After ingesting a liquid, a patient presents with pinpoint pupils, respiratory depression, excessive salivation, bradycardia, sweating, and lacrimation. What is the treatment of choice?

1. A

   A. Pralidoxime

2. B

   B. Atropine

3. C

   C. Flumazenil

4. D

   D. Naloxone

Appeared in: INI-CET EXAM -2026

Explanation

• The patient is presenting with a classic cholinergic toxidrome, characterized by symptoms of excessive acetylcholine stimulation.
• This syndrome is often remembered by the mnemonic DUMBELS: Diarrhea, Urination, Miosis (pinpoint pupils), Bradycardia/Bronchospasm, Emesis, Lacrimation, Salivation.
• Atropine is a muscarinic antagonist that directly blocks the effects of acetylcholine at muscarinic receptors, thereby reversing life-threatening symptoms like bradycardia, bronchospasm, and excessive secretions.
• It is the first-line and life-saving antidote administered to stabilize the patient's airway, breathing, and circulation in an acute cholinergic crisis.

Why Other Options Were Wrong

• Option A: Pralidoxime is an acetylcholinesterase reactivator. While it is a crucial part of the treatment for organophosphate poisoning, it is not the first-line drug for immediate symptom control. It works to reverse the nicotinic effects (muscle weakness) and is given as an adjunct to atropine.
• Option C: Flumazenil is the reversal agent for benzodiazepine overdose (e.g., diazepam, lorazepam). Benzodiazepine toxicity presents with sedation and respiratory depression but does not cause the cholinergic symptoms seen in the patient.
• Option D: Naloxone is the antidote for opioid overdose. While opioid toxicity also causes pinpoint pupils and respiratory depression, it is associated with 'dry' symptoms (dry skin, constipation), not the 'wet' symptoms (salivation, sweating, lacrimation) of a cholinergic crisis.

Related Visual

Clinical Relevance

• Nursing practice connection: Safe nursing care depends on performing Pharmacological management of cholinergic crisis (organophosphate poisoning) in the correct sequence, documenting the action clearly, and monitoring for the expected response.
• Recognizing toxidromes (a group of signs and symptoms constituting the basis for a diagnosis of poisoning) is a critical nursing skill in the emergency department.
• The priority nursing intervention for a patient with cholinergic crisis is to maintain a patent airway by suctioning excessive secretions and preparing for potential intubation, while administering atropine as ordered.
• What if? If the patient had pinpoint pupils and respiratory depression but was also noted to have dry mucous membranes and absent bowel sounds, the diagnosis would shift to opioid overdose, and the treatment of choice would be Naloxone.

How to Approach the Question

• First, analyze the cluster of symptoms presented in the clinical scenario: pinpoint pupils, respiratory depression, salivation, bradycardia, sweating, lacrimation.
• Identify the toxidrome. These symptoms are classic for a cholinergic crisis (too much acetylcholine). Use mnemonics like DUMBELS or SLUDGE to confirm.
• Recall the common causes of a cholinergic crisis, such as poisoning with organophosphate insecticides.
• Evaluate the given options, which are all antidotes for different types of poisoning.
• Match the correct antidote to the identified toxidrome. Atropine is the specific antidote for the muscarinic effects of a cholinergic crisis.
• Differentiate from other options by recalling the key signs of other overdoses. For example, opioid overdose also causes pinpoint pupils but lacks the 'wet' symptoms (salivation, lacrimation).

Concept Tested & Keywords

• Concept Tested: Pharmacological management of cholinergic crisis (organophosphate poisoning).
• Stem keywords: pinpoint pupils, respiratory depression, excessive salivation, bradycardia, sweating, lacrimation, ingesting a liquid
• Lead-in keywords: treatment of choice
• Clinical cues: The combination of pinpoint pupils, respiratory depression, and excessive secretions (salivation, sweating, lacrimation) is a hallmark of cholinergic toxidrome.

Question ID

QWyI9ATee4n43zKMnGJqHa

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Reference Book

E6 Ghai Essential Pediatrics(pp 26-904 of 913) p. 755-757

E6 Medicine Davidson Principles Practice 24e p. 166-168

E6 Nelson Textbook of Pediatrics(2024) — Volume 2 p. 2263-2265