Organic Phosphorous Compound and Carbamate Toxicity Follow-up

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

Further Inpatient Care

  • Most patients who require therapy for OPC poisoning warrant admission to the hospital for continued monitoring and treatment. Patients who require continuous monitoring or treatment should be admitted to the ICU.
  • Patients with clinically significant poisoning should be evaluated frequently to monitor their airway and respiratory secretions. In addition, frequent neurologic examination should be performed to evaluate for neuromuscular blockade.
  • Therapy is largely titrated to the physical findings. Atropinization is based on the drying of respiratory secretions, and oxime therapy is based on an improvement in neuromuscular signs.
  • A toxicologist may be of help in determining specific aging and reactivation times of the particular OPC or carbamate agent.
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Further Outpatient Care

  • Patients without any symptoms and with questionable or minimal exposure to OPCs or carbamates may be considered for discharge after 6-12 hours of observation.
  • Patients with residual neurologic symptoms should be given a follow-up appointment with a neurologist.
  • Follow-up with a psychiatrist should be arranged as indicated.
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Complications

  • Intermediate syndrome
    • Intermediate syndrome was first described in 1987 as a sudden respiratory paresis, with weakness in cranial nerves and proximal-limb and neck flexor muscles.[39]
    • These clinical features appear 24-96 hours after exposure and are distinct from the previously described delayed neurotoxicity (see below).
    • Although intermediate syndrome is incompletely understood, more recent reports suggest that this is due to presynaptic and postsynaptic dysfunction of neuromuscular transmission and that it may result from insufficient oxime treatment.[40, 41]
    • Repetitive nerve stimulation studies may help in predicting which patients with intermediate syndrome are at risk for developing respiratory failure.[42]
  • OPC-induced delayed neurotoxicity
    • OPC-induced delayed neurotoxicity (OPCIDN) is a sensorimotor polyneuropathy that typically occurs 9-14 days after OP exposure.
    • The patient initially presents with distal motor weakness and sensory paresthesias in the lower extremities, which may progress proximally and eventually affect the upper extremities.
    • Most sources suggest that the mechanism involves inhibition of neuropathy target esterase (NTE), an enzyme that metabolizes esters in nerve cells.
    • Some patients may recover over 12-15 months, but permanent losses with spasticity and persistent upper motor neuron findings have been reported.[13]
  • Pancreatitis
    • Pancreatitis has been reported as a rare complication.
    • One case series reported that 12.76% of OP poisonings were associated with acute pancreatitis, although this has not been the experience in other series.[43, 44]
  • Cardiac complications
    • Cardiac arrhythmias have been associated with OPC poisoning.
    • The most common ECG abnormality is QTc prolongation.[16]
    • Cardiac complications may be due to direct cardiac toxicity.[45]
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Prognosis

  • In severe poisoning, death usually occurs within the first 24 hours if it is untreated.
  • With nerve-agent poisoning, death may occur within minutes if untreated.
    • Even with adequate respiratory support, intensive care, and specific treatment with atropine and oximes, the mortality rate is still high in severe poisonings.[46]
    • A delay in treatment can also lead to late and permanent neurologic sequelae.
    • Most patients with minimal symptoms fully recover.
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Patient Education

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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.

References

  1. Zhao X, Wu C, Wang Y, Cang T, Chen L, Yu R, et al. Assessment of toxicity risk of insecticides used in rice ecosystem on Trichogramma japonicum, an egg parasitoid of rice lepidopterans. J Econ Entomol. Feb 2012;105(1):92-101. [Medline].

  2. Chen SW, Gao YY, Zhou NN, Liu J, Huang WT, Hui L, et al. Carbamates of 4'-demethyl-4-deoxypodophyllotoxin: synthesis, cytotoxicity and cell cycle effects. Bioorg Med Chem Lett. Dec 15 2011;21(24):7355-8. [Medline].

  3. Masson P. Evolution of and perspectives on therapeutic approaches to nerve agent poisoning. Toxicol Lett. Sep 25 2011;206(1):5-13. [Medline].

  4. US EPA Office of Pesticide Programs. FY 2002 Annual Report. Washington, DC: US Environmental Protection Agency. Available at http://www.epa.gov/oppfead1/annual/2002/2002annualreport.pdf.

  5. Calvert GM, Plate DK, Das R, Rosales R, Shafey O, Thomsen C, et al. Acute occupational pesticide-related illness in the US, 1998-1999: surveillance findings from the SENSOR-pesticides program. Am J Ind Med. Jan 2004;45(1):14-23. [Medline].

  6. Watson WA, Litovitz TL, Klein-Schwartz W, Rodgers GC Jr, Youniss J, Reid N, et al. 2003 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. Sep 2004;22(5):335-404. [Medline].

  7. Eddleston M, Phillips MR. Self poisoning with pesticides. BMJ. Jan 3 2004;328(7430):42-4. [Medline].

  8. Tsao TC, Juang YC, Lan RS, Shieh WB, Lee CH. Respiratory failure of acute organophosphate and carbamate poisoning. Chest. Sep 1990;98(3):631-6. [Medline].

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

  10. Okumura T, Takasu N, Ishimatsu S, Miyanoki S, Mitsuhashi A, Kumada K, et al. Report on 640 victims of the Tokyo subway sarin attack. Ann Emerg Med. Aug 1996;28(2):129-35. [Medline].

  11. Eddleston M, Karalliedde L, Buckley N, Fernando R, Hutchinson G, Isbister G, et al. Pesticide poisoning in the developing world--a minimum pesticides list. Lancet. Oct 12 2002;360(9340):1163-7. [Medline].

  12. Greenaway C, Orr P. A foodborne outbreak causing a cholinergic syndrome. J Emerg Med. May-Jun 1996;14(3):339-44. [Medline].

  13. Aaron C. Ford: Clinical Toxicology. St Louis, MO: MD Consult; 2001:818-28.

  14. Worek F, Koller M, Thiermann H, Szinicz L. Diagnostic aspects of organophosphate poisoning. Toxicology. Oct 30 2005;214(3):182-9. [Medline].

  15. Kiss Z, Fazekas T. Arrhythmias in organophosphate poisonings. Acta Cardiol. 1979;34(5):323-30. [Medline].

  16. Yurumez Y, Yavuz Y, Saglam H, Durukan P, Ozkan S, Akdur O, et al. Electrocardiographic findings of acute organophosphate poisoning. J Emerg Med. Jan 2009;36(1):39-42. [Medline].

  17. Eyer P. The role of oximes in the management of organophosphorus pesticide poisoning. Toxicol Rev. 2003;22(3):165-90. [Medline].

  18. Butera R, Locatelli C, Barretta S. Secondary exposure to malathion in emergency department healthcare workers. Clin Toxicol. 2002;40:386.

  19. Stacey R, Morfey D, Payne S. Secondary contamination in organophosphate poisoning: analysis of an incident. QJM. Feb 2004;97(2):75-80. [Medline].

  20. Koksal N, Buyukbese MA, Guven A, Cetinkaya A, Hasanoglu HC. Organophosphate intoxication as a consequence of mouth-to-mouth breathing from an affected case. Chest. Aug 2002;122(2):740-1. [Medline]. [Full Text].

  21. Geller RJ, Singleton KL, Tarantino ML, Drenzek CL, Toomey KE. Nosocomial poisoning associated with emergency department treatment of organophosphate toxicity--Georgia, 2000. J Toxicol Clin Toxicol. 2001;39(1):109-11. [Medline].

  22. Little M, Murray L,. Consensus statement: risk of nosocomial organophosphate poisoning in emergency departments. Emerg Med Australas. Oct-Dec 2004;16(5-6):456-8. [Medline].

  23. Li Y, Tse ML, Gawarammana I, Buckley N, and Eddleston M. Systematic review of controlled clinical trials of gastric lavage in acute organophosphorus pesticide poisoning. Clin Toxicol. Mar 2009;47(3):179-92. [Medline].

  24. LeBlanc FN, Benson BE, Gilg AD. A severe organophosphate poisoning requiring the use of an atropine drip. J Toxicol Clin Toxicol. 1986;24(1):69-76. [Medline].

  25. Worek F, Kirchner T, Backer M, Szinicz L. Reactivation by various oximes of human erythrocyte acetylcholinesterase inhibited by different organophosphorus compounds. Arch Toxicol. 1996;70(8):497-503. [Medline].

  26. Buckley NA, Eddleston M, Szinicz L. Oximes for acute organophosphate pesticide poisoning. Cochrane Database Syst Rev. 2005;(1):CD005085. [Medline]. [Full Text].

  27. Johnson MK, Jacobsen D, Meredith TJ. Evaluation of antidotes for poisoning in organophorus pesticides. Emerg Med. 2000;12(1):22-37.

  28. Willems JL, De Bisschop HC, Verstraete AG, Declerck C, Christiaens Y, Vanscheeuwyck P, et al. Cholinesterase reactivation in organophosphorus poisoned patients depends on the plasma concentrations of the oxime pralidoxime methylsulphate and of the organophosphate. Arch Toxicol. 1993;67(2):79-84. [Medline].

  29. Thiermann H, Szinicz L, Eyer F, Worek F, Eyer P, Felgenhauer N, et al. Modern strategies in therapy of organophosphate poisoning. Toxicol Lett. Jun 30 1999;107(1-3):233-9. [Medline].

  30. Worek F, Backer M, Thiermann H, Szinicz L, Mast U, Klimmek R, et al. Reappraisal of indications and limitations of oxime therapy in organophosphate poisoning. Hum Exp Toxicol. Aug 1997;16(8):466-72. [Medline].

  31. Thompson DF, Thompson GD, Greenwood RB, Trammel HL. Therapeutic dosing of pralidoxime chloride. Drug Intell Clin Pharm. Jul-Aug 1987;21(7-8):590-3. [Medline].

  32. Thiermann H, Mast U, Klimmek R, Eyer P, Hibler A, Pfab R, et al. Cholinesterase status, pharmacokinetics and laboratory findings during obidoxime therapy in organophosphate poisoned patients. Hum Exp Toxicol. Aug 1997;16(8):473-80. [Medline].

  33. 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].

  34. Cherian AM, Jeyaseelan L, Peter JV. Effectiveness of 2-PAM (pralidoxime) in the treatment of organophosphorus poisoning (OPP): a randomised double blind placebo controlled trial. Philadelphia, PA: INCLEN Trust; 1997. INCLEN Monograph Series on Critical International Health Issues.

  35. 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 2006;368(9553):2136-2141. [Medline].

  36. Sundwall A. Minimum concentrations of N-methylpyridinium-2-aldoxime methane sulphonate (P2S) which reverse neuromuscular block. Biochem Pharmacol. Dec 1961;8:413-7. [Medline].

  37. 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].

  38. Güven M, Sungur M, Eser B, Sari I, Altuntas F. The effects of fresh frozen plasma on cholinesterase levels and outcomes in patients with organophosphate poisoning. J Toxicol Clin Toxicol. 2004;42(5):617-23. [Medline].

  39. Senanayake N, Johnson MK. Acute polyneuropathy after poisoning by a new organophosphate insecticide. N Engl J Med. Jan 21 1982;306(3):155-7. [Medline].

  40. De Bleecker J, Van den Neucker K, Colardyn F. Intermediate syndrome in organophosphorus poisoning: a prospective study. Crit Care Med. Nov 1993;21(11):1706-11. [Medline].

  41. 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].

  42. 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 2008;5(7):e147. [Medline].

  43. Sahin I, Onbasi K, Sahin H, Karakaya C, Ustun Y, Noyan T. The prevalence of pancreatitis in organophosphate poisonings. Hum Exp Toxicol. Apr 2002;21(4):175-7. [Medline].

  44. Harputluoglu MM, Kantarceken B, Karincaoglu M, Aladag M, Yildiz R, Ates M, et al. Acute pancreatitis: an obscure complication of organophosphate intoxication. Hum Exp Toxicol. Jun 2003;22(6):341-3. [Medline].

  45. Anand S, Singh S, Nahar Saikia U, Bhalla A, Paul Sharma Y, Singh D. Cardiac abnormalities in acute organophosphate poisoning. Clin Toxicol (Phila). Mar 2009;47(3):230-5. [Medline].

  46. Munidasa UA, Gawarammana IB, Kularatne SA, Kumarasiri PV, Goonasekera CD. Survival pattern in patients with acute organophosphate poisoning receiving intensive care. J Toxicol Clin Toxicol. 2004;42(4):343-7. [Medline].

  47. CDC. Centers for Disease Control and Prevention (CDC). Nosocomial poisoning associated with emergency department treatment of organophosphate toxicity--Georgia, 2000. MMWR Morb Mortal Wkly Rep. Jan 5 2001;49(51-52):1156-8. [Medline].

  48. Worek F, Diepold C, Eyer P. Dimethylphosphoryl-inhibited human cholinesterases: inhibition, reactivation, and aging kinetics. Arch Toxicol. Feb 1999;73(1):7-14. [Medline].

 
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