Case Presentation
Christopher Lin and Wendy Zhou
Hospital Admission
CC: Consumption of 470ml of organophosphate (陶斯松)
with symptoms of vomiting and urinary incontinence
- Patient was immediately sent to ER on 06/15/2015
Patient History
Patient Name:楊 X 雄
(Chart #1337553)
Age: 56yo
Gender: Male
Medication History:
nil
Past Social History:
Past Medical History:
Occupation: nil
1. HTN
Smoking: nil
2. Bipolar disorder
Drinking: nil
Past Surgical History:
Family history:
nil
Non-contributory
Organophosphates MOA
 Organophosphates phosphorylate the serine hydroxyl
residue on Acetylcholine esterase, which inactivates
AChE, increasing ACh levels, which can activate
nicotinic and muscarinic receptors.
 Parasympathetic (SLUDGEM) – Salivation, lacrimation,
urination, diaphoresis, GI upset, emesis, miosis and
muscle spasm (Patient had fewer symptoms)
 Generally, parasympathetic effects dominate most
organs except for the vasculature, whereas
sympathetics dominate vasculature --> hypertension
Physical Examination
● General appearance: weakness
● Vital Sign: T/P/R= 37.8°C/100bpm/20 breaths per min;
BP=153/93 mmHg; spO2: 95%
● Glassgow Coma Scale: E4 M6 V5=15 with mild delay response,
clear conscious
● HEENT: grossly normal, pupil size 2.5/2.5mm, light reflex positive
● Neck: supple, no JVP, no bruits, no lymphadenopathy, no thyroid
gland enlargement
● Chest/Lung: symmetric expansion, rhonchi
● Heart: regular heart beat, PMI at 5th intercostal space, no
gallop/murmur/thrill/heave
● Abdomen: Soft, tympanic percussion, no hepatosplenomegaly, no
tenderness, negative Murphy’s
● Bowel sounds: normoactive
● Extremities: freely movable, skin turgor fair, no edema,
ecchymosis, or cyanosis
Work-Up
1. Patient immediately received gastric lavage and was
administered Carbomix and Pralidoxime
2. EKG: Sinus rhythm, rate 99/min, poor R wave progression
3. Labs: low pO2, low SO2e, low HCO3, low aPTT, hypokalemia,
elevated liver enzymes and LDH, hyperglycemia, WBC, urine
occult blood, positive glucose, WBC, and RBC in urine
4. Admission Diagnosis:
a. Organophosphate intoxication
b. Suicide attempt
c. Hypertension
EKG
Labs (06/15/15)
pH
7.359
pCO2
37.7
pO2
50.8
HCO3
20.8
SaO2
84.8
ABG
6/15/15
Blood
BUN
19
Glc
145
Ca
10
Cr
1.14
SGPT
79
SGOT
67
LDH
241
Na
137
K
3.4
CBC
WBC
27.72
RBC
5.78
Hb
17.5
Hct
50
MCV
86.5
MCH
30.3
MCHC
35
RDW
13.1
Plt
276
Labs 06/15/15 (cont’d)
Culture
Urine
Gastric Juice OB
Sputum
Negative
Negative
Negative
Turbidity
neg
Glc
++++
Bilirubin
neg
Nitrate
negative
Leukocytes
positive
Ketone
+
SG
1.017
Urine
Urobilinogen
normal
Rbc
10 - 20
Wbc
20 - 30
Occult Blood
+
pH
6
06/15/15 CXR
Plan on 6/15
1. NPO with IV hydration
2. Administer empirical antibiotic therapy with
Amoxicillin/Clavulanate (Curam)
3. Check gastric juice occult blood and give PPI
4. Consult psychiatrist
Meds and Supplementation
on 6/15
 Saline injection 0.9% 500ml
 Tai-Ta NO.5 injection 400ml (Dextrose (Glucose) and
Electrolyte Solutions 400mL/bt): Includes K+ to treat his
hypokalemia
 Curam inj. 1.2gm (Amoxicillin/Clavulanate): Empirical
therapy for possible infection (increased WBC)
 Pantoloc inj. 40 mg (Proton Pump inhibitor)
Progress Note on 6/17
• Irritable Mood
• Glassgow Coma Scale: E4V4M6
• T/P/R: 35.8, 94, 26
• BP: 147/83
• Urine output: 1990ml
pH
pCO2
pO2
HCO3
SaO2
7.441
31.1
63.9
20.7
93.4
Meds and Supplementation
on 6/17
 Continue Curam inj 1.2gm
 Maintain hydration (NS 0.9% 500ml)
 O2 supplementation to address low pO2 and SaO2
 Administer medication for bipolar disorder
 Vakin 500mg (valproate sodium- anticonvulsant)
 Alpraline 0.5mg (Xanax, anti-anxiety)
 Syndoman 15mg (Dalmane, benzodiazepine)
 Olzapine (antipsychotic) 10 mg
Progress Note on 06/19
 Low grade fever (37.7)
 Increased sputum production
 Few crackles present during lung examination
 SpO2 = 95%
Plan:
 CXR
 Continue O2 supplementation
 Continue antibiotic use (Curam)
Progress Note on 6/20
 Fever persists
 Breathing sounds clear after sputum suction
 CXR showed no findings of pneumonia
pH
7.469
pCO2
34.5
pO2
66.5
HCO3
24.5
SaO2
94.4
Plan:
 Normal Saline 0.9% 500ml
 Continue antibiotic use
 Continue O2 supplementation
 Continue PAM inj 25mg/ml 20ml
06/20/15 CXR
Pralidoxime
Pralidoxime dosing
 Adults: 30 mg/kg (typically 1-2 g) administered IV over
15–30 minutes IM, SubQ, repeated 60 minutes later.
 Or given 500 mg/h continuous IV infusion.
Pralidoxime w/ Atropine
 Pralidoxime has an important role in reversing paralysis
of the respiratory muscles by decreasing their
overstimulation (via muscarinic receptors)
 Due to poor blood–brain barrier penetration, little effect
on CNS-mediated respiratory drive
 Use atropine to reverse excess parasympathetic
effects, has CNS effects
Current Conditions







low grade fever
cough with sputum
TPR: 37.7, 98, 26
BP: 179/80mmHg
Mild respiratory distress
No dyspepsia
No stool passage for 4 days
pH
7.414
pCO2
45.4
pO2
91.9
HCO3
28.4
SaO2
97.1
Action and Plan:
1.
2.
3.
4.
Continue curam use
Obtain culture results
Follow CBC/DC and ABG
Dulcolax (laxative)
bisacodyl sup 10mg
5. Continue O2 mask
supplementation
6. Transferred to general
ward after EICU
administration since 06/15