Volume 3 - Issue 1
Battle of two drugs: Who won? - An unusual presentation
MRCEM Resident - 1st year, Department of Emergency Medicine, Kauvery Hospital, Chennai, India
*Correspondence: silvera30@gmail.com
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 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. What if a person consumes both at the same time? Will both drugs compete to nullify the effect or not?
Case Presentation
A 28 years gentleman, with no comorbidity and no known drug allergy, presented to ER at 8 PM on 17/8/2021 with alleged H/O consumption of monocrotophos 36% (OPC) around 30 ml and Tab. Cetirizine 10 mg × 50 nos (total aggregate of 500 mg) at his residence around 10 AM (the same day). He was said to be in depression following demise of his mother recently. He was apparently normal till 4 PM after which he had one episode of vomiting (containing food particles, non-blood stained) and giddiness.
He confessed to his friend that he has consumed the above-mentioned medications. Initially, he was rushed to government general hospital around 5 PM where gastric decontamination was done and activated charcoal was introduced through a nasogastric tube. He was also treated with Inj. Pralidoxime 3 g intravenously. He consumes ethanol occasionally.
On Examination at ER
Airway: Patent, self maintained
Breathing: RR - 20/ min, SpO2 - 99% RA, B/L air entry equal, no added breath sounds, single breath count >10
Circulation
BP - 160/100 mm Hg. HR - 112/ min,
CVS - S1S2 normal, no murmur, JVP - Normal, B/L Peripheral pulses well felt
PA - Soft, non-tender, no organomegaly, bowel sounds heard.
Disability
GCS - E4V5M6 [15/ 15]
B/L pupils pin point, sluggishly reacting to light 1 mm
CBG - 149 mg/dl
|
R |
L |
Power UL |
5/5 |
5/5 |
LL |
5/5 |
5/5 |
DTR |
+ |
+ |
Tone |
N |
N |
Plantar |
↓ |
↓ |
Sensory |
+ |
+ |
Fasciculations noted in B/L Quadriceps femoris muscle, B/L lower eyelid and lips.
Exposure
ECG
ABG (RA)
pH |
7.348 |
PCO2 |
48.2 mmHg |
PO2 |
71 mmHg |
BE |
1 mmol/ L |
HCO3 |
26.5 mmol/ L |
TCO2 |
28 mmol/ L |
SO2 |
93% |
LAC |
2.11 mmol/ L |
PT-INR - 0.99
CHEM - 8
Na+ |
141 mmol/L |
K+ |
3.3 mmol/L |
Cl - |
106 mmol/L |
ica |
1.16 mmol/L |
GLU |
124 mg/dl |
BUN |
13 mg/dl |
CREAT |
0.9 mg/dl |
HCT |
49% PCV |
HB |
16.7 g/dl |
Blood Investigations
|
17/8/21 |
18/8/21 |
19/8/21 |
26/8/21 |
Urea |
28.6 |
26.2 |
31.2 |
65.3 |
Creatine |
0.83 |
0.73 |
0.75 |
0.70 |
SGOT |
24.6 |
- |
- |
66.2 |
SGPT |
29.6 |
- |
- |
201.7 |
ALP |
69.4 |
- |
- |
95.1 |
GGT |
|
|
|
238.6 |
CBC |
17/8/21 |
18/8/21 |
HB |
16.0 |
15.3 |
WBC |
26800 |
19400 |
Platelet |
258000 |
243000 |
Neutophil |
85.2 |
92.1 |
Lymphocyte |
8.9 |
4.4 |
Monocyte |
5.5 |
3.4 |
Basophil |
0.3 |
0.1 |
ABG |
18/8/21 |
19/8/21 |
22/8/21 |
PCO2 |
32 |
77 |
34 |
PO2 |
491 |
116 |
88 |
SO2 |
99.6 |
98.8 |
98.4 |
Lac |
2.4 |
0.7 |
1.0 |
Follow up:
Discussion
Pathophysiology of OPC Toxicity
Organo phosphate
Acetyl choline esterase inhibitors
Increases acetyl choline in synaptic cleft
Overstimulation of ach receptors
Muscarinic
Salivation
Lacrimation
Urination
Defecation
GI cramps
Emesis
Nicotinic
Muscle weakness
Twitching
Fasciculation
Hypertension
Paralysis
Pharmacology of Antihistamines
Side Effects
Pharmacokinetics
Conclusion
We had received another patient with alleged history of accidental consumption of OPC (chlorpyrifos) of 20 ml at his residence around 8 pm. He was brought to ER at 11 pm the same day. On arrival at the ER he was agitated, with secretions pooling through his oral cavity. Comparing both, there were no secretions noted in our index patient till 18 h of post consumption of OPC which could be due to anti-cholinergic effect of anti- histamines. Hence it is postulated that anti-histamines have a protective role on the airway by delaying onset of respiratory distress due to secretions caused by organophosphates. More studies are required to explore the use of anti-histamines in management of OPC poisoning. In the battle of two drugs, anti-histamines over-powered action of OPC.
Acknowledgement
I would like to thank, Drs. Aslesha, Consultant and Clinical lead, Dr. Sridhar, Intensivist, Dr. Vidya, Consultant, Dr. Vetri, Consultant, Dr. Niveanthini, Consultant for helping me to prepare this article.
References
Dr. Silvera Samson Raj
MRCEM Resident
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