Clinic Hours

History: A 27 yr old female brought to ED with A/H/O ingestion of 50ml of Dichlorvos solution at her home 35 minutes ago. On arrival primary survey was

A – Airway compromised

B – Breathing Laboured, Spo2 – 37% on RA, B/L crepts +nt

C – BP – 166/78 mmhg P – 90 bpm

D – E1V2M2 Pupils – B/L constricted, RBS – 112 mg/dl

ABG done shows ph 6.98 pco2 23 pO2 68 hco3 13 Lac 17 AG 22. What’s the diagnosis and how will you manage this patient?

Answer: Dichlorvos is an organophosphate compound.

Look for signs & symptoms of OP poisoning & ask the attendants to bring the sample  :

• Muscarinic manifestations : DUMBELS – Diarrhoea; Urinary incontinence; Miosis; Bradycardia, Bronchorrhea and Bronchospasm; Emesis; Lacrimation, Low blood pressure; Salivation and Sweating. Others include abdominal cramps, hypertension, fascicu­lations, muscle weakness, confusion, coma, seizures.
• Nicotinic manifestations: Twitching, fasciculations, weakness, diminished respiratory effort, HTN & tachycardia.
• CNS manifestations: Anxiety, restlessness, tremors, convulsions, confusion, weakness and coma.

Diagnosis:

• Clinical diagnosis is based on the toxidrome
• History of exposure
• ABG, ECG (Prolong QT), CBC, LFT, KFT
• Cholinesterase assay if available

Rx plan: 

1. Evaluate ABCD.
2. Stable patient: Decontamination (Healthcare workers should wear PPE).
3. Unstable patient: Resuscitation first followed by decontamination. (Never use succinylcholine for intubation).
4. Gastric lavage within first 1hr of ingestion (Seal GL sample for MLC) with NS & activated charcoal is given orally at a dose of 1-2 g/kg body weight.
5. Inj. Atropine 1mg or 0.01 to 0.04 mg/kg IV. Double the dose every time and target end points is atropinisation (Clear chest on auscultation with no wheeze, HR>80, pupils no longer pinpoint, dry axilla & SBP >90 mmHg). Once atropinised set up an infusion of atropine at an hourly dose of 10-20% of the total dose of atropine given initially.
6. Inj. Pralidoxime (2-PAM) is a cholinesterase reactivator. It is effective for nicotinic as well as muscarinic features of toxicity. 30 mg/kg initially over 20 mins followed by a constant infusion at 9 mg/kg/ hour. It is usually continued for 12-24 hrs.

Complications: 

• Intermediate Syndrome – Syndrome of muscular paralysis occurs within 24-96 hours after ingestion of an organophosphate and following treat­ment of acute cholinergic syndrome. Muscle weakness affects predominantly neck flexors, proximal limb muscles, those supplied by cranial nerves & respiratory muscles.
• Organophosphate-lnduced Delayed Polyneuropathy (OPIDN) – Cramping muscle pain in the lower limbs, distal numbness and paraesthesia followed by progressive weakness, depres­sion of deep tendon reflexes in the lower limbs > the upper limbs.

Ddx :

• Carbamate toxicity
• Nicotine toxicity
• Methacholine toxicity
• Arecoline toxicity
• Bethanechol toxicity
• Pilocarpine toxicity
• Pyridostigmine toxicity
• Neostigmine toxicity
• Mushroom poisoning
• Poison hemlock

Clinical Rounds by ClinicHours

History: A 60 yr female with history of fall from 5 stairs at her residence. No history of LOC/ ENT bleed/ seizure/ vomiting/ FND. On examination B/L periorbital discoloration can be noted. What’s the likely diagnosis?

Answer: Raccoon eyes sign aka panda eyes is periorbital ecchymosis with sparing of the tarsal plate and is a physical examination finding indicative of a base of skull fracture of the anterior cranial fossa. It has positive predictive value of 85%. Also seen in metastatic neuroblastoma, Kaposi sarcoma, multiple myeloma, and amyloidosis.

Clinical Rounds by ClinicHours

History: A 35 yr old male working with germicides accidentally came in contact with hydrofluoric acid presented to ED with blue-gray appearance with surrounding erythema of skin with extreme pain. How will you manage this in your ED?

Answer:  Decontaminate the patient by removing contaminated clothing and do copious irrigation for 15-30 mins.

• Apply 2.5 % Calcium gluconate gel LA.
• Inj 10% Calcium gluconate ID at rate of 0.5mL/cm2 OR 40 ml D5 + 10 mL 10%  calcium gluconate infusion over 4 hrs.

Clinical Rounds by ClinicHours

History: A 55 yr old male presented to ED with severe left-sided chest pain from 20 minutes radiating to the left arm associated with SOB and diaphoresis. Bp – 140/82mmhg, P – 84 bpm, spo2 – 92% on RA. ECG done. What’s the diagnosis?

Answer: Posterior MI is suggested by the following changes in V1-3:

• Horizontal ST depression
• Tall, broad R waves (>30ms)
• Upright T waves
• Dominant R wave (R/S ratio > 1) in V2

Posterior infarction is confirmed by the presence of ST elevation and Q waves in the posterior leads (V7-9). Leads V7-9 are placed on the posterior chest wall in the following positions (see diagram below):

Source: LITFL

OR you can invert the ECG to see a typical STEMI. For example:

Source: LITFL

The above patient was taken for thrombolysis after stabilization. ECG after thrombolysis.

Clinical Rounds by ClinicHours

History: A 67-year-old male k/c/o CKD-5 on MHD thrice weekly with Type2DM & HTN presented to ED with SOB, anasarca and AMS. P – 164 bpm irregular, SP02- 80 % on RA, RR – 30, R/E – B/L AE ↓ with B/L crepitations +nt. E3V2M5. ABG – pH 7.17, pCO2 9.7, Na+ 135, k+ 4.5, Lac 10.7, Glu 141, HCO3- 3.6. ECG was done. What’s the diagnosis?

Answer: ECG shows irregularly irregular narrow complex tachycardia with absent P waves & ST ↓ V4-V6 which is s/o Atrial fibrillation.

Classification is dependent on the presentation and duration of atrial fibrillation as below:

First episode – initial detection of AF regardless of symptoms or duration
Recurrent AF – More than 2 episodes of AF
Paroxysmal AF – Self-terminating episode < 7 days
Persistent AF – Not self-terminating, duration > 7 days
Long-standing persistent AF – > 1 year
Permanent AF – Duration > 1 yr in which rhythm control interventions are not pursued or are unsuccessful.

How will you manage the above patient in the ED? Write down in the comment section. 

Clinical Rounds by ClinicHours