Answer quizzER 1.1

quizzER Winners:

Brian McMichael          Rob Klever               Marjan Siadat

Samuel Lee                 Jeff McMenomy        David Mishkin

Allison Loynd              Scott Ottolini            Devon Moore

Julie Nguyen               Brian Kern                Richard Gordon

Last Week’s Question


The answer is c.

The patient drank insecticide, which is primarily composed of organophosphate compounds (e.g., Malathion). These compounds inhibit acetylcholinesterase, the enzyme responsible for the breakdown of acetylcholine. The patient is having a “cholinergic crisis.” Overstimulation of muscarinic and nicotinic receptors leads to his symptoms, commonly remembered by the mnemonics SLUDGE (Salivation, Lacrimation, Urination, Defecation, Gastrointestinal [GI] upset, Emesis) or DUMBBELS (Defecation, Urination, Miosis, Bronchospasm, Bronchorrhea, Emesis, Lacrimation, Salivation). The treatment for organophosphate toxicity is atropine and pralidoxime (2-PAM). Atropine is an anticholinergic, therefore it competitively inhibits the excess acetylcholine. Pralidoxime works to regenerate acetylcholinesterase, therefore also limiting the amount of acetylcholine available in neuronal synapses.

(a) Pilocarpine is a non-selective muscarinic receptor agonist  that is used in the treatment of chronic open-angle glaucoma and acute angle-closure glaucoma.  Suxamethonium, also known as succinylcholine, is a depolarizing neuromuscular blocker.  It imitates the action of acetylcholine at the neuromuscular junction, acting on muscle type nicotinic receptors, but it is not degraded by acetylcholinesterase, rather by butyrylcholinesterase, a plasma cholinesterase. (b) N-Acetylcysteine is used in APAP (Acetaminophen) overdoses. (d) Flumazenil reverses benzodiazepines (e.g., diazepam). (e) Physostigmine is a reversible cholinesterase inhibitor. Its effect is to increase acetylcholine in the pre- and postsynaptic junctions. This will worsen the patient’s condition by exacerbating the cholinergic syndrome.

Thank you for everyone who submitted an answer.  Please stay tuned for next week’s quizzER.

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training.

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