material used during final exam preparation hope benefit for all *at own risk

1. Case 2.
A 38-year-old farm worker presents to your ED with hypersalivation, urinary
incontinence, diarrhea, and muscle weakness after being in a recently “sprayed
field”.
He has prominent wheezing and is producing copious amounts of clear sputum.
History Taking Points
Kathirasan, 38y, married, farmer, came to ED with the chief complaint of body
weakness 5 hours prior to admission
- Hx of exposure to insect spray 7 hours prior to admission
Through inhalation route
Ask for type of aerosol spray
- Body weakness
Sudden onset
Gradually progressive
Affecting both upper limbs
Movement restricted
Associated with shortness of breath, muscle cramping
- Diarrhea
2 episodes within 5 hours
Sudden onset
Watery consistency
No foul smelling
No blood
Associated with nausea, vomiting and abdominal pain
- Urinary incontinence
3 episodes within 5 hours
- Hypersalivation
Drooling of saliva
Associated with productive cough
Clear sputum
Otherwise, no syncopal attack, no chest pain, no fitting episode, no drowsy, no fall,
no injury to head, no unilateral weakness, no numbness, no headache, no blurring of
vision, no photophobia, no neck stiffness, no slurring of speech, no aura preceding
the event
- No hx of allergy
- No hx of medications taken
- No known medical illness
- No hx of surgical
- Last meal was 7 hours prior to admission
Physical Examination
On examination, the patient, who was a well-built man, was conscious but not
oriented.

2. - Oxygen saturation was 98%.
- His pulse was regular at 78 beats/min and his blood pressure was 139/88 mmHg.
- Neurological examination was unremarkable.
Investigations
Laboratory results showed a leucocytosis of 15.3x10(9)/L (range from 4.3 to
9.8x10(3)/L).
Liver function and kidney function tests were normal.
Arterial blood gas analysis showed metabolic acidosis with pH 7.31, pCO2 of 31
mmHg, pO2 of 96 mmHg and bicarbonate of 16 mmol/L.
An urgent CT scan of the brain and paranasal sinuses was done immediately on
admission and was reported as normal.
The chest X-ray showed no abnormalities.
An electrocardiogram showed no conduction abnormalities.
Investigations Justification(rationale)
laboratorycholinesterase
assays
-usedtoassesspotential toxicity.
-redcell acetylcholinesterase enzymaticactivitywill be more
accurate indicatorforsynapticcholinesteraseinhibition
-butplasmabutyrylcholinesterase iseasiertoassayand more
available.
ECG commonabnormalities:correlate withdegreeof toxicityand
outcome.
-ventriculardysthymias
-torsade de points
-idioventricularrhythms
-atrioventricularblocks
- prolongationof the QTinterval (severityandmortality)
Provisional diagnosis: Organophosphate poisoning
Differential Diagnosis:
- Stroke
- Head injury
- Migraine
- Diabetic Ketoacidosis

3. - Hyperglycemic Hyperosmolar State
- Meningitis
- Encephalitis
- Alcohol poisoning
Management
Managementin ED
Airway ● Secure the airwaythroughendotracheal intubation
Breathing ● 100 % Oxygensupplementation
Circulation ● EstablishanIV line (2 large bore cannulas) withbaseline blood
samplingthatcan include determinationof cholinesterase
levels
Monitorvital signs ● BP, RR,PR, Temperature,SPO2
Decontamination ● Protective clothingmustbe wornto preventsecondary
poisoningof healthcare workers
● Handle & dispose all clothesashazardouswaste
● Wash patientwithsoapandwater
● Handle anddispose of waterrunoff ashazardouswaste
Antidote ● Initial bolus:1.2-3.0mg IV
● Double the dose every5minute toachieve adequate
atropinization(evidencedbyclearchestonauscultation,HR
>80 bpm, SBP> 80 mmHg)
● Follow withcontinuousinfusion(10-20% perhourof initial
dose of Atropine)-Infusionrate varyfrom0.4-4mg/hour IV
● Adjustinfusionrate tomaintainadequateatropinization&
avoidAtropine toxicity(absentbowelsound,hyperthermia,
delirium)
● StopAtrophine if dryingupmucousmembrane (bronchorrhea)
Pralidoxime ● Activate the cholinesterase
● Give ASAP(mayevenbeengiven24-48 hoursafter exposure)
● Dose:30 mg/kgIV mixedwithNS,infusedover5-10minutes
● Followedbycontinuousinfusion:8mg/kg/hrfor24-48 hours
BenzodiazepinesIV ● If patienthas seizure
2. True or false.
A. Garlic like odor may assist in diagnosis. (T)
B. Succinylcholine should be used when neuromuscular blockade is needed. (F)

4. C. Tachycardia and pupil dilatation are end point for atropine therapy.(F)
D. Atropine can reverse the muscle weakness.(T)
E. Atropine is one of therapeutic agents for seizures. (F)
3: Regarding organophosphate poisoning:
a. Salivation is sign of muscarinic effect (T)
b. Occur through inhalation (T)
c. Gastric lavage for organophosphate ingestion(F)
d. History of exposure is needed to make a
diagnosis(T)
e. Atropine is the drug of choice(T)
4. Regarding carbamates:
a. Transiently inhibit the cholinesterase enzyme (T)
b. Muscle weakness is the clinical feature for
carbamates poisoning (T)
c. Activated charcoal is the treatment for carbamates
Ingestion (T)
d. Adrenaline is the drug of choice (F)
e. Personal protective equipments to prevent from exposure (T)