eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Toxicology

Toxicity, Organophosphates: Follow-up

Author: William Freudenthal, MD, Staff Physician, Department of Emergency Medicine, St. Vincent Hospital Indianapolis, IN
Coauthor(s): Mark Ralston, MD, Department of Pediatric Emergency Medicine, Clinical Assistant Professor, Mary Bridge Children's Hospital, Tacoma WA
Contributor Information and Disclosures

Updated: Jan 23, 2008

Follow-up

Further Inpatient Care

  • Admit patients to the hospital if they require therapy with anticholinergenic agents or 2-PAM. Monitoring, respiratory support, and ventilation may be needed.
  • Consult poison control center personnel for information regarding the specific agent, the length of inpatient treatment, and the duration of likely toxicity.

Further Outpatient Care

  • Patients with minor or no symptoms of toxicity after organophosphate exposure may be discharged from the emergency department after 6 hours of observation.
  • Discharged patients usually do not require outpatient medications.

Transfer

  • Transfer pediatric patients with severe life-threatening exposures to a facility with a pediatric intensivist and intensive care unit.
  • Patients should be clinically stable before their transfer.

Deterrence/Prevention

  • Use of safety lids on accessible containers of pesticides
  • Proper storage of chemicals in the home
  • Legislation regarding the sale and storage of dangerous chemicals

Complications

  • Intermediate syndrome can develop 24-96 hours after exposure.10
    • This syndrome is characterized by weakness in the motor cranial nerves, proximal limb muscles, neck flexors, and respiratory muscles.
    • The syndrome tends to occur in patients with prolonged exposure before treatment.
    • A combination of presynaptic and postsynaptic impairment of neuromuscular transmission probably causes the syndrome.
  • A delayed peripheral neuropathy may develop days to weeks after the exposure.
  • Patients may also have persistent CNS effects, weakness, lethargy, fatigue, and memory impairment.
  • Shahar et al reported extrapyramidal parkinsonism as a complication of acute organophosphate poisoning.11,12 Symptoms developed 5 days after exposure and completely resolved after treatment with amantadine.

Prognosis

  • The prognosis for patients treated early is excellent; most patients fully recover in 7-10 days.
  • Patients with toxicity untreated for more than 24 hours may have a prolonged and severe course with lasting neurologic complications.

Miscellaneous

Medicolegal Pitfalls

  • Organophosphate poisoning can have various atypical presentations, especially in young children.
    • Physicians must consider and treat potential life-threatening complications, even if confirmatory laboratory or diagnostic tests are not available.
    • The variation in presentations can potentially lead to misdiagnosis and subsequent medicolegal pitfalls.
  • After acute organophosphate poisoning is confirmed, the patient should be admitted to intensive care with staff experienced in treating critically ill children. Physicians should be keenly aware of their hospitals' capabilities and criteria for transfer to a tertiary care center.
  • Most organophosphate poisonings occur in the home and may be secondary to improper storage, the illegal use of chemicals, or suicidal or homicidal actions. All exposures should be thoroughly investigated to avoid missing potential cases of abuse or neglect.
  • Exposures can occur on children's playgrounds, fields, and gardens and should be investigated to prevent the exposure of other children.
 


More on Toxicity, Organophosphates

Overview: Toxicity, Organophosphates
Differential Diagnoses & Workup: Toxicity, Organophosphates
Treatment & Medication: Toxicity, Organophosphates
Follow-up: Toxicity, Organophosphates
Multimedia: Toxicity, Organophosphates
References
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References

  1. Bryant S, Singer J. Management of toxic exposure in children. Emerg Med Clin North Am. Feb 2003;21(1):101-19. [Medline].

  2. Lawrence DT, Kirk MA. Chemical terrorism attacks: update on antidotes. Emerg Med Clin North Am. May 2007;25(2):567-95; abstract xi. [Medline].

  3. Barthold CL, Schier JG. Organic phosphorus compounds--nerve agents. Crit Care Clin. Oct 2005;21(4):673-89, v-vi. [Medline].

  4. 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].

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

  6. 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].

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

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

  9. 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].

  10. 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].

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

  12. 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].

  13. 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].

  14. 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.

  15. 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].

  16. 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].

  17. 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].

  18. 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].

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

  20. [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].

  21. 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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Further Reading

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Keywords

organophosphate, carbamate poisoning, organophosphate poisoning, organophosphate exposure, OP, OP poisoning, OP exposure, OP toxicity, insecticide poisoning, insecticide exposure, insecticide toxicity, pesticide poisoning, pesticide exposure, pesticide toxicity, pseudocholinesterase, cholinesterase, tachycardia, respiratory failure, diaphoresis, diarrhea, urination, miosis, bradycardia, bronchorrhea, bronchospasm, emesis, lacrimation, salivation, DUMBELS, pulmonary edema, SLUDGE

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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 Ralston, MD, Department of Pediatric Emergency Medicine, Clinical Assistant Professor, Mary Bridge Children's Hospital, Tacoma WA
Mark Ralston, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Medical Editor

Michael E Mullins, MD, Assistant Professor, Department of Emergency Medicine, Washington University School of Medicine
Michael E Mullins, MD is a member of the following medical societies: American Academy of Clinical Toxicology and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Jeffrey R Tucker, MD, Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut and Connecticut Children's Medical Center
Jeffrey R Tucker, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Pediatrics, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

CME Editor

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: Nothing to disclose.

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.

 
 
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