Summary: Malathion poisoning is difficult to manage due to its unpredictable toxicity and highly transmissible nature. This case demonstrates the tumultuous patient journey and the importance of appropriate personal protective equipment (PPE). A 25-year-old previously well man presented to the ED for altered mental status in a postictal state with notable tachycardia. Given pungent secretions, all attending personnel wore gowns, gloves, goggles, and N95 masks. His clothes were removed, double-bagged, and he was wiped down. The toxicology service was consulted and guided subsequent management. He was given IV atropine boluses and pralidoxime infusion. He was intubated in the ED and given activated charcoal via nasogastric tube. He was continued on IV Atropine infusion. The attending ED staff experienced possible side effects of poisoning (lightheadedness and vomiting). The clinical impression was a cholinergic toxidrome, likely organophosphate poisoning. Red blood cell (RBC) cholinesterase levels were low. Blood toxicology revealed malathion. He suffered two cardiac arrests on Days 6 and 8 that coincided with low intravenous atropine infusion rates. He also required reintubation during the second cardiac arrest. RBC cholinesterase levels remained low until Day 13. IV atropine infusion was terminated on Day 13 when the secretions stopped. IV pralidoxime was stopped on Day 14, and he was transferred out of the ICU the same day. He had no neurological deficits when he was discharged to a psychiatric hospital on Day 17. This case highlights the clinical dilemmas when managing a patient with malathion poisoning concerning safety for extubation, cessation of atropine infusion, and the risks from vagal overstimulation during procedures like intubation and suctioning. Although malathion has low volatility, secondary contamination of staff can still occur due to the presence of volatile hydrocarbons or solvents off-gassing when the patient vomits and during suctioning. Management of these patients can be resource-intensive.
Jaffar et al. (Sun,) studied this question.