Approach Considerations
Because of risks of respiratory compromise or recurrent symptoms, hospitalizing all symptomatic patients for at least 48 hours in a high acuity setting is recommended. Patients who are asymptomatic 12 hours after organophosphate exposure can be discharged, because symptom onset should usually occur within this time frame.
Following occupational exposure, patients should not be allowed to return to work with organophosphates until serum cholinesterase activity returns to 75% of the known baseline level. Also, establishing baseline cholinesterase levels for workers with known organophosphate exposure is recommended. [17]
Patients with concomitant trauma or blast injury should be treated according to standard advanced trauma life support (ATLS) protocol. Decontamination of patients should always be considered to prevent poisoning of medical personnel.
Decontamination
Remove all clothing from 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.
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 plasma cholinesterase and may result in prolonged paralysis. In addition to atropine, pralidoxime (2-PAM) and benzodiazepines (eg, diazepam) are mainstays of medical therapy (see Medication).
Central venous access and arterial lines may be needed to treat the patient with organophosphate toxicity who requires multiple medications and blood-gas measurements.
Continuous cardiac monitoring and pulse oximetry should be established; an electrocardiogram (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.
Consultations
Optimal recommendations are made on a case-by-case scenario. Consider discussing each case with a medical toxicologist or the regional poison center (1-800-222-1222).
Prevention
Health care providers must avoid contaminating themselves while handling patients poisoned by organophosphates. The potential for cross-contamination is highest in treating patients after massive dermal exposure.
Use personal protective equipment, such as neoprene or nitrile 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 caring for patients with significant contamination.
