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Difficulty: MediumInitial Stabilization and Triage

A 48-year-old agricultural worker is brought to the emergency department triage area by his coworkers in a private truck after he accidentally spilled a concentrated organophosphate pesticide on his clothing 20 minutes ago. He is confused, profusely sweating, and vomiting. Vital signs are temperature 36.5°C (97.7°F), heart rate 42/min, blood pressure 88/55 mm Hg, respiratory rate 28/min, and oxygen saturation 86% on room air. Physical examination reveals pinpoint pupils, excessive salivation, and diffuse wheezing with copious crackles. Widespread muscle fasciculations are noted.

Arrange the following initial stabilization and management steps in the most appropriate chronological order, from first to last.

  1. 1Don chemical-resistant personal protective equipment
  2. 2Remove the patient's contaminated clothing and decontaminate the skin
  3. 3Secure the airway, suction secretions, and provide oxygen
  4. 4Administer high-dose intravenous atropine
  5. 5Administer intravenous pralidoxime

Answer

The correct sequence is to first protect the healthcare team, then stop the patient's exposure, establish basic life support, and finally administer targeted antidotes in order of physiological priority.
The appropriate triage and stabilization sequence for a patient with acute hazardous material exposure begins with ensuring provider safety by donning personal protective equipment (PPE). Once it is safe to approach the patient, the immediate priority is halting the ongoing exposure through rapid decontamination, which primarily involves clothing removal and skin irrigation. Following decontamination, standard resuscitation principles (ABCs) apply: securing the airway, suctioning copious secretions, and providing supplemental oxygen are prioritized to treat hypoxia. After establishing basic life support, definitive pharmacological therapy is administered. For organophosphate poisoning, high-dose intravenous atropine is given first to reverse life-threatening muscarinic effects (bronchorrhea, bronchospasm, and profound bradycardia). Finally, intravenous pralidoxime is administered to regenerate acetylcholinesterase and treat nicotinic effects (such as muscle fasciculations and weakness).

Step-by-Step Solution

1
Ensure scene and provider safety.
Don chemical-resistant personal protective equipment.
Providers must protect themselves before approaching a patient contaminated with a hazardous material like organophosphates.
2
Stop the ongoing toxic exposure.
Remove the patient's contaminated clothing and decontaminate the skin.
Decontamination prevents further dermal absorption and eliminates the primary source of ongoing toxicity.
3
Initiate basic life support and stabilize vital functions.
Secure the airway, suction secretions, and provide oxygen.
Airway compromise is the leading cause of death in these patients. Correcting hypoxia is critical prior to atropine administration to avoid precipitating ventricular fibrillation.
4
Reverse life-threatening muscarinic toxicity.
Administer high-dose intravenous atropine.
Atropine dries copious respiratory secretions, reverses bronchospasm, and treats profound bradycardia.
5
Treat nicotinic toxicity and prevent enzyme aging.
Administer intravenous pralidoxime.
Pralidoxime targets nicotinic receptors to reverse muscle fasciculations and weakness, including respiratory muscle fatigue, but is a secondary priority to airway clearance and atropine.

Key Concept

In hazardous material exposures (e.g., organophosphates), the stabilization sequence is: Provider Safety (PPE) → Patient Decontamination → Basic Life Support (ABCs) → Specific Antidotes (Atropine, then Pralidoxime).
Estimated Time:1m 30s
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Topics

Initial Stabilization and Triage

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