A 32-year-old male was brought to the emergency room unconscious after allegedly consuming an unknown quantity of an insecticide containing chlorpyrifos and cypermethrin. Upon examination, he was intubated and found to have normal vital signs and lung function. Over the next few weeks, he was treated with atropine, activated charcoal, PAM infusion, and antibiotics while remaining intubated and experiencing seizures, fever spikes, and fluctuations in consciousness. He was eventually successfully extubated and discharged on day 17 after receiving intensive care.

1. CASE PRESENTATION
MODERATOR-DR.PALEPU GOPAL
SPEAKER – DR.GANGA BHAVANI

2. CHIEF COMPLAINT
• A 32year old male patient arrived to the ER on 4/6/22 at 11am with
alleged history of consumption of op poisoning [Chlorpyrifos (50%),
Cypermethrin (5%)].

3. History of present illness
• On 4/6/22 at 10.30 am he was found to be in unresponsive state at
his residence, noticed by his colleagues.They found an empty poison
bottle(brand- Chandrika 505) beside the patient.Exact time of
consumption and quantity of intake is unknown.They immediately
brought the patient to the hospital.

4. Past history - Nil
 Family history – Insignificant
Personal history – Nil
Allergic history - Nil

5. ON EXAMINATION- DAY1 IN ICU
 AIRWAY – Intubated with 8.5 sized ETT, fixed at 22cm
 BREATHING – Mechanically ventilated with VCV - 40/6/18/450
RR- 18,Equal rise of hemithorax
Oxygenation – P/f ratio – 480 according to ABG
Minimal secretions
USG of lungs – No abnormality noted
CIRCULATION – HR-105 ,BP- 120/70mmHg
Warm peripheries
On Atropine @ 2mg/hr

6. DISABILITY – Mechanically ventilated
EXPOSURE – PUNGENT SMELL NOTICED
GENERAL EXAMINATION – No pallor,icterus,clubbing,cyanosis,lymphadenopathy,edema
HR-105/min , BP- 120/70mmhg,
RESPIRATORY SYSTEM -
Inspection - Chest is symmetrical, Trachea central in position,
RR- 18,Equal rise of hemithorax
Palpation - All inspectory findings are confirmed.
Percussion - Resonant sounds are heard
Auscultation - Bilateral breath sounds heard.No abnormal sounds heard.
 ABDOMINAL – Soft
No organomegaly
BS – present

7.  CARDIOVASCULAR SYSTEM - S1S2 heard, No murmurs heard
 Neurological system – GCS- E3VTM6
Pupils- B/L 4mm, Reacting to light
Power – 5/5 in all limbs

8. • At ER – a)Body wash and gastric lavage were given
b) White colored pungent smelling fluid was aspirated from
ryles tube
c) Activated charcoal of 50g was given through Ryles Tube.
d) Inj. Atropine 1mg/iv – 5 doses were given with every 5min
interval. After atropinization 2mg/hr infusion started.
Serum cholinesterase levels sent - 242

9. DRUG METHOF ADMINISTRATION DOSE AND FREQUENCY DURATION
ATROPINE INFUSION 0.8mg – 2mg/hr ( Adjusted
based on signs of
atropinisation )
Day 1- Day 6 (got
extubated )
Day 6 - Day 9
ATROPINE BOLUS DOSES 2mg 4th hourly
2mg 6th hourly
Day 6 – 10am and 2pm
Day 10 - Day 11
Day 12 – Day 13
GLYCOPYRROLATE BOLUS DOSES 1mg 6th hourly Day 14- Day 15
PAM INFUSION 500mg per hour (20ml/hr) Day 2 – Day 5

10. He was tolerating PSV mode
• On Day 5(8/6/22)
His GCS dropped to E3VTM5
Neurology consultation taken
EEG was normal
• On Day 6 (9/6/22)
Extubated at 2pm and got reintubated on same day at 6pm.
• On Day 10(13/6/22)
Bedside percutaneous tracheostomy done

11. • On Day 11 (14/6/22)
Non convulsive seizures precipitated.
EEG and NCS were done.
• On Day 12 (15/6/22)
Weaning trials inititated.
• On Day 13 (16/6/22)
He developed extrapyramidal symptoms
MRI brain done- Normal
He developed fever spikes
Blood and tracheal cultures sent and antibiotics escalated to Meropenem

12. • On Day 16 (19/6/22)
He continued to have fever spikes
Cultures revealed no growth
Antibiotics escalated to Ceftazidime and Aztreonam
• On Day 17 (20/6/22)
He got discharged

13. THANK YOU