Organophosphate Toxicity Treatment & Management

  • Author: Kenneth D Katz, MD, FAAEM, ABMT; Chief Editor: Michael R Pinsky, MD, CM, FCCP, FCCM   more...
 
Updated: Jan 23, 2012
 

Medical Care

Airway control and adequate oxygenation are paramount in organophosphate (OP) poisonings. Intubation may be necessary in cases of respiratory distress due to laryngospasm, bronchospasm, bronchorrhea, or seizures. Immediate aggressive use of atropine may eliminate the need for intubation. Succinylcholine should be avoided because it is degraded by acetylcholinesterase (AChE) and may result in prolonged paralysis.

  • Continuous cardiac monitoring and pulse oximetry should be established; an ECG should be performed. Torsades de Pointes should be treated in the standard manner. The use of intravenous magnesium sulfate has been reported as beneficial for organophosphate toxicity. The mechanism of action may involve acetylcholine antagonism or ventricular membrane stabilization.
  • Remove all clothing and gently cleanse patients suspected of organophosphate exposure with soap and water because organophosphates are hydrolyzed readily in aqueous solutions with a high pH. Consider clothing as hazardous waste and discard accordingly.
  • Health care providers must avoid contaminating themselves while handling patients. Use personal protective equipment, such as neoprene gloves and gowns, when decontaminating patients because hydrocarbons can penetrate nonpolar substances such as latex and vinyl. Use charcoal cartridge masks for respiratory protection when decontaminating patients who are significantly contaminated.
  • Irrigate the eyes of patients who have had ocular exposure using isotonic sodium chloride solution or lactated Ringer's solution. Morgan lenses can be used for eye irrigation.
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Surgical Care

Patients with trauma or blast injury should be treated according to standard advanced trauma life support (ATLS) protocol. Patient decontamination should always be considered to prevent medical personnel poisoning.

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Contributor Information and Disclosures
Author

Kenneth D Katz, MD, FAAEM, ABMT  Assistant Professor, Division of Medical Toxicology, Department of Emergency Medicine, University of Pittsburgh Medical Center; Medical Director, Pittsburgh Poison Center

Kenneth D Katz, MD, FAAEM, ABMT is a member of the following medical societies: American Academy of Emergency Medicine and American College of Medical Toxicology

Disclosure: Nothing to disclose.

Coauthor(s)

Daniel E Brooks, MD  Co-Medical Director, Banner Good Samaritan Poison and Drug Information Center, Department of Medical Toxicology, Banner Good Samaritan Medical Center

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

Disclosure: Nothing to disclose.

Specialty Editor Board

Lisa Kirkland, MD, FACP, CNSP, MSHA  Assistant Professor, Department of Internal Medicine, Division of Hospital Medicine, Mayo Clinic; ANW Intensivists, Abbott Northwestern Hospital

Lisa Kirkland, MD, FACP, CNSP, MSHA is a member of the following medical societies: American College of Physicians, Society of Critical Care Medicine, and Society of Hospital Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Om Prakash Sharma, MD, FRCP, FCCP, DTM&H  Professor, Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Southern California Keck School of Medicine

Om Prakash Sharma, MD, FRCP, FCCP, DTM&H is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Osler Society, American Thoracic Society, New York Academy of Medicine, and Royal Society of Medicine

Disclosure: Nothing to disclose.

Timothy D Rice, MD  Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, St Louis University School of Medicine

Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Michael R Pinsky, MD, CM, FCCP, FCCM  Professor of Critical Care Medicine, Bioengineering, Cardiovascular Disease and Anesthesiology, Vice-Chair of Academic Affairs, Department of Critical Care Medicine, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine

Michael R Pinsky, MD, CM, FCCP, FCCM is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American Heart Association, American Thoracic Society, Association of University Anesthetists, European Society of Intensive Care Medicine, Shock Society, and Society of Critical Care Medicine

Disclosure: LiDCO Ltd Honoraria Consulting; iNTELOMED Intellectual property rights Board membership; Edwards Lifesciences Honoraria Consulting; Applied Physiology, Ltd Honoraria Consulting; Cheetah Medical Consulting fee Consulting

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Marina C Furtado, MD, and Lisa Chan, MD, FACEP, to the development and writing of this article.

References

  1. Bouvier G, Seta N, Vigouroux-Villard A, Blanchard O, Momas I. Insecticide urinary metabolites in nonoccupationally exposed populations. J Toxicol Environ Health B Crit Rev. Nov-Dec 2005;8(6):485-512. [Medline].

  2. Boobis AR, Ossendorp BC, Banasiak U, Hamey PY, Sebestyen I, Moretto A. Cumulative risk assessment of pesticide residues in food. Toxicol Lett. Aug 15 2008;180(2):137-50. [Medline].

  3. Yurumez Y, Durukan P, Yavuz Y, et al. Acute organophosphate poisoning in university hospital emergency room patients. Intern Med. 2007;46(13):965-9. [Medline].

  4. Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH, Heard SE. 2007 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 25th Annual Report. Clin Toxicol (Phila). Dec 2008;46(10):927-1057. [Medline].

  5. Sudakin DL, Power LE. Organophosphate exposures in the United States: a longitudinal analysis of incidents reported to poison centers. J Toxicol Environ Health A. Jan 15 2007;70(2):141-7. [Medline].

  6. Corriols M, Marin J, Berroteran J, Lozano LM, Lundberg I, Thorn A. The Nicaraguan Pesticide Poisoning Register: constant underreporting. Int J Health Serv. 2008;38(4):773-87. [Medline].

  7. Abdel Rasoul GM, Abou Salem ME, Mechael AA, Hendy OM, Rohlman DS, Ismail AA. Effects of occupational pesticide exposure on children applying pesticides. Neurotoxicology. Sep 2008;29(5):833-8. [Medline].

  8. Levy-Khademi F, Tenenbaum AN, Wexler ID, Amitai Y. Unintentional organophosphate intoxication in children. Pediatr Emerg Care. Oct 2007;23(10):716-8. [Medline].

  9. Moretto A. Experimental and clinical toxicology of anticholinesterase agents. Toxicol Lett. Dec 28 1998;102-103:509-13. [Medline].

  10. Jayawardane P, Dawson AH, Weerasinghe V, Karalliedde L, Buckley NA, Senanayake N. The spectrum of intermediate syndrome following acute organophosphate poisoning: a prospective cohort study from Sri Lanka. PLoS Med. Jul 15 2008;5(7):e147. [Medline].

  11. Rajapakse BN, Thiermann H, Eyer P, Worek F, Bowe SJ, Dawson AH, et al. Evaluation of the Test-mate ChE (cholinesterase) field kit in acute organophosphorus poisoning. Ann Emerg Med. Dec 2011;58(6):559-564.e6. [Medline].

  12. Liu JH, Chou CY, Liu YL, et al. Acid-base interpretation can be the predictor of outcome among patients with acute organophosphate poisoning before hospitalization. Am J Emerg Med. Jan 2008;26(1):24-30. [Medline].

  13. Eisenkraft A, Gilat E, Chapman S, Baranes S, Egoz I, Levy A. Efficacy of the bone injection gun in the treatment of organophosphate poisoning. Biopharm Drug Dispos. Apr 2007;28(3):145-50. [Medline].

  14. de Silva HJ, Wijewickrema R, Senanayake N. Does pralidoxime affect outcome of management in acute organophosphorus poisoning?. Lancet. May 9 1992;339(8802):1136-8. [Medline].

  15. Pawar KS, Bhoite RR, Pillay CP, Chavan SC, Malshikare DS, Garad SG. Continuous pralidoxime infusion versus repeated bolus injection to treat organophosphorus pesticide poisoning: a randomised controlled trial. Lancet. Dec 16 2006;368(9553):2136-41. [Medline].

  16. [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].

  17. Geller RJ, Lopez GP, Cutler S, Lin D, Bachman GF, Gorman SE. Atropine availability as an antidote for nerve agent casualties: validated rapid reformulation of high-concentration atropine from bulk powder. Ann Emerg Med. Apr 2003;41(4):453-6. [Medline].

  18. Rajpal S, Ali R, Bhatnagar A, Bhandari SK, Mittal G. Clinical and bioavailability studies of sublingually administered atropine sulfate. Am J Emerg Med. Feb 2010;28(2):143-50. [Medline].

  19. Yavuz, Y, Yurumez Y, Ciftci J et al. Effect of diphenhydramine on myocardial injury caused by organophosphate poisoning. Clin Tox. 2007;46:67-70.

  20. Pajoumand A, Shadnia S, Rezaie A, Abdi M, Abdollahi M. Benefits of magnesium sulfate in the management of acute human poisoning by organophosphorus insecticides. Hum Exp Toxicol. Dec 2004;23(12):565-9. [Medline].

  21. Peter JV, Cherian AM. Organic insecticides. Anaesth Intensive Care. Feb 2000;28(1):11-21. [Medline].

  22. Weissman BA, Raveh L. Therapy against organophosphate poisoning: the importance of anticholinergic drugs with antiglutamatergic properties. Toxicol Appl Pharmacol. Oct 15 2008;232(2):351-8. [Medline].

  23. London L, Myers JE. Use of a crop and job specific exposure matrix for retrospective assessment of long-term exposure in studies of chronic neurotoxic effects of agrichemicals. Occup Environ Med. Mar 1998;55(3):194-201. [Medline].

  24. Bailey B. Organophosphate poisoning in pregnancy. Ann Emerg Med. Feb 1997;29(2):299. [Medline].

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

  26. Ben Abraham R, Rudick V, Weinbroum AA. Practical guidelines for acute care of victims of bioterrorism: conventional injuries and concomitant nerve agent intoxication. Anesthesiology. Oct 2002;97(4):989-1004. [Medline].

  27. Bird SB, Gaspari RJ, Dickson EW. Early death due to severe organophosphate poisoning is a centrally mediated process. Acad Emerg Med. Apr 2003;10(4):295-8. [Medline].

  28. Chuang FR, Jang SW, Lin JL, Chern MS, Chen JB, Hsu KT. QTc prolongation indicates a poor prognosis in patients with organophosphate poisoning. Am J Emerg Med. Sep 1996;14(5):451-3. [Medline].

  29. Clark, RF. Insecticides: Organic Phosphorus compounds and Carbamates. In: Goldfrank LR, Flomenbaum NE, Lewin NA, Nelson LS, Howland MA, Hoffman RS, eds. Goldfrank's Toxicologic Emergencies. Stamford, Ct: Appleton & Lange. 8th ed. 2006:1497-1512.

  30. Dart RC. Organophosphate Insecticides. In: The 5-minute Toxicology Consult. Philadelphia: Lippincott Williams & Wilkins; 2000:554-5.

  31. DeWan A, Klein RJ, Hoh J. Linkage disequilibrium mapping for complex disease genes. Methods Mol Biol. 2007;376:85-107. [Medline].

  32. Johnson S, Peter JV, Thomas K, Jeyaseelan L, Cherian AM. Evaluation of two treatment regimens of pralidoxime (1 gm single bolus dose vs 12 gm infusion) in the management of organophosphorus poisoning. J Assoc Physicians India. Aug 1996;44(8):529-31. [Medline].

  33. Khurana D, Prabhakar S. Organophosphorus intoxication. Arch Neurol. Apr 2000;57(4):600-2. [Medline].

  34. Komurcu S, Turhal S, Altundag K, et al. Safety and efficacy of transdermal fentanyl in patients with cancer pain: phase IV, Turkish oncology group trial. Eur J Cancer Care (Engl). Jan 2007;16(1):67-73. [Medline].

  35. Leikin JB, Thomas RG, Walter FG, Klein R, Meislin HW. A review of nerve agent exposure for the critical care physician. Crit Care Med. Oct 2002;30(10):2346-54. [Medline].

  36. Mileson BE, Chambers JE, Chen WL, et al. Common mechanism of toxicity: a case study of organophosphorus pesticides. Toxicol Sci. Jan 1998;41(1):8-20. [Medline].

  37. Newmark J. Nerve agents. Neurol Clin. May 2005;23(2):623-41. [Medline].

  38. Peter JV, Moran JL, Pichamuthu K, Chacko B. Adjuncts and alternatives to oxime therapy in organophosphate poisoning--is there evidence of benefit in human poisoning? A review. Anaesth Intensive Care. May 2008;36(3):339-50. [Medline].

  39. Saxena A, Sun W, Dabisch PA, et al. Efficacy of human serum butyrylcholinesterase against sarin vapor. Chem Biol Interact. Sep 25 2008;175(1-3):267-72. [Medline].

  40. 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].

  41. Solomon GM, Moodley J. Acute chlorpyrifos poisoning in pregnancy: a case report. Clin Toxicol (Phila). May 2007;45(4):416-9. [Medline].

  42. Wagner SL. Diagnosis and treatment of organophosphate and carbamate intoxication. Occup Med. Apr-Jun 1997;12(2):239-49. [Medline].

  43. Yamashita M, Yamashita M, Tanaka J, Ando Y. Human mortality in organophosphate poisonings. Vet Hum Toxicol. Apr 1997;39(2):84-5. [Medline].

 
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