What were several patients from a theme park exposed to, presenting with respiratory distress, diarrhea, sweating, miosis, and altered mental status?

Organophosphate (Nerve Agent) Exposure

These patients were exposed to an organophosphate compound or nerve agent. The constellation of respiratory distress, diarrhea, sweating, miosis (pinpoint pupils), and altered mental status represents the classic cholinergic toxidrome from acetylcholinesterase inhibition 1, 2.

Clinical Recognition

The presentation matches the characteristic SLUDGE syndrome (Salivation, Lacrimation, Urination, Defecation, Gastric cramps, Emesis) plus respiratory distress and altered mental status 3. Key distinguishing features include:

• Miosis (pinpoint pupils) - pathognomonic for cholinergic excess 1, 2
• Respiratory distress - from bronchospasm, bronchorrhea, and respiratory muscle weakness 1, 2
• Excessive secretions - sweating and diarrhea from muscarinic overstimulation 1, 3
• Altered mental status - from central nervous system effects 1, 2

Multiple patients presenting simultaneously from a single location (theme park) suggests either intentional release (bioterrorism) or accidental mass exposure 1.

Immediate Management Algorithm

1. Provider Safety First

• Healthcare workers must use personal protective equipment immediately - organophosphates can cause secondary poisoning through contact with contaminated clothing, secretions, and emesis 1, 2
• Document cases exist where healthcare workers required atropine, pralidoxime, and intubation for 24 hours after exposure to patient secretions without PPE 1, 2

2. Decontamination

• Remove all contaminated clothing and perform copious irrigation with soap and water 2
• Isolate contaminated materials to prevent off-gassing exposure to staff 1

3. Antidote Administration (Do Not Delay)

Atropine:

• Give 1-2 mg IV immediately for adults (0.02 mg/kg for children, minimum 0.1 mg) 2
• Double the dose every 5 minutes until bronchorrhea, bronchospasm, and bradycardia resolve 2
• Therapeutic endpoint is "atropinization": dry lungs, adequate oxygenation, dry skin/mucous membranes, mydriasis 2
• Tachycardia is NOT a contraindication to continued atropine - it is an expected effect and the nicotinic stimulation from organophosphate itself may cause tachycardia 2

Pralidoxime (2-PAM):

• Give 1-2 g IV (adults) as loading dose, administered slowly by infusion 2
• Follow with continuous infusion at 400-600 mg/hour (adults) or 10-20 mg/kg/hour (children) 2
• Must be given early before "aging" of the phosphorylated enzyme occurs 2
• American Heart Association gives Class 2a recommendation with Level A evidence 2
• Always administer concurrently with atropine - pralidoxime alone is insufficient for respiratory depression 2

Benzodiazepines:

• Administer diazepam or midazolam for seizures and agitation 2

4. Airway Management

• Early endotracheal intubation is recommended for life-threatening poisoning 2, 4
• NEVER use succinylcholine or mivacurium - these depolarizing agents are metabolized by cholinesterase and are contraindicated in organophosphate poisoning 2, 5, 6
• Use alternative neuromuscular blockers if needed 2

Critical Pitfalls to Avoid

• Do not wait for laboratory confirmation - treatment must be instituted immediately based on clinical presentation 2
• Do not stop atropine due to tachycardia or fever - these are expected effects and inadequate atropinization leads to respiratory failure and death 2
• Do not handle gastric contents without PPE - healthcare workers have required intensive care after exposure to contaminated emesis 1, 2
• Do not delay intubation - three patients with intermediate syndrome died due to delayed recognition of respiratory failure 4

Monitoring and Complications

Watch for delayed complications:

• Intermediate syndrome occurs in ~20% of patients, typically 2-4 days after exposure when acute symptoms resolve 7, 4
• Presents with weakness of respiratory muscles, neck muscles, and proximal limbs requiring prolonged ventilation (7-21 days) 7
• Respiratory failure is the most common cause of death - monitor respiratory rate closely (increase from 22 to 38 breaths/min signals impending failure) 4
• Rhabdomyolysis from calcium overload in skeletal muscle - monitor creatine kinase and potassium, treat with hydration and urine alkalinization 2

Specific Exposure Context

Given the theme park setting with multiple simultaneous victims, consider:

• Nerve agents (sarin, tabun, soman, VX) - these are among the most lethal compounds known with LCt50 values 500 times more toxic than hydrogen cyanide 1
• The Tokyo sarin attack resulted in over 100 healthcare providers developing symptoms from secondary exposure 1
• Organophosphate pesticides are more commonly encountered but less likely in mass casualty scenarios 1