2 :‫תרגול פרמקולוגיה מספר‬

Alshiek Jonia, MD
jonia.alshiek@gmail.com
 ‫סיפור מקרה‬

‫חקלאי בן ‪ ,52‬הגיע למיון בניידת ט"נ‪ ,‬בליווי אשתו‪ ,‬לאחר‬

‫שעבד כל היום בשדה‪ .‬במיון רואים שהחולה עדיין בבגדי‬
‫עבודה‪ .‬נמצא בהכרה מעורפלת‪ ,‬ובמצוקה נשימתית קשה‪.‬‬
‫מהו הצעד הראשון והחשוב בשלב זה???‬
 1)Initial management

1)Decontamination:
a.Avoid further exposure

b.Protection: gowns and gloves

c.Irrigation: ocular and dermal

exposure

d.Remove and discard clothing

 1)Initial management
2) Stabilization ABC:

A: AIRWAY protection most commonly needed.

B: BREATHING
C: CIRULATION - IV access for antidotes and fluids
‫מה אתם חושבים שהייתה הסיבה‬
‫למצבו????‬
Organophosphate
Intoxication
 PHARMACOLOGY

1.Absorption:
By any routes:

(1) transdermal

(2) transconjunctival

(3) inhalation

(4) through GI tract

(5) parenteral
 PHARMACOLOGY
2.Metabolism: via liver

Parathion  Paraoxon

3.Onset of toxicology depends on:

(1) route

(2) degree of exposure

(3) fat solubility

(4) affinity to the cholinesterase active site

(5) direct or indirect effect

 MECHANISM
(1) Inhibition of cholinesterase

(2) Accumulation and prolonged effect of Ach

(3) Sites:M1-5, N
a. Parasympathetic:
Ganglionic nicotinic sites
Postganglionic muscarinic sites

b. Sympathetic: ganglionic nicotinic site

c. skeletal muscle(N-M junction): nicotinic

sites

d. CNS sites
‫איזה סמפטומים וסימנים נוספים נצפה למצוא‬
‫אצל החולה הזה???‬
 CLINICAL FEATURES
General considerations :
(1) within minutes to 12 hours

(2) low dose: muscarinic symptoms

(3) severe intoxication: nicotinic and CNS

may predominant
 CLINICAL FEATURES
Muscarinic effects:
* within minutes

* SLUDGE
S =Salivation
L =Lacrimation
U =Urination
D =Diarrhea
G =GI cramps
E =Emesis
 CLINICAL FEATURES
Muscarinic effects:
*Other effects:

a.Miosis: in the early stage

mydriais may occur later

b.Bradycardia

c.Bronchorrhea

d.Bronchonstriction
 CLINICAL FEATURES
Nicotinic effects:
*appear after muscarinic effects

*moderate to severe intoxication

*MTWHF:
M =Mydriais , muscle cramps

T =Tachycardia

W =Weakness

H =Hypertension (also M3)

F =Fasciculations
 CLINICAL FEATURES
CNS effects: non specific
(1) confusion

(2) agitation

(3) lethargy

(4) seziure

(5) coma
 CLINICAL FEATURES
Causes of death:
(1) Muscarinic effects:
a.Excessive pulmonary secretions
b.Bronchoconstriction
c.Pulmonary edema

(2) Nicotinic effects:

a.Respiratory muscle paralysis

(3) CNS effects:

a.Respiratory center depression
 2)Management – next step
Antidotes
1) Atropine:
a.effect:
competitive, reversible inhibition of Ach at
muscarinic receptors: glands> heart,
respiratory system, GIT, smooth muscles
and CNS > acid secretion in stomach.
No effect on nicotinic receptor
(N-M junction):can’t reverse muscle
weakness

b.bronchorrheahypoxiatachycardia
more atropin
 2)Management – next step
Antidotes

1)Pralidoxime

*effect on nicotinic receptor

THE END