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HYC Case Presentation

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

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HYC Case Presentation

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  1. HYC Case Presentation Lance N. Okeke, MD October 15, 2009

  2. 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

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

  4. 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

  5. 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

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. Clinical Manifestations: First 24 Hours • Salivation • Lacrimation • Urination • Defacation • Gastric Emesis • Bronchorrhea • Bronchospasm • Bradycardia

  15. Clinical Manifestations: Day 2-5 • Neck weakness • Proximal muscle weakness • Cranial nerve abnormalities • Respiratory insufficiency

  16. 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

  17. 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

  18. 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

  19. 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

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