{"id":3173,"date":"2021-09-11T06:34:01","date_gmt":"2021-09-11T06:34:01","guid":{"rendered":"https:\/\/www.kauveryhospital.com\/ima-newsletters\/?p=3173"},"modified":"2025-04-11T03:57:00","modified_gmt":"2025-04-11T03:57:00","slug":"battle-of-two-drugs-who-won","status":"publish","type":"post","link":"https:\/\/www.kauveryhospital.com\/ima-journal\/ima-journal-september-2021\/battle-of-two-drugs-who-won\/","title":{"rendered":"Battle Of Two Drugs – Who Won?"},"content":{"rendered":"

[vc_row][vc_column][vc_column_text]<\/p>\n

An Unusual Presentation<\/strong><\/h1>\n

ABSTRACT<\/strong><\/h2>\n
    \n
  • Organo Phosphate \/ Insecticide ingestion is the most common modality of suicide in India, Which causes excessive secretions [Cholinergic effect] in our body.<\/li>\n
  • Anti-Histamines are groups of drugs that are used in allergic reactions and are also known to have an effect in decreasing secretions [Anti-Cholinergic effect] in our body.<\/li>\n
  • What if a person consumes both at the same time? Will both drugs compete to nullify the effect or not?<\/li>\n<\/ul>\n

    CASE REPORT<\/strong><\/h2>\n

    28 years Gentleman with no comorbids and no known drug allergy presented to ER at 8PM on 17\/8\/2021 with alleged H\/O consumption of monocrotophos 36% [OPC] around 30ML and TAB.CETIRIZINE 10mg tablets* 50nos [total aggregate of 500mg] at his residence around 10AM [the same day]. He was said to be in depression following demise of his mother recently. He was
    \napparently normal till 4PM after which he had one episode of vomitting (containing food particies, non blood stained) and giddiness.<\/p>\n

    He confessed to his friend that he has consumed the above-mentioned medications. Intially, he was rushed to government general hospital around 5PM where gastric decontamination was done and activated charcoal was introduced
    \nthrough a nasogastric tube. He was also treated with INJ.PRALIDOXIME 3gm intravenously. He consumes ethanol occasionally.<\/p>\n

    ON INITIAL EVALUATION IN ER<\/strong><\/h2>\n

    AIRWAY<\/strong>
    \nPatent, self maintained
    \nBREATHING<\/strong>
    \nRR – 20\/ min, Spo2 – 99% RA, B\/L air entry equal, no added breath sounds, single breath count >10
    \nCIRCULATION<\/strong>
    \nBP – 160\/ 100 mmHg. HR – 112\/ min,
    \nCVS – S1S2 \u2a01, no murmur, JVP – Normal, B\/L PPWF \u2a01,
    \nPA – Soft, non-tender, no organomegally, bowel sounds heard.
    \nDISABILITY<\/strong>
    \nGCS – E4V5M6 [15\/ 15]
    \nB\/L pupils pin point – Sluggishly reacting to light 1mm
    \nCBG – 149mg\/dl
    \n\"\"<\/p>\n

      \n
    • Fasiculations noted in B\/L Quadriceps femoris muscle , B\/L lower eyelid and lips.<\/li>\n<\/ul>\n

      EXPOSURE<\/strong><\/h2>\n
        \n
      • \n
          \n
        • 16 F Ryles tube with activated charcoal in place.<\/li>\n
        • 18 G venflon in dorsum of right hand.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n

          ECG<\/strong>
          \n\"\"<\/h2>\n
            \n
          • Rate \u2243 115\/ min<\/li>\n
          • Sinus Rythm<\/li>\n
          • Normal Axis<\/li>\n
          • S1Q3T3 Pattern<\/li>\n
          • No other specific ST – T Changes<\/li>\n<\/ul>\n

            ABG (RA)<\/strong><\/p>\n

            pH – 7.348
            \nPCO2 – 48.2 mmHg
            \nPO2 – 71 mmHg
            \nBE – 1 mmol\/ L
            \nHCO3 – 26.5 mmol\/ L
            \nTCO2 – 28 mmol\/ L
            \nSO2 – 93%
            \nLAC – 2.11 mmol\/ L<\/p>\n

            PT-INR – 0.99<\/strong>
            \nCHEM – 8<\/strong><\/p>\n

            Na+ – 141 mmol\/ L
            \nK+ – 3.3 mmol \/ L
            \nCl- – 106 mmol\/ L
            \nica – 1.16 mmol\/ L
            \nGLU – 124 mg\/ dl
            \nBUN – 13 mg\/ dl
            \nCREAT – 0.9 mg\/ dl
            \nHCT – 49% PCV
            \nHB – 16.7 g\/ dl<\/p>\n

            PATHOPHYSIOLOGY OF OPC<\/h2>\n

            \"\"
            \nPHARMACOLOGY OF ANTI-HISTAMINES<\/strong><\/p>\n

              \n
            • Blocks HI – Histamine receptors.<\/li>\n
            • Anti-Allergic – Suppression of leukotriene and pro Inflammatory cytokine production.<\/li>\n
            • Anti-inflammatory effect – Decrease in production of granulocytic macrophage factor<\/li>\n<\/ul>\n

              SIDE EFFECTS<\/b><\/h2>\n
                \n
              • Depression of CNS – (Disorders of coordination, fatigue, dizziness, diplopia, tremor, euphoria, nervousness, insommia).<\/li>\n
              • Disturbance of GI Functions – (increased appettie, nausea, vomitting, constipation of diarrhea).<\/li>\n
              • M- cholino blocking activity – (dryness of mucous nembranes, blurred vision, impotence, ischuria, tachycardia, psychosis).<\/li>\n<\/ul>\n

                PHARMACO KINETICS<\/b><\/h2>\n
                  \n
                • Action of drug noted within 30 – 60 minutes of post-consumption.<\/li>\n
                • Half life 8 – 10 hours.<\/li>\n
                • Eliminated by kidneys (apparent total body clearance – 53 ml\/min).<\/li>\n<\/ul>\n

                  BACK TO CASE REPORT – FOLLOW UP<\/strong><\/h2>\n
                    \n
                  • Patient was shifted to ICU and was started on INJ Atrophine infusion in view of bradycardia due to parasympathetic overactivity. TTM not used.<\/li>\n
                  • The next day around 4AM, he developed severe respiratory distress due to respiratory muscle weakness secondary to OPC induced excessive acetylcholine at neuromuscular junction. He was intubated and connected to a mechanical ventilator. He was slowly weaned off from supports and patient discharged on
                    \n4\/9\/2021.<\/li>\n<\/ul>\n

                    BLOOD INVESTIGATION<\/strong>
                    \n\"\"
                    \n\"\"<\/h2>\n

                    PROPOSED THEORY<\/strong><\/h2>\n
                      \n
                    • We have received another patient with alleged history of accidental consumption of OPC (chlorpyrifos) of 20ml at his residence around 8pm. He was brought to ER at 11pm the same day. On arrival at the ER he was agitated, with secretions
                      \npooling through his oral cavity.<\/li>\n
                    • Comparing both cases, there were no secretions noted in our former patient uptill 18 hours of post consumption of OPC which could be due to anti-cholinergic effect of anti- histamines.<\/li>\n
                    • Hence it is concluded that Anti-histamines has a protective role on the airway by delaying onset of respiratory distress due to secretions caused by organophosphates.<\/li>\n<\/ul>\n

                      Hence it is concluded that Anti-histamines has a protective role on the airway by delaying onset of respiratory distress due to secretions caused by organophosphates.<\/p>\n

                      REFERENCE<\/strong><\/h2>\n

                      \u2022 https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK482318\/
                      \n\u2022 https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC4694283\/
                      \n\u2022 https:\/\/pubmed.ncbi.nlm.nih.gov\/2892445\/
                      \n\u2022 https:\/\/pubmed.ncbi.nlm.nih.gov\/2866055\/
                      \n\u2022 https:\/\/pubmed.ncbi.nlm.nih.gov\/1677249\/
                      \n\u2022 https:\/\/pubmed.ncbi.nlm.nih.gov\/1979802\/
                      \n\u2022 https:\/\/gsconlinepress.com\/journals\/index.php\/gscbps\/article\/view\/gscbps-2021-0024
                      \n\u2022 https:\/\/scholar.google.com\/scholar?hl=en&as_sdt=0%2C5&q=organophosphate+and+cetrizine+&btnG=#d=gs_qabs&u=%23p%3DGNgnndDSoZIJ
                      \n\u2022 https:\/\/pesquisa.bvsalud.org\/portal\/resource\/pt\/emr-40605
                      \n\u2022 https:\/\/scholar.google.com\/scholar?hl=en&as_sdt=0%2C5&q=organophosphate+and+cetrizine+&btnG=#d=gs_qabs&u=%23p%3DmC8908oRpC0J
                      \n\u2022 http:\/\/www.fao.org\/3\/w5715e\/w5715e04.htm#:~:text=Severe%20poisoning%20will%20affect%20the,extremities%20and%
                      \n20the%20respiratory%20muscles.
                      \n\u2022 https:\/\/www.researchgate.net\/publication\/263842305_ANTIHISTAMINES_PROMISING_ANTIDOTES_OF_ORGANOPHOSPHORUS_POISONING<\/p>\n

                       <\/p>\n

                      \"\"Dr.Silvera Samson<\/strong>
                      \nMRCEM Resident – Department of Emergency Medicine[\/vc_column_text][\/vc_column][\/vc_row]<\/p>\n","protected":false},"excerpt":{"rendered":"

                      [vc_row][vc_column][vc_column_text] An Unusual Presentation ABSTRACT Organo Phosphate \/ Insecticide ingestion is the most common modality of suicide in India, Which causes excessive secretions [Cholinergic effect] in our body. Anti-Histamines are<\/p>\n","protected":false},"author":2,"featured_media":3174,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[33],"tags":[],"class_list":["post-3173","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-ima-journal-september-2021"],"yoast_head":"\nBattle Of Two Drugs - Who Won?<\/title>\n<meta name=\"description\" content=\"Organo Phosphate \/ Insecticide ingestion is the most common modality of suicide in India, Which causes excessive secretions [Cholinergic effect] in our body.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.kauveryhospital.com\/ima-journal\/ima-journal-september-2021\/battle-of-two-drugs-who-won\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Battle Of Two Drugs - 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