![]() Increased acetylcholine at nicotinic sites at the neuromuscular junction causes muscle fasciculations and flaccid paralysis due to excess acetylcholine at the neuromuscular junction. Activation of muscarinic receptors in the eye by excess acetylcholine will produce miosis and blurry vision. Acetylcholine accumulation at muscarinic receptors produces an increase in secretions which can manifest as bronchorrhea, salivation, tearing and sweating, bronchoconstriction, tightness in the chest, wheezing, bradycardia, vomiting, increased gastrointestinal motility, abdominal tightness, diarrhea, and cramps. ![]() Physical exam findings depend on which receptors experience accumulation of acetylcholine. Nerve agents have been used in subways by terrorist groups and by dictators to suppress communities within countries as well. Sarin is a well-known chemical warfare agent that continues to be a threat worldwide. Accidental exposure accounted for the other 10% with homicidal use less than 1%. More than 90% of the non-occupational incidents were intentional with a fatality rate exceeding 10%. Poisoning due to occupational exposure only accounted for one-fifth of the incidental contact, with a fatality rate of less than 1%. The American Association of Poison Control Centers reported 86914 human exposures to pesticides in the United States in 1996 alone. One million of these exposures were found to be unintentional, while the other 2 million exposures were secondary to suicidal attempts. There are about 3000000 exposures to organophosphates or carbamates worldwide each year with approximately 200000 fatalities as a result of exposure. Organophosphates have been used worldwide for over 50 years as insecticides, though usage has decreased in the past 10 to 20 years. These drugs may cause weakness, but a cholinergic crisis is very rare with drugs taken at therapeutic doses. ![]() Essentially, any agent that creates an abundance of acetylcholine at the synapse may cause cholinergic toxicity. These drugs include drugs used to treat myasthenia gravis such as edrophonium and neostigmine, pilocarpine used for glaucoma, and Alzheimer drugs such as rivastigmine and donepezil. It is well known for being involved in terrorist attacks in Japan in 19.Ĭholinergic drugs may cause a cholinergic crisis during clinical use or after an overdose. Sarin gas was made originally in Germany in 1938 as a pesticide. Sarin gas is a nerve gas typically seen in chemical warfare. Exposure to these insecticides may be through inhalation of vapors, ingestion, or direct contact of the chemical with the skin or mucous membrane. The most common cause of cholinergic toxicity worldwide is exposure to organophosphate and carbamate insecticides. Cholinergic toxicity may result from insecticides, nerve agents, medications, and mushrooms. ![]()
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