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The patient’s presentation is characteristic of poisoning by organophosphate cholinesterase inhibitors (see Chapter 58). Ask the coworker if he can identify the agent used. Decontami-nate the patient by removal of clothing and washing affected areas. Ensure an open airway and ventilate with oxygen. For muscarinic effects, administer atropine (0.5–5 mg) intrave-nously until signs of muscarinic excess (dyspnea, lacrimation, confusion) subside. To treat nicotinic excess, infuse 2-PAM (initially a 1–2% solution in 15–30 minutes) followed by infu-sion of 1% solution (200–500 mg/h) until muscle fasciculations cease. Respiratory support is required because 2-PAM does not enter the central nervous system and may not reactivate “aged” organophosphate-cholinesterase complex. If needed, decon-taminate the coworker and isolate all contaminated clothing.
Achilles J. Pappano, PhD
JH, a 63-year-old architect, complains of urinary symptoms to his family physician. He has hypertension, and during the last 8 years, he has been adequately managed with a thiazide diuretic and an angiotensin-converting enzyme inhibitor. During the same period, JH developed the signs of benign prostatic hypertrophy, which eventually required prostatectomy to relieve symptoms. He now complains that he has an increased urge to urinate as well as urinary fre-quency, and this has disrupted the pattern of his daily life. What do you suspect is the cause of JH’s problem? What information would you gather to confirm your diagnosis? What treatment steps would you initiate?
Cholinoceptor antagonists, like the agonists, are divided into muscarinic and nicotinic subgroups on the basis of their specific receptor affinities. Ganglion blockers and neuromuscular junction blockers make up the antinicotinic drugs. The ganglion-blocking drugs have little clinical use and are discussed at the end of this chapter. Neuromuscular blockers are heavily used and are discussed in Chapter 27. This chapter emphasizes drugs that block muscarinic cholinoceptors.