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. Other symptoms include increased sweating, salivation, bronchial secretions along with miosis (constricted pupils).^{[ citation needed ]}

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 ^[2]
• Miosis ^[3] 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)

Causes

Cholinergic crisis, sometimes known by the mnemonic "SLUDGE syndrome" (salivation, lacrimation, urination, defecation, gastrointestinal distress, and emesis), ^[4] 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, aldicarb)
  • nicotine poisoning can be thought of as a subset of cholinergic crisis, as it also involves excessive parasympathetic stimulation. ^[5]
• Ingestion of certain poisonous fungi (particularly the muscarine-containing members of the genera Inocybe and Clitocybe ).
• In medicine, this is seen in patients with myasthenia gravis who take too high a dose of medications such as cholinesterase inhibitors, or seen following general anaesthesia, when too high a dose of a cholinesterase inhibitor drug is given to reverse surgical muscle paralysis.

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]

The neuromuscular junction, where the brain communicates with muscles (like the diaphragm, the main breathing muscle), works by acetylcholine activating nicotinic acetylcholine receptors and leading to muscle contraction. Atropine only blocks muscarinic acetylcholine receptors (a different receptor class than the nicotinic receptors at the neuromuscular junction), so it will not improve the muscle strength and ability to breathe in someone with cholinergic crisis. Such a patient will require neuromuscular-blocking drugs and mechanical ventilation until the crisis resolves on its own.^{[ citation needed ]}

See also

• Physostigmine
• Edrophonium

References

1. Asensio JA, Trunkey DD (Apr 20, 2015). Current Therapy of Trauma and Surgical Critical Care E-Book. Elsevier Health Sciences. p. 31. ISBN   9780323079808 . Retrieved 2 October 2017.
2. Burchum J (2014-12-02). Lehne's Pharmacology for Nursing Care. Elsevier Health Sciences. ISBN   9780323340267.
3. Reddy DS, Colman E (May 2017). "A Comparative Toxidrome Analysis of Human Organophosphate and Nerve Agent Poisonings Using Social Media". Clinical and Translational Science. 10 (3): 225–230. doi:10.1111/cts.12435. PMC   5421825 . PMID   28238224.
4. Wagner MJ, Promes SB (1 January 2007). Last Minute Emergency Medicine : A Concise Review for the Specialty Boards. McGraw Hill Professional. p. 12. ISBN   978-0-07-150975-6.
5. Schep LJ, Slaughter RJ, Beasley DM (September 2009). "Nicotinic plant poisoning". Clinical Toxicology. 47 (8): 771–81. doi:10.1080/15563650903252186. PMID   19778187. S2CID   28312730.
6. Lott, Erica L.; Jones, Elizabeth B. (2024), "Cholinergic Toxicity", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID   30969605 , retrieved 2024-02-01