TABLE 5.2 Acute Cholinergic Syndrome

Site of Action

Signs and Symptoms



Miosis, marked, usually maximal (pinpoint), sometimes unequal

Ciliary body

Frontal headache, eye pain on focusing, blurring of vision

Nasal mucous membranes

Rhinorrhea, hyperemia

Bronchial tree

Chest tightness, prolonged wheezing, dyspnea, chest pain, increased bronchial secretion, cough, cyanosis, pulmonary edema


Anorexia, nausea, vomiting, abdominal cramps, epigastric and substernal tightness with heartburn and eructation, diarrhea, tenesmus, involuntary defecation

Sweat glands

Increased sweating

Salivary glands

Increased salivation

Lacrimal glands

Increased lacrimation




Frequency, involuntary micturition


Striated muscle

Easy fatigue, mild weakness, muscular twitching, fasciculations, cramps, generalized weakness or flaccid paralysis (including muscles of respiration), with dyspnea and cyanosis

Sympathetic ganglia

Pallor, transitory elevation of blood pressure followed by hypotension

Central nervous system


Immediate (acute) effects: generalized weakness, depression of respiratory and circulatory centers with dyspnea, cyanosis, and hypotension; convulsions, loss of consciousness, and coma


Delayed (chronic) effects: giddiness, tension, anxiety, jitteriness, restlessness, emotional lability, excessive dreaming, insomnia, nightmares, headaches, tremor, withdrawal and depression, bursts of slow waves of elevated voltage on electrogram, drowsiness, difficulty concentrating, slowness of recall, confusion, slurred speech, ataxia


SOURCE: Gunderson et al., 1992.

occurred when the acute cholinergic effect is limited to miosis (contraction of the pupil), rhinorrhea (an extreme type of runny nose), and depressed cholinesterase levels in the blood. Finally, low-level exposure may have occurred even though there are no immediately detectable cholinergic signs and symptoms (Brown and Brix, 1998). The health effects of low levels of sarin exposure are of

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