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Retired NBME 23 Answers

nbme23/Block 4/Question#34 (reveal difficulty score)
A 44-year-old man who is a farmer and has ...
Area labeled โ€˜Dโ€™ ๐Ÿ” / ๐Ÿ“บ / ๐ŸŒณ / ๐Ÿ“–
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submitted by โˆ—mcl(671)
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To expand on this, organophosphates are commonly used as insecticides, and function by binding acetylcholinesterase and "deactivating" it, so to speak. This results in an excess of ACh within the synapse, which causes sludge syndrome (vomiting, sweating, diarrhea -- basically lots of fluids). The treatment for this is typically atropine (antimuscarininic), and pralidoxime (if given early enough, can "reactivate" the ACh-ases). The diagram given does not show ACh-ase, only the ACh-R, therefore D is the best answer.

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lowyield  Also according to uworld you give atropine before pralidoxime because pralidoxime can cause an initial exacerbation (even though you might think you should give pralidoxime first because it is time sensitive) +5
handsome  FA 2020 Pg 248 "Atropine>pralidoxime" +1
fhegedus  FA 2020 page 241 says atropine is given for muscarinic symptoms (DUMBBELLS) while pralidoxime is primarily used for the nicotinic symptoms of acetylcholinesterase poisoning. The q stem has muscarinic symptoms (vomiting, diarrhea, salivation), so the best option to give atropine, which acts at muscarinic receptors +1

To expand further, atropine is used to reverse MUSCARINIC symptoms (i.e. "DUMBBELSS": Diarrhea, Urination, Miosis, Bradycardia, Bronchospasm, Emesis, Lacrimation, Salivation, Sweating) and it can also cross the BBB to relieve the CNS symptoms (i.e. respiratory depression, lethargy, seizures, coma). However, pralidoxime is used to reverse NICOTINIC symptoms (i.e. the neuromuscular blockade). Pralidoxime CANNOT cross the BBB and therefore cannot relieve CNS symptoms. And always give atropine before pralidoxime because pralidoxime can cause transient acetylcholinesterase inhibition, which will worsen the symptoms.

+1/- fatboyslim(118)


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submitted by โˆ—mousie(272)
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Organophosphate poisoning = Antidote = Atropine (Airway M receptor blocker) = dilation of bronchioles

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