Organophosphate poisoning

SUBJECTIVE DATA
NAME: XYZ AGE: 24 SEX: M Weight: 78 kg DOA: 7/12/2019
CHIEF COMPLAINTS:
• Pt. bought by relatives in altered state within 30 minutes of
insecticide poisoning
• Approx. 70 ml ingested within 10 minutes consisting 50%
Chlorpyriphosphate + 5% Cypermethrins as active constituents.
OP POISONING- RIDDHI 2

OBJECTIVE DATA
▪ MEDICAL H/O: N/S No h/o DM,HTN
▪ SOCIAL H/O: Smoking
▪ FAMILY H/O: N/A
▪ PREVIOUS ALLERGIES: N/S

PHYSICAL EXAMINATION
• GENERAL: semiconscious, afebrile
• VITALS: BP- 144/95 Pulse: 78/min SpO2: 99% RR: 22/min
• HEENT: Pupils dilated bilaterally
• CVS: S1S2 no murmur
• CNS: semiconscious, responds to verbal commands, doesn’t talk, agitated
• RS: Few crepts
• MS: Fasiculations ++
• GIT: ET feeding 30tsp/day
• GU:N
• EXT: No clubbing, cyanosis ,pallor

LAB INVESTIGATIONS
HAEMATOLOGY
i. Hb: 11g/ dL
ii. ESR: 23 mm/hr
iii. AGT: 102 IU/L
iv. WBC: 13100/cumm
v. NEUT: 91%
vi. LYM: 7%
vii. MCV: 105 fl
viii. BSL: 108mg/ dL
SERUM ELECTROLYTES
S.Na(129-
135mEq/L
)
S.K(3.5-
5.5
mEq/L)
S.Ca(4.3 to
5.3mEq/L)
7/12 148 3 1.04
8/12 132 2.9 1.05
10/12 129 2.5 1.04
12/12 146 3.3 1.06

LAB INVESTIGATIONS
ABG
❑ pH-7.60
❑ pCO2- 30mm Hg
❑ pO2- 125 mm Hg
❑ HCO3- 34.6mmol/L
❑ TCO2- 36mmol/L
COAGULATION
❑ PTT: 21.6(11-12)
❑ INR: 1.8
❑ P RATIO: 1.8

LAB INVESTIGATIONS
PLASMA AMMONIA
• 8/12: 523 µ/L
• 10/12: 467µg/ d L(30-
86µg/ d L)
• 12/12: 613 µg/ d L
SERUM CHOLINESTERASE
• 7/12: 2051 µ/L(5320-
12920µ/L)
• 9/12: 1556 µ/L
• 10/12: 2092µ/L
• 12/12: 1827µ/L

MRI: BRAIN WITHOUT CONTRAST

MRI: SMALL, FOCAL AREA OF ABNORMAL SIGNAL INTENSITY NOTED IN MIDLINE
CEREBELLUM/ CEREBELLAR NODULE- LIKELY SUBACUTE ISCHEMIC INFARCTS

ECG
⮚ 7/12: Sinus tachycardia; Poor R wave progression(V3)
⮚ 8/12: Sinus tachycardia; Low T wave (V5)
⮚ 9/12: : Sinus tachycardia; Low T wave (V5)
⮚ 10/12: Sinus tachycardia; Poor R wave progression(V2) ST
depression(V4)
⮚ 11/12: : Sinus tachycardia; Poor R wave progression(V2); Low T
wave (V5)
⮚ 12/12: : Sinus tachycardia; Flattened T wave(aVL,V4,V6)ST
Depression(V4)

ASSESSMENT TO CURRENT THERAPY
❖ FINAL DIAGNOSIS: ORGANOPHOSPHATE POISONING
❖ GOALS OF THERAPY:
I. To increase quality of life
II. Prevent comorbidity, mortality & further progression of disorder
III. Reduce adverse events of current therapy and optimize therapy

INJ. PAM INFUSION AT 10ML/HR(D1-D7)
¤ GENERIC: PRALIDOXIME
¤ CATEGORY: Antidote
¤ MOA: Reactivates cholinesterase that had been inactivated by phosphorylation due to exposure to
organophosphate pesticides and cholinesterase-inhibiting nerve agents (eg, terrorism and chemical
warfare agents such as sarin) by displacing the enzyme from its receptor sites; removes the phosphoryl
group from the active site of the inactivated enzyme.
¤ INDICATIONS: Treatment of muscle weakness and/or respiratory depression secondary to poisoning
due to organophosphate anticholinesterase pesticides and terrorism nerve agents; control of overdose
of anticholinesterase medications used to treat myasthenia gravis (ambenonium, neostigmine,
pyridostigmine)
¤ CONTRAINDICATIONS: Hypersensitivity, and other situations where the risk of administration clearly
outweighs possible benefit.
¤ ADVERSE EVENTS: difficult or rapid breathing, difficulty in focusing the eyes, difficulty with speaking,
dizziness, fast, pounding, or irregular heartbeat or pulse, muscle stiffness or weakness
¤ PREGNANCY: US FDA pregnancy category: Not assigned
¤ STD. DOSE: Initial dose: 1 to 2 g, preferably as an IV infusion in 100 mL of normal saline, over 15 to 30
minutes; if an infusion is not practical or if pulmonary edema is present, the dose should be given
slowly (over at least 5 minutes) by IV injection as a 50 mg/mL solution in Sterile Water for Injection
(e.g., 1000 mg in 20 mL)
Second dose: 1 to 2 g may be indicated after about 1 hour if muscle weakness has not been relieved
Additional doses may be given every 10 to 12 hours if muscle weakness persists.

INJ. ATROPINE INFUSION AT 1 ML/HOUR(D1-D8)
¤ CATEGORY: Anticholinergic,Antidote, Antispasmodic Agent, Gastrointestinal
¤ MOA: Blocks the action of acetylcholine at parasympathetic sites in smooth muscle,
secretory glands, and the CNS; increases cardiac output, dries secretions. Atropine
reverses the muscarinic effects of cholinergic poisoning due to agents with
acetylcholinesterase inhibitor activity by acting as a competitive antagonist of
acetylcholine at muscarinic receptors.
¤ INDICATIONS: Antidote, perioperative anesthesia, stress echocardiography, rapid
sequence intubation, mushroom poisoning
¤ CONTRAINDICATIONS:There are no contraindications listed in the manufacturer’s
labeling.
¤ ADVERSE EVENTS: xerostomia (dry mouth), dry skin, blurred vision, cycloplegia,
mydriasis, photophobia, anhidrosis, urinary hesitancy and retention, tachycardia,
palpitation, xerophthalmia, and constipation,
¤ PREGNANCY: US FDA pregnancy category: C
¤ STD.DOSE: 0.4 mg to 0.6 mg, IV, intramuscularly, or subcutaneously

INJ.MONOCEF 1G BD(D1-D4)
¤ GENERIC: Ceftriaxone
¤ CATEGORY: Antibacterial agent
¤ MOA: Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-
binding proteins (PBPs) which in turn inhibits the final transpeptidation step of
peptidoglycan synthesis in bacterial cell walls, thus inhibiting cell wall biosynthesis.
¤ INDICATIONS: Bone and joint infections (osteomyelitis and/or discitis,prosthetic joint
infection, septic arthritis,Gonococcal infection, uncomplicated (cervical/urethral,
rectal, and pharyngealIntra-abdominal infection, community-acquired, Lower
respiratory tract infections, Meningitis, Pelvic inflammatory disease, Urinary tract
infection
¤ CONTRAINDICATIONS: concomitant use with intravenous calcium-containing
solutions/products, IV use of ceftriaxone solutions containing lidocaine
¤ ADVERSE EVENTS: chest pain, chills, cough, sores, ulcers, SOB
¤ PREGNANCY: US FDA pregnancy category: B
¤ STD. DOSE: 1 to 2 g IV or IM once a day (or in equally divided doses twice a day)
Duration of therapy: 4 to 14 days OP POISONING- RIDDHI 14

INJ. PAN 40MG IV OD(D1-D8)
¤ Generic– Pantoprazole
¤ Category- Proton Pump Inhibitor
¤ MOA–It is a proton pump inhibitor,inhibits H,K ATPase enzyme
which secretes HCl in parietal cells of stomach
¤ Indications-Ulcers and reflux oesophagitis,GERD,Zollinger-Ellison
syndrome
¤ Contraindication- Hypersensitivity
¤ Side effects- Headache, diarrhea, dizziness
¤ Pregnancy–US FDA pregnancy category Not Assigned:This drug is
only recommended for use during pregnancy when there are no
alternatives and the benefit outweighs the risk.
¤ Warnings–Prolonged treatment (greater than 24-36 months) may
cause vitamin B12 deficiency.
¤ Std. Dose–20-80 mg/day

INJ. EMESET 4MG IV TDS(D1-D8)
¤ GENERIC: Ondansetron
¤ CATEGORY: 5-HT3-receptor antagonist ,Anti emetic
¤ MOA: Ondansetron is a selective 5-HT3-receptor antagonist which blocks serotonin, both
peripherally on vagal nerve terminals and centrally in the chemoreceptor trigger zone
¤ INDICATIONS: CINV, Post operative nausea/vomiting,pregnancy associated
nausea,vomiting. Gastroparesis
¤ CONTRAINDICATIONS: Hypersensitivity, concomitant use with apomorphine
¤ ADVERSE EVENTS: confusion, dizziness, fever, fatigue, gastric pain
¤ STD. DOSE: recommended dose: 0.15 mg/kg IV, with the first dose (infused over 15
minutes) 30 minutes before the start of emetogenic chemotherapy and subsequent doses
given 4 and 8 hours after the first dose.
-Maximum dose: 16 mg per dose

INJ. GEREMERO 2.5MG IV SOS(D1-D8)
¤ GENERIC: Meropenem
¤ CATEGORY: Antibiotic, Carbapenem
¤ MOA: Carbapenems inhibit bacterial cell wall synthesis by binding to the penicillin-
binding proteins and interfering with cell wall formation.
¤ INDICATIONS: Intraabdominal Infection, Nosocomial Pneumonia, Skin and Structure
Infection Skin or Soft Tissue Infection, Meningitis
¤ CONTRAINDICATIONS: Seizure
¤ ADVERSE EVENTS: Constipation ,redness, swelling at the injection site,
thrombocytopenia
¤ PRECAUTIONS: Tell your doctor about all your other medicines, especially:
divalproex sodium;
probenecid; or
valproic acid.
¤ STD. DOSE: Reconstitute infusion vials containing 500 mg or 1 g with a compatible IV
solution (e.g., 0.9% sodium chloride, 5% dextrose) to provide solutions containing
approximately 2.5–50 mg/mL. OP POISONING- RIDDHI 17

INJ. PIPZO 4.5 GM IV TDS(D5-D8)
¤ Generic– Piperacillin and Tazobactam
¤ Category- Antibiotic,Penicillin
¤ MOA–Piperacillin/tazobactam is a beta-lactam/beta-lactamase
inhibitor combination with a broad spectrum of antibacterial activity
encompassing most Gram-positive and Gram-negative aerobic
bacteria and anaerobic bacteria, including many pathogens
producing beta-lactamase
¤ Indications– peritonitis, UTI, septicemia, pneumonia and other
nosocomial infections
¤ Contraindications–Hypersensitivity, seizures
¤ Adverse effects– thrombocytopenia,headache, diarrhea
¤ Pregnancy–US FDA pregnancy category B
¤ Warnings– Do not administer in case of hypersensitivity, cystic
fibrosis or with any vaccinations or immunization.
¤ Std. Dose– 0.5-4.5 g iv every 6 hours

TB. MONTEK FX HS(D5-D8)
¤ GENERIC: Montelukast 10mg+ Foxofenadine 120mg
¤ CATEGORY: Anti asthmatic, Bronchodilator
¤ MOA: Fexofenadine is an active metabolite of terfenadine and like terfenadine it
competes with histamine for H1-receptor sites on effector cells in the gastrointestinal
tract Montelukast Selective leukotriene receptor antagonist that inhibits the
cysteinyl leukotriene receptor. Cysteinyl leukotrienes and leukotriene receptor
occupation have been correlated with the pathophysiology of asthma ract, blood
vessels and respiratory tract
¤ INDICATIONS: Rhinitis, asthma, pharyngitis, lower and upper respiratory
infections,airway obstruction, pulmonary obstruction
¤ CONTRAINDICATIONS: Hypersensitivity
¤ ADVERSE EVENTS: flu like ,symptoms, headache, trouble swallowing,
¤ PREGNANCY: US FDA pregnancy category NOT ASSIGNED: Not assigned
¤ STD. DOSE: MONTELUKAST- 10 mg orally once a day
FOXOFENADINE- 180 mg orally once a day OR 60 mg orally 2 times a day
-Maximum dose: 180 mg/day OP POISONING- RIDDHI 19

CAP. MACPHYLLIN 100MG BD(D4-D8)
¤ GENERIC: Acebrophylline
¤ CATEGORY: Anti asthmatic, Bronchodilator
¤ MOA: smooth muscle relaxation (ie, bronchodilation) and suppression of the
response of the airways to stimuli (ie, non-bronchodilator prophylactic effects).
Bronchodilation is mediated by inhibition of two isoenzymes, phosphodiesterase
(PDE III and, to a lesser extent, PDE IV)
¤ INDICATIONS: asthma, bronchitis, COPD,bradycardia
¤ CONTRAINDICATIONS: allergy, Hypersensitivity to xanthine derivatives; coronary
artery disease (where cardiac stimulation might prove harmful); peptic ulcers;
coadministration with ephedrine in children.
¤ ADVERSE EVENTS: acid base imbalance, irregular heartbeat, persistent
vomiting,diuresis,
¤ PREGNANCY: US FDA pregnancy category C
¤ STD. DOSE: Initial dose: 300 mg per day given as evenly divided doses every 6 to 8
hours
After 3 days, if starting dose was tolerated: 400 mg per day given as evenly divided
doses every 6 to 8 hours

INJ. LASIX 20MG IV STAT & BD(D3-D8)
¤ GENERIC: FUROSEMIDE
¤ CATEGORY: Diuretic –high ceiling
¤ MOA: Primarily inhibits reabsorption of sodium and chloride in the ascending loop of Henle and
proximal and distal renal tubules, interfering with the chloride-binding cotransport system, thus
causing its natriuretic effect
¤ INDICATIONS: Management of edema associated with heart failure, cirrhosis of the liver (ie,
ascites), or renal disease (including nephrotic syndrome); acute pulmonary edema.
¤ CONTRAINDICATIONS: Hypersensitivity to sulfonamide-derived drugs; complete renal
shutdown; hepatic coma and precoma; uncorrected states of electrolyte depletion,
hypovolemia, dehydration, hyperbilirubinemia
¤ ADVERSE EVENTS: electrolyte depletion, painful urination, syncope, SIADH
¤ PRECAUTIONS: Furosemide is a potent diuretic which, if given in excessive amounts, can lead to
a profound diuresis with water and electrolyte depletion.
¤ PREGNANCY: US FDA pregnancy category C
¤ STD. DOSE: Initial dose: 20 to 40 mg IV (slowly over 1 to 2 minutes) or IM once; may repeat
with the same dose or increase by 20 mg no sooner than 2 hours after the previous dose until
the desired diuretic effect has been obtained.
Maintenance dose: Administer the dose that provided the desired diuretic effect once or twice a
day. OP POISONING- RIDDHI 21

INJ. KESOL 20CC IN RL OVER 7-8H BD(D6-
D8)
¤ GENERIC: Potassium chloride
¤ CATEGORY: Electrolyte supplement,replacement
¤ MOA: Potassium is the major cation of intracellular fluid and is essential for the
conduction of nerve impulses in heart, brain, and skeletal muscle; contraction of
cardiac, skeletal and smooth muscles; maintenance of normal renal function, acid-
base balance, carbohydrate metabolism, and gastric secretion
¤ INDICATIONS: Hypokalemia: Treatment or prevention of hypokalemia.
¤ CONTRAINDICATIONS: hyperkalemia, renal failure, Renal impairment with oliguria,
anuria, or azotemia; Addison disease (untreated); ventricular fibrillation; salt-losing
adrenal hyperplasia; extensive tissue breakdown as in severe burns, acute
dehydration, and heat cramps; increased sensitivity to potassium administration (eg,
congenital paramyotonia, adynamia episodica hereditaria); hyperadrenalism
associated with adrenogenital syndrome; digitalis-induced, second- or third-degree
heart block.
¤ ADVERSE EVENTS: constipation, SOB,bradycardia
¤ PREGNANCY: US FDA pregnancy category Not Assigned
¤ STD. DOSE: If serum potassium is 2.5 mEq/L or higher, rate should not exceed 10
mEq/hour, and manufacturers recommend that concentration not exceed 40 mEq/L
Maximum daily dose: 200 mEq OP POISONING- RIDDHI 22

INJ. SERENACE 5MG SOS IF
BEHAVIORALLY UNCONTROLLED(D6-D8)
¤ GENERIC: HALOPERIDOL
¤ CATEGORY: First Generation (Typical) Antipsychotic
¤ MOA: Haloperidol is a butyrophenone antipsychotic that nonselectively blocks
postsynaptic dopaminergic D2 receptors in the brain
¤ INDICATIONS: Behavioral disorders, hyperactivity, schizophrenia, Tourette syndrome
¤ CONTRAINDICATIONS: Significant depressive states; previous spastic
diseases, Parkinson disease; severe CNS depression; coma; dementia with Lewy
bodies
¤ ADVERSE EVENTS: akathisia, blurred vision, constipation, weight gain, and
xerostomia.
¤ PREGNANCY: US FDA pregnancy category: C
¤ STD. DOSE: Prompt control acute agitation: 2 to 5 mg IM every 4 to 8 hours
-The frequency of IM administration should be determined by patient response and
may be given as often as every hour.
Maximum dose: 20 mg/day

SYP. DUPHALAC (D4-D8)
¤ GENERIC: Lactulose
¤ CATEGORY: Osmotic laxative, Ammonium Detoxicant
¤ MOA: The bacterial degradation of lactulose resulting in an acidic pH inhibits the
diffusion of NH3 into the blood by causing the conversion of NH3 to NH4+; also
enhances the diffusion of NH3 from the blood into the gut where conversion to NH4+
occurs; produces an osmotic effect in the colon with resultant distention promoting
peristalsis
¤ INDICATIONS: acute & chronic constipation, hepatic encephalopathy
¤ CONTRAINDICATIONS: Patients requiring a low galactose diet
¤ ADVERSE EVENTS: Gaseous distention, belching, flatulence, borborygmi, abdominal
discomfort (e.g., cramping). Dehydration and hyponatremia in infants.
¤ PREGNANCY: pregnancy category B
¤ STD. DOSE: Initial dose: 15 mL orally once a day. Therapy should be continued until
normal bowel function resumes. OP POISONING- RIDDHI 24

TB. RIFAGUT 550MG BD(D6-D8)
¤ GENERIC: Rifaximin
¤ CATEGORY: Anti bacterial, Rifamycin
¤ MOA: Rifaximin inhibits bacterial RNA synthesis by binding to bacterial DNA-
dependent RNA polymerase.
¤ INDICATIONS: hepatic encephalopathy, traveller’s diarrhea, IBS,C.diff diarrhea
¤ CONTRAINDICATIONS: Hypersensitivity to rifaximin, other rifamycin antibiotics
¤ ADVERSE EVENTS: flatulence, abdominal pain, bowel urgency, headache, nausea,
and rectal tenesmus
¤ PREGNANCY: US FDA pregnancy category: Not assigned.
¤ STD. DOSE: hepatic encephalopathy:250- 550 mg orally twice a day
25
OP POISONING- RIDDHI

INJ. THIAMINE 100MG IV OD(D7-D8)
¤ GENERIC: Vitamin B1
¤ CATEGORY: Vitamin, Water Soluble
¤ MOA: An essential coenzyme in carbohydrate metabolism by combining with
adenosine triphosphate to form thiamine pyrophosphate.
¤ INDICATIONS: An essential coenzyme in carbohydrate metabolism by combining with
adenosine triphosphate to form thiamine pyrophosphate., DIETARY SUPPLEMENT,
ethylene glycol poisoning
¤ CONTRAINDICATIONS: Hypersensitivity to thiamine
¤ ADVERSE EVENTS: coughing, itching, difficulty in swallowing
¤ PREGNANCY:Thiamine has been assigned to pregnancy category A (injectable)
¤ STD. DOSE: 100 to 250 mg IV or IM once daily for 3 to 5 days followed by 100 mg
orally 3 times daily for 1 to 2 weeks then 100 mg orally daily thereafter
26

INJ. HEPAMERZ 5MG IV TDS(D6-D8)
¤ GENERIC: L-Ornithine + L-Asparate
¤ MOA: Hepamerz Injection 10ml is a combination of two amino acids which works by
protecting the liver from harmful chemical substances (free radicals), thus preventing
liver damage. L-ornithine- L-aspartate (LOLA), the salt of the natural amino acids
ornithine and aspartate acts through the mechanism of substrate activation to
detoxify ammonia
¤ INDICATIONS: Cirrhosis, jaundice, hemolytic anemia, ALD
¤ CONTRAINDICATIONS: Hyperalbuminemia
¤ ADVERSE EVENTS: severe rashes, difficulty in swallowing, shortness of breath,
swelling, etc
¤ PREGNANCY: Not assigned
¤ STD. DOSE: 5-10 ml(1mg/ml)
27

INJ. HYDROCORT 100MG IV STAT & TDS
¤ GENERIC:Hydrocortisone
¤ MOA: Short-acting corticosteroid with minimal sodium-retaining potential; decreases inflammation
by suppression of migration of polymorphonuclear leukocytes and reversal of increased capillary
permeability
¤ INDICATIONS: Allergic,dericamatological & edematous state. Acute
adrenocortical insufficiency, severe ulcer colitis, chorioretinitis, rheumatological disorders and
neoplastic disorders.
¤ CONTRAINDICATIONS: systemic fungal infections, thrombocytopenic purpura
¤ ADVERSE EVENTS: acne, increased hair growth,
¤ PREGNANCY: US FDA:pregnancy category: C
¤ STD. DOSE: IM, IV: Initial: 100 to 500 mg/dose at intervals of 2, 4, or 6 hours

PLANNING
● THERAPEUTIC MONITORING: BP
S.Na
ECG
S.ammonia
mental status SaO2
● TOXICITY MONITORING: Atropine
● DISCHARGE MONITORING: Patient not discharged
● DISCHARGE MEDICATIONS: --

POINT TO PATIENT representative
❖ About the disease: The patient is in the said condition due to ingestion of
insecticide containing harmful chemicals. This has psychiatric effects
rendering in an uncontrolled, aggressive behaviour along with major
pathological manifestations.
❖ About lifestyle modifications:
The patient needs to be in observation even after the vitals are stable for a
minimum period of 2 weeks.
The patient will need to go under therapy (psychosocial).
Fiber rich ,low fat diet can be resumed after discharge.

POINT TO PHYSICIAN
⮚ CONTRAINDICATED: Concomitant use of agents with anticholinergic properties may potentiate the risk of upper
gastrointestinal injury associated with oral solid formulations of potassium chloride. The proposed mechanism
involves increased gastrointestinal transit time due to reduction of stomach and intestinal motility by
anticholinergic agents, thereby creating a high localized concentration of potassium ions in the region of a
dissolving tablet or capsule and increasing the contact time with GI mucosa.
⮚ MONITOR: Some neuroleptic agents may cause prolongation of the QT interval. MANAGEMENT: Caution is
advised when neuroleptics must be used concomitantly with medications that can cause potassium and/or
magnesium disturbances. Serum electrolytes should be monitored and any abnormalities corrected prior to
initiating therapy with a neuroleptic.
⮚ HALOPERIDOL & ATROPINE: Use of neuroleptics in combination with other neuroleptics or anticholinergic
agents may increase the risk of tardive dyskinesia
⮚ MONITOR: Chronic use of proton pump inhibitors (PPIs) may induce hypomagnesemia, and the risk may be
increased during concomitant use of diuretics or other agents that can cause magnesium loss. The mechanism
via which hypomagnesemia may occur during long-term PPI use is unknown, although changes in intestinal
absorption of magnesium may be involved.
⮚ ATROPINIZATION: Signs of atropinization such as flushing, mydriasis, tachycardia, and dry mouth and nose may
occur earlier than expected during coadministration with pralidoxime relative to administration of atropine alone,
particularly if the total dose of atropine has been large and the administration of pralidoxime was delayed.

POINT TO PHYSICIAN

Organophosphate poisoning

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