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Learning Station 4 Toxicologic Emergencies Extra Case

1999 American Heart Association

Extra-Credit Toxicology Case

Case 6 in the Toxicology Learning Station Stump-the-Stars for advanced learners who want extra cases Extra-extra-credit: If the victims name in Case 6 is Cary Grant, can you name the movie?

The following materials on Toxicology Case 6 were prepared by Sal Silvestri, MD, of Miami, FL. The AHA appreciates the numerous volunteers, like Dr. Silvestri, who give so generously of their time and expertise.

Toxicology Case 6

35-year-old farmer was working in his field when it was unexpectedly crop-dusted by a confused pilot 1 hour later: he complains of difficulty breathing ROS: GI: + N/V/D, abdominal cramps Skin: + profuse sweating Eye: + blurred vision CNS: + dizziness and restlessness GU: + incontinence

Toxicology Case 6
VS: T = 100.8F, BP = 90/50 mm Hg, HR = 42 bpm, RR = 36/min PE: physical exam reveals HEENT: profuse diaphoresis, BL constricted pupils, visual acuity, copious tearing Lungs: diffuse BL rales, rhonchi, and wheezes ABD: hyperactive bowel sounds.

Describe your approach to this patient


Initial Approach
Primary ABCD Survey Not in cardiac arrest Airway clear, labored respirations Pulse present, slow, and weak Secondary ABCD Survey A and B: intubation not indicated C: oxygenIVmonitor fluids D: differential diagnosis?

What is your differential diagnosis?


Differential Diagnosis
Partial airway obstruction? Heat emergency? Acute coronary syndrome? Respiratory problem with hypoxia? Poisoning?

What are we dealing with?


Differential Diagnosis
Organophosphates (parathion, malathion) Anticholinesterases ( acetylcholine) Amanita mushrooms Betel nut Bethenecol Carbamates Pilocarpine Define the toxidrome!

A Nerve Agent at Work

Organophosphates Common insecticides: malathion, diazinon, chlorpyrifos History of use in terrorist attacks The Tokyo sarin vapor attack in tunnel Readily available Cheap

Mechanism of Action

Organophosphates and nerve agents inhibit acetylcholinesterase This allows acetylcholine to accumulate Acetylcholine produces hyperstimulation of cholinergic nervous system Muscarinic stimulation: smooth muscles contract (eg, airway constriction); glands produce mega-secretions Nicotinic stimulation: skeletal muscles contract (twitching)

Cholinergic Toxidrome SLUDGE

Salivation Lacrimation Urination Defecation Gastrointestinal (nausea, cramps) Emesis

Look for pinpoint pupils!


Cholinergic Toxidrome
Muscarinic Effects General: sweating Eye: lacrimation, pupils constricted, blurred vision Pulmonary: wheezing, rales, bronchorrhea GI: salivation, n/v/d, cramps, tenesmus CV: bradycardia, hypotension GU: urinary incontinence Nicotinic Effects Muscle: fasciculations, cramps, weakness, twitching Sympathetic ganglia: tachycardia, hypertension CNS: anxiety, restlessness, confusion, ataxia, coma, seizures, insomnia

What is the toxin-specific therapy?


Case Progression

Patient becomes flaccid Patient cannot speak Patient begins to have a seizure

How do you treat nerve-agent emergencies?


Treatment Considerations

Scene safety (prevent cross-contamination) Removal of agent (decontamination) Wet Strip Rinse Dry Cover


Drug Therapy 1

Atropine (dry them up) Antagonizes muscarinic effects Dries secretions and relaxes smooth muscle Dose: 2 mg IV, IM, or ET q 5 min
Patients who have significant insecticide exposure may require huge amounts of drug (2000 to 3000 mg)

Do not rely on heart rate or size of pupil Give until secretions start drying up May cause arrhythmias if patient is hypoxic

Drug Therapy 2

Pralidoxime chloride (2-PAMCL) Helps at nicotinic sites Will not reverse muscarinic effects Removes nerve agent from AChE Dose: 600 mg IV IM For severe exposure 1 g infusion per hour Second component of military Mark 1 kit If hypertension develops, phentolamine 5 mg IV

Drug Therapy 3

Diazepam 5 to 10 mg IV Use prophylactically to prevent seizures Use to decrease seizure activity Confirm that the patient is seizing and not having muscle twitching


Organophosphate Poisoning
Summary Treatment Atropine: 1 to 2 mg, IV push prn Pralidoxime (2-PAMCL) 600 mg IV IM Diazepam 5 to 10 mg IV


Case Progression
Assume multiple people exposed One patient presents with only minor signs and symptoms During transport he becomes progressively worse

What is going on?


Case Progression

Nerve agent remains on clothes More agent absorbed harder to manage Creates major cross-contamination problem Proper field decontamination neglected Patients should get better, not worse!


Cholinergic Toxicity Essentials

Remember SLUDGE mnemonic Respiratory signs: most significant Are noncardiogenic in etiology End point of atropine administration the drying of secretions Pralidoxime is necessary in addition to atropine


KEY: early recognition of signs and symptoms Consult clinical toxicologists Know local resources for these emergencies Treat aggressively with drug therapy Protect yourself and others from contamination