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Organophosphorus poisoning
1. Dr Manazir
Dept of Anaesthesiology & Critical Care
Jawaharlal Nehru Medical College
AMU, Aligarh
2. Raju a 27 yr old male, brought to casualty at
1:00 am with history of sudden loss of
consciousness in his room after having a
family quarrel.
He had 4 episodes of non-bilious vomiting.
No h/o blood in vomitus.
H/O of incontinence of urine and faeces.
H/O Alcoholism
4. Pupils: B/L pinpoint, non reacting to light
Tone: Increased
Power: Movement Against gravity
Plantar reflex: Non elicitable
Bowel sounds: Exaggerated
Normal
Size..???
10. They can be classified as three categories:
A. Derivatives of phosphoric (H3PO4), phosphorus
(H3PO3) & phosphinic acid (H3PO2) e.g
dichlorvos, glufosinate
B. Derivatives of phosphine (PH3).
C. Derivatives of phosphorothioates(c=s) e.g diazinon,
parathion, and bromophos
11. • Nerve agents
• Insecticides
• Glaucoma treatments
• Myasthenia gravis
• Potential uses in alzheimer’s disease and dementia
13. Organophosphates vs. Carbamates
Organophosphates Carbamates
Cholinesterase Non-reversible reversible
Symptoms Vomiting, diarrhea, exhaustion,
convulsion, miosis
Atropine yes Yes
Aging of enzyme Yes No
2-PAM Yes, within a few
hours
No
23. 88% of patients initially deny any exposure history.
Petroleum or garlic-like odor.
If doubt exists a trial of atropine (0.01 to 0.02
mg/kg) may be employed
The absence of s/s of anticholinergic effects
following atropine challenge strongly supports the
diagnosis .
26. Red cell acetylcholinesterase inhibition is a good
marker of severity
Red cell ACEs ≥ 30% - normal muscle function,
no atropine
Less than 10% - deranged funct., high dose
atropine
Between 10-30%- moderate impairment and need
for atropine.
Recovers @ 1% per day
27. Plasma butyrylcholinesterase activity does not
relate to severity of poisoning
More easily performed
A depression of 25% or more – severe .
Recovers @ 7% per day
28. These enzymes facilitate the decision
about
When to stop oxime and
Allow cautious weaning of a patient
30. 1. Check airway, breathing, circulation.
2. Monitor Vitals and cardiac rhythm
3. Look for signs & symptoms
4. Obtain IV access
5. Remove contaminated clothes & wash the
skin thoroughly with soap & water.
Management of organophosphate
poisoning
31. 6. Atropine intravenously as soon as possible for
symptomatic patient
7. Pralidoxime (Reactivator)
8. Gastric lavage once the patient is stabilized &
within 2 hours of ingestion with activated
charcoal (50 g in 200 ml)
9. Maintenance atropine infusion
32. Wash at least 3 times with soap (containing
chlorhexidine and alcohol) and water, paying
particular attention to hair, skin folds and
underneath nail beds.
33. Gastric lavage decreases absorption by 42% if
done within 20 min
By 16% if performed at 60 min
Choice of fluid is tap water @ 5-10 ml/kg
Performed by first aspirating the stomach and
then repetitively instilling & aspirating fluid
34. Lateral position better - delays spont.
Absorption
No evidence that larger tube better
Preferably done on awake patients
ET tube preferred if GCS is low.
35. Start with 1.8-3.0 mg fast iv bolus
After 3-5minutes check
1. Bronchorroea & bronchospasm
2. Bradycardia ( <60 )
3. Miosis
4. Excessive sweating
5. Hypotension
If not corrected double the dose of atropine every
5 minutes until signs of atropinization.
36. 1. Clear chest on auscultation with no wheeze
2. Heart rate >80 beats/min
3. Pupils no longer pinpoint
4. Dry axillae
5. Systolic blood pressure >80 mmHg
37. D5 + 10-20% of the total initial dose of
atropine on an hourly basis. (after
stabilization)
STOP atropine infusion if features of toxicity
42. 1. Acute cholinergic crisis
2. Intermediate syndrome (IMS)—major cause
of morbidity and mortality
3. Delayed neuropathy
43. Excess acetylcholine at NMJ causes downregulation
of nicotinic receptors- muscles affected
Inadequate oxime therapy,
Respiratory failure without muscarinic signs
Muscle necrosis,
Failure of postsynaptic acetylcholine release, and
oxidative stress-related myopathy.
44. C/F typically occur within 24 to 96 hours &
persists for 4-18 days
Affecting conscious patients without cholinergic
signs, and
Involve the muscles of respiration, proximal
limb muscles, neck flexors, and muscles
innervated by motor cranial nerves
45. Assess flexor neck strength regularly (head
lift & hold against resistance)
Weakness is a sign of peripheral respiratory
failure (intermediate syndrome).
TV checked every 4 hrly.
TV< 5 mL/kg / VC<15 mL/kg, PaO2<
60mmHg on FiO2 of >60% or apnoeic spells
suggest mechanical Ventilation need.
46. 1. Organophosphate induced delayed neuropathy
(OPIDN)
o 2-3 weeks after large dose
oPeripheral/distal neuropathy (proximal sparing)
oDue to inhib Neuropathy Target Esterases (NTE)
oRecovery can take up to 12 month
2. Chronic organophosphate induced
neuropsychiatric disorder (COPIND)
48. Prophylactic diazepam shown to decrease
neurocognitive dysfunction after poisoning.
Diazepam 0.1-0.2 mg/kg IV, repeat as necessary if
seizures occur.
Phenytoin has no effect on organophosphate agent-
induced seizures.
49. FRUSEMIDE – for persistent pulmonary
oedema after full atropinization.
50. Magnesium
Reduces acetylcholine release
Block pre-synaptic calcium channel
Clonidine
Decrease the presynaptic synthesis and release of acetylcholine
(Central > peripheral synapse)
NaHCO3
Reversible Ach esterase - pyridostigmine
Glutamate antagonist
54. It is a dual chamber autoinjector
1. Atropine sulfate and
2. Pralidoxime
Only effective against the nerve agents tabun
(ga), sarin (gb), soman (gd) and vx.
55. A newer model, the ATNAA (Antidote
Treatment Nerve Agent Auto-Injector),[1]
Has atropine and the pralidoxime in one
syringe
56. Signs &
Symptoms
Atropine Dose 2-PAM Dose
Severe Respiratory
Distress,
Agitation
3 Auto-injectors (6
mg)
Monitor every 5
minutes
3 Auto-injectors
(1.8 gms)
Mild Respiratory
Distress
2 Auto-injectors (4
mg)
Monitor every 10
minutes
1 Auto-injector
(600 mg)
Asymptomatic
None
Monitor for signs &
symptoms
every 15 minutes
none
57. Read the label before
selecting and applying
any pesticide.