History

Patients with organophosphorous compound (OPC) or carbamate toxicity usually have a history of exposure, which may be self-injurious, occupational, environmental, or exploratory in nature. Pesticides may be rapidly be absorbed through the skin, lungs, gastrointestinal (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.

Physical Examination

In the Tokyo sarin attack, miosis was the most common (> 90%) indicator of OPC poisoning.^[25]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 causes tachycardia. Second, nicotinic acetylcholine (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 following 3 clinical effects on nerve endings:

Nicotinic effects at neuromuscular junctions and sympathetic ganglia
Central nervous system (CNS) effects
Muscarinic effects.

Nicotinic signs and symptoms may include mydriasis, tachycardia, weakness, hypertension, and fasciculations (mnemonic days of the weak MTWHF). 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. The SLUDGE/BBB mnemonic is as follows:

Salivation
Lacrimation
Urination
Defecation
GI symptoms
Emesis
Bronchorrhea
Bronchospasm
Bradycardia

The DUMBELS mnemonic is as follows:

Diarrhea and diaphoresis
Urination
Miosis
Bronchorrhea, bronchospasm, and bradycardia
Emesis
Lacrimation
Salivation

Differential Diagnoses

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Author

Daniel K Nishijima, MD, MAS Professor of Emergency Medicine, Vice Chair of Research, Department of Emergency Medicine, University of California, Davis, School of Medicine

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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 Attending Physician in Emergency Medicine and Medical Toxicology, Excela Health System

Fred Harchelroad, MD, FACMT, FAAEM, FACEP is a member of the following medical societies: American College of Medical Toxicology

Disclosure: Nothing to disclose.

Chief Editor

David Vearrier, MD, MPH Professor of Emergency Medicine, Department of Emergency Medicine, University of Mississippi Medical Center

David Vearrier, MD, MPH is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Medical Toxicology, American College of Occupational and Environmental Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Dana A Stearns, MD Assistant Director of Undergraduate Education, Department of Emergency Medicine, Massachusetts General Hospital; Associate Director, Undergraduate Clerkship in Surgery, Massachusetts General Hospital/Harvard Medical School; 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.