Organic Phosphorous Compound and Carbamate Toxicity Clinical Presentation

  • Author: Daniel K Nishijima, MD; Chief Editor: Asim Tarabar, MD   more...
 
Updated: Apr 2, 2012
 

History

Patients usually have a history of OPCs or carbamates exposure, either suicidal or unintentional. Pesticides can rapidly be absorbed through the skin, lungs, GI tract, and mucous membranes. The rate of absorption depends on the route of absorption and the type of OPC or carbamate. Symptoms usually occur within a few hours after GI ingestion and appear almost immediately after inhalational exposure.

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Physical

In the Tokyo sarin attack, miosis was the most common (>90%) indicator of OP poisoning.[10] Bradycardia is not a reliable finding, and patients may be tachycardic, for 2 reasons: First, hypoxia due to bronchorrhea and bronchospasm can lead to sympathetic outflow, which overrides parasympathetic vagal stimulation of the heart and which causes tachycardia. Second, nicotinic ACh receptors are present in both sympathetic and parasympathetic ganglia. These ganglionic effects in the sympathetic system may contribute to tachycardia.

Patients often present with evidence of a cholinergic toxic syndrome, or toxidrome. It is useful to remember the toxidrome in terms of the 3 clinical effects on nerve endings: nicotinic effects at neuromuscular junctions and autonomic ganglia, CNS effects, and muscarinic effects. Nicotinic signs and symptoms include weakness, fasciculations, and paralysis, whereas CNS effects may lead to seizures and CNS depression. Two common mnemonics to remember the muscarinic signs and symptoms of the cholinergic toxidrome are SLUDGE/BBB and DUMBELS, as follows:

  • SLUDGE/BBB mnemonic
    • S = Salivation
    • L = Lacrimation
    • U = Urination
    • D = Defecation
    • G = GI symptoms
    • E = Emesis
    • B = Bronchorrhea
    • B = Bronchospasm
    • B = Bradycardia
  • DUMBELS mnemonic
    • D = Diarrhea and diaphoresis
    • U = Urination
    • M = Miosis
    • B = Bronchorrhea, bronchospasm, and bradycardia
    • E = Emesis
    • L = Lacrimation
    • S = Salivation
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Causes

Agricultural exposure is the most common cause of OPC and carbamate poisoning. The World Health Organization (WHO) classifies these poisonings as class I (extremely toxic) to class III (slightly hazardous). The WHO advocates banning or strong restrictions on the use of class I pesticides and a reduction in the use of pesticides to a minimal number of compounds that are less hazardous than others.[11]

OPCs may also be encountered in the military setting or as the result of a terrorist attack with nerve agents such as sarin, VX, or soman.

In addition to their use as insecticides, carbamates are used to treat certain medical diseases, such as glaucoma and myasthenia gravis (neostigmine, physostigmine). Some case reports describe clinical illness from foodborne outbreaks due to contamination with OPC-containing pesticides.[12]

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Contributor Information and Disclosures
Author

Daniel K Nishijima, MD  Staff Physician, Department of Emergency Medicine, University of California Davis Medical Center

Daniel K Nishijima, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Sage W Wiener, MD  Assistant Professor, Department of Emergency Medicine, State University of New York Downstate Medical Center; Assistant Director of Medical Toxicology, Department of Emergency Medicine, Kings County Hospital Center

Sage W Wiener, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Dana A Stearns, MD  Assistant Director of Undergraduate Education, Department of Emergency Medicine, Massachusetts General Hospital; Assistant Professor of Surgery, Harvard Medical School

Dana A Stearns, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

John T VanDeVoort, PharmD  Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

Fred Harchelroad, MD, FACMT, FAAEM, FACEP  Director of Medical Toxicology, Allegheny General Hospital

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD  Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

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