Pediatric Organophosphates Toxicity Treatment & Management
- Author: William Freudenthal, MD; Chief Editor: Timothy E Corden, MD more...
Prehospital care includes the following:
Ensure airway support and ventilation and perform endotracheal intubation, if necessary, in patients with respiratory failure.
Circulatory support with intravenous (IV) access, fluids, and cardiac and pulse oximetry monitoring can facilitate safe transport.
Decontamination is of the utmost importance in minimizing continued exposure and to protect providers and other patients from contamination. Decontamination involves removing all of the patient's clothing and washing him or her with water and soap.
By describing the scene, prevalent odors, or other casualties, prehospital providers may provide important clues to the presence of exposure.
Emergency department care
Assess the patient's airway, breathing, and circulation (ABCs). Secure the airway and perform cardiovascular resuscitation if needed. Endotracheal intubation may be necessary for airway protection and ventilatory support.
If the patient's condition is stable, decontamination is the next priority. Patients who are inadequately decontaminated may expose rescue personnel and hospital staff to the toxin. Prehospital providers may also need decontamination. The dermal decontamination of exposed individuals is a priority before they enter the emergency department, where they can contaminate other patients and staff members. Gastric decontamination with activated charcoal should be performed in cases of ingestion.
Severe exposures require expeditious anticholinergic therapy. Atropine antagonizes the central and muscarinic effects by blocking these receptors. Atropine does not bind to nicotinic receptors; hence, muscular weakness, including respiratory muscle weakness, is not affected.
Anticholinergic agents should be used in doses large enough to reverse the cholinergic signs. Some authors recommend giving atropine until signs of atropinization appears. These signs include warm, dry, flushed skin; dilated pupils; and an increased heart rate.
Atropine should be used for at least 24 hours to reverse the cholinergic signs while the organophosphate is metabolized. Atropine is indicated when evidence of bronchorrhea and other secretions is present.
Pralidoxime (2-PAM) is a cholinesterase reactivator and the antidote for organophosphate poisoning. Administer 2-PAM to patients with organophosphate exposure and signs of muscle and respiratory muscle weakness. This drug primarily affects the nicotinic receptors and does not reverse the CNS effects. Administer 2-PAM as soon as possible because its effectiveness decreases with prolonged exposure due to the aging of the organophosphate-cholinesterase bond. Administer 2-PAM as an IV infusion after a loading dose until signs of weakness improve.
Treat seizures that do not respond to 2-PAM with benzodiazepines. In experimental models, midazolam effectively terminates seizures caused by organophosphates; however, the efficacy of benzodiazepines decreases when these drugs are given 30 minutes or more after organophosphate exposure or seizure onset.
In a child with acute, severe organophosphate poisoning that was unresponsive to standard treatments, Yesilbas and colleagues reported successful treatment with high-volume continuous venovenous hemodiafiltration and therapeutic plasma exchange combined with lipid infusion.
Avoid the use of morphine, caffeine, loop diuretics, theophylline, and succinylcholine in patients with organophosphate poisoning because these drugs can increase the toxicity of the exposure.
See the list below:
Consult a medical toxicologist or poison control center personnel early in the course of treatment.
Consult a critical care specialist early in severe poisonings for ongoing care outside the emergency department.
Bryant S, Singer J. Management of toxic exposure in children. Emerg Med Clin North Am. 2003 Feb. 21(1):101-19. [Medline].
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. 2011 Jan. 74(14):927-42. [Medline].
Lawrence DT, Kirk MA. Chemical terrorism attacks: update on antidotes. Emerg Med Clin North Am. 2007 May. 25(2):567-95; abstract xi. [Medline].
Mowry JB, Spyker DA, Cantilena LR Jr, McMillan N, Ford M. 2013 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 31st Annual Report. Clin Toxicol (Phila). 2014 Dec. 52 (10):1032-283. [Medline]. [Full Text].
Barthold CL, Schier JG. Organic phosphorus compounds--nerve agents. Crit Care Clin. 2005 Oct. 21(4):673-89, v-vi. [Medline].
Zwiener RJ, Ginsburg CM. Organophosphate and carbamate poisoning in infants and children [published erratum appears in Pediatrics 1988 May;81(5):683]. Pediatrics. 1988 Jan. 81(1):121-6. [Medline].
Lifshitz M, Shahak E, Sofer S. Carbamate and organophosphate poisoning in young children. Pediatr Emerg Care. 1999 Apr. 15(2):102-3. [Medline].
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].
Sofer S, Tal A, Shahak E. Carbamate and organophosphate poisoning in early childhood. Pediatr Emerg Care. 1989 Dec. 5(4):222-5. [Medline].
Mortensen ML. Management of acute childhood poisonings caused by selected insecticides and herbicides. Pediatr Clin North Am. 1986 Apr. 33(2):421-45. [Medline].
Burillo-Putze G, Hoffman RS, Howland MA, Duenas-Laita A. Late administration of pralidoxime in organophosphate (fenitrothion) poisoning. Am J Emerg Med. 2004 Jul. 22(4):327-8. [Medline].
Reddy SD, Reddy DS. Midazolam as an anticonvulsant antidote for organophosphate intoxication--A pharmacotherapeutic appraisal. Epilepsia. 2015 Jun. 56 (6):813-21. [Medline].
Yesilbas O, Kihtir HS, Altiti M, Petmezci MT, Balkaya S, Bursal Duramaz B, et al. Acute severe organophosphate poisoning in a child who was successfully treated with therapeutic plasma exchange, high-volume hemodiafiltration, and lipid infusion. J Clin Apher. 2015 Aug 14. [Medline].
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].
Horton MK, Kahn LG, Perera F, Barr DB, Rauh V. Does the home environment and the sex of the child modify the adverse effects of prenatal exposure to chlorpyrifos on child working memory?. Neurotoxicol Teratol. 2012 Sep-Oct. 34(5):534-41. [Medline].
Shahar E, Bentur Y, Bar-Joseph G, et al. Extrapyramidal parkinsonism complicating acute organophosphate insecticide poisoning. Pediatr Neurol. 2005 Nov. 33(5):378-82.
Shahar E, Bentur Y, Bar-Joseph G, Cahana A, Hershman E. Extrapyramidal parkinsonism complicating acute organophosphate insecticide poisoning. Pediatr Neurol. 2005 Nov. 33(5):378-82. [Medline].
Saunders M, Magnanti BL, Correia Carreira S, Yang A, Alamo-Hernández U, Riojas-Rodriguez H, et al. Chlorpyrifos and neurodevelopmental effects: a literature review and expert elicitation on research and policy. Environ Health. 2012 Jun 28. 11 Suppl 1:S5. [Medline]. [Full Text].
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. 2006 Nov. 24(7):822-7. [Medline].
Ellenhorn MJ. Organophosphates. Ellenhorn's Medical Toxicology: Diagnosis and Treatment of Human Poisoning. 2nd ed. Baltimore, MD: Lippincott, Williams and Wilkins; 1997. 1614-21.
Karr CJ, Solomon GM, Brock-Utne AC. Health effects of common home, lawn, and garden pesticides. Pediatr Clin North Am. 2007 Feb. 54(1):63-80, viii. [Medline].
Kovacic P. Mechanism of organophosphates (nerve gases and pesticides) and antidotes: electron transfer and oxidative stress. Curr Med Chem. 2003 Dec. 10(24):2705-9. [Medline].
Kozer E, Mordel A, Haim SB, Bulkowstein M, Berkovitch M, Bentur Y. Pediatric poisoning from trimedoxime (TMB4) and atropine automatic injectors. J Pediatr. 2005 Jan. 146(1):41-4. [Medline].
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. 1999 Sep. 17(5):435-87. [Medline].
O'Malley M. Clinical evaluation of pesticide exposure and poisonings. Lancet. 1997 Apr 19. 349(9059):1161-6. [Medline].
Peter JV, Moran JL, Graham P. Oxime therapy and outcomes in human organophosphate poisoning: an evaluation using meta-analytic techniques. Crit Care Med. 2006 Feb. 34(2):502-10. [Medline].
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].