Pediatric Organophosphates Toxicity Clinical Presentation

  • Author: William Freudenthal, MD; Chief Editor: Timothy E Corden, MD   more...
 
Updated: Nov 15, 2011
 

History

  • Most symptoms appear within 12-24 hours of exposure.
  • Exposure can occur by means of ingestion, dermal exposure, or inhalation.
  • Children often ingest home pesticides they find in unmarked or poorly stored containers.
  • Children can also be exposed when playing in areas recently treated with organophosphate compounds.
  • A history of possible exposure combined with physical signs and symptoms consistent with exposure often lead to diagnosis.
  • Many organophosphates can irritate the skin and mucous membranes. Some have a characteristic odor, such as a garliclike smell.
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Physical

Physical findings vary according to the route of exposure, the age of patient, and the specific chemical.

  • Muscarinic findings may include the following:[6]
    • Diaphoresis and diarrhea, urination, miosis, bradycardia, bronchorrhea, bronchospasm, emesis, lacrimation and salivation (DUMBELS)
    • Wheezing and/or bronchoconstriction
    • Pulmonary edema
    • Increased pulmonary and oropharyngeal secretions
    • Sweating
    • Bradycardia
    • Abdominal cramping and intestinal hypermotility
    • Miosis
  • Nicotinic findings may include the following:
    • Muscle fasciculations (twitching)
    • Fatigue
    • Paralysis
    • Respiratory muscle weakness
    • Diminished respiratory effort
    • Tachycardia
    • Hypertension
  • CNS findings may include the following:
    • Anxiety
    • Restlessness
    • Confusion
    • Headache
    • Slurred speech
    • Ataxia
    • Seizures
    • Coma
    • Central respiratory paralysis
    • Altered level of consciousness and/or hypotonia
  • Predominant symptoms and signs vary according to the age of the affected person. Children, particularly young children, present with altered levels of consciousness rather than the classic DUMBELS signs that are most commonly observed in adults.
    • Zwiener and Ginsburg (1988) retrospectively examined 37 patients aged 1 month to 11 years who had been exposed to insecticides.[7] The most common signs were miosis, excessive salivation, muscle weakness, and lethargy. Approximately 49% of these children presented with tachycardia.
    • Lifshitz et al (1999) retrospectively examined 36 children aged 2-8 years who were exposed to organophosphates or carbamates in Israel.[8] The authors observed a decreased level of consciousness, including coma, stupor, and hypotonicity in all children.
    • Lima and Reis (1995) reported carbamate poisoning in Rio de Janeiro.[9] Symptoms included salivation, lacrimation, urination, defecation, GI distress, and emesis (SLUDGE) and were more commonly observed in adults than in children.
    • Sofer et al (1989) retrospectively examined 25 patients aged 3 months to 7 years with carbamate or organophosphate poisoning in Israel.[10] The most common presenting symptoms were CNS depression, stupor, coma, and flaccidity. The classic SLUDGE symptoms were more likely to be absent in these children.
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Causes

Exposure to organophosphates through the skin, mucous membranes, conjunctiva, GI tract, or respiratory systems is the cause of organophosphate toxicity.

Other diagnostic considerations include the following:

  • Toxicity due to various poisons, such as carbamates, phosgene, paraquat,[11] and nerve agents, can cause symptoms similar to those of organophosphates.
  • In young children, suspect organophosphate poisoning if they have any illness that depresses the level of consciousness.
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Contributor Information and Disclosures
Author

William Freudenthal, MD  Staff Physician, Department of Emergency Medicine, St. Vincent Hospital Indianapolis, IN

William Freudenthal, MD is a member of the following medical societies: American College of Emergency Physicians and Association of Military Surgeons of the US

Disclosure: Nothing to disclose.

Coauthor(s)

Mark E Ralston, MD, MPH  Staff Pediatrician, Naval Hospital Oak Harbor; Assistant Professor of Pediatrics, F Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences

Mark E Ralston, MD, MPH is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael E Mullins, MD  Assistant Professor, Division of Emergency Medicine, Washington University in St Louis School of Medicine; Attending Physician, Emergency Department, Barnes-Jewish Hospital

Michael E Mullins, MD is a member of the following medical societies: American Academy of Clinical Toxicology and American College of Emergency Physicians

Disclosure: Johnson & Johnson stock ownership None; Savient Pharmaceuticals stock ownership None

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Jeffrey R Tucker, MD  Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut School of Medicine, Connecticut Children's Medical Center

Disclosure: Merck Salary Employment

Daniel Rauch, MD, FAAP  Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine

Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine

Disclosure: Baxter Honoraria Consulting

Chief Editor

Timothy E Corden, MD  Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin

Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, and Wisconsin Medical Society

Disclosure: Nothing to disclose.

References

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  2. Sadaka Y, Broides A, Tzion RL, Lifshitz M. Organophosphate acetylcholine esterase inhibitor poisoning from a home-made shampoo. J Emerg Trauma Shock. Jul 2011;4(3):433-4. [Medline]. [Full Text].

  3. van Heel W, Hachimi-Idrissi S. Accidental organophosphate insecticide intoxication in children: a reminder. Int J Emerg Med. Jun 15 2011;4(1):32. [Medline]. [Full Text].

  4. Sexton K, Ryan AD, Adgate JL, Barr DB, Needham LL. Biomarker measurements of concurrent exposure to multiple environmental chemicals and chemical classes in children. J Toxicol Environ Health A. Jan 2011;74(14):927-42. [Medline].

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  7. Zwiener RJ, Ginsburg CM. Organophosphate and carbamate poisoning in infants and children [published erratum appears in Pediatrics 1988 May;81(5):683]. Pediatrics. Jan 1988;81(1):121-6. [Medline].

  8. Lifshitz M, Shahak E, Sofer S. Carbamate and organophosphate poisoning in young children. Pediatr Emerg Care. Apr 1999;15(2):102-3. [Medline].

  9. Lima JS, Reis CA. Poisoning due to illegal use of carbamates as a rodenticide in Rio de Janeiro. J Toxicol Clin Toxicol. 1995;33(6):687-90. [Medline].

  10. Sofer S, Tal A, Shahak E. Carbamate and organophosphate poisoning in early childhood. Pediatr Emerg Care. Dec 1989;5(4):222-5. [Medline].

  11. Mortensen ML. Management of acute childhood poisonings caused by selected insecticides and herbicides. Pediatr Clin North Am. Apr 1986;33(2):421-45. [Medline].

  12. Burillo-Putze G, Hoffman RS, Howland MA, Duenas-Laita A. Late administration of pralidoxime in organophosphate (fenitrothion) poisoning. Am J Emerg Med. Jul 2004;22(4):327-8. [Medline].

  13. De Bleecker JL. The intermediate syndrome in organophosphate poisoning: an overview of experimental and clinical observations. J Toxicol Clin Toxicol. 1995;33(6):683-6. [Medline].

  14. Shahar E, Bentur Y, Bar-Joseph G, et al. Extrapyramidal parkinsonism complicating acute organophosphate insecticide poisoning. Pediatr Neurol. Nov 2005;33(5):378-82.

  15. Shahar E, Bentur Y, Bar-Joseph G, Cahana A, Hershman E. Extrapyramidal parkinsonism complicating acute organophosphate insecticide poisoning. Pediatr Neurol. Nov 2005;33(5):378-82. [Medline].

  16. Brahmi N, Mokline A, Kouraichi N, Ghorbel H, Blel Y, Thabet H. Prognostic value of human erythrocyte acetyl cholinesterase in acute organophosphate poisoning. Am J Emerg Med. Nov 2006;24(7):822-7. [Medline].

  17. Ellenhorn MJ. Organophosphates. In: Ellenhorn's Medical Toxicology: Diagnosis and Treatment of Human Poisoning. 2nd ed. Baltimore, MD: Lippincott, Williams and Wilkins; 1997:1614-21.

  18. Karr CJ, Solomon GM, Brock-Utne AC. Health effects of common home, lawn, and garden pesticides. Pediatr Clin North Am. Feb 2007;54(1):63-80, viii. [Medline].

  19. Kovacic P. Mechanism of organophosphates (nerve gases and pesticides) and antidotes: electron transfer and oxidative stress. Curr Med Chem. Dec 2003;10(24):2705-9. [Medline].

  20. Kozer E, Mordel A, Haim SB, Bulkowstein M, Berkovitch M, Bentur Y. Pediatric poisoning from trimedoxime (TMB4) and atropine automatic injectors. J Pediatr. Jan 2005;146(1):41-4. [Medline].

  21. Litovitz TL, Klein-Schwartz W, Caravati EM, et al. 1998 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. Sep 1999;17(5):435-87. [Medline].

  22. O'Malley M. Clinical evaluation of pesticide exposure and poisonings. Lancet. Apr 19 1997;349(9059):1161-6. [Medline].

  23. [Best Evidence] Peter JV, Moran JL, Graham P. Oxime therapy and outcomes in human organophosphate poisoning: an evaluation using meta-analytic techniques. Crit Care Med. Feb 2006;34(2):502-10. [Medline].

  24. Schexnayder S, James LP, Kearns GL, Farrar HC. The pharmacokinetics of continuous infusion pralidoxime in children with organophosphate poisoning. J Toxicol Clin Toxicol. 1998;36(6):549-55. [Medline].

 
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