Org a No Phosphate Poisoning Latestttttttt (2)

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Faizah Binti Abdul Rauf

ORGANOPHOSPHATEPOISONING


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ORGANOPHOSPHATECOMPOUND

OP compunds are diverse group ofchemical used in both domestic andindustrial settings

Examples:

Insecticides : malathion, parathion,diazinon

Nerve Gases : soman, sarin, tabun

Ophthalmic agents: echothiophate,isoflurophate

Antihelmintics : trichlorfon

Herbicides : tribufos [DEF], merphos


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OP POISONING

Usually from suicidal and accidental events.

Can occur through

- inhalation

- ingestion

- absorbtion (cutaneous)

v Generally oral or respiratory exposures

result in signs or symptoms within threehours.

v while symptoms of toxicity from dermalabsorption may be delayed up to 12 hours.


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PATHOTPHYSIOLOGY

Organophosphorous compounds bind toacetylcholinesterase

Inhibit acetylcholinesterase

ACh accumulates throughout the nervoussystem

Resulting in overstimulation of muscarinicand nicotinic receptors.


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CLINICAL MANIFESTATION

Can be divided into 3 categories

1) Muscarinic effects:

) SLUDGE: (Salivation, sweating,Lacrimation, Urination, Diarrhea, GI upset,Emesis)

) DUMBELS: (diaphoresis and diarrhea,urination, miosis, bradycardia,bronchospasm, bronchorrhea; emesis,

lacrimation, sweating and salivation)


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or SLUDGE BBB

SLUDGE = Salivation,Lacrimation,Urination,

Defecation,Gastric Emptying.

BBB = Bradycardia,

Bronchorrhea,Bronchospasm.


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2) Nicotinic effects:

- diaphoresis, hypoventilation, tachycardia

- Muscle fasciculations, areflexia, cramps

and weakness leading to flaccid muscleparalysis.

3) CNS effects:

- Anxiety, insomnia, confusion- Resp. depression

- Seizures and coma


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In children

Seizures are more common (22%-25%).

Lethargy and coma (54%-96%).

Flaccid muscle weakness,miosis,excessive salivationare common presenting signs


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ACH: acetylcholine; Epi: epinephrine; NE: norepinephrine; NMJ: neuromuscular

junction.


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DIAGNOSIS (clinicalfindings)v 88% of parents initially deny any exposure

history.

v petroleum or garlic-like odor.

v If doubt exists a trial of Atropine (0.01to 0.02 mg/kg) may be employed.

The absence of signs or symptoms ofanticholinergic effects following atropinechallenge strongly supports the diagnosis


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DIAGNOSIS (Lababnormalities)

RBC acetylcholinesterase activity:

Represents that was found on RBC membranesimilar to that found in neuronal tissue.

Therefore, more accurately reflects NS AChEinhibitor.

Determine the effectiveness of antidotetherapy.

Plasma (or pseudo-) cholinesteraseactivity:

more easily performed.


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MANAGEMENT

1) Initial resuscitation

v)Deliver 100 % oxygen via facemask

v)Strongly consider intubation:

patients who appear mildly poisoned may rapidlydevelop respiratory failure.

v)Consider volume resuscitation with normalsaline or ringer to treat Bradycardia and

hypotension.v)Monitor ECG, vital signs every 5-15 min, pulse

oximetry.

v) In cases of dermal exposure aggressivedecontamination with complete removal of the


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2) Drug therapy

Use activated charcoal within one hour ofan ingestion.

dosage: 1g/kg body wtAtropine : 1st drug to be given

Competes with acetylcholine at

muscarinic receptors.Major use: reduce broncorrhea and

bronchospasm


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DOSAGE:

Adult:

v Initial dose 2 mg IV bolus.

v Doubled every 10 min until bronchial secretions andwheezing stop .

Paeds:

v Initial dose 0.05 mg/kg IV bolus.

v Doubled every 10 min until bronchial secretions arecontrolled.


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v Keep a maintenance dose of atropine for 2-3 days after disappearing of manifestation.

vTachycardia and mydriasisare notappropriate markers for therapeuticimprovement, as they may indicatecontinued hypoxia, hypovolemia, or

sympathetic stimulation.

v Fever, musclefibrillation, and delirium arethe main signs ofatropine toxicitythatindicate that atropine administration should


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Pralidoxime

Cholinesterase reactivating agent that areeffective in treating both muscarinic andnicotinic symptoms.

v Use within 48 hours after poisoning.

v

Use with concurrent ofatropine.

v Effects will be apparent within 30 minutes

v Dosage: Adult:- 1g IV, Children:- 25-50


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Benzodiazepine (diazepam)

-To reduce anxiety and restlessness and tocontrol convulsions

- Dosage: -5-10 mg IV for anxiety orrestlessness

-up to 10-20 mg IV for control ofconvulsions.

Org a No Phosphate Poisoning Latestttttttt (2)

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