itọto): Ipadanu lainidii ti iṣakoso àpòòtọ (aisedeede ito).
• D (Igbẹ/Igbẹgbẹ): Ibẹru omi gbuuru ati ikun ti o lagbara.
• G (Ibanujẹ Ifun inu): ifasilẹ iwa-ipa ati awọn inudidun inu.
• E (Emesis): Eebi ti o leralera (nigbagbogbo ti o n run gaan ti **ata ilẹ tabi epo epo/erosin kerosene *** lati ọdọ awọn ti ngbe ipakokoropaeku).
• **M (Awọn ọmọ ile-iwe Miosis / Pinpoint) ***: Awọn ọmọ ile-iwe mejeeji ni idinamọ si ** 1 si 2 awọn aami pinpoint milimita 1 ti kii ṣe dilate ninu okunkun, ti o tẹle pẹlu iran isunmọ to dara ati irora brow lati isan iṣan ciliary.
• *(Ninu DUMBBELS mnemonic, awọn mẹta B's ṣe afihan ta "Killer B's" **: Bronchorrhea [awọn aṣiri ẹdọfóró omi pipọ], ** B *** ronchospasm [awọn atẹgun atẹgun ti o ni wiwọ], ati ** B *** radycardia [o lọra oṣuwọn ọkan].)

B. Nicotinic Neuromuscular & Awọn ami Aanu (Mnemonic: Awọn Ọjọ Ọsẹ: M-T-W-Th-F)¶

Nigbati awọn iṣan omi acetylcholine ti o pọ si awọn olugba nicotinic lori awọn iṣan egungun, o kọkọ nfa ibọn atunwi rudurudu (iṣan iṣan), ati lẹhinna ** depolarizes ati yọkuro awo-igbẹhin mọto ***, nfa pipe ** paralysis flaccid ** (aami si iwọn apọju ti oogun paralytic succinylcholine): - M (Mydriasis: Iyatọ Tete lẹẹkọọkan): Ṣọwọn, ikọlu ẹgbẹ aanu ni kutukutu le jẹ ki awọn ọmọ ile-iwe jẹ deede ṣaaju ki muscarinic pinpoint miosis bori. - T (Tachycardia & Haipatensonu: Oju Iboju Ibanujẹ Tete): Nitori awọn olugba nicotinic tun mu medulla adrenal ṣe idalẹkun adrenaline, to 20% si 30% ti awọn alaisacholinergic ti o ni majele pupọ ni ibẹrẹ wa pẹlu oṣuwọn ọkan FAST FAST (tachycardia) ati titẹ ẹjẹ giga sinu ikọlu ati ikọlu ọkan. Maṣe ṣe akoso majele cholinergic nitori pe pulse naa yara ni ibẹrẹ. - W (Ailagbara) ***: Ailagbara iṣan gbbogbo ti o ga, ailera rọ ọrun (ailagbara lati gbe ori kuro ni irọri), ati pipadanu awọn ifasilẹ tendoni jinlẹ. - Th (Iwariri ati Imudara Isan): Ti o han, ripping-bi aran ati yiyi awọn okun iṣan labẹ awọ ara (paapaa lori awọn ipenpeju, ahọn, ọmọ malu, ati àyà). - F (Flacid Paralysis of the Diaphragm): Pipari iṣan atẹgun ti o pe ti o yori si idaduro atẹgun.

Tooxidrome 2: The Anticholinergic (Antimuscarinic) Delirium ("Gbẹ, Gbona, Pupa, Afọju, Mad, ati Kikun")¶

1. Awọn Okunfa ti o wọpọ ti Majele Anticholinergic¶

Majele Anticholinergic waye nigbati oogun kan tabi majele ọgbin ni idije ** ṣe idiwọ awọn olugba muscarinic acetylcholine (M1 nipasẹ M5)** kọja ọpọlọ, ọkan, oju, awọn eegun lagun, ikun, ati àpòòtọ (akiyesi pe awọn oogun “anticholinergic” boṣewa ko ** ṣe idiwọ awọn olugba nicotinic skeletal isan, nitorinaa alaisan naa ni agbara)

• ** Awọn Antihistamines Ipilẹ-Ori-Ori-Oju-Oju-Iran ati Awọn iranlọwọ oorun (Idi #1 Ìdílé)**:
• ** Diphenhydramine *** (ti a ta bi Benadryl, ZzzQuil, Sominex, Nytol, Unisom, Tylenol PM, Advil PM) ati Doxylamine (Unisom SleepTabs, NyQuil), ** Dimenhydrinate ** (Dramamine), ** Chlorpheniramine ***, ati **Hydroxyzine.
• ** Diphenhydramine Double-Ewu ***: Ni awọn iwọn apọju nla (fun apẹẹrẹ, awọn italaya awujọ awujọ ọdọ tabi awọn ingestions ingestion), diphenhydramine kii ṣe ** kii ṣe idiwọ awọn olugba muscarin: o tun dina ** awọn ikanni iṣuu soda ọkan ọkan (gẹgẹbi antidepressant tricyclic tricyclic)) RS 00, nfa ** tachycardia, ati ipo epilepticus ijagba ***.
• ** Iwe oogun Antimuscarinic, Psychiatric, ati Awọn oogun Atọpa ***:
• ** Awọn Antidepressants Tricyclic (TCAs): Amitriptyline, nortriptyline, doxepin, imipramine (wo wa irin ile, aspirin, ati itọnisọna iwọn apọju tricyclic).
• ** Awọn Antipsychotics aṣoju aṣoju ***: Quetiapine (Seroquel), olanzapine (Zyprexa), clozapine, chlorpromazine.
• ** Overactive Badder & GI Antispasmodics ***: Oxybutynin, tolterodine, solifenacin, dicyclomine, hyoscyamine, glycopyrrolate.
• ** Awọn oju oju oju oju oju & Awọn abulẹ Aisan išipopada ***: ** Atropine, homatropine, cyclopentolate, tabi tropicamide ** oju silė (ti ọmọde ba gbe mì, igo kan jẹ apaniyan), ati ** scopolamine ** awọn abulẹ transdermal.
• ** Awọn isunmi iṣan & Awọn oogun Antiparkinsonian ***: Cyclobenzaprine (Flexeril), orphenadrine, benztropine, trihexyphenidyl.
• ** Awọn ohun ọgbin alkaloid Tropane Oloro ati Tii (Atropine, Scopolamine, ati Hyoscyamine) ***:
• ** Jimsonweed (* Datura stramonium * / "Apple elegun" / "Ipè Eṣu")**: Awọn ọdọ tabi awọn afunfun ti o gbe awọn pods irugbin spiky mì tabi pọnti * Datura * tii ṣe idagbasoke jinle, delirium anticholinergic ọjọ-pupọ.
• ** Nightshade apaniyan (Atropa belladonna)**: Awọn eso dudu didan dabi blueberries ati pe o ni awọn ifọkansi giga ti atropine ninu.
• ** Ipè Angeli (Brugmansia)**, Henbane (Hyoscyamus niger), Mandrake (Mandragora), ati awọn teas egboigi ti a doti pẹlu belladonna alkaloids.

2. Ti idanimọ Classic Anticholinergic Rhyme¶

Awọn oniwosan mọ awọn ẹya pataki mẹfa ti majele antimuscarinic nipa lilo orin ile-iwosan Ayebaye:

1. "Gbẹ bi Egungun" (Anhidrosis ati Xerostomia: Ami Iyatọ #1):
2. Nitoripe awọn olugba M3 muscarinic ti o wa lori lagun ati awọn keekeke ti o ni iyọ ti dina, **armpits (axillae) alaisan, ikun, ọpẹ, ati iwaju jẹ egungun gbẹ patapata si ifọwọkan *** ati ahọn ati awọn ẹrẹkẹ inu ti gbẹ ati alalepo.
3. **"Gbona bi Ehoro" (Anhidrotic Hyperthermia) ***:
4. Nitoripe alaisan ko le lagun lati yọ ooru kuro lakoko ti iṣẹ-ṣiṣe iṣan ti o ni rudurudu n ṣẹda ooru inu, iwọn otutu ara n gun lọ si ** 38.5 si 41.0 iwọn Celsius (101.3 si 105.8 iwọn Fahrenheit) tabi ga julọ ***.
5. ** “Pupa bi Beet” (Vasodilation Cutaneous / Flushing) ***:
6. Dina eefin itutu agbaiye nfa idapada isanpada ti awọn capillaries awọ ara ti o kọja oju, ọrun, ati àyà oke ni igbiyanju lati tan ooru jade, ti n ṣe agbejade Pink/pupa didan didan “atropine flush.”
7. ** "Afọju bi Adan" (Mydriasis ati Cycloplegia) ***:
8. Dina iṣan sphincter iris gba ọmọ ile-iwe laaye lati dilate sinu ** nla, 6 si 9 millimeter dudu iyika (mydriasis) ** ti o fesi lọra tabi rara si filaṣi, lakoko ti paralysis ti iṣan lẹnsi ciliary (** cycloplegia ***) jẹ ki o ṣee ṣe lati dojukọ awọn nkan nitosi tabi ka ọrọ.
9. ** “Aṣiwere bi Hatter” (Antimuscarinic Delirium Central) ***:
10. Dinamọ awọn olugba M1 ninu ọpọlọ fa iyatọ, iyipada ** delirium agitated ***:
    • ** Mumbling, aṣọ, aiṣedeede "ẹnu-owu" ọrọ ** (bibẹrẹ gbolohun kan ni deede ati itọpa sinu sisọ ti ko ni oye).
    • ** Wiwo Lilliputian ati awọn hallucinations tactile *: Ri awọn idun kekere ti inu, awọn spiders, awọn okun, tabi awọn eniyan lori awọn iwe ibusun ati ** nigbagbogbo fa tabi mu awọn nkan alaihan ni afẹfẹ tabi lori awọn aṣọ wọn ("carphologia" tabi "floccillation").
11. ** "Kikun bi Flask" ati "Tachy bi Flea" (Iduro Itọto Pupọ, Awọn ohun ifun ti ko wa, ati Sinus Tachycardia) ***:
12. Idilọwọ awọn idaduro vagal M2 lori ọkan nfa ** sinus tachycardia (110 si 160+ bpm)**, eyiti o jẹ nigbagbogbo ** ami ibẹrẹ ati ami ifarabalẹ julọ ** ti majele anticholinergic.
13. Dina ikun ati àpòòtọ M3 awọn olugba paralyzes intestinal peristalsis (** idakẹjẹ tabi isansa ifun awọn ohun / ileus **) ati ki o clamps awọn ito sphincter nigba ti paralyzing awọn àpòòtọ odi, nfa irora ** idaduro ito nla (àpòòtọ distended ti o ni 500 si 1,200 milimita 200 milimita ti omi) nigbagbogbo nmu urine. delirious alaisan thrash ni ibusun titi ti nọọsi fi sii kan Foley catheter.

Tabili lafiwe Titunto: Cholinergic vs Anticholinergic vs. Sympathomimetic Toxidromes¶

(Akiyesi ofin ile-iwosan ni oke: Bawo ni o ṣe sọ fun aritated, tachycardic, dilated-akẹẹkọ Alaisan Anticholinergic yato si alaisan Cocaine/Methamphetamine Sympathomimetic? Fi ọwọ kan awọn apa wọn ki o tẹtisi ikun wọn.)

Awọn Ilana Antidote Ile-iwosan: Bii Awọn Onisegun Yipada Tooxidrome kọọkan¶

1. Yiyipada Ẹjẹ Cholinergic: Atropine + Pralidoxime (2-PAM) + Benzodiazepines¶

Nigbati organophosphate tabi alaisan ti o ni majele ti carbamate de ni yara pajawiri ti o rì sinu awọn aṣiri ti iṣan:

• Aditidote 1: Atropine inu iṣọn-ẹjẹ (Dina Awọn olugba Muscarinic: Gbigbe awọn “Killer B's”):
• ** Iwọn akọkọ ***: Awọn agbalagba gba ** 1 miligiramu si 3 mg IV *** (0.02 si 0.05 mg / kg ninu awọn ọmọde).
• ** Ilana Ilọpo Ilọpo Ilọsiwaju (Eddleston / WHO Protocol)**: Ko dabi bradycardia ti o ṣe deede (nibiti 3 miligiramu ti atropine jẹ iwọn lilo ti o pọju), alaisan ti o ni majele organophosphate le nilo ** 50 si 500+ milligrams ti atropine ni awọn wakati 24 akọkọ *. Ti ẹdọforo alaisan tun wa ni tutu pẹlu awọn crackles / mimi lẹhin iṣẹju 3 si 5, awọn dokita ** DOUBLE iwọn lilo atropine ti tẹlẹ ni gbogbo iṣẹju 3 si 5 ** (2 mg, lẹhinna 4 mg, lẹhinna 8 mg, lẹhinna 16 mg, lẹhinna 32 mg) titi ti ** awọn aaye ipari mẹta ti "Atropinization" ti waye:
  1. ** Ko àyà kuro lori auscultation *** (odo bronchorrhea tabi mimi: ** aaye ipari #1 ***),
  2. ** Iwọn ọkan ju 80 lu fun iṣẹju kan **, ati
  3. ** Iwọn ẹjẹ sistolic ju 80 si 90 mmHg lọ.
• • (Ofin: ** Iwọn ọmọ ile-iwe ko ni lo bi aaye ipari fun didaduro atropine **, nitori eto IV atropine ti n pa ẹdọforo kuro ni pipẹ ṣaaju ki o to di awọn ọmọ ile-iwe pinpoint, ati ** atropine ni ipa ZERO lori paralysis iṣan nicotinic **.)
• Antidote 2: Pralidoxime inu iṣọn-ẹjẹ / 2-PAM tabi Obidoxime (Mu pada Agbara iṣan Nicotinic pada):
• Nitoripe atropine nikan ṣe idiwọ awọn keekeke ti muscarinic ati pe ko le ṣe atunṣe paralysis nicotinic diaphragm, awọn dokita ṣe abojuto ** oxime ***, ** Pralidoxime chloride (1 si 2 giramu IV ju iṣẹju 15 si 30 ni awọn agbalagba; 20 si 50 mg / kg ninu awọn ọmọde, atẹle nipasẹ idapo IV lemọlemọ ti 500 mg / hour) ti molecular IV ti 500 miligiramu / hour, eyiti o ṣiṣẹ ni 500 miligiramu. organophosphate molecule pa acetylcholinesterase henensiamu **ṣaaju ki o to "ti ogbo" jẹ ki awọn mnu yẹ ***.
• Aditidote 3: Benzodiazepines inu iṣan (Diazepam tabi Midazolam):
• Da aarin cholinergic imulojiji ati idilọwọ hypoxic/excitotoxic ipalara ọpọlọ.

2. Yiyipada Idaamu Anticholinergic: Benzodiazepines, Sodium Bicarbonate, ati Physostigmine¶

Nigbati alaisan kan ba de pẹlu delirium anticholinergic ti o lagbara lati diphenhydramine, jimsonweed, tabi awọn oogun oogun:

• **Igbese 1: Lẹsẹkẹsẹ 12-asiwaju ECG si iboju fun Idena ikanni Sodium-ikanni (QRS ju 100 ms) ati Ifagun QT ***:
• Diphenhydramine (Benadryl), dimenhydrinate, ati awọn antidepressants tricyclic (amitriptyline) dina awọn ikanni iṣuu soda ọkan ọkan. Ti eka QRS lori ECG ba gbooro ju 100 milliseconds *** (tabi ti ebute R-igbi pataki kan ba wa lori 3 mm ni asiwaju aVR), awọn dokita lesekese titẹ ** Hypertonic Sodium Bicarbonate inu iṣọn (1 si 2 mEq/kg IV bolus) lati dín eka QRS dín ati ṣe idiwọ ventrimicular ventricular apaniyan.
• **Igbese 2: Idekuro ito (Foley Catheter) ati IV Benzodiazepines ***:
• Gbigbe catheter ito kan lati fa iṣan ti o ni irora ti o ni irora (800+ milimita) ati fifun iṣan titrated lorazepam (1 si 2 miligiramu IV) tabi midazolam/diazepam ni ailewu ṣe ifọkanbalẹ irẹwẹsi-si iwọntunwọnsi, dinku iwọn otutu ara, ati idilọwọ rhabdomyolysis. * (Ikilọ: Awọn dokita yago fun haloperidol tabi droperidol ni majele anticholinergic nitori awọn antipsychotics ni awọn ohun-ini anticholinergic inu ati ki o fa aarin QT gun.)*
• **Igbese 3: Agbogun Ipinnu Kan pato: Physostigmine inu iṣan (Tabi Rivastigmine) ***:
• ** Kini Physostigmine jẹ **: Ko dabi neostigmine tabi pyridostigmine (eyiti o gba agbara awọn amines quaternary ti * ko le sọdá sinu ọpọlọ), ** Physostigmine ** jẹ ohun ti ko gba agbara ** elere giga amine reversible acetylcholinesterase inhibitor ** ti o kọja idena-ọpọlọ ẹjẹ larọwọto. Laarin ** 5 si awọn iṣẹju 10 ** ti idapo iṣọn-ẹjẹ ti o lọra (0.5 miligiramu si 2.0 miligiramu ti fomi po ni iyọ 10 milimita ati fi sii laiyara lori ** o kere ju awọn iṣẹju 5 ** ninu awọn agbalagba; 0.02 mg / kg to 0.5 mg ninu awọn ọmọde), physostigmine ṣe igbelaruge acetylcholine, ifọkanbalẹ si inu ọpọlọ ati jijẹ ibaraẹnisọrọ.
• ** Awọn ofin aabo to muna fun Physostigmine ***:
  1. ** MAA ṢE fun Fisisọgimine ni oogun Antidepressant Tricyclic (TCA) apọju tabi ti ECG ba fihan QRS ti o gbooro ju 100 ms, gigun PR, tabi bradycardia ***: Ninu majele TCA, physostigmine le ṣaju lojiji ** idaduro ọkan asystolic cardiac ***.
  2. ** Fi sii laiyara lori iṣẹju marun 5 ni kikun ***: Titari physostigmine ni iyara pupọ nfa awọn ikọlu cholinergic tabi bradycardia; lẹgbẹ ibusun **atropine *** nigbagbogbo wa ni fifa soke ni syringe ni idaji iwọn lilo physostigmine lati yi ipadabọ cholinergic eyikeyi ti o pọju pada.
  3. ** Yiyan ode oni Lakoko Awọn aito Physostigmine (Rivastigmine)**: Bii physostigmine, oogun Alusaima rivastigmine jẹ oludena carbamate acetylcholinesterase ti aarin ti o kọja idena-ọpọlọ ẹjẹ. Awọn onimọran majele ti iṣoogun n pọ si ni ** oral or transdermal patch rivastigmine ** lati ṣe idiwọ isọdọtun anticholinergic delirium (niwọn igba ti physostigmine iṣọn-ẹjẹ ba wọ ni iṣẹju 60 si 90, lakoko ti ikun oloro ti n gba diphenhydramine tabi awọn irugbin jimsonweed tẹsiwaju itusilẹ majele fun wakati 24 si 48).

Awọn nọmba pajawiri agbegbe ati awọn ilana ile-ibẹwẹ¶

• *United States ati Canada : Pe 911 lẹsẹkẹsẹ fun eyikeyi iyipada ipo opolo, ijagba, tabi ifihan ipakokoropaeku, ati pe ** Iṣakoso majele ni 1-800-222-1222 (US) tabi ** 1-844-POISON-X (Canada) lati sọrọ taara pẹlu onimọran iṣoogun ti igbimọ kan. Ile-iwosan iṣaaju HazMat ati awọn ẹgbẹMS gbe **DuoDote / Ma I awọn abẹrẹ alafọwọyi (2.1 miligiramu atropine + 600 mg pralidoxime kiloraidi) ** labẹ awọn ilana CHEMPACK / CDC / ACMT.
• ** United Kingdom : Pe 999 fun ọkọ alaisan pajawiri (ati Ina/HazMat ti kemikali iṣẹ-ogbin ba kan). Awọn apa pajawiri ti ile-iwosan tẹle ** Iṣẹ Alaye Awọn majele ti Orilẹ-ede (NPIS / TOXBASE) ati ** Royal College of Emergency Medicine (RCEM)* awọn itọnisọna antidote fun iwọn atropine inu iṣọn-giga, mesilate pralidoxime, sodium bicarbonate, ati physostigmine.
• **European Union ***: Kiakia 112 kaakiri gbogbo awọn orilẹ-ede ọmọ ẹgbẹ EU. Awọn ẹka majele ti ile-iwosan tẹle ** Ẹgbẹ Yuroopu ti Awọn ile-iṣẹ Oloro ati Awọn onimọ-jinlẹ Ile-iwosan (EAPCCT) *** awọn iṣedede (lilo obidoxime tabi pralidoxime lẹgbẹẹ atropine fun organophosphates, ati physostigmine salicylate [Anticholium] fun aarun antimuscarinic aarin).
• ** Australia ati Ilu Niu silandii *: Pe 000 ni Australia tabi 111 ni Ilu Niu silandii, ki o si kan si Ile-iṣẹ Ala Awọn majele ni 13 11 26 (Australia) tabi 0800 764 766 (New Zealand).
• India ati Asia-Pacific ***: Kiakia ** 112 *** ni India (tabi ** 108 *** ọkọ alaisan), ** 995 ** ni Singapore, ** 119 *** ni Japan ati South Korea, tabi ** 999 *** ni Ilu Họngi Kọngi ati Malaysia. Kọja igberiko Asia-Pacific awọn agbegbe ogbin, imukuro awọ ara iyara ati ilana ilana atropine IV ti Eddleston ni kiakia jẹ igun ile ti itọju pajawiri ile-iwosan.

Awọn ibeere ti a beere nigbagbogbo¶

Kini ọna ti o yara ju ni ẹgbẹ ibusun lati sọ fun apọju Anticholinergic (bii Benadryl tabi Jimsonweed) yato si Cocaine tabi iwọn apọju Methamphetamine?¶

Ni wiwo akọkọ, awọn alaisan mejeeji dabi iru wọn: mejeeji ni ibinu, gbigbona, gbigbona, ṣiṣan, tachycardic (oṣuwọn ọkan iyara), ati ni awọn ọmọ ile-iwe ti o gbooro (mydriasis). Awọn iyatọ meji ti o yara ju ibusun ni awọn apa ati ikun: fi ọwọ kan awọn ihamọra alaisan (axillae) ki o tẹtisi ikun wọn. Alaisan sympathomimetic (kokeni tabi methamphetamine) ni o ni lagun, awọn apa tutu ati awọn ohun ifun inu deede. Alaisan anticholinergic “gbẹ bi egungun”: apa ati awọ ara wọn gbẹ patapata bi iwe iyanrin, ẹnu wọn gbẹ ti owu, awọn ohun ifun wọn dakẹ, ati àpòòtọ wọn kun fun idaduro ito.

Kini adape SLUDGEM duro fun ninu majele cholinergic?¶

SLUDGEM jẹ mnemonic iṣoogun ti ayebaye fun apọju parasympathetic muscarinic ti a rii ninu ipakokoropaeku organophosphate, ipakokoro carbamate, oluranlowo nafu, tabi majele oogun cholinergic: Salivation (drooling), Lacrimation (yiya), ito (ailokun), Igbẹgbẹ (igbẹgbẹ), Gastrointestinal (igbẹgbẹ gbuuru), Iyọkuro 1. 2 mm awọn ọmọ ile-iwe). Awọn oniwosan ile-iwosan nigbagbogbo so SLUDGEM pọ pẹlu “Apaniyan B mẹta” (Bronchorrhea [mimu ninu awọn aṣiri ẹdọfóró omi], Bronchospasm [mimi nla], ati Bradycardia [oṣuwọn ọkan ti o lọra]) nitori Killer B's ati paralysis diaphragm nicotinic jẹ awọn okunfa iku gangan.

Kini idi ti iwọn apọju ti Benadryl (diphenhydramine) tabi Tylenol PM le fa awọn rhythms ọkan ti o ku ati ikọlu?¶

Diphenhydramine kii ṣe antihistamine nikan ati muscarinic acetylcholine blocker; ni awọn ifọkansi apọju, ilana kemikali rẹ tun ṣe idiwọ awọn ikanni iṣuu soda yara ati awọn ikanni potasiomu ninu iṣan ọkan, ni ihuwasi ti o fẹrẹ jẹ aami si iwọn apọju apaniyan Tricyclic Antidepressant (TCA). Dina awọn ikanni iṣuu soda ọkan n fa fifalẹ itọnisọna itanna nipasẹ awọn ventricles (fifẹ eka QRS ti o ti kọja 100 milliseconds) ati pe o le fa tachycardia ventricular lojiji, Torsades de Pointes, hypotension, ati ipo ijagba warapa, eyiti awọn dokita ile-iwosan yiyipada lẹsẹkẹsẹ pẹlu hypertonic sodium bicarbonate inu iṣọn.

Kini idi ti awọn dokita ma n fun ni awọn iwọn lilo nla ti Atropine ni majele ipakokoropaeku paapaa lẹhin awọn ọmọ ile-iwe alaisan ti tan tẹlẹ?¶

Ni organophosphate tabi carbamate oloro ipakokoropaeku, ibi-afẹde ti atropine inu iṣan kii ṣe lati jẹ ki awọn ọmọ ile-iwe wo deede: ibi-afẹde ni lati gbẹ omi omi ti o ni idẹruba igbesi aye ti iṣan omi awọn ẹdọforo (bronchorrhea) ati mu pada oṣuwọn ọkan ati titẹ ẹjẹ. Nitoripe atropine eto eto de ọdọ ẹdọforo ati ọkan ni awọn iwọn oriṣiriṣi ju iris ti oju, didaduro atropine nikan nitori awọn ọmọ ile-iwe dilate fi alaisan naa silẹ ni awọn aṣiri ti iṣan. Awọn dokita ṣe ilọpo iwọn atropine IV ni gbogbo iṣẹju 3 si 5 titi ti àyà yoo fi dun patapata ati ki o gbẹ lori stethoscope kan.

Bawo ni ẹnikan ti o ni Myasthenia Gravis ṣe le sọ boya ailera wọn lojiji jẹ Ẹjẹ Myasthenic tabi Ẹjẹ Cholinergic lati mu Mestinon pupọ (pyridostigmine)?¶

Mejeeji aawọ myasthenic (ipa acetylcholine kekere pupọ lati igbunaya aisan tabi ikolu) ati idaamu cholinergic (pupọ acetylcholine lati gbigbe awọn iwọn lilo ti pyridostigmine/Mestinon ti o pọ ju) fa ailera iṣan ti o ṣakopọ pupọ, awọn ipenpeju sisọ, iṣoro gbigbe, ati ikuna atẹgun. Bibẹẹkọ, idaamu cholinergic kan nigbagbogbo pẹlu awọn amọran muscarinic SLUDGEM, gẹgẹ bi jijẹ inu, gbuuru, itọ pupọ ati awọn aṣiri ti iṣan, lagun, didi iṣan (fasciculations), oṣuwọn ọkan lọra, ati awọn ọmọ ile-iwe pinpoint kekere. Nitori awọn rogbodiyan mejeeji ṣe ihalẹ mimi laarin awọn iṣẹju, maṣe gbiyanju lati ṣe idanwo tabi ṣatunṣe awọn iwọn lilo ni ile: pe 911/112/999 lẹsẹkẹsẹ ki awọn dokita ile-iwosan le ni aabo ọna atẹgun ni akọkọ ati dawọ awọn oogun anticholinesterase lailewu ni ICU.

• Itọsọna yii n pese alaye eto-ẹkọ pajawiri ati pe ko rọpo igbelewọn iṣoogun ọjọgbọn tabi ijumọsọrọ Iṣakoso Majele. Nitori awọn majele cholinergic ati anticholinergic le yara fa idalọwọduro ọna atẹgun, paralysis ti atẹgun, awọn ijagba, ati idaduro ọkan ọkan, a ṣeduro ni iyanju gbigba ọwọ ti o ni ifọwọsi lori iranlọwọ akọkọ ati iṣẹ CPR lati Red Cross, St John Ambulance, tabi olupese ikẹkọ agbegbe ti a fọwọsi.

Jẹmọ awọn itọsọna¶

• Organophosphate ipakokoropaeku, oluranlowo nerve, ati oloro ipakokoro
• Ifunfun olu igbo (amatoxin ati muscarine) ati jijẹ ohun ọgbin oloro
• Afikun irin, salicylate (aspirin), ati iwọn apọju antidepressant tricyclic
• Aisan Serotonin, iṣọn aiṣedeede neuroleptic, ati awọn ibaraẹnisọrọ oogun
• Aisan Guillain-Barre, aawọ myasthenic, ati pipọ paralysis triage

Awọn orisun ati osise itoni¶

• ** Ile-ẹkọ giga ti Ile-ẹkọ giga ti Ilu Amẹrika ti Toxicology (ACMT) ati Ẹgbẹ Amẹrika ti Awọn ile-iṣẹ Iṣakoso majele (AAPCC, United States): ** * Awọn Itọsọna Iṣeduro Iṣegun ati Awọn iṣeduro Antidote fun Cholinergic (Atropine / Pralidoxime) ati Antimuscarinic (Physostigmine / Sodium Bicarbonate) Tooxidromes *.
• ** Ajo Agbaye ti Ilera (WHO):** * Itọju Ile-iwosan ti Ọti mimu ipakokoropaeku nla: Organophosphorus ati Carbamate Insecticides * ati * Eddleston Rapid Atropinization Regimen (Lancet)*.
• ** Awọn ile-iṣẹ fun Iṣakoso ati Idena Arun (CDC) ati Ẹka Ilera ti AMẸRIKA ati Awọn Iṣẹ Eda Eniyan (CHEMPACK / ASPR): *** Awọn Itọsọna Iṣoogun Iṣoogun Prehospital ati Ile-iwosan fun Awọn aṣoju Neerve ati Awọn ipakokoropaeku Organophosphate *.
• ** Iṣẹ Alaye Awọn majele ti Orilẹ-ede (NPIS / TOXBASE) ati Ile-ẹkọ giga Royal ti Oogun Pajawiri (RCEM, United Kingdom):** * Isakoso ti Arun Anticholinergic Arun, Majele Diphenhydramine, ati Organophosphate Poisoning*.
• ** U.S. Ounje ati Oògùn (FDA):** * Itaniji Aabo Oògùn lori Awọn iṣoro ọkan to ṣe pataki, Awọn ijagba, ati Iku lati Diphenhydramine Iwọn Iwọn giga (“Ipenija Benadryl”) apọju.