NORCET -4 , 2023
Medical & Surgical Nursing
Medium
A 35 year old farmer brought to emergency with history of multiple time vomiting, loose stool & breathlessness for two hours while he was fumigating his crops. On examination he was drowsy & had excessive salivation, involuntary defecation, pulse rate 46/minute, BP-90/60 mmHg , respiratory rate-14/minute, pupils- bilaterally constricted, twitching in bilateral calf muscles. Chest auscultation revealed bilateral crackles. What is the likely poisoning?
Appeared in: NORCET -4 , 2023
Explanation
- Organophosphorus compounds, common in pesticides, inhibit the enzyme acetylcholinesterase, leading to an excess of acetylcholine.
- This acetylcholine surplus overstimulates muscarinic and nicotinic receptors, causing a predictable set of symptoms known as a cholinergic crisis.
- The patient's presentation—including constricted pupils, excessive salivation, involuntary defecation, bradycardia, and muscle twitching—is a textbook example of this crisis.
- The history of fumigating crops provides a clear exposure route, confirming the diagnosis.
Why Other Options Were Wrong
- Option A: Opioid overdose presents with the classic triad of CNS depression, respiratory depression, and pinpoint pupils (miosis). However, it does not cause the 'wet' cholinergic symptoms like excessive salivation, diarrhea, or muscle fasciculations.
- Option B: Aluminium phosphide is a fumigant that releases phosphine gas. Its toxicity leads to severe cardiovascular collapse, profound shock, metabolic acidosis, and multi-organ failure, but not the specific cholinergic signs seen in the patient.
- Option C: Acute arsenic poisoning typically causes severe gastroenteritis (often described as 'rice-water' stools), a garlic-like odor on the breath, and can lead to shock. It does not produce the specific combination of miosis, bradycardia, and excessive secretions.
Related Visual
Clinical Relevance
- Nursing practice connection: This is primarily an exam-oriented knowledge point with limited direct bedside application, so retain Recognition and management of Organophosphorus poisoning and its associated cholinergic toxidrome as background academic context rather than a clinical decision trigger.
- Rapid recognition of the cholinergic toxidrome is a critical nursing skill in the emergency department, as immediate intervention can be life-saving.
- Nurses must prioritize personal protective equipment (PPE) and patient decontamination to prevent self-exposure and stop ongoing absorption of the poison.
- The administration of atropine is guided by clinical endpoints, not fixed doses. The nurse must titrate the dose until secretions are dry and the heart rate improves, a process known as 'atropinization'.
How to Approach the Question
- First, analyze the patient's history: a farmer fumigating crops points directly to pesticide exposure.
- Next, systematically review the signs and symptoms provided in the clinical scenario.
- Group the symptoms into a recognizable pattern or 'toxidrome'. In this case, the symptoms (salivation, defecation, constricted pupils, bradycardia, twitching) form the classic cholinergic toxidrome.
- Evaluate the options provided. Match the identified toxidrome to the substance known to cause it.
- Organophosphorus compounds are well-known acetylcholinesterase inhibitors that cause a cholinergic crisis.
- Rule out the other options by comparing their known effects to the patient's presentation. Opioids, aluminium phosphide, and arsenic all have different clinical pictures.
Concept Tested & Keywords
- Concept Tested: Recognition and management of Organophosphorus poisoning and its associated cholinergic toxidrome.
- Stem keywords: farmer, fumigating, vomiting, loose stool, breathlessness, excessive salivation, involuntary defecation, bradycardia
- Lead-in keywords: likely poisoning
- Clinical cues: The patient's occupation as a farmer and recent activity of fumigating crops are significant clues pointing towards pesticide exposure.
- Clinical cues: The combination of muscarinic symptoms (DUMBELS) and nicotinic symptoms (muscle twitching) is the hallmark of organophosphate poisoning.
Question ID
Qyx5tIl6HBI7aQ7mtDlgVR
Reference Book
E6 Medicine Davidson Principles Practice 24e p. 165-167
E6 Ghai Essential Pediatrics(pp 26-904 of 913) p. 755-757
E6 Nelson Textbook of Pediatrics(2024) — Volume 1 p. 763-765
Practise the full NORCET -4 , 2023
Attempt every question from this paper in a timed mock, then review the full solution for each one.
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