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Difficulty: MediumInitial Stabilization and Triage

A 52-year-old man is brought to the emergency department by coworkers after collapsing in an agricultural field where he was spraying pesticides. On arrival, he is confused, agitated, and incontinent of urine and feces. Physical examination reveals profuse diaphoresis, copious salivation, and diffuse wheezing on lung auscultation. His pupils are 1 mm bilaterally. Vital signs show a temperature of 37.1 C (98.8 F), heart rate of 42/min, blood pressure of 85/55 mmHg, respiratory rate of 28/min, and oxygen saturation of 87% on room air. He is actively coughing up large amounts of clear, frothy secretions. Which of the following are the most appropriate simultaneous initial steps in the management of this patient? (Select all that apply)

  1. Administration of intravenous atropineAnswer
  2. Complete removal of the patient's clothing and dermal decontaminationAnswer
  3. C
    Rapid sequence intubation using succinylcholine
  4. D
    Administration of intravenous physostigmine
  5. E
    Transfer to the radiology suite for a non-contrast computed tomography scan of the head

Answer

The most appropriate simultaneous initial steps are the administration of intravenous atropine and the complete removal of the patient's clothing with dermal decontamination.
This patient presents with a classic cholinergic toxidrome (diaphoresis, salivation, miosis, bradycardia, wheezing, incontinence) due to occupational organophosphate pesticide exposure. Organophosphates irreversibly inhibit acetylcholinesterase, leading to massive acetylcholine accumulation at muscarinic and nicotinic receptors. The immediate life-threats are respiratory failure (from profound bronchorrhea and bronchospasm) and hemodynamic collapse (from severe bradycardia). The most urgent initial stabilization step is to simultaneously administer intravenous atropine to competitively antagonize muscarinic receptors (improving heart rate and drying airway secretions) and to perform complete dermal decontamination by removing all clothing and thoroughly washing the patient. Decontamination is critical in triage to stop ongoing transdermal absorption and prevent the poisoning of healthcare workers.

Step-by-Step Solution

1
Identify the toxidrome based on the clinical presentation and context.
The patient's agricultural work, bradycardia, miosis, salivation, wheezing, and incontinence indicate a cholinergic crisis, most likely from organophosphate poisoning.
Recognizing the DUMBELS mnemonic (Diaphoresis/Diarrhea, Urination, Miosis, Bradycardia/Bronchorrhea/Bronchospasm, Emesis, Lacrimation, Salivation) establishes the diagnosis.
2
Determine the most critical, immediate life-threats.
The patient is in respiratory distress due to severe bronchorrhea and bronchospasm, complicated by cardiogenic shock from severe bradycardia.
Airway compromise from excessive secretions and hemodynamic instability require immediate pharmacological reversal of muscarinic effects.
3
Select the appropriate simultaneous interventions for initial stabilization.
Administer high-dose intravenous atropine while simultaneously removing all of the patient's clothing and washing the skin.
Atropine dries secretions and improves heart rate. Dermal decontamination stops ongoing absorption and protects emergency department staff from secondary exposure.

Key Concept

Initial stabilization of severe organophosphate toxicity requires immediate administration of atropine to manage life-threatening muscarinic symptoms (bronchorrhea, bronchospasm, bradycardia) alongside concurrent dermal decontamination to halt further absorption.
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Topics

Initial Stabilization and Triage

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