Medication Summary

Control of clinically significant cholinergic excess is the key to management. Anticholinergic agents can be used to substantially reduce or eliminate the secretory effects of muscarinic excess. Endpoints for therapy include elimination of bronchorrhea (atropine) and improved muscle strength (oximes). Reaching these endpoints may require more medication than commonly prescribed.

Class Summary

This drug is used to bind recently ingested agents, thereby limiting systemic absorption. It is not useful for noningestion exposures.

Activated charcoal (Liqui-Char)

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Reduces systemic absorption through the alimentary tract. Emergency treatment in poisoning caused by drugs and chemicals. Network of pores present adsorbs 100-1000 mg of drug per gram charcoal. Does not dissolve in water. For maximum effect, administer within 30 min of poison ingestion.

Class Summary

Anticholinergics, such as atropine, cause pharmacologic antagonism of excess anticholinesterase activity at muscarinic receptors. Oximes reverse the inhibition of AChE and nicotinic effects, including muscle paralysis.

Atropine IV/IM (Atropair)

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Used for GI or pulmonary distress in known or suspected OP or carbamate poisonings. Continue until bronchoconstriction and bronchorrhea controlled. High doses may be required in first 24 h of treatment. Treatment may be required for 48 h in severe cases. May need to reduce doses with concurrent oximes.

Pralidoxime (2-PAM, Protopam)

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Indications include muscle weakness (especially respiratory) in known or suspected OP poisoning. Rarely needed in carbamate poisonings. Muscle strength should increase in 30 min. Must be used early in poisoning, before OP-AChE bond has aged, to be effective. May help prevent intermediate and delayed neuromuscular and neuropsychiatric OP syndromes.

Class Summary

This drug is used to control seizures.

Diazepam (Valium)

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Depresses all levels of CNS (eg, limbic and reticular formation), possibly by increasing GABA activity.

Lorazepam (Ativan)

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DOC for treatment of status epilepticus because persists in CNS longer than diazepam. Rate of injection not to exceed 2 mg/min. May be administered IM if IV access not available.

Midazolam (Versed)

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Alternative to terminate refractory status epilepticus. Because water soluble, takes approximately 3 times longer than diazepam to peak EEG effects. Wait 2-3 min to fully evaluate sedative effects before starting procedure or repeating dose. Has twice the affinity for benzodiazepine receptors than diazepam. May be administered IM if vascular access unavailable.

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. 2012 Feb. 105(1):92-101. [QxMD MEDLINE Link].
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. 2011 Dec 15. 21(24):7355-8. [QxMD MEDLINE Link].
Masson P. Evolution of and perspectives on therapeutic approaches to nerve agent poisoning. Toxicol Lett. 2011 Sep 25. 206(1):5-13. [QxMD MEDLINE Link].
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. 2002 Oct 12. 360(9340):1163-7. [QxMD MEDLINE Link].
Quandt SA, Pope CN, Chen H, Summers P, Arcury TA. Longitudinal Assessment of Blood Cholinesterase Activities Over 2 Consecutive Years Among Latino Nonfarmworkers and Pesticide-Exposed Farmworkers in North Carolina. J Occup Environ Med. 2015 Aug. 57 (8):851-7. [QxMD MEDLINE Link]. [Full Text].
Greenaway C, Orr P. A foodborne outbreak causing a cholinergic syndrome. J Emerg Med. 1996 May-Jun. 14(3):339-44. [QxMD MEDLINE Link].
Atwood D and Paisley-Jones C. Pesticides Industry Sales and Usage: 2008-2012 Market Estimates. United States Environmental Protection Agency. Available at https://www.epa.gov/sites/default/files/2017-01/documents/pesticides-industry-sales-usage-2016_0.pdf. 2017; Accessed: August 21, 2021.
Calvert GM, Beckman J, Prado JB, Bojes H, Schwartz A, Mulay P, et al. Acute Occupational Pesticide-Related Illness and Injury -United States, 2007-2011. MMWR Morb Mortal Wkly Rep. 2016 Oct 14. 63 (55):11-16. [QxMD MEDLINE Link]. [Full Text].
Gummin DD, Mowry JB, Beuhler MC, Spyker DA, Brooks DE, Dibert KW, et al. 2019 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 37th Annual Report. Clin Toxicol (Phila). 2020 Dec. 58 (12):1360-1541. [QxMD MEDLINE Link]. [Full Text].
Eddleston M, Phillips MR. Self poisoning with pesticides. BMJ. 2004 Jan 3. 328(7430):42-4. [QxMD MEDLINE Link].
Lifshitz M, Shahak E, Sofer S. Carbamate and organophosphate poisoning in young children. Pediatr Emerg Care. 1999 Apr. 15(2):102-3. [QxMD MEDLINE Link].
Tsao TC, Juang YC, Lan RS, Shieh WB, Lee CH. Respiratory failure of acute organophosphate and carbamate poisoning. Chest. 1990 Sep. 98(3):631-6. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Senanayake N, Johnson MK. Acute polyneuropathy after poisoning by a new organophosphate insecticide. N Engl J Med. 1982 Jan 21. 306(3):155-7. [QxMD MEDLINE Link].
Indira M, Andrews MA, Rakesh TP. Incidence, predictors, and outcome of intermediate syndrome in cholinergic insecticide poisoning: a prospective observational cohort study. Clin Toxicol (Phila). 2013 Nov. 51 (9):838-45. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
De Bleecker J, Van den Neucker K, Colardyn F. Intermediate syndrome in organophosphorus poisoning: a prospective study. Crit Care Med. 1993 Nov. 21(11):1706-11. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Aaron C. Ford: Clinical Toxicology. St Louis, MO: MD Consult; 2001. 818-28.
Sahin I, Onbasi K, Sahin H, Karakaya C, Ustun Y, Noyan T. The prevalence of pancreatitis in organophosphate poisonings. Hum Exp Toxicol. 2002 Apr. 21(4):175-7. [QxMD MEDLINE Link].
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. 2003 Jun. 22(6):341-3. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Ye C, Zhang Q, Chao Y, Yin C. Case Report: Effective Treatment for Acute Chlorpyrifos Poisoning Complicated by a Non-ST-Segment Elevation Myocardial Infarction. Front Cardiovasc Med. 2021. 8:623708. [QxMD MEDLINE Link]. [Full Text].
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. 1996 Aug. 28(2):129-35. [QxMD MEDLINE Link].
Worek F, Koller M, Thiermann H, Szinicz L. Diagnostic aspects of organophosphate poisoning. Toxicology. 2005 Oct 30. 214(3):182-9. [QxMD MEDLINE Link].
Mu Y, Hu B, Gao N, Pang L. Prognostic value of the neutrophil-to-lymphocyte ratio in acute organophosphorus pesticide poisoning. Open Life Sci. 2021. 16 (1):703-710. [QxMD MEDLINE Link]. [Full Text].
Kiss Z, Fazekas T. Arrhythmias in organophosphate poisonings. Acta Cardiol. 1979. 34(5):323-30. [QxMD MEDLINE Link].
Eyer P. The role of oximes in the management of organophosphorus pesticide poisoning. Toxicol Rev. 2003. 22(3):165-90. [QxMD MEDLINE Link].
Butera R, Locatelli C, Barretta S. Secondary exposure to malathion in emergency department healthcare workers. Clin Toxicol. 2002. 40:386.
Stacey R, Morfey D, Payne S. Secondary contamination in organophosphate poisoning: analysis of an incident. QJM. 2004 Feb. 97(2):75-80. [QxMD MEDLINE Link].
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. 2002 Aug. 122(2):740-1. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
Little M, Murray L,. Consensus statement: risk of nosocomial organophosphate poisoning in emergency departments. Emerg Med Australas. 2004 Oct-Dec. 16(5-6):456-8. [QxMD MEDLINE Link].
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. 2009 Mar. 47(3):179-92. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Buckley NA, Eddleston M, Szinicz L. Oximes for acute organophosphate pesticide poisoning. Cochrane Database Syst Rev. 2005. (1):CD005085. [QxMD MEDLINE Link]. [Full Text].
Johnson MK, Jacobsen D, Meredith TJ. Evaluation of antidotes for poisoning in organophorus pesticides. Emerg Med. 2000. 12(1):22-37.
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. [QxMD MEDLINE Link].
Thiermann H, Szinicz L, Eyer F, Worek F, Eyer P, Felgenhauer N, et al. Modern strategies in therapy of organophosphate poisoning. Toxicol Lett. 1999 Jun 30. 107(1-3):233-9. [QxMD MEDLINE Link].
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. 1997 Aug. 16(8):466-72. [QxMD MEDLINE Link].
Thompson DF, Thompson GD, Greenwood RB, Trammel HL. Therapeutic dosing of pralidoxime chloride. Drug Intell Clin Pharm. 1987 Jul-Aug. 21(7-8):590-3. [QxMD MEDLINE Link].
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. 1997 Aug. 16(8):473-80. [QxMD MEDLINE Link].
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. 1996 Aug. 44(8):529-31. [QxMD MEDLINE Link].
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. 1997.
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. [QxMD MEDLINE Link].
Sundwall A. Minimum concentrations of N-methylpyridinium-2-aldoxime methane sulphonate (P2S) which reverse neuromuscular block. Biochem Pharmacol. 1961 Dec. 8:413-7. [QxMD MEDLINE Link].
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. 2004 Dec. 23(12):565-9. [QxMD MEDLINE Link].
Basher A, Rahman SH, Ghose A, Arif SM, Faiz MA, Dawson AH. Phase II study of magnesium sulfate in acute organophosphate pesticide poisoning. Clin Toxicol (Phila). 2013 Jan. 51 (1):35-40. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].

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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.

Sections Organic Phosphorous Compound and Carbamate Toxicity
Overview
Presentation
DDx
Workup
Treatment
Medication
References

Organic Phosphorous Compound and Carbamate Toxicity Medication

Medication Summary

GI decontaminant