2025 – PAGE 210 – EMERGENCY MEDICINE & TOXICOLOGY
CHOLINERGICS
Cholinergics include ORGANophosphates (pilocarpine and pesticide ingredients), neostigmine, and bethanaCHOL. Do not get cholinergics and anticholinergics confused! Symptoms of exposure include diarrhea, urination, miosis, bronchospasm, emesis, lacrimation, salivation, lethargy, wheezing, and bradycardia. Treat with ATROPINE or PRALIDOXIME. Use benzodiazepines for CNS symptoms. Without treatment, symptoms can persist for weeks.
MNEMONICS: “COLON”-ergic. A COLON is an ORGAN (ORGANophosphates). Now look at the DUMBELLS made out of COLON”-ergic ORGANs including a heart and a “CHOLIN” below to remind you of the major DUMBELLS symptoms associated with COLON-ergics: Diarrhea, Urination, Miosis, Bronchospasm, Emesis, Lacrimation, Lethargy, and Salivation.
ANTICHOLINERGICS
Use of anticholinergics may result in fever, blurred vision, DRY MOUTH/EYES, hyperthermia, psychosis, DECREASED BOWEL SOUNDS/MOTILITY, URINARY RETENTION, and tachycardia. These patients also have MYDRIASIS. Medications with anticholinergic effects include diphenhydramine, ATROPINE, pralidoxime, TRICYCLIC ACIDS (TCAs), and JIMSON WEED. Treat with CHARCOAL. For severe cases in which central signs, peripheral signs, and symptoms of anticholinergic poisoning are present, treat with physostigmine.
PEARL: Due to decreased bowel motility, it is OKAY to give charcoal even after 60 minutes for an anticholinergic ingestion! For other medications, though, 60 minutes is the limit.
MNEMONICS: HOT as a hare, BLIND as a bat, DRY as a bone, RED as a beet, MAD as a hatter while the BOWEL and BLADDER lose their tone, and the HEART runs alone. In AAA$, the third A is for Anticholinergics or Atropine. For Jimson WEED, imagine Harold and Kumar smoking “WEED” at a White Castle® that has plenty of food, but NO DRINKS (DRY mouth, slow passage of foods in the GI tract because the food is “dry”).
TRICYCLIC ANTIDEPRESSANT (TCA) TOXICITY
Tricyclic Antidepressant (TCA) toxicity can result in all of the anticholinergic symptoms. Distinguishing features include tachycardia, labile blood pressure, coma, seizures, ANION GAP ACIDOSIS, a wide QRS COMPLEX, QT prolongation, and possible ventricular fibrillation. Treat with sodium BICarbarbonate. If the patient presents within one hour of ingestion, you may also try charcoal.
MNEMONICS: Treatment is sodium BICarbonate ≈ BIC ≈ BIKE ≈ bicycle, like a tricycle and triCYCLic acids. Or, imagine a depressed patient who is on a TCA. In order to lift his spirits, you play some loud music with some heavy BASE (bicarb).
MNEMONICS: “tri-C-A” = Cardiac abnormalities (HR, BP) and arrhythmias, Complex long, Convulsions, and Acidosis (or Arrhythmias).
SALICYLATES
ASPIRIN (ASA) and OIL OF WINTERGREEN are considered salicylates. Patients’ initial tachypnea is a response to a PRIMARY ANION GAP METABOLIC ACIDOSIS (“mudpileS”). After that, patients develop a PRIMARY RESPIRATORY ALKALOSIS. The major causes of death are cerebral edema, pulmonary edema, electrolyte disturbances, and eventual cardiovascular collapse. Salicylates also cause decreased gastric motility. A level >100 is bad. Measure the level at 2–6 hours. Treat with charcoal, hydration, bicarbonate to alkalinize the urine, and/or hemodialysis. Gastric decontamination is paramount!
PEARLS: Consider MULTIPLE doses of charcoal (even AFTER 60 minutes) because of the decreased GI motility.
MNEMONIC: Imagine mixing a purely white powder (ASA) with a purely black powder (charcoal) over and over again until you have a perfect gray color.