Opioid Withdrawal

ID/CC HPI PE

Labs

Imaging Gross Pathology Micro Pathology Treatment

Discussion

A 30-year-old farmer is brought to the emergency room with severe abdominal cramps and vomiting.

The patient is also restless and is salivating profusely. He has been working with a new pesticide for the past three months.

Patient is nearly stuporous; cyanosis with marked respiratory distress; bilateral miotic pupils; marked salivation and lacrimation; moderate dehydration; hyperactive bowel sounds; fecal and urinary incontinence.

ABGs: marked hypoxemia with hypercapnia; uncompensated respiratory acidosis. Prerenal azotemia on

RFTs. Lytes: hyperkalemia.

CXR is normal.

Specific therapy includes administration of atropine (to offset cholinergic effects) and pralidoxime (chemically restores acetylcholinesterase if administered early); supportive management for respiratory support and hemodialysis.

Organophosphates like parathion and carbamates are widely used as pesticides, and several nerve agents developed for chemical warfare are rapid-acting and potent organophosphates. All of these toxins inhibit the enzyme acetylcholinesterase, preventing the breakdown of acetylcholine at cholinergic synapses. Whereas the organophosphates may cause permanent damage to the enzyme, carbamates have a transient and reversible effect.

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