Review Question - QID 105622

Action	Numeric Key	Letter Key	Function Key
Choose 1	1
Choose 2	2
Choose 3	3
Choose 4	4
Choose 5	5
Submit Response			Enter
Previous Question			Left Arrow
Next Question		N	Right Arrow
Open/Close Bookmode		C
Open Image			Spacebar

Toxicology Toxicology Drug Introduction QID: 105622 (M2.PH.14.12)

QID 105622 (Type "105622" in App Search)

A 37-year-old farmer presents to the emergency department with acute onset of complaints of diarrhea, excessive tearing, and increased saliva production. He is concerned that he is dehydrated, as he has also been urinating with increased frequency over the past several hours. His temperature is 97.6°F (36.4°C), blood pressure is 111/64 mmHg, pulse is 60/min, respirations are 10/min, and oxygen saturation is 98% on room air. Physical exam is significant for a moderately agitated and diaphoretic man who demonstrates pinpoint pupils. Which of the following is the most appropriate next step in management?

Type & Select Correct Answer

Type in at least one full word to see suggestions list

Atropine

38%

6/16

Diphenhydramine

1/16

Naloxone

12%

2/16

Physostigmine

0/16

Transcutaneous pacing

38%

6/16

Select Answer to see Preferred Response

Review TC In New Tab

This patient is presenting with diarrhea, urinary incontinence, excessive tearing, and increased salivation which is concerning for a cholinergic toxidrome which is most likely a result of organophosphate poisoning. Treatment includes administration of atropine.

Organophosphates are acetylcholinesterase inhibitors which lead to decreased breakdown of acetylcholine (resulting in increased levels of acetylcholine). Excess acetylcholine is characterized by symptoms of diarrhea, urination, miosis, bronchospasm, bradycardia, emesis, lacrimation, lethargy, and salivation (DUMBBELLS is a common mnemonic). Atropine is the treatment of choice due to its anticholinergic activity that blocks the peripheral action of excess acetylcholine. It should be administered until respiratory symptoms (bronchorrhea and increased respiratory secretions) resolve. Additionally, pralidoxime or 2-PAM is also given to reactivate acetycholinesterase.

Incorrect Answers:
Answer 2: Diphenhydramine is an antihistamine with anticholinergic properties which in overdose, can cause an anticholinergic toxidrome (hot/dry skin, confusion, urinary retention, and constipation). Despite its anticholinergic properties, it is not the antidote of choice for a cholinergic toxidrome.

Answer 3: Naloxone is an opioid receptor antagonist and would be given in opioid overdose which presents with miosis, decreased bowel sounds, and bradypnea.

Answer 4: Physostigmine is an acetylcholinesterase inhibitor. It is commonly used as a treatment for myasthenia gravis to increase cholinergic transmission. Administration of this agent would exacerbate the patient's symptoms and further increase acetylcholine levels.

Answer 5: Transcutaneous pacing could be given in a patient with heart block who is bradycardic and/or not perfusing well. It is generally not indicated first line in the management of a cholinergic toxidrome and would not address the other symptoms this patient is having other than his bradycardia.

Bullet Summary:
Atropine is the treatment of choice for a cholinergic toxidrome.

Rating

Please Rate Question Quality

4.4

(15)