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Cholinergic crisis, organophosphate poisoning (mechanism of disease)

This is a flowchart on cholinergic crisis (including organophosphate poisoning), covering the etiology, pathophysiology, manifestations, and management. ADDITIONAL TAGS: Risk factors / SDOH Cell / tissue damage Nervous system path Cholinergic crisis Medicine / drugs Infectious / microbial Biochem / organic chem Immunology / inflammation Signs / symptoms Tests / imaging / labs Environment / toxins Genetics / hereditary Flow physiology Pathophysiology + Management Etiology Manifestations Irreversible inhibition of acetylcholinesterase ↑ acetylcholine levels Activation of acetylcholine receptors (muscarinic and nicotinic) → parasympathetic nervous system overactivation Exposure to organophosphate insecticides (parathion or E605) Farmer, field work Exposure to nerve agents (sarin, VX, Novichok agents) Excess dose of cholinesterase inhibitors Patient with myasthenia gravis (taking pyridostigmine) Following general anesthetic, to reverse neuromuscular blockade (with neostigmine) Military, war Garlic-like or petrol-like odor Odorless, tasteless Blue dye stains mucosa, saliva Poisonous fungi (containing muscarine: Inocybe and Clitocybe) Nicotine poisoning? DUMBBELLSS: Diarrhea Urination Miosis Bronchospasm Bradycardia Emesis (vomiting) Lacrimation Lethargy Sweating Salivation Fasciculations Weakness Spasms Paralysis Bronchorrhea Respiratory failure (greatest danger) Seizures +/- coma Hypotension Decontaminate patient (use PPE) Secure airway + oxygen Competitive agonist at muscarinic receptors Atropine Regen acetylcholinesterase by dephosphorylation Oximes: pralidoxime (2-PAM), obidoxime Benzodiazepines Wheezing