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Tomioka T, Shimoyama K, Tanino Y, Hirayama M, Homma H. Utility of Automated Infrared Pupillometry in Assessing the Prolonged Course of Organophosphate Poisoning: A Case Report. Cureus 2024; 16:e58872. [PMID: 38800312 PMCID: PMC11116839 DOI: 10.7759/cureus.58872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2024] [Indexed: 05/29/2024] Open
Abstract
Central and autonomic nervous system signs of organophosphate poisoning (OP), such as altered consciousness, noticeable lacrimation, and salivation, can be influenced by medications used in intensive care settings, such as atropine and pralidoxime methyl (PAM). Because of this, there are no established methods for assessing the duration of OP while receiving antidotal treatment. In the present case, we used the Neurological Pupil Index (NPi) to evaluate the duration of OP in an 82-year-old woman who attempted suicide by ingesting up to 100 mL of fenitrothion. Until hospitalization day (HD) 20, discontinuation of atropine led to the recurrence of altered consciousness, while its reinstatement resulted in improvement; this made it difficult to assess the prolongation of OP based on signs and symptoms. Until HD 20, the NPi remained at 0/0, and subsequently, it increased. Additionally, even after discontinuing atropine, consciousness, tearing, and salivation did not worsen, indicating recovery from OP. On HD 26, serum acetylcholinesterase (AChE) levels were elevated above the measurable level for the first time, following an increase in the NPi. In this case, assessing the persistence of OP based on signs was challenging because these signs improved with atropine and PAM treatment. The improvement in NPi levels coincided with an improvement in poisoning, suggesting that NPi is useful for evaluating the duration of OP. NPi is noninvasive and sensitive compared to AChE, which is used to gauge the persistence of OP and could be used to allow earlier cessation of medication and guide appropriate treatment durations.
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Affiliation(s)
- Takuya Tomioka
- Department of Emergency and Critical Care Medicine, Tokyo Medical University, Tokyo, JPN
| | - Keiichiro Shimoyama
- Department of Emergency and Critical Care Medicine, Tokyo Medical University, Tokyo, JPN
| | - Yusuke Tanino
- Department of Emergency and Critical Care Medicine, Tokyo Medical University, Tokyo, JPN
| | - Masaru Hirayama
- Department of Emergency and Critical Care Medicine, Tokyo Medical University, Tokyo, JPN
| | - Hiroshi Homma
- Department of Emergency and Critical Care Medicine, Tokyo Medical University, Tokyo, JPN
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Baker E, Southern C, Martinez J. Atropine sulfate as a continuous intravenous infusion for the treatment of organophosphate toxicity in a cat. JFMS Open Rep 2024; 10:20551169241249637. [PMID: 38799116 PMCID: PMC11119382 DOI: 10.1177/20551169241249637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024] Open
Abstract
Case summary A 1-year-old male neutered domestic shorthair cat presented on an emergency basis with clinical signs suspected to be secondary to organophosphate (OP) toxicity. The control of clinical abnormalities (bradycardia, obtundation, tachypnea, anorexia) was achieved using high-dose continuous rate intravenous infusion (CRI) of atropine sulfate (maximum rate 0.1 mg/kg/h). After 5 days of hospitalization, the patient made a full clinical recovery without the development of atropine toxicity, intermediate syndrome or delayed polyneuropathy at 4 weeks after discharge. Relevance and novel information Treatment of OP toxicity in cats is sparsely reported in veterinary literature. Current standards of treatment and published protocols recommend the use of atropine sulfate as intermittent boluses for the treatment of muscarinic signs of toxicity; however, there is a paucity of information regarding the safety and efficacy of atropine sulfate as a CRI for severe toxicosis as described in humans. This report includes the first published case using such a treatment protocol in a cat.
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Affiliation(s)
- Edward Baker
- Department of Small Animal Clinical Sciences, University of Florida, Gainesville, FL, USA
| | - Carl Southern
- Department of Small Animal Clinical Sciences, University of Florida, Gainesville, FL, USA
| | - Jennifer Martinez
- Department of Small Animal Clinical Sciences, University of Florida, Gainesville, FL, USA
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Lavonas EJ, Akpunonu PD, Arens AM, Babu KM, Cao D, Hoffman RS, Hoyte CO, Mazer-Amirshahi ME, Stolbach A, St-Onge M, Thompson TM, Wang GS, Hoover AV, Drennan IR. 2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2023; 148:e149-e184. [PMID: 37721023 DOI: 10.1161/cir.0000000000001161] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
In this focused update, the American Heart Association provides updated guidance for resuscitation of patients with cardiac arrest, respiratory arrest, and refractory shock due to poisoning. Based on structured evidence reviews, guidelines are provided for the treatment of critical poisoning from benzodiazepines, β-adrenergic receptor antagonists (also known as β-blockers), L-type calcium channel antagonists (commonly called calcium channel blockers), cocaine, cyanide, digoxin and related cardiac glycosides, local anesthetics, methemoglobinemia, opioids, organophosphates and carbamates, sodium channel antagonists (also called sodium channel blockers), and sympathomimetics. Recommendations are also provided for the use of venoarterial extracorporeal membrane oxygenation. These guidelines discuss the role of atropine, benzodiazepines, calcium, digoxin-specific immune antibody fragments, electrical pacing, flumazenil, glucagon, hemodialysis, hydroxocobalamin, hyperbaric oxygen, insulin, intravenous lipid emulsion, lidocaine, methylene blue, naloxone, pralidoxime, sodium bicarbonate, sodium nitrite, sodium thiosulfate, vasodilators, and vasopressors for the management of specific critical poisonings.
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Khonje V, Hart J, Venter J, Deonarain S, Grossberg S. Acute organophosphorus toxicity in a regional hospital in Johannesburg, South Africa: A retrospective chart review. Afr J Emerg Med 2023; 13:104-108. [PMID: 37152660 PMCID: PMC10160343 DOI: 10.1016/j.afjem.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 02/23/2023] [Accepted: 04/04/2023] [Indexed: 05/09/2023] Open
Abstract
Introduction Intentional and accidental organophosphorus exposures pose a significant healthcare-related burden on South African communities. This study will review the demographics, characteristics and clinical course of patients presenting with features of acute organophosphorus toxicity to a regional Emergency Centre in Johannesburg, South Africa. Methods This was a retrospective chart review of all patients treated for possible acute organophosphorus toxicity from January 2020 to August 2021. Results A total of 205 patients were identified of which 134 patients were included in the study. The median age was 26 years with a male predominance (male= 56%, female=44%). 109 patients (81.3%) survived, 18 patients (13.4%) demised and the outcome of 7 patients (5.2%) was unknown. The median hospital length of stay was 8 days, (IQR= 5-13 days), and the longest hospital stay was 37 days in ICU. Atropinisation dose was significantly higher for intubated patients (median=140.0mg; IQR=90mg-219.5mg) compared to patients who were not intubated (median=60mg; IQR=20.5mg-120mg, p < 0.05). The length of stay was significantly higher for intubated patients (median=11 days; IQR=7-15 days) compared to patients who were not intubated (median=5 days; IQR=3-8 days, p < 0.00). There was a moderate positive correlation between atropinisation dose and length of stay (Correlation coefficient = 0.37, p < 0.00). There was a moderate negative correlation between atropinisation dose and cholinesterase level (Correlation coefficient= - 0.39, p < 0.00). Of those reported to have adverse effects 78.6%, were related to atropine toxicity. Conclusion Our study shows a high mortality rate secondary to organophosphorus toxicity. Significant exposures and thus higher doses of atropine were associated with increased length of stay and need for intubation. We found a high incidence of atropine-related adverse effects. More studies are needed to further establish the balance between the therapeutic and adverse effects of high-dose atropine as a treatment modality for organophosphorus toxicity.
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Affiliation(s)
- Vanessa Khonje
- Emergency Department, Thelle Mogoerane Regional Hospital, Vosloorus, Gauteng, South Africa
- Corresponding author:
| | - Jedd Hart
- Emergency Department, Thelle Mogoerane Regional Hospital, Vosloorus, Gauteng, South Africa
- Division of Emergency Medicine, Faculty of Health Sciences, University of Witwatersrand, Gauteng, South Africa
| | - Jakus Venter
- Emergency Department, Thelle Mogoerane Regional Hospital, Vosloorus, Gauteng, South Africa
- Division of Emergency Medicine, Faculty of Health Sciences, University of Witwatersrand, Gauteng, South Africa
| | - Saisha Deonarain
- Emergency Department, Thelle Mogoerane Regional Hospital, Vosloorus, Gauteng, South Africa
| | - Saul Grossberg
- Emergency Department, Thelle Mogoerane Regional Hospital, Vosloorus, Gauteng, South Africa
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Eddleston M. CON: Oximes should be used routinely in organophosphorus insecticide poisoning. Br J Clin Pharmacol 2022; 88:5070-5073. [PMID: 34989015 DOI: 10.1111/bcp.15217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 12/20/2021] [Accepted: 12/24/2021] [Indexed: 11/30/2022] Open
Abstract
Organophosphorus (OP) insecticide poisoning causes respiratory failure due to acetylcholinesterase (AChE) inhibition. The AChE reactivating antidote pralidoxime was developed in the 1950s and soon noted to benefit patients occupationally poisoned with the highly potent OP insecticide parathion. Routine use of pralidoxime and other oximes such as obidoxime then became widely recommended. However, nearly all severe cases of OP poisoning now result from self-poisoning with large volumes of less potent (WHO hazard class Ib and II) insecticides and co-formulated solvents. Unfortunately, oxime clinical trials have never shown benefit from their use for these patients, and some have shown that pralidoxime may be associated with harm, including increased mortality. Oximes should not be used routinely for the care of OP insecticide poisoned patients until translational and clinical studies have identified a safe and effective oxime regimen and identified the patients who benefit.
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Affiliation(s)
- Michael Eddleston
- Pharmacology, Therapeutics & Toxicology, Centre for Cardiovascular Science, and Centre for Pesticide Suicide Prevention, University of Edinburgh, Edinburgh, UK
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Bhalla A, Kumar HM, Pannu A, Kumar S, Sharma N. Magnesium sulfate in organophosphorus compound poisoning: A prospective open-label clinician-initiated intervention trial with historical controls. Int J Crit Illn Inj Sci 2022; 12:33-37. [PMID: 35433392 PMCID: PMC9008281 DOI: 10.4103/ijciis.ijciis_67_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 10/04/2021] [Accepted: 10/09/2021] [Indexed: 11/04/2022] Open
Abstract
Background: Methods: Results: Conclusion:
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Pannu AK, Garg S, Bhalla A, Dhibar DP, Sharma N. Lipid emulsion for the treatment of acute organophosphate poisoning: an Open-Label randomized trial. Clin Toxicol (Phila) 2021; 60:602-608. [PMID: 34928182 DOI: 10.1080/15563650.2021.2013496] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Many organophosphate (OP) pesticides are lipid-soluble; therefore, intravenous lipid emulsion (ILE) has been evaluated as a possible treatment for acute poisoning. A single bolus dose of 100 ml of 20% ILE was found safe in a pilot observational study. This randomized trial aimed to assess the effectiveness and safety of an extended dose of ILE in acute OP poisoning. METHODS This was an investigator-initiated, parallel-group, open-label, randomized controlled trial conducted at PGIMER, Chandigarh (India), from January 2019 to June 2020, in patients aged above 13 years with acute OP poisoning. The primary efficacy outcome was to study the change in atropine dose requirement (total and over the first 24 h) for cholinergic crisis after giving an initial bolus dose of 100 ml of 20% ILE followed by an infusion of 100 ml of 20% ILE over 6 h in addition to the standard care. The secondary efficacy outcomes were to detect the effects on hemodynamic variables, length of hospital stay, and duration of mechanical ventilation required. The incidence of adverse events was evaluated. RESULTS A total of 45 patients were assigned to receive either ILE (intervention group, n = 23) or normal saline (control group, n = 22) in addition to standard treatment. Baseline variables in both groups were comparable. The median dose of atropine (in mg) in the first 24 h and at complete resolution in the ILE group were similar to the control group (124.0 versus 141.8, p-value 0.916; and 150.8 versus 175.0, p-value 0.935). Hemodynamic variables (systolic and diastolic blood pressures, mean arterial pressure, and pulse rate) over 24, 48, and 72 h of treatment, length of hospital stay, and duration of mechanical ventilation were also unaffected by ILE. Case fatality was 4 and not statistically different between intervention and control groups (1 versus 3, p-value 0.346). There was no excessive fever, dyspnea, elevation of serum amylase, or pancreatitis from ILE. CONCLUSION ILE has no apparent benefit in acute OP poisoning. However, an extended dose appears safe for the indication.
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Affiliation(s)
- Ashok Kumar Pannu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sahil Garg
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashish Bhalla
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Deba Prasad Dhibar
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Navneet Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Abstract
Organophosphorus (OP) compounds remain a leading cause of self-poisoning and mortality, especially in South East Asia, China, and Africa. Organophosphorus causes an acute cholinergic syndrome by inhibiting acetylcholinesterase. Atropine remains the mainstay of treatment, but recently some promising therapies are in the pipeline. Oximes are used widely in the management of organophosphorus poisoning, however clinical efficacy remains to be established. Magnesium sulfate, calcium channel blockers (nimodipine), plasma alkalinizing agents, β-2 agonists, nicotinic receptor antagonists, clonidine, and lipid emulsions are promising treatment alternatives. However, large phase III trials are required to establish their efficacy.
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Hon KL, Hui WF, Leung AK. Antidotes for childhood toxidromes. Drugs Context 2021; 10:dic-2020-11-4. [PMID: 34122588 PMCID: PMC8177957 DOI: 10.7573/dic.2020-11-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 04/20/2021] [Indexed: 11/21/2022] Open
Abstract
Background Poisoning causes significant morbidity and sometimes mortality in children worldwide. The clinical skill of toxidrome recognition followed by the timely administration of an antidote specific for the poison is essential for the management of children with suspected poisoning. This is a narrative review on antidotes for toxidromes in paediatric practice. Methods A literature search was conducted on PubMed with the keywords “antidote”, “poisoning”, “intoxication”, “children” and “pediatric”. The search was customized by applying the appropriate filters (species: humans; age: birth to 18 years) to obtain the most relevant articles for this review article. Results Toxidrome recognition may offer a rapid guide to possible toxicology diagnosis such that the specific antidote can be administered in a timely manner. This article summarizes toxidromes and their respective antidotes in paediatric poisoning, with an emphasis on the symptomatology and source of exposure. The antidote and specific management for each toxidrome are discussed. Antidotes are only available for a limited number of poisons responsible for intoxication. Antidotes for common poisonings include N-acetyl cysteine for paracetamol and sodium thiosulphate for poisoning by cyanide. Conclusion Poisoning is a common cause of paediatric injury. Physicians should be familiar with the recognition of common toxidromes and promptly use specific antidotes for the management of childhood toxidromes.
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Affiliation(s)
- Kam Lun Hon
- Department of a Paediatrics and Adolescent Medicine, The Hong Kong Children's Hospital, Hong Kong
| | - Wun Fung Hui
- Department of a Paediatrics and Adolescent Medicine, The Hong Kong Children's Hospital, Hong Kong
| | - Alexander Kc Leung
- Department of Pediatrics, The University of Calgary and The Alberta Children's Hospital, Calgary, Alberta, Canada
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Pannu AK, Bhalla A, Vishnu RI, Garg S, Dhibar DP, Sharma N, Vijayvergiya R. Cardiac injury in organophosphate poisoning after acute ingestion. Toxicol Res (Camb) 2021; 10:446-452. [PMID: 34141158 DOI: 10.1093/toxres/tfab036] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/19/2021] [Accepted: 03/25/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction Sparse data and conflicting evidence exist on the prevalence and prognosis of organophosphate (OP)-related cardiac toxicity. We aimed to characterize the cardiac abnormalities of OP after an acute cholinergic crisis in adults without previous cardiovascular conditions. Patients and Methods We did a prospective observational study in a tertiary-care hospital of north India (Postgraduate Institute of Medical Education and Research, Chandigarh) in 74 patients aged ≥ 13 years admitted with acute OP poisoning after self-ingestion. A systemic evaluation, including clinical characteristics, electrocardiography, and echocardiography, was performed to estimate the prevalence and prognosis of cardiac injury. A rate-corrected QT interval was calculated using Bazett's method, and >440 milliseconds was used to define prolongation. Results Chlorpyrifos was the most commonly ingested OP (n = 29). The patients had a similar occurrence of hypotension (n = 10) and hypertension (n = 9) at admission, and electrocardiography demonstrated sinus tachycardia in 38 (51.3%) and sinus bradycardia in one case. During the hospital stay, 3 out of 74 patients had a prolonged rate-corrected QT interval (457, 468, and 461 milliseconds), and one patient developed supraventricular tachycardia. Eight (10.8%) patients developed the intermediate syndrome, and six (8.1%) died. None of the hemodynamic or electrocardiographic abnormalities was associated with in-hospital mortality or intermediate syndrome development on univariant analysis. Baseline echocardiography at hospital discharge was performed in 27 patients (admitted during 2018) and normal in all except mild tricuspid regurgitation in one. At a 6-month follow-up, 23 cases were available for cardiovascular screening (including echocardiography) and had a normal evaluation. Conclusion Cardiac toxicity is uncommon after acute OP self-ingestion and lacks prognostic significance.
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Affiliation(s)
- Ashok Kumar Pannu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, 4th Floor, F Block, Nehru Hospital, PGIMER, Chandigarh 160012, India
| | - Ashish Bhalla
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, 4th Floor, F Block, Nehru Hospital, PGIMER, Chandigarh 160012, India
| | - R I Vishnu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, 4th Floor, F Block, Nehru Hospital, PGIMER, Chandigarh 160012, India
| | - Sahil Garg
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, 4th Floor, F Block, Nehru Hospital, PGIMER, Chandigarh 160012, India
| | - Deba Prasad Dhibar
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, 4th Floor, F Block, Nehru Hospital, PGIMER, Chandigarh 160012, India
| | - Navneet Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, 4th Floor, F Block, Nehru Hospital, PGIMER, Chandigarh 160012, India
| | - Rajesh Vijayvergiya
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, 3rd Floor, Block - C, Advanced Cardiac Center, PGIMER, Chandigarh 160012, India
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Eddleston M, Chowdhury FR. Organophosphorus poisoning: the wet opioid toxidrome. Lancet 2021; 397:175-177. [PMID: 33357495 DOI: 10.1016/s0140-6736(20)32749-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 12/17/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Michael Eddleston
- Centre for Pesticide Suicide Prevention and Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK; National Poisons Information Service-Edinburgh, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK.
| | - Fazle Rabbi Chowdhury
- Department of Internal Medicine, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka, Bangladesh; Toxicology Society of Bangladesh, Dhaka, Bangladesh
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Pannu AK, Bhalla A, Vishnu RI, Dhibar DP, Sharma N, Vijayvergiya R. Organophosphate induced delayed neuropathy after an acute cholinergic crisis in self-poisoning. Clin Toxicol (Phila) 2020; 59:488-492. [PMID: 33078989 DOI: 10.1080/15563650.2020.1832233] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Despite organophosphate pesticide is the most prevalent cause of acute poisoning in low- and middle-income countries, data on organophosphate induced delayed neuropathy (OPIDN) are limited. We aimed to characterize organophosphates' long-term effects on the peripheral nervous system after an acute cholinergic crisis in adults. METHODS We performed a prospective observational study in an academic hospital of north India in patients aged 13-40 years with acute organophosphate ingestion. After resolving the cholinergic crisis, the patients were followed for six months with neurologic assessments, including history, neurologic examination, and nerve conduction study (NCS). RESULTS Twenty-three patients were recruited to the study. All but one had normal neurological examination and NCS at discharge from hospital a median duration of six days (interquartile range, 3-10) after self-poisoning. Eight (34.8%) developed OPIDN during the six-month follow-up. Three patients had symptomatic neuropathy, and NCS detected subclinical peripheral nerve involvement in five. All cases were associated with chlorpyrifos ingestion (8/17 total chlorpyrifos cases). Two OPIDN cases had foot drop and gait ataxia at three-month which persist at six-month. One patient had distal paresthesia at three months, which improved at a six-month follow-up. NCS in OPIDN cases invariably revealed axonal degeneration, injury to motor fibers more than sensory fibers, and frequent peroneal nerve involvement. None of the baseline characteristics, including the ingested amount, predicted clinical or subclinical OPIDN in chlorpyrifos self-poisoned patients on a univariant analysis. CONCLUSION Peripheral nerve involvement is not uncommon after recovery from a cholinergic crisis in chlorpyrifos self-poisoning and debilitating in some patients. Detection of subclinical injury on NCS may provide an early window to prevent severe symptomatic neuropathy.
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Affiliation(s)
- A K Pannu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - A Bhalla
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - R I Vishnu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - D P Dhibar
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - N Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - R Vijayvergiya
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Dhanarisi J, Shihana F, Harju K, Mohamed F, Verma V, Shahmy S, Vanninen P, Kostiainen O, Gawarammana I, Eddleston M. A pilot clinical study of the neuromuscular blocker rocuronium to reduce the duration of ventilation after organophosphorus insecticide poisoning. Clin Toxicol (Phila) 2019; 58:254-261. [DOI: 10.1080/15563650.2019.1643467] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Jeevan Dhanarisi
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Fathima Shihana
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Department of Pharmacology, School of Medical Sciences, University of Sydney, Sydney, Australia
| | - Kirsi Harju
- VERIFIN, Finnish Institute for Verification of the Chemical Weapons Convention, Department of Chemistry, University of Helsinki, Helsinki, Finland
| | - Fahim Mohamed
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Department of Pharmacology, School of Medical Sciences, University of Sydney, Sydney, Australia
- Department of Pharmacy, Faculty of Allied Health Sciences, University of Peradeniya, Peradeniya, Sri Lanka
| | - Vasundhara Verma
- Department of Pharmacology, Toxicology, & Therapeutics, University/BHF Centre for Cardiovascular Science, and Centre for Pesticide Suicide Prevention, University of Edinburgh, Edinburgh, UK
| | - Seyed Shahmy
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- National Science & Technology Commission, Colombo, Sri Lanka
| | - Paula Vanninen
- VERIFIN, Finnish Institute for Verification of the Chemical Weapons Convention, Department of Chemistry, University of Helsinki, Helsinki, Finland
| | - Olli Kostiainen
- VERIFIN, Finnish Institute for Verification of the Chemical Weapons Convention, Department of Chemistry, University of Helsinki, Helsinki, Finland
| | - Indika Gawarammana
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Department of Medicine, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Michael Eddleston
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Department of Pharmacology, Toxicology, & Therapeutics, University/BHF Centre for Cardiovascular Science, and Centre for Pesticide Suicide Prevention, University of Edinburgh, Edinburgh, UK
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Affiliation(s)
- Fred M Henretig
- From the Division of Emergency Medicine and Poison Control Center, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia (F.M.H.); the Department of Homeland Security, Washington, DC (M.A.K.); and the Division of Medical Toxicology, Department of Emergency Medicine, University of Connecticut Health Center and Hartford Hospital, Hartford (C.A.M.)
| | - Mark A Kirk
- From the Division of Emergency Medicine and Poison Control Center, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia (F.M.H.); the Department of Homeland Security, Washington, DC (M.A.K.); and the Division of Medical Toxicology, Department of Emergency Medicine, University of Connecticut Health Center and Hartford Hospital, Hartford (C.A.M.)
| | - Charles A McKay
- From the Division of Emergency Medicine and Poison Control Center, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia (F.M.H.); the Department of Homeland Security, Washington, DC (M.A.K.); and the Division of Medical Toxicology, Department of Emergency Medicine, University of Connecticut Health Center and Hartford Hospital, Hartford (C.A.M.)
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Herbert J, Thiermann H, Worek F, Wille T. COPD and asthma therapeutics for supportive treatment in organophosphate poisoning. Clin Toxicol (Phila) 2019; 57:644-651. [PMID: 30696282 DOI: 10.1080/15563650.2018.1540785] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Context: Nerve agents like sarin or VX have repeatedly been used in military conflicts or homicidal attacks, as seen in Syria or Malaysia 2017. Together with pesticides, nerve agents assort as organophosphorus compounds (OP), which inhibit the enzyme acetylcholinesterase. To counteract subsequent fatal symptoms due to acetylcholine (ACh) accumulation, oximes plus atropine are administered, a regimen that lacks efficacy in several cases of OP poisoning. New therapeutics are in development, but still need evaluation before clinical employment. Supportive treatment with already approved drugs presents an alternative, whereby compounds from COPD and asthma therapy are likely options. A recent pilot study by Chowdhury et al. included β2-agonist salbutamol in the treatment of OP-pesticide poisoned patients, yielding ambiguous results concerning the addition. Here, we provide experimental data for further investigations regarding the value of these drugs in OP poisoning. Methods: By video-microscopy, changes in airway area were analyzed in VX-poisoned rat precision cut lung slices (PCLS) after ACh-induced airway contraction and subsequent application of selected anticholinergics/β2-agonists. Results: Glycopyrrolate and ipratropium efficiently antagonized an ACh-induced airway contraction in VX-poisoned PCLS (EC50 glycopyrrolate 15.8 nmol/L, EC50 ipratropium 2.3 nmol/L). β2-agonists formoterol and salbutamol had only negligible effects when solely applied in the same setting. However, combination of formoterol or salbutamol with low dosed glycopyrrolate or atropine led to an additive effect compared to the sole application [50.6 ± 8.8% airway area increase after 10 nmol/L formoterol +1 nmol/L atropine versus 11.7 ± 9.2% (10 nmol/L formoterol) or 8.6 ± 5.9% (1 nmol/L atropine)]. Discussion: We showed antagonizing effects of anticholinergics and β2-agonists on ACh-induced airway contractions in VX-poisoned PCLS, thus providing experimental data to support a prospective comprehensive clinical study. Conclusions: Our results indicate that COPD and asthma therapeutics could be a valuable addition to the treatment of OP poisoning.
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Affiliation(s)
- Julia Herbert
- a Bundeswehr Institute of Pharmacology and Toxicology , Neuherbergstraße 11, Munich , Germany
| | - Horst Thiermann
- a Bundeswehr Institute of Pharmacology and Toxicology , Neuherbergstraße 11, Munich , Germany
| | - Franz Worek
- a Bundeswehr Institute of Pharmacology and Toxicology , Neuherbergstraße 11, Munich , Germany
| | - Timo Wille
- a Bundeswehr Institute of Pharmacology and Toxicology , Neuherbergstraße 11, Munich , Germany
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16
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Chowdhury FR, Dewan G, Verma VR, Knipe DW, Isha IT, Faiz MA, Gunnell DJ, Eddleston M. Bans of WHO Class I Pesticides in Bangladesh-suicide prevention without hampering agricultural output. Int J Epidemiol 2019; 47:175-184. [PMID: 29024951 PMCID: PMC5837375 DOI: 10.1093/ije/dyx157] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 07/26/2017] [Indexed: 11/27/2022] Open
Abstract
Background Pesticide self-poisoning is a major problem in Bangladesh. Over the past 20-years, the Bangladesh government has introduced pesticide legislation and banned highly hazardous pesticides (HHPs) from agricultural use. We aimed to assess the impacts of pesticide bans on suicide and on agricultural production. Methods We obtained data on unnatural deaths from the Statistics Division of Bangladesh Police, and used negative binomial regression to quantify changes in pesticide suicides and unnatural deaths following removal of WHO Class I toxicity HHPs from agriculture in 2000. We assessed contemporaneous trends in other risk factors, pesticide usage and agricultural production in Bangladesh from 1996 to 2014. Results Mortality in hospital from pesticide poisoning fell after the 2000 ban: 15.1% vs 9.5%, relative reduction 37.1% [95% confidence interval (CI) 35.4 to 38.8%]. The pesticide poisoning suicide rate fell from 6.3/100 000 in 1996 to 2.2/100 000 in 2014, a 65.1% (52.0 to 76.7%) decline. There was a modest simultaneous increase in hanging suicides [20.0% (8.4 to 36.9%) increase] but the overall incidence of unnatural deaths fell from 14.0/100 000 to 10.5/100 000 [25.0% (18.1 to 33.0%) decline]. There were 35 071 (95% CI 25 959 to 45 666) fewer pesticide suicides in 2001 to 2014 compared with the number predicted based on trends between 1996 to 2000. This reduction in rate of pesticide suicides occurred despite increased pesticide use and no change in admissions for pesticide poisoning, with no apparent influence on agricultural output. Conclusions Strengthening pesticide regulation and banning WHO Class I toxicity HHPs in Bangladesh were associated with major reductions in deaths and hospital mortality, without any apparent effect on agricultural output. Our data indicate that removing HHPs from agriculture can rapidly reduce suicides without imposing substantial agricultural costs.
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Affiliation(s)
- Fazle Rabbi Chowdhury
- Department of Medicine, Sylhet MAG Osmani Medical College, Sylhet, Bangladesh.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,OSD, Health Directorate (DGHS), Dhaka, Bangladesh
| | - Gourab Dewan
- Department of Medicine, Rangamati Medical College, Rangamati, Bangladesh
| | - Vasundhara R Verma
- Pharmacology, Toxicology, & Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Duleeka W Knipe
- School of Social and Community Medicine, University of Bristol, Bristol, UK.,South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya, Sri Lanka
| | - Ishrat Tahsin Isha
- Department of Medicine, Sylhet MAG Osmani Medical College, Sylhet, Bangladesh
| | | | - David J Gunnell
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Michael Eddleston
- Pharmacology, Toxicology, & Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.,South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya, Sri Lanka
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17
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Eddleston M. Novel Clinical Toxicology and Pharmacology of Organophosphorus Insecticide Self-Poisoning. Annu Rev Pharmacol Toxicol 2019; 59:341-360. [DOI: 10.1146/annurev-pharmtox-010818-021842] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Organophosphorus insecticide self-poisoning is a major global health problem, killing over 100,000 people annually. It is a complex multi-organ condition, involving the inhibition of cholinesterases, and perhaps other enzymes, and the effects of large doses of ingested solvents. Variability between organophosphorus insecticides—in lipophilicity, speed of activation, speed and potency of acetylcholinesterase inhibition, and in the chemical groups attached to the phosphorus—results in variable speed of poisoning onset, severity, clinical toxidrome, and case fatality. Current treatment is modestly effective, aiming only to reactivate acetylcholinesterase and counter the effects of excess acetylcholine at muscarinic receptors. Rapid titration of atropine during resuscitation is lifesaving and can be performed in the absence of oxygen. The role of oximes in therapy remains unclear. Novel antidotes have been tested in small trials, but the great variability in poisoning makes interpretation of such trials difficult. More effort is required to test treatments in adequately powered studies.
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Affiliation(s)
- Michael Eddleston
- Pharmacology, Toxicology, and Therapeutics Unit, Centre for Cardiovascular Science, and Centre for Pesticide Suicide Prevention, University of Edinburgh, Edinburgh EH16 4TJ, United Kingdom
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18
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Ralston MSA, Murray MBP, Vela-Duarte D, Orjuela KD, Pastula DM. Neuroterrorism Preparedness for the Neurohospitalist. Neurohospitalist 2018; 9:151-159. [PMID: 31244972 DOI: 10.1177/1941874418806668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
In this review article, we highlight several potential biologic and chemical agents of "neuroterrorism" of which neurohospitalists should be aware: anthrax, botulism toxin, brucella, plague, smallpox, organophosphates and nerve agents, cyanide, and carfentanil. Such agents may have direct neurologic effects, resulting in encephalopathy, paralysis, and/or respiratory failure. Neurohospitalists should be on the lookout for abnormal neurologic syndrome clustering, especially among patients presenting to the emergency department. If use of such a "neuroterrorism" agent is suspected, the neurohospitalist should immediately consult with emergency department personnel, infection control, infectious disease physicians, and/or Poison Control to make sure the scene is safe and to stabilize and isolate patients if necessary. The neurohospitalist should also immediately contact their local and/or state health department (or alternatively the US Centers for Disease Control and Prevention Emergency Operations Center) to report their suspicions and to obtain guidance and assistance.
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Affiliation(s)
- Maj Samuel A Ralston
- Emory University School of Medicine, Atlanta, GA, USA.,United States Army, Army Medical Department (AMEDD) Center and School, Fort Sam Houston, TX, USA
| | - Maj Brian P Murray
- Emory University School of Medicine, Atlanta, GA, USA.,United States Air Force, Institute of Technology, Wright-Patterson AFB, OH, USA
| | - Daniel Vela-Duarte
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Karen D Orjuela
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Daniel M Pastula
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA.,Department of Medicine (Infectious Diseases), University of Colorado School of Medicine, Aurora, CO, USA.,Department of Epidemiology, Colorado School of Public Health, Aurora, CO, USA
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19
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Ohbe H, Jo T, Matsui H, Fushimi K, Yasunaga H. Cholinergic Crisis Caused by Cholinesterase Inhibitors: a Retrospective Nationwide Database Study. J Med Toxicol 2018; 14:237-241. [PMID: 29907949 PMCID: PMC6097965 DOI: 10.1007/s13181-018-0669-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 05/03/2018] [Accepted: 05/31/2018] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION In contrast to information on the effects of organophosphate, pesticide, or environmental exposures, data on cholinergic crisis caused by pharmaceutical cholinesterase inhibitors are sparse. The present study aimed to describe the characteristics, demographics, and mortality of patients with cholinergic crisis caused by pharmaceutical cholinesterase inhibitors using a nationwide inpatient database in Japan. METHODS We identified patients diagnosed with cholinergic crisis as a result of taking cholinesterase inhibitor medications in the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2016. We examined the patients' characteristics, treatments, and mortality. RESULTS A total of 235 patients with cholinergic crisis were identified during the 69-month study period. Forty-eight patients required mechanical ventilation (20.4%), and 15 patients died (6.4%) in hospital. The median lengths of hospital stay and intensive care unit stay were 15 days (interquartile range, 6-42) and 4 days (2-8), respectively. Approximately half of all hospitalized patients required catecholamines, atropine, or mechanical ventilation, while the other half did not require any of these treatments. Patients who required catecholamines, atropine, or mechanical ventilation were more likely to die and had longer hospital stays. CONCLUSIONS Cholinergic crisis caused by pharmaceutical cholinesterase inhibitors is a rare but potentially life-threatening condition. Patients who require mechanical ventilation and catecholamines or atropine have a poorer prognosis.
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Affiliation(s)
- Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
| | - Taisuke Jo
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
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20
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Brvar M, Chan MY, Dawson AH, Ribchester RR, Eddleston M. Magnesium sulfate and calcium channel blocking drugs as antidotes for acute organophosphorus insecticide poisoning – a systematic review and meta-analysis. Clin Toxicol (Phila) 2018; 56:725-736. [DOI: 10.1080/15563650.2018.1446532] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Miran Brvar
- Pharmacology, Toxicology, and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Ming Yin Chan
- Accident and Emergency Department, Pamela Youde Nethersole Eastern Hospital, Hong Kong, ROC
| | - Andrew H. Dawson
- Sydney Medical School, University of Sydney, Sydney, Australia
- South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Kandy, Sri Lanka
| | | | - Michael Eddleston
- Pharmacology, Toxicology, and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Kandy, Sri Lanka
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21
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Chowdhury FR, Rahman MM, Ullah P, Ruhan AM, Bari MS, Alam MMJ, Uddin MM, Maruf S, Patwary MI, Eddleston M. Salbutamol in acute organophosphorus insecticide poisoning – a pilotdose-response phase II study. Clin Toxicol (Phila) 2018; 56:820-827. [DOI: 10.1080/15563650.2018.1440587] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Fazle Rabbi Chowdhury
- Department of Medicine, Sylhet MAG Osmani Medical College, Sylhet, Bangladesh
- Centre for Tropical Medicine and Global Health Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Md. Mustafezur Rahman
- Department of Medicine, Sylhet MAG Osmani Medical College, Sylhet, Bangladesh
- Department of Gastroenterology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Parash Ullah
- Department of Medicine, Sylhet MAG Osmani Medical College, Sylhet, Bangladesh
- Department of Medicine, Shaheed Suhrawardy Medical College Hospital, Dhaka, Bangladesh
| | - Abdul Mumith Ruhan
- Department of Medicine, Sylhet MAG Osmani Medical College, Sylhet, Bangladesh
| | - Md. Shafiqul Bari
- Department of Medicine, Sylhet MAG Osmani Medical College, Sylhet, Bangladesh
| | - M. M. Jahangir Alam
- Department of Medicine, Sylhet MAG Osmani Medical College, Sylhet, Bangladesh
| | - Md. Moyeen Uddin
- Department of Medicine, Sylhet MAG Osmani Medical College, Sylhet, Bangladesh
| | - Shomik Maruf
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Md. Ismail Patwary
- Department of Medicine, Sylhet MAG Osmani Medical College, Sylhet, Bangladesh
| | - Michael Eddleston
- Department of Pharmacology, Toxicology, & Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya, Sri Lanka
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22
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Eddleston M, Chowdhury FR. Pharmacological treatment of organophosphorus insecticide poisoning: the old and the (possible) new. Br J Clin Pharmacol 2015; 81:462-70. [PMID: 26366467 DOI: 10.1111/bcp.12784] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 09/09/2015] [Accepted: 09/11/2015] [Indexed: 01/31/2023] Open
Abstract
Despite being a major clinical and public health problem across the developing world, responsible for at least 5 million deaths over the last three decades, the clinical care of patients with organophosphorus (OP) insecticide poisoning has little improved over the last six decades. We are still using the same two antidotes - atropine and oximes - that first came into clinical use in the late 1950s. Clinical research in South Asia has shown how improved regimens of atropine can prevent deaths. However, we are still unsure about which patients are most likely to benefit from the use of oximes. Supplemental antidotes, such as magnesium, clonidine and sodium bicarbonate, have all been proposed and studied in small trials without production of definitive answers. Novel antidotes such as nicotinic receptor antagonists, beta-adrenergic agonists and lipid emulsions are being studied in large animal models and in pilot clinical trials. Hopefully, one or more of these affordable and already licensed antidotes will find their place in routine clinical care. However, the large number of chemically diverse OP insecticides, the varied poisoning they produce and their varied response to treatment might ultimately make it difficult to determine definitively whether these antidotes are truly effective. In addition, the toxicity of the varied solvents and surfactants formulated with the OP active ingredients complicates both treatment and studies. It is possible that the only effective way to reduce deaths from OP insecticide poisoning will be a steady reduction in their agricultural use worldwide.
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Affiliation(s)
- Michael Eddleston
- Pharmacology, Toxicology, & Therapeutics, University of Edinburgh, Edinburgh, UK.,National Poisons Information Service - Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
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23
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Hulse EJ, Davies JOJ, Simpson AJ, Sciuto AM, Eddleston M. Respiratory complications of organophosphorus nerve agent and insecticide poisoning. Implications for respiratory and critical care. Am J Respir Crit Care Med 2015; 190:1342-54. [PMID: 25419614 DOI: 10.1164/rccm.201406-1150ci] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Organophosphorus (OP) compound poisoning is a major global public health problem. Acute OP insecticide self-poisoning kills over 200,000 people every year, the majority from self-harm in rural Asia. Highly toxic OP nerve agents (e.g., sarin) are a significant current terrorist threat, as shown by attacks in Damascus during 2013. These anticholinesterase compounds are classically considered to cause an acute cholinergic syndrome with decreased consciousness, respiratory failure, and, in the case of insecticides, a delayed intermediate syndrome that requires prolonged ventilation. Acute respiratory failure, by central and peripheral mechanisms, is the primary cause of death in most cases. However, preclinical and clinical research over the last two decades has indicated a more complex picture of respiratory complications after OP insecticide poisoning, including onset of delayed neuromuscular junction dysfunction during the cholinergic syndrome, aspiration causing pneumonia and acute respiratory distress syndrome, and the involvement of solvents in OP toxicity. The treatment of OP poisoning has not changed over the last 50 years. However, a better understanding of the multiple respiratory complications of OP poisoning offers additional therapeutic opportunities.
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Affiliation(s)
- Elspeth J Hulse
- 1 Pharmacology, Toxicology, and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
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24
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Lee KJ, Shin JW, Moon J, Lim JA, Byun JI, Kim TJ, Shin YW, Lee ST, Jung KH, Lee SK, Chu K. An illustrative case of mixed pesticide poisoning with remarkable improvement: a case report. J Neurol Sci 2014; 344:232-3. [PMID: 24993470 DOI: 10.1016/j.jns.2014.06.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 06/11/2014] [Accepted: 06/13/2014] [Indexed: 01/08/2023]
Affiliation(s)
- Keon-Joo Lee
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Jung-Won Shin
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Jangsup Moon
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Jung-Ah Lim
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Jung-Ick Byun
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Tae-Joon Kim
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Yong-Won Shin
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Soon-Tae Lee
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Keun-Hwa Jung
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Sang Kun Lee
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Kon Chu
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea; Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea.
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25
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Konickx LA, Bingham K, Eddleston M. Is oxygen required before atropine administration in organophosphorus or carbamate pesticide poisoning? - A cohort study. Clin Toxicol (Phila) 2014; 52:531-7. [PMID: 24810796 PMCID: PMC4134047 DOI: 10.3109/15563650.2014.915411] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background Early and adequate atropine administration in organophosphorus (OP) or carbamate insecticide poisoning improves outcome. However, some authors advise that oxygen must be given before atropine due to the risk of inducing ventricular dysrhythmias in hypoxic patients. Because oxygen is frequently unavailable in district hospitals of rural Asia, where the majority of patients with insecticide poisoning present, this guidance has significant implications for patient care. The published evidence for this advice is weak. We therefore performed a patient cohort analysis to look for early cardiac deaths in patients poisoned by anticholinesterase pesticides. Methods We analysed a prospective Sri Lankan cohort of OP or carbamate-poisoned patients treated with early atropine without the benefit of oxygen for evidence of early deaths. The incidence of fatal primary cardiac arrests within 3 h of admission was used as a sensitive (but non-specific) marker of possible ventricular dysrhythmias. Results The cohort consisted of 1957 patients. The incidence of a primary cardiac death within 3 h of atropine administration was 4 (0.2%) of 1957 patients. The majority of deaths occurred at a later time point from respiratory complications of poisoning. Conclusion We found no evidence of a high number of early deaths in an observational study of 1957 patients routinely given atropine before oxygen that might support guidance that oxygen must be given before atropine. The published literature indicates that early and rapid administration of atropine during resuscitation is life-saving. Therefore, whether oxygen is available or not, early atropinisation of OP- and carbamate-poisoned patients should be performed.
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Affiliation(s)
- L A Konickx
- Pharmacology, Toxicology and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh , UK
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26
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Karami-Mohajeri S, Nikfar S, Abdollahi M. A systematic review on the nerve–muscle electrophysiology in human organophosphorus pesticide exposure. Hum Exp Toxicol 2013; 33:92-102. [DOI: 10.1177/0960327113489047] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This article presents a systematic review of the recent literature on the scientific support of electromyography (EMG) and nerve conduction velocity (NCV) in diagnosing the exposure and toxicity of organophosphorus pesticides (OP). Specifically, this review focused on changes in EMG, NCV, occurrence of intermediate syndrome (IMS), and OP-induced delayed polyneuropathy (OPIDN) in human. All relevant bibliographic databases were searched for human studies using the key words “OP poisoning”, “electromyography”, “nerve conduction study,” and “muscles disorders”. IMS usually occurs after an acute cholinergic crisis, while OPIDN occurs after both acute and chronic exposures. Collection of these studies supports that IMS is a neuromuscular junction disorder and can be recorded upon the onset of respiratory failure. Due to heterogeneity of reports on outcomes of interest such as motor NCV and EMG amplitude in acute cases and inability to achieve precise estimation of effect in chronic cases meta-analysis was not helpful to this review. The OPIDN after both acute and low-level prolonged exposures develops peripheral neuropathy without preceding cholinergic toxicity and the progress of changes in EMG and NCV is parallel with the development of IMS and OPIDN. Persistent inhibition of acetylcholinesterase (AChE) is responsible for muscle weakness, but this is not the only factor involved in the incidence of this weakness in IMS or OPIDN suggestive of AChE assay not useful as an index of nerve and muscle impairment. Although several mechanisms for induction of this neurodegenerative disorder have been proposed as were reviewed for this article, among them oxidative stress and resulting apoptosis can be emphasized. Nevertheless, there is little synchronized evidence on subclinical electrophysiological findings that limit us to reach a strong conclusion on the diagnostic or prognostic use of EMG and NCV for acute and occupational exposures to OPs.
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Affiliation(s)
- S Karami-Mohajeri
- Department of Toxicology and Pharmacology, Faculty of Pharmacy and Pharmaceutical Sciences Research Center, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - S Nikfar
- Department of Pharmacoeconomics and Pharmaceutical Administration, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
- Food and Drug Laboratory Research Center, Food and Drug Organization, Tehran, Islamic Republic of Iran
| | - M Abdollahi
- Department of Toxicology and Pharmacology, Faculty of Pharmacy and Pharmaceutical Sciences Research Center, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
- Department of Pharmacoeconomics and Pharmaceutical Administration, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
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27
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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; 51:35-40. [PMID: 23311540 DOI: 10.3109/15563650.2012.757318] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Acute organophosphorus (OP) poisoning is relatively common and a major cause of death from poisoning in developing countries. Magnesium has been shown to be of benefit in animal models. METHODS We conducted a phase II study of bolus doses of (MgSO4) in 50 patients with acute organophosphate poisoning. Patients eligible for inclusion had ingested OP and had cholinergic symptoms consistent with moderate or severe poisoning. All patients received standard care of atropinization titrated to control muscarinic symptoms and pralidoxime. The trial was run in 4 sequential groups of patients. Participants in each group received a different total dose of MgSO4 (20%) administered as intermittent bolus doses infused over 10-15 min or placebo. There was one control patient for every 4 patients who received MgSO4. Group A (16 patients) received a total of 4 gm MgSO4 as a single bolus, group B (8 patients) received 8 gm (in two 4 gm doses q4H), group C (8 patients) received 12 gm (in three 4 gm doses q4H) group D (8 patients) received 16 gm (in four 4 gm doses q4H) and control (10 patients) received placebo). Patients were closely monitored for any adverse reaction like significant clinical neuromuscular disturbance and respiratory depression. RESULTS No adverse reactions to magnesium were observed. The 24 hour urinary magnesium concentration were statistically different between 16 gm (234.74 ± 74.18 mg/dl) and control (118.06 ± 30.76 mg/dl) (p = 0.019), while it was much lower than the 80% of the intravenous magnesium load. Six patients died in control group compared to 3 in 4 gm, 2 in 8 gm and 1 in 12 gm group. There was no mortality in 16 gm group. CONCLUSION Magnesium was well tolerated in this study. Larger studies are required to examine for efficacy.
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Affiliation(s)
- A Basher
- In Charge, SK Hospital, Mymensingh, Bangladesh.
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Chung SP, Roh HK. Antidote for organophosphate insecticide poisoning: atropine and pralidoxime. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2013. [DOI: 10.5124/jkma.2013.56.12.1057] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Sung Phil Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hyung-Keun Roh
- Division of Clinical Pharmacology, Department of Internal Medicine, Gachon University Graduate School of Medicine, Incheon, Korea
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