Competitively blocks muscarinic sites (does nothing for nicotinic-related muscle paralysis)
May require massive dosage (hundreds of milligrams)
Dosing
Adult: Initial bolus of 2-6mg IV; titrate by doubling dose q5-30m until tracheobronchial secretions controlled
Once secretions controlled → start IV gtt 0.02-0.08 mg/kg/hr
Child: 0.05-0.1mg/kg (at least 0.1mg) IV; repeat bolus q2-30m until tracheobronchial secretions controlled
Once secretions controlled → start IV gtt 0.025 mg/kg/hr
No max dose, doses >400mg have been reported
Once secretions controlled → start IV gtt 0.02-0.08 mg/kg/hr
Child: 0.05-0.1mg/kg (at least 0.1mg) IV; repeat bolus q2-30m until tracheobronchial secretions controlled
Once secretions controlled → start IV gtt 0.025 mg/kg/hr
AKA 2-PAM
For Organophosphate poisoning only - reactivates AChE by removing phosphate group → oxime-OP complex then excreted by kidneys.
This must be done before "aging" occurs - conformational change that makes OP bond to AChE irreversible
Pralidoxime can actually bind and inhibit AChE once all AChE enzymes have aged, and can make the toxicity worse
Window to aging depends on the agent, and is a matter of debate, but pralidoxime within 1-2 hours of exposure is the goal
Dosing
Adult: 1-2gm IV over 15-30min; repeat in 1 hour if needed or 50 mg/hr infusion.
Child: 20-40mg/kg IV over 20min; repeat in 1 hour if needed or 10-20 mg/kg/hr infusion.
This must be done before "aging" occurs - conformational change that makes OP bond to AChE irreversible
Pralidoxime can actually bind and inhibit AChE once all AChE enzymes have aged, and can make the toxicity worse
Window to aging depends on the agent, and is a matter of debate, but pralidoxime within 1-2 hours of exposure is the goal
Adult: 1-2gm IV over 15-30min; repeat in 1 hour if needed or 50 mg/hr infusion.
Child: 20-40mg/kg IV over 20min; repeat in 1 hour if needed or 10-20 mg/kg/hr infusion.
Electronic cigarettes
Anticholinergic Toxicity
Dirty bomb
Organophosphate Toxicity
Hazmat exposure
Sympathomimetic Toxicity
Caustic cocktail
Neuroleptic Malignant Syndrome 