Cholinergic Crisis and Nerve Agents
Objective: Recognize a cholinergic toxidrome. Scene safety and decontamination come first. Give antidotes only from the issued kit. Do not scale a routine bradycardia atropine dose.
Why this matters
Organophosphate pesticides and nerve agents both raise acetylcholine. Patients are wet from secretions: saliva, tears, vomit, urine, and fluid in the lungs. Pupils are small. The heart is often slow. Muscles fasciculate, then weaken. Seizures can follow.
The same picture can be a farm exposure or a deliberate release. Either way, a contaminated rescuer becomes the next patient. Scene safety and decontamination come first. Antidotes come only from the issued kit. They are not a bradycardia atropine dose you multiply in your head. This page does not list milligrams.
- Scene safety and decontamination before close contact. Do not ventilate mouth-to-mouth.
- Small pupils, secretions, wet lungs, bradycardia, weakness, and seizures are the cholinergic picture.
- Atropine and pralidoxime only from the kit you were issued, on the incident or protocol instruction. Do not scale a routine bradycardia atropine dose. No milligrams on this page.
- This is a wet, bradycardic, small-pupil patient. I want decon before they enter a clean ambulance.
- I am not using my bradycardia atropine dose as a nerve-agent dose.
- Airway with a bag and suction, once I am protected.
Clinical sequence
- Stop at the edge of the scene. If multiple patients are seizing or gasping and an odor or a spray was reported, this may be a hazardous-materials event. Follow the incident plan.
- Once the patient is decontaminated by the method your service uses, support the airway. Suction secretions. Bag with oxygen. These lungs are full of fluid from secretions, not from heart failure.
- Monitor the heart. Bradycardia is common. Do not reach for the ordinary bradycardia atropine syringe and invent a larger dose.
- If you carry issued autoinjectors, including a DuoDote-type kit, use them only under the protocol or the incident commander’s medical plan. How many kits to use is a local decision based on secretions and breathing. This page does not store that number.
- Seizures get the benzodiazepine your protocol names, in the route you can actually give. Tell the hospital this was a cholinergic exposure so they do not give succinylcholine casually. You do not need to give that warning as a drug order. You need to say the exposure.
Teaching points
- SLUDGE and DUMBBELS are memory lists for secretions. The dangerous features are bradycardia, bronchorrhea, and bronchospasm. The patient in front of you matters more than completing the acronym.
- Mild exposure can be isolated tearing. Severe exposure cannot breathe. Do not wait for every letter of the acronym to support the airway.
- Pair this with overdose toxidromes so you do not call a cholinergic patient an opioid patient only because the pupils are small. Opioid patients are usually not drenched in secretions with muscle fasciculations.
Common errors
- Entering a sprayed area in a duty uniform.
- Bagging without suction while the airway fills.
- Scaling a routine bradycardia atropine dose without the issued kit or the protocol.
Practice
One-minute check
Three farm workers are vomiting, wheezing, and bradycardic after spraying. Say where you stage, what you suction, and which atropine you will not use.
Sources & Further Study
Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.
- HHS CHEMM — nerve agent hospital management — cholinergic signs and the role of antidotes; field dosing stays on the authorized kit
- NASEMSO National Model EMS Clinical Guidelines (2022) — hazardous-materials and poisoning care are operational plans, not a dose table on this site
Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.
Check Your Understanding
Questions drawn only from this lesson. After you check, the key is highlighted. Education practice — not a certification exam.