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TLM. FOWZAN
FACULTY OF MEDICINE
RAJARATA UNIVERSITY
     SRI LANKA
Organophosphate(insecticide)
organophosphate poisoning accounts for nearly one third of
hospital admissions from poisoning in Sri Lanka.
Commonly using trades are follows.
Malathion, parathion, diazinon, fenthione, chlorpyrifos.

Action
inhibit acetylcholine esterase enzyme
at nerve endings by phosphorylation

       acetylcholine at receptor sites

clinical features
            depends on route of entry


 ingestion       inhalation     eye contact
Ingestion
Muscarinic effects(post ganglionic   Nicotinic effects (neuro muscular
parasympathetic nerve ending)        junction)
•   Bronchospasm(wheezing)           •   Muscle weakness
•   Bronchorrhoea
                                     •   Fasciculation
•   Productive cough
•   Dyspnoea                         •   Paralysis
•   Hypotension                      •   Muscle twitching
•   Bradycardia
•   Cardiac arrhythmia
•   Diarrhoea
•   Vomiting
•   Salaivation
•   Tenesmus
•   Miosis
•   Lacrimation
•   Blurred vision
Nicotinic and muscarinic   Ach receptors in the
Ach receptors in the CNS   sympathetic system
•   Confusion              • Excessive sweating
•   Agitation              Other effects
•   Respiratory failure
•   Ataxia                 • hyperglycaemia
•   convulsion             • Acute pancreatitis
Inhalation                    Eye contact
•   Cough                     •   Irritation
•   Difficulty in breathing   •   Pain
•   Bronchitis                •   Lacrimation
•   Pneumonia                 •   Miosis
                              •   Blurring vision
                              •   Photophobia
All the clinical
  features in
from head to
      Toe
Management of organophosphate poisoning

  1. check airway, breathing, circulation.
  2. monitor arterial oxygen saturation, cardiac rhythms, BP,
      Pulse rate.
  3. look for signs & symptoms.
  4. obtain IV access.
  5. remove the contaminated clothes&wash the skin
      thoroughly with soap & water
  6. give atropine intravenously as soon as possible for
      symptomatic patient
  7. perform gastric decontamination with gastric lavage once
      the patient is stabilised & within two hours of ingestion.
  8. give activated charcoal (50 g in 200 ml)
  9. maintainance atropine infusion
  10. give pralidoxime.
OROPHARYNGEAL AIRWAY USED   AMBU VENTILATION & ET TUBE




GASTRIC LAVAGE              ACTIVATED CHARCOAL
Atropinisation
-start with 1.8-3.0 mg fast iv bolus
-after 3-5minutes check the five parameters of cholinergic
poisoning
     1. Poor air entry into the lungs due to bronchorroea &
         bronchospasm
      2.excessive sweating
      3. bradycardia ( <60 )
      4. hypotension
      5. miosis
-If above parameters are not corrected

double the dose of atropine every 5 minutes until atleast 3/5 of
    below parameters corrected
            -clear chest with no wheeze
            -dry axillae
            -heart rate 80-100 bpm
            -systolic BP > 90 mmhg
            -pupils no longer pinpoint
Maintenance infusion
once the patient is stable start an infusion of 5% dextrose containing 10-20% of the
total initial dose of atropine on an hourly basis

stop atropine infusion if features of toxicity appears
                   -confusion
                   -urinary retention
                   -hyperthermia
                  - bowel ileus
                  - agitation
                  - flushing
                  - tachycardia
Pralidoxime
give 30mg/kg loading dose Iv over 10-20mins followed by
 continuous infusion of 8-10mg/kg/hr until clinical recovery.
Management of complications
 1.Respiratory failure- ET intubation and mechanical
     ventilation required if
        - tidal volume <5mm/kg
        - vital capacity < 15 ml/kg
         -apnoic spells are present
         -PaO2 < 08 Kpa& FiO2 > 60%
         -severe pulmonary oedema
 2.Pulmonary oedema- give furosemide 40-80 mg iv
 3.convulsion – give 5-10 mg iv diazepam
 4.intermediate syndrome
     weakness of neck flexion                tachypnoea
     use of accessory muscle of respiration sweating
     proximal muscle weakness                nasal flaring
     cranial nerve palsies
 5. ventricular tachycardia- temporary pacing
 6.bronchopneumonia- antibiotics & chest physiotherapy
ORGANOPHOSPHATE POISONING AND MANAGEMENT

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ORGANOPHOSPHATE POISONING AND MANAGEMENT

  • 1. TLM. FOWZAN FACULTY OF MEDICINE RAJARATA UNIVERSITY SRI LANKA
  • 2. Organophosphate(insecticide) organophosphate poisoning accounts for nearly one third of hospital admissions from poisoning in Sri Lanka. Commonly using trades are follows. Malathion, parathion, diazinon, fenthione, chlorpyrifos. Action inhibit acetylcholine esterase enzyme at nerve endings by phosphorylation acetylcholine at receptor sites clinical features depends on route of entry ingestion inhalation eye contact
  • 3. Ingestion Muscarinic effects(post ganglionic Nicotinic effects (neuro muscular parasympathetic nerve ending) junction) • Bronchospasm(wheezing) • Muscle weakness • Bronchorrhoea • Fasciculation • Productive cough • Dyspnoea • Paralysis • Hypotension • Muscle twitching • Bradycardia • Cardiac arrhythmia • Diarrhoea • Vomiting • Salaivation • Tenesmus • Miosis • Lacrimation • Blurred vision
  • 4. Nicotinic and muscarinic Ach receptors in the Ach receptors in the CNS sympathetic system • Confusion • Excessive sweating • Agitation Other effects • Respiratory failure • Ataxia • hyperglycaemia • convulsion • Acute pancreatitis
  • 5. Inhalation Eye contact • Cough • Irritation • Difficulty in breathing • Pain • Bronchitis • Lacrimation • Pneumonia • Miosis • Blurring vision • Photophobia
  • 6. All the clinical features in from head to Toe
  • 7. Management of organophosphate poisoning 1. check airway, breathing, circulation. 2. monitor arterial oxygen saturation, cardiac rhythms, BP, Pulse rate. 3. look for signs & symptoms. 4. obtain IV access. 5. remove the contaminated clothes&wash the skin thoroughly with soap & water 6. give atropine intravenously as soon as possible for symptomatic patient 7. perform gastric decontamination with gastric lavage once the patient is stabilised & within two hours of ingestion. 8. give activated charcoal (50 g in 200 ml) 9. maintainance atropine infusion 10. give pralidoxime.
  • 8. OROPHARYNGEAL AIRWAY USED AMBU VENTILATION & ET TUBE GASTRIC LAVAGE ACTIVATED CHARCOAL
  • 9. Atropinisation -start with 1.8-3.0 mg fast iv bolus -after 3-5minutes check the five parameters of cholinergic poisoning 1. Poor air entry into the lungs due to bronchorroea & bronchospasm 2.excessive sweating 3. bradycardia ( <60 ) 4. hypotension 5. miosis -If above parameters are not corrected double the dose of atropine every 5 minutes until atleast 3/5 of below parameters corrected -clear chest with no wheeze -dry axillae -heart rate 80-100 bpm -systolic BP > 90 mmhg -pupils no longer pinpoint
  • 10. Maintenance infusion once the patient is stable start an infusion of 5% dextrose containing 10-20% of the total initial dose of atropine on an hourly basis stop atropine infusion if features of toxicity appears -confusion -urinary retention -hyperthermia - bowel ileus - agitation - flushing - tachycardia Pralidoxime give 30mg/kg loading dose Iv over 10-20mins followed by continuous infusion of 8-10mg/kg/hr until clinical recovery.
  • 11.
  • 12. Management of complications 1.Respiratory failure- ET intubation and mechanical ventilation required if - tidal volume <5mm/kg - vital capacity < 15 ml/kg -apnoic spells are present -PaO2 < 08 Kpa& FiO2 > 60% -severe pulmonary oedema 2.Pulmonary oedema- give furosemide 40-80 mg iv 3.convulsion – give 5-10 mg iv diazepam 4.intermediate syndrome weakness of neck flexion tachypnoea use of accessory muscle of respiration sweating proximal muscle weakness nasal flaring cranial nerve palsies 5. ventricular tachycardia- temporary pacing 6.bronchopneumonia- antibiotics & chest physiotherapy