Intra-aural Route of Insecticide Poisoning
A 51-year-old housewife with no premorbid illness presented to the emergency department within 2 h of allegedly pouring monocrotophos (WHO Class Ib OP compound) into both her ears with the intention of deliberate self-harm after a family dispute. The daughter witnessed her pouring the OP compound into her ears as an impulsive act with no oral consumption. She had gastric cramps and loose stools with no other SLUDGE symptoms (SLUDGE–salivation, lacrimation, urination, defecation, gastric cramps and emesis). She also complained of burning sensation in both the ears. On examination she was drowsy, restless, and disoriented to time, place, and person. Her heart rate was 100/min, blood pressure was 100/70 mmHg, respiratory rate was 22/min, and pupil size was 2 mm bilaterally. She did not have neck muscle weakness or fasciculations. Examination of the ears did not reveal any sign of local inflammation, and bilateral tympanic membrane appeared intact. Rest of the systemic examination was unremarkable. Plasma butyrylcholinesterase level was 1141 U/L (reference range 3000-8000 U/L), thus confirming OP poisoning. Multiple aural irrigations with normal saline were performed to decrease further absorption of monocrotophos. Bolus doses of atropine were given to maintain the heart rate above 100/min. A low-dose atropine infusion was administered for 2 days and the patient was monitored in the ward for 5 days. She did not develop intermediate syndrome and was subsequently discharged after psychiatry counseling.