Patients with acute poisoning present with classical symptoms of cholinergic excess. Two acronyms are used as mnemonic devices to aid in memorization of symptoms:

1. DUMBELS: diarrhea, urination, miosis, bronchospasm, emesis, lacrima-tion, and salivation

2. SLUDGE: salivation, lacrimation, urination, diarrhea, gastrointestinal distress, and emesis

Both mnemonics emphasize the muscarinic side of the cholinergic crisis, while no acronym has been suggested for the nicotinic side, often manifesting as fas-ciculations, muscle weakness, hypertension, and tachycardia. Additional mus-carinic effects include reduction of sinus node and atrioventricular conduction, causing bradyarrhythmias or resultant ventricular dysrhythmias (56).

Organophosphate poisoning should be suspected in any agricultural workers who present with constricted pupils, especially if they also exhibit restlessness, emotional lability, or confusion. Other warning signs include slurred speech, ataxia, tremor, muscle weakness with cramping, fasciculations, and, less commonly, seizures. In these cases a rapid and reliable measurement of red blood cell esterase activity may be both of confirmatory diagnostic and of significant prognostic value (see Chapter 9) (56).

Emergency physicians have agreed on the classification of the degree of severity of poisoning based on easily measured red blood cell cholinesterase (see Chapter 9 for a discussion of baselines):

1. Mild poisoning: loss of 20% to 50% of baseline activity

2. Moderate poisoning: observed activity of only 10% to 20% of the expected baseline (80% to 90% loss of activity)

3. Severe poisoning: patients with less than 10% of esterase activity (or more than 90% loss) (56)

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