Transcript 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
• Pt was working on his family farm without event
on the day of admission
Details
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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 40s60s 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
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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:
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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
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Salivation
Lacrimation
Urination
Defacation
Gastric Emesis
Bronchorrhea
Bronchospasm
Bradycardia
Clinical Manifestations:
Day 2-5
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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