For Examiner Only
Case Organophosphate release
Author: Valerie Dobiesz, MD
Reviewer: Vivek Parwani, MD
Approved: 12/28/05
ORAL CASE SUMMARY
CONTENT AREA
Toxicology and Disaster Medicine
SYNOPSIS OF CASE
An unknown gas is released in the downtown rapid transit station. It is described as a thick mist,
and was found in 5 separate stops. Thousands of commuters rapidly fled the stations to the
streets. The patient presents with a severe cholinergic toxidrome
SYNOPSIS OF HISTORY
50 year old male found at the rapid transit station by paramedics in severe respiratory distress.
The paramedics have no past medical history at the scene and are handling multiple patients.
The patient was noted to have eye tearing, SOB with wheezing, vomiting and diarrhea.
SYNOPSIS OF PHYSICAL
Middle aged man in severe respiratory distress. He is bradycardic and tachypneic
Pt is vomiting and having diarrhea shortly after arrival. His pupils are miotic and tearing
He has copious secretions from mouth and bilateral wheezing
CRITICAL ACTIONS
1. Skin decontamination (PC)
2. Utilizes Appropriate Personal Protective Equipment
3. Recognition of cholinergic toxidrome (MK)
4. Airway control with intubation (PBL)
5. Antidote administered (atropine and pralidoxime) (SBP)
SCORING GUIDELINES
(Critical Action No.)
1. Score down if patient not decontaminated on arrival.
2. Score down if staff does not use PPE, score up is patient anticipates and wears PPE and has
patient decontaminated prior to entry into ED
3. Score down if cholinergic toxidrome not identified on history and physical exam
4. Score down if does not address airway on arrival
5. Score down if antidote not given, must give both atropine and pralidoxime, large amounts of
atropine will be required and titrated to bronchial secretions
FOR EXAMINER ONLY
For Examiner Only
PLAY OF CASE GUIDELINES
(Critical Action No.)
1. ACTION - paramedics call with disaster situation and exposure of patient to unknown gas
CONSEQUENCE - candidate should request decontamination on arrival to ED. Staff should wear
masks, gowns, and gloves (PPE). If not, staff begins to become symptomatic with eye tearing,
salivation, nausea, vomiting. If still no thought to decontamination a staff member may seize. A
nurse may prompt this by stating she is not caring for the patient until that gas is cleaned off the
patient.
2. ACTION – the candidate should quickly assess the need for definitive airway management
and intubate the patient without delay.
CONSEQUENCE -if not patient becomes apneic and cyanotic. Nurse may prompt candidate by
stating that the patient is getting weak and the pulse ox is now 82%
3. ACTION – candidate should recognize the cholinergic toxidrome on physical examination
CONSEQUENCE if not, nurse will ask what the doctor thinks may be going on and point out
features such as miosis, salivation, lacrimation, vomiting, diarrhea, bradycardia, etc. Nurse may
suggest calling the poison center.
4. ACTION – candidate should administer atropine and pralidoxime (2PAM)
CONSEQUENCE – if not, the patient will lose consciousness and seize. The nurse will ask if
there is an antidote that can be given for this unknown gas exposure
FOR EXAMINER ONLY
For Examiner Only
Critical Actions
1.
Skin decontamination (PC)
This critical action is met by Decontamination prior to entering the ED
Cueing Guideline: Nurse won’t care for the patient until he is cleaned up.
2.
Personal Protective Equipment
This critical action is met by wearing of donning appropriate PPE.
Cweing Guideline: Staff may start tearing if mask and gown are not worn
3.
Recognition of cholinergic toxidrome (MK)
This critical action is met by Recognize cholinergic toxidrome
Cueing Guideline: The nurse points out the features of the toxidrome such as miosis, salivation,
lacrimation, bradycardia, etc and asks what these symptoms may be caused by
4.
Airway control with intubation (PBL)
This critical action is met by Intubates the patient
Cueing Guideline: Patient de-saturates, becomes cyanotic, and seizes
5. Antidote administered (atropine and pralidoxime)
(SBP)
This critical action is met by Administers antidote
Cueing Guideline: Nurse asks if there is an antidote available
For Examiner Only
History Data Panel
Age: 50
Sex: Male
Method of Transportation: Ambulance
Name: Bruce Erickson
Person giving information: Paramedics
Presenting complaint: SOB, exposure to unknown gas
Onset and Description of Complaint: Immediately after exposure to gas at rapid transit station
Past Medical History
Allergies: none
Medical: Hypertension
Surgical: Appendectomy
Last Meal: Breakfast
Habits
Smoking: none
Drugs: none
Alcohol: occasional beer on weekends
Family Medical History
Father: Atrial fibrillation
Mother: None
Siblings: none
Social History
Married: yes
Children: 4
Employed: Sports journalist
Education: BA
PMD: Dr. Roy
For Examiner Only
Physical Data Panel
General Appearance: Middle aged man in severe respiratory distress. Pt is noted to be vomiting
and having several episodes of diarrhea shortly after arrival
Vital Signs:
BP
:
P
:
R
:
T
:
O2Sat
:
Glucose :
140/80
40
34
98.7
88% RA
108
Neurological: No focal deficits
Mental Status: Anxious
Head: Atraumatic
Eyes: pupils 2mm bilat not reactive and frequent tearing
Ears: normal
Mouth: +copious secretions from mouth, no erythema/edema
Neck: normal
Skin: moist, no rashes, no evidence of trauma
Chest: tachypneic, bilateral wheezing
Heart: bradycardic
Abdomen: soft, hyperactive bowel sounds, no guarding, no rigidity
Extremities: normal
Rectal: large amount of watery stool heme negative
Pelvic: Defer
Back: normal
Other exam findings: None
For Examiner Only
Lab Data Panel
Stimulus #2 – CBC
WBC
Hgb
Hct
Platelets
Differential
Segs
Lymphs
Monos
Eos
10/mm3
14g/dL
40%
216/mm3
80%
10%
3%
1%
Stimulus #3 – Chemistry
Na+
140 mEq/L
K+
3.6 mEq/L
HCO324mEq/L
Cl112mEq/L
Glucose
95mg/dL
BUN
12 mg/dL
Creatinine
1.0mg/dL
Stimulus #4 – Urinalysis
Color
Yellow
Sp Gravity
1.010
Glucose
Negative
Protein
Negative
Ketone
Negative
Leuk. Est.
Negative
Nitrite
Negative
WBC
0/HPF
RBC
0/HPF
Stimulus #5 – Serum cholinesterase level –
pending Erythrocyte acetylcholinesterase
activity level - pending
Stimulus #6 – Pulse ox – 88% on room air
Stimulus #7 – ABG – pH 7.32/PO2 66/PCO2
28/Bicarb 17/ 88% sat
Stimulus #8 – EKG – sinus bradycardia, rate
40, no acute ischemia
Stimulus #9 – CXR - nl heart, pulmonary
edema
VERBAL REPORTS
For Examiner Only
Stimulus Inventory
Stimulus #1 – Emergency Admitting Form
Stimulus #2 – CBC
Stimulus #3 – Chemistry
Stimulus #4 – Urinalysis
Stimulus #5 – Serum cholinesterase level – pending
Erythrocyte acetylcholinesterase activity level - pending
Stimulus #6 – Pulse ox 88% on room air
Stimulus #7 – ABG – pH 7.32/PO2 66/PCO2 28/Bicarb 17/ 88% sat
Stimulus #8 – EKG – sinus bradycardia, rate 52, no acute ischemia
Stimulus #9 – CXR - nl heart, pulmonary edema
FOR EXAMINER ONLY
Mock Oral Feedback Form – ABEM model
Case
Date:
Examiner:
Examinee:
Data acquisition
Worst
1
NOTES
2
3
4
5
6
7
8
Best
Problem solving
Worst
1
NOTES
2
3
4
5
6
7
8
Best
Patient management
Worst
1
2
NOTES
3
4
5
6
7
8
Best
Resource utilization
Worst
1
2
NOTES
3
4
5
6
7
8
Best
Health care provided
Worst
1
2
NOTES
3
4
5
6
7
8
Best
4
5
6
7
8
Best
Comprehension of path physiology
Worst
1
2
3
4
NOTES
5
6
7
8
Best
Clinical competence (overall)
Worst
1
2
3
NOTES
5
6
7
8
Best
Patient Interpersonal relations
Worst
1
2
3
NOTES
4
Dangerous actions and
Critical Actions
1. Skin decontamination (PC)
 omissions
2. Appropriate PPE

3. Recognition of cholinergic toxidrome (MK)

4. Airway control with intubation (PBL)

toxidrome not identified immed 4.
5. Antidote administered (atropine and pralidoxime)
(SBP)
6.

does not address airway 5.
FOR EXAMINER ONLY
1 patient not decontaminated 2.
staff does not use PPE, score up
if staff anticipate pt 3. cholinergic
antidote not given, must give both

atropine and pralidoxime
Mock Oral Feedback Form – Core Competencies
Date:
Examiner:
Does not meet
expectations
Examinee:
Meets
Expectations
Exceeds
Expectations
1. Patient care
2. Medical
knowledge
3. Interpersonal
skills and
communication
4. Professionalism
5. Practice-based
learning and
improvement
6. Systems-based
practice
Dangerous actions and
Critical Actions
1. Skin decontamination (PC)
 omissions
2. Appropriate PPE

3. Recognition of cholinergic toxidrome (MK)

4. Airway control with intubation (PBL)

toxidrome not identified immed 4.
5. Antidote administered (atropine and pralidoxime)
(SBP)
6.

does not address airway 5.
FOR EXAMINER ONLY
1 patient not decontaminated 2.
staff does not use PPE, score up
if staff anticipate pt 3. cholinergic
antidote not given, must give both

atropine and pralidoxime
Stimulus #1
ABEM General Hospital
Emergency Admitting Form
Name
: Bruce Erickson
Age
: 50
Sex
: Male
Method of Transportation : Ambulance
Person giving information : Paramedics
Presenting complaint
: SOB, exposure to unknown gas
Background:
The paramedics call you on the radio alerting you to a disaster situation with multiple victims.
They are bringing a middle aged man found at the scene with moderate to severe respiratory
distress. Witnesses at the scene reported seeing a thick mist at the rapid transit station
Vital Signs
Pulse 40
Resp 44
BP 140/80
Stimulus #2 – CBC
WBC
Hgb
Hct
Platelets
Differential
Segs
Lymphs
Monos
Eos
10/mm3
14g/dL
40%
216/mm3
80%
10%
3%
1%
Stimulus #3 – Chemistry
Na+
140 mEq/L
K+
3.6 mEq/L
HCO324mEq/L
Cl112mEq/L
Glucose
95mg/dL
BUN
12 mg/dL
Creatinine
1.0mg/dL
Stimulus #4 – Urinalysis
Color
Yellow
Sp Gravity
1.010
Glucose
Negative
Protein
Negative
Ketone
Negative
Leuk. Est.
Negative
Nitrite
Negative
WBC
0/HPF
RBC
0/HPF
Stimulus #5
Serum cholinesterase level – pending
Erythrocyte acetylcholinesterase activity level - pending
Stimulus #6 – Pulse ox 88% on room air
Stimulus #7 – ABG – pH 7.32/PO2 66/PCO2 28/Bicarb 17/ 88% sat
Stimulus #8 – EKG
Stimulus #9 – CXR