HYC Case Presentation

Lance N. Okeke, MD October 15, 2009

Case

• Pt is a 25 y.o M with no past medical history found unconscious by his brother at 6 pm the day of admission

• Brother claims that the patient had no symptoms preceding this event

• Pt was working on his family farm without event on the day of admission

Details

• The patient has no known past medical history • He takes no medications • He has no known drug allergies • Family history is non-contributory

Social History

• Pt has a history of alcohol abuse and dependency • He currently drinks 8-10 beers a day and a couple of

cups of the local brew, changaa• Changaa is an illegal alcoholic brew made of fermented

maize or sorghum, often contaminated with methanol • He is single, sexually active• HIV status is unknown • He works on his family farm in Marakwet District, Rift

Valley Province, Kenya

Context

• 8pm: Pt presented to casualty ward obtunded • 10pm: Pt transferred to medicine ward still

obtunded breathing 4-6 times a minute and bradycardic. He gets atropine with HRs in 40s-60s through the night

• 9am: Pt goes into cardiac arrest and is identified by sister team. CPR is commenced immediately

Physical Examination

• Pt is obtunded, with intermittent periods of emesis • Vital signs (after pulse recovered): BP 90/50 HR 34 RR 0-4 Temp unknown O2 sat 92%• HEENT

– Pupils were constricted and sluggishly reactive to light – Buccal mucosa was moist– CN could not be assessed – No evidence of trauma on the head – Poor dentition

Physical Examination

• Lungs: – Few spontaneous breath sounds – Rhonchi heard in all lung fields – No dullness to percussion – No wheezes heard

• Heart:– HR of 20s to 40s when recovered – Regular rhythm– No murmurs auscultated, no friction rub, PMI not determined

Physical Examination

• Abdomen: – Soft, non tender, nondistended– No organomegaly – Normal active bowel sounds

• Extremities– Cool to touch but not cyanotic – Weak femoral pulse– No edema

• Skin– No suspicious skin lesions – Grooming was poor

Labs

• Chemistries– Na 137, K 3.9, Cl 109, Cr 0.8, Glucose 34mg/dL

• CBC– WBC 1.8– Hgb 16.5 Hct 52.8 – Plts 244K

• HIV Rapid Test negative • ABG not available

Events

• 9am: CPR commenced, pt was ventilated with bag mask • He continued to be regain pulse intermittently in 40s • Received 2mg of atropine q15 mins, 1 amp of D50 for

hypoglycemia, multiple doses of bicarb to reverse acidosis • Rounds of CPR and bag mask duty rotated amongst 6 medical

students • 11am: pulse regained permanently. Minimal spontaneous breathing • Pt’s had recurrent “mothball”-odored emesis throughout

rescucitation effort• 1:30pm: manual ventilation stopped, pt with 4-6 spontaneous

breaths a minute

Organophosphates

• Organophosphates are a group of agents composed of carbon and phosphoric acid derivatives

• They are the main component of many agricultural and domestic pesticides

• Have been used in the past as an agent of bioterrorism (Tokyo subway, 1995)

• Common members of this group include sarin (“Nerve Gas”), malathion and parathion

Organophosphate: Mechanism of Action

• Bind to acetylcholinesterase, the enzyme that breaks down acetylcholine

• Leads to excess acetylcholine in the synapse• The result is excessive parasympathetic drive

Organophosphate Poisoning

• 3 million cases a year with 300,000 fatalities • Mostly seen in agricultural areas due to

availability of pesticide • Agents can be absorbed through skin, lungs and

gastrointestinal tract

Toxicol Rev 2003;22(3):165-90

Clinical Manifestations: First 24 Hours

• Salivation • Lacrimation • Urination • Defacation • Gastric Emesis• Bronchorrhea• Bronchospasm• Bradycardia

Clinical Manifestations: Day 2-5

• Neck weakness• Proximal muscle weakness• Cranial nerve abnormalities • Respiratory insufficiency

Management

• ABC’s• Atropine 2mg THEN double dose every 5

minutes until tachycardia or pupillary dilation• Pralidoxime 30mg/kg over 30 minutes THEN

8mg/kg/hr infusion • Benzodiazepine for day 2-5 prn

Conclusion

• Pt’s brother states that he saw a half-empty bottle of “COWDIP” (malathion) next to the patient’s unconcious body

• He suspects that he may have mistaken this for some for of ethanol

Conclusion

• Pt commenced regular spontaneous breath 20 hours after admission

• On HD 2, pt regained consciousness although he was delirious

• On HD 4, pt was able to communicate reliably • Pt was seen by psych consult service on HD 7• Pt was medically discharged on hospital day 10

References

• Eddleston M; Phillips “Self poisoning with pesticides” MR BMJ 2004 Jan 3;328(7430):42-4

• Khurana D; Prabhakar S “Organophosphorus intoxication” Arch Neurol 2000 Apr;57(4):600-2