Approach Considerations

The history of exposure is the most important piece of information. Laboratory studies may include the following:

Rapid bedside glucose fingerstick test
Electrolytes
Renal panel
Liver function tests
Creatine phosphokinase (CPK)
Lactate
Arterial or venous blood gasUrinalysis
Urine pregnancy testing in women of childbearing age
Electrocardiography
Screening serum and urinary toxicology panels, particularly acetaminophen and salicylate levels if intentional exposure is suspected
Chlorinated hydrocarbon levels (can be measured, but not clinically helpful nor routinely available)

Plasma and red blood cell cholinesterase testing may be considered in cases in which organophosphorus compound co-exposure may have occurred or if offending toxicant has not been determined and the patient presents with signs or symptoms consistent with a cholinergic toxidrome.

Possible abnormal findings by organ system are as follows:

Pulmonary - Increased alveolar–arterial (A-a) gradient, hypoxemia (see the A-a Gradient calculator)
Cardiovascular - Sinus tachycardia or bradycardia, QTc prolongation, nonspecific ST-segment changes
Gastrointestinal - Transaminitis and hyperbilirubinemia
Hematologic - Leukocytosis and prolonged activated partial thromboplastin time (aPTT)
Renal - Acidemia, azotemia, creatinine elevation, hyperkalemia

Chest radiography may be indicated in the case of aspiration or acute lung injury. An abdominal radiograph may show evidence of radiopaque chlorinated pesticide.^[27]When the history of exposure is unclear, a head CT scan/lumbar puncture should be considered to rule out a central nervous system process or infection as a cause of seizures and altered mental status.

If necessary, gas chromatographic analytical studies of serum, adipose tissue, urine, and breast milk can be considered for documentation of exposure. For occupational purposes, performing adipose tissue biopsy testing for estimating total body burden of an exposed population is possible. This has no application in acute treatment of an individual exposed patient.

For the emergency department clinician, the above studies are unlikely to be of any acute clinical value because the likelihood of a rapid test result is small. However, obtaining samples for these examinations may be valuable for the extended-term evaluation and treatment of the patient.

Postmortem Forensic Examination

In a postmortem forensic examination, brain analytical studies are warranted because severity of toxicity correlates with CNS concentration of these insecticides. Therefore, when a patient's death possibly is caused by acute or chronic pesticide exposure, alert the coroner so that appropriate safety issues may be addressed. This action is especially important in occupationally related cases.

Treatment & Management

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