NEUROTOXICOLOGY CASES

KEVIN O'CONNELL MD

“Jesus”

35y/o male brought in by police, destroyed apartment, yelling that he was Jesus, agitated requiring multiple officers to bring him to ER in handcuffs

P=110, Temp=100F BP190/85 RR=20 No previous psych hx Ativan and Haldol for sedation

“Jesus”

Tox neg, ETOH neg, ASA and APAP neg EKG: sinus tach, nl intervals Eval by mental health Transfer to psych facility

Signout

“Walking Rounds”

“I saw that guy a few days ago and he was normal”

Given Hycodan for cough/bronchitis Cancel psych transfer – admit ICU

Hycodan

Hydrocodone and homatropine cough syrup

Anticholinergic med

ANTICHOLINERGIC TOXICITY

Inhibition of muscarinic cholinergic neurotransmission

“red as a beet, dry as a bone, blind as a bat, mad as a hatter, hot as a hare”

Tachycardia, hallucinations, delerium

Treatment

Benzodiazepines Supportive care Physostigmine

Case #2 “Agitated”

37 y/o female presents agitated, confused. Family denies any med or drug use. Sick for few days, decrease po intake, nausea.

Patient unable to answer any questions, trying to get off stretcher. Fluctuating level of consciousness, confused.

P=130's BP= 140/80 RR=24 T=37c

“Agitated”

Pupils 6-7 mm bilat Skin dry, flushed Delirium Icteric sclera

“Agitated”

EKG: sinus tach, nl intervals Tox: neg CBC nl, chem nl, creat=2.0 T Bili=5.6 AST=1450 ALT= 5000 APAP=108

Treatment

IV fluids, Ativan IV NAC VIT K (INR=2.3)

Physostigmine for delirium/agitation ICU (Transfer to Boston)

Other Anticholinergics

Military agents/Terrorist agents “Incapacitants” BZ – (3 Quinuclidinyl Benzilate) Agent 15

Jimson Weed

Anticholinergic Used by kids hallucinations agitation

Mushrooms

Muscaria

Case #3 “Too much body fluids”

45 y/o male drank bottle of insecticide as overdose attempt

Vomiting, sweaty, incontinent of urine and feces SOB Restless, anxious, tremulous BP=170/80 P=120 RR=28 T=37 Hazmat suits for decon

Organophosphates Overdose

SLUDGE: salivation, lacrimation, urination, defecation, GI distress, emesis

Don't forget bronchorrhea DUMBELS: diarrhea, urination, miosis,

bronchorrhea, emesis, lacrimation, salivation Inhibits AchE Carbamates, V and G nerve gases similar

Mad as a Hatter

Where is this from Also found in Minamata Bay

Mercury Poisoning

Central and peripheral symptoms Organic/elemental/ organic mercury Infants and children have worse effects Accumulation in fish