Organophosphate Poisoning:

by ER staffs

cide)
-organophosphate poisoning
accounts for nearly one third
of hospital admissions from
poisoning
-Commonly using trades are
follows.
Malathion, parathion,
diazinon, fenthione,
chlorpyrifos.
Organophosphate
poisoningresults from
exposure to
organophosphates(OPs),
which cause the inhibition
of acetylcholinesterase
(AChE), leading to the
accumulation of
acetylcholine (ACh) in the
body.(toxicity)

Who are at risk?

This kind of poison
was used as chemical
weapon during the
Persian-Gulf war.
WWII
Used in Damascus,
Syria in 2013
(chemical known as
sarin)
Jamaican ginger palsy
accident.
Farmers, using
insecticides.
Children (from

clinical features
depends on route of
entry

ingestion
inhalation
direct contact

Ingestion
Muscarinic effects(post ganglionic
parasympathetic nerve ending)

Bronchospasm(wheezing)
Bronchorrhoea
Productive cough
Dyspnoea
Hypotension
Bradycardia
Cardiac arrhythmiaNicotinic effects (neuro
muscular junction)
Diarrhoea
Vomiting
Muscle
Salivation
weakness
Tenesmus
Fasciculation
Miosis (pin point pupil)
Paralysis
Lacrimation
Muscle twitching
Blurred vision

Nicotinic and
muscarinic Ach
receptors
in the CNS
Confusion

Agitation
Ataxia
Convulsion
Respiratory failure

Ach receptors in the

sympathetic system

Excessive sweating
Hyperglycemia
Acute pancreatitis

Inhalation

Eye contact

Cough
Difficulty in breathing
Bronchitis
Pneumonia

Irritation
Pain
Lacrimation
Miosis
Blurring vision
Photophobia

Diagnostic
test:
Measurements of OP metabolites in both the blood and
urine can be used to determine if a person has been
exposed to organophosphates. Specifically in the blood,
metabolites of cholinesterases, such as
butyrylcholinesterase(BuChE) activity in plasma,
neuropathy target esterase(NTE) in lymphocytes, and of
acetylcholinesterase(AChE) activity in red blood cells.
The most widely used portable testing device is the Testmate ChE field test,which can be used to determine levels
of Red Blood Cells (RBC), AChE and plasma (pseudo)
cholinesterase (PChE) in the blood in about four minutes.
This test has been shown to be just as effective as a regular
laboratory test and because of this, the portable ChE field
test is frequently used by people who work with pesticides
on a daily basis.

Other diagnostic test

include:
Leukocytosis
Hemoconcentration
Metabolic and/or
respiratory acidosis
Hyperglycemia
Hypokalemia
Hypomagnesemia
Elevated troponin levels
Elevated amylase levels
Elevated liver function test
results

Management of organophosphate poisoning

1. check airway, breathing, circulation.
2. monitor arterial oxygen saturation, cardiac
rhythms, BP,
Pulse rate.
3. look for signs & symptoms.
4. obtain IV access.
5. remove the contaminated clothes&wash the
skin thoroughly with soap & water
6. give atropine intravenously as soon as possible
for symptomatic patient
7. perform gastric decontamination with gastric
lavage once the patient is stabilised & within two
hours of ingestion.
8. give activated charcoal (50 g in 200 ml)
9. maintainance atropine infusion
10. give pralidoxime.

Managemen
t:

OROPHARYNGEAL AIRWAY USED

VENTILATION & ET TUBE

GASTRIC LAVAGE
CHARCOAL

AMBU

ACTIVATED

PRALIDOXIME
CHOLRIDE

ATOPHINE
SULPHATE

ACTIVAT
ED
CHARCO
AL

Atropinisation
-start with 1.8-3.0 mg fast iv bolus
-after 3-5minutes check the five parameters of cholinergic
poisoning
1. Poor air entry into the lungs due to bronchorroea &
bronchospasm
2.excessive sweating
3. bradycardia ( <60 )
4. hypotension
5. miosis
-If above parameters are not corrected
double the dose of atropine every 5 minutes until atleast 3/5 of below parameters
corrected
-clear chest with no wheeze
-dry axillae
-heart rate 80-100 bpm
-systolic BP > 90 mmhg
-pupils no longer pinpoint

Maintenance infusion
once the patient is stable start an infusion of 5% dextrose containing 10-20%
of the total initial dose of atropine on an hourly basis
stop atropine infusion if features of toxicity appears
-confusion
-urinary retention
-hyperthermia
- bowel ileus
- agitation
- flushing
- tachycardia
Pralidoxime
give 30mg/kg loading dose Iv over 10-20mins followed by
continuous infusion of 8-10mg/kg/hr until clinical recovery.

1.Respiratory failure- ET intubation and

mechanical
ventilation required if
- tidal volume <5mm/kg
- vital capacity < 15 ml/kg
-apnoic spells are present
-PaO2 < 08 Kpa& FiO2 > 60%
-severe pulmonary oedema
2.Pulmonary oedema- give furosemide 40-80
mg iv
3.convulsion give 5-10 mg iv diazepam
4.intermediate syndrome
weakness of neck flexion
tachypnoea
use of accessory muscle of respiration
sweating
proximal muscle weakness
nasal
flaring
cranial nerve palsies
5. ventricular tachycardia- temporary pacing
6.bronchopneumonia- antibiotics & chest