Mild Nerve Agent Exposure: Recognizing the SLUDGE/Cholinergic Syndrome

Nerve agents (organophosphates: sarin, VX, soman; novichoks) inhibit acetylcholinesterase → acetylcholine excess at synapses. Mild exposure produces a recognizable cholinergic toxidrome.

Mild Exposure Symptoms (DUMBELS / SLUDGE)

• Diarrhea
• Urination
• Miosis (pinpoint pupils)
• Bronchorrhea / Bronchospasm
• Emesis (vomiting)
• Lacrimation
• Salivation / Sweating

Plus: rhinorrhea, headache, dizziness, nausea, blurred vision, eye pain, muscle fasciculations, weakness, anxiety.

Progression to Moderate/Severe

• Seizures, loss of consciousness, apnea, flaccid paralysis (nicotinic crisis).
• Death from respiratory failure.

Immediate Actions

1. Evacuate upwind/uphill.
2. Decontaminate: Remove clothing (cut off), flush skin/eyes with copious water/soap.
3. Medical antidotes (EMS/hospital):
   • Atropine (titrated to clear secretions/HR >80).
   • Oxime (pralidoxime/obidoxime) — reactivates AChE if given early.
   • Benzodiazepine (midazolam) for seizure prophylaxis.

Key Principle

Mild symptoms can rapidly progress. All suspected exposures require emergent medical evaluation, even if initially asymptomatic. Delayed toxicity (intermediate syndrome, OPIDN) can occur days-weeks later.