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Atropine
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Lorazepam
Pancuronium
Pyridostigmine
Succinylcholine
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This patient who presents with nausea, vomiting, diarrhea, miosis, sweating, and wheezing after driving past a spill most likely has organophosphate poisoning. This poisoning should be treated with the muscarinic antagonist atropine. Organophosphates are industrial compounds that are commonly used as insecticides and herbicides. They function by irreversibly inhibiting acetylcholinesterase and thereby blocking the metabolism of acetylcholine at nerve terminals. This results in overstimulation of the muscarinic and nicotinic acetylcholine receptors. Common muscarinic effects include nausea, vomiting, diarrhea, urination, lacrimation, salivation, sweating, miosis, wheezing, and bradycardia. The treatment of organophosphate poisoning includes the muscarinic antagonist atropine, pralidoxime to dissociate the poison from its receptor, and benzodiazepines to terminate seizures. The indication for also using pralidoxime is muscle weakness or respiratory depression. Chuang et al. studied the prevalence of seizures in patients with organophosphate poisoning. They found that the hazard ratio was 13 times higher in young adults compared to the control population. Incorrect Answers: Answer 2: Lorazepam is a benzodiazepine that can be used in the treatment of seizures in patients with organophosphate poisoning; however, it has no effect on the muscarinic symptoms seen in this patient. Answer 3: Pancuronium is a non-depolarizing nicotinic acetylcholine receptor inhibitor that is used during anesthesia; however, the main toxicity of organophosphate poisoning occurs due to the overactivation of muscarinic receptors. Answer 4: Pyridostigmine is an acetylcholinesterase inhibitor that can be used to treat atropine overdose. Anticholinergic syndrome would present with flushing, constipation, kidney stones, and altered mental status. It has the same mechanism of action as organophosphates so this drug would worsen symptoms in this patient. Answer 5: Succinylcholine is a depolarizing nicotinic receptor that prevents further nicotinic acetylcholine activity by keeping all receptors in a refractory state. It functions as a paralytic medication and can be used during surgery. This drug would not have any effect on the muscarinic receptors that drive organophosphate toxicity. Bullet Summary: Organophosphate poisoning should be treated using atropine to inhibit muscarinic activity, pralidoxime to dissociate the toxin, and benzodiazepines to terminate seizures.
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