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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

14. 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

15. 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

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

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

18. 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

20. 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

21. 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

22. 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