Paralytic ileus as a complication of atropine therapy following severe organophosphate poisoning

A case report of cholinesterase inhibitor poisoning: cholinesterase activities and analytical methods for diagnosis and clinical decision making

Suicidal ingestion of organophosphorus (OP) or carbamate (CM) compounds challenges health care systems worldwide, particularly in Southeast Asia. The diagnosis and treatment of OP or CM poisoning is traditionally based on the clinical appearance of the typical cholinergic toxidrome, e.g. miosis, salivation and bradycardia. Yet, clinical signs might be inconclusive or even misleading. A current case report highlights the importance of enzymatic assays to provide rapid information and support clinicians in diagnosis and rational clinical decision making. Furthermore, the differentiation between OP and CM poisoning seems important, as an oxime therapy will most probably not provide benefit in CM poisoning, but—as every pharmaceutical product—it might result in adverse effects. The early identification of the causing agent and the amount taken up in the body are helpful in planning of the therapeutic regimen including experimental strategies, e.g. the use of human blood products to facilitate scavenging of the toxic agent. Furthermore, the analysis of biotransformation products and antidote levels provides additional insights into the pathophysiology of OP or CM poisoning. In conclusion, cholinesterase activities and modern analytical methods help to provide a more effective treatment and a thorough understanding of individual cases of OP or CM poisoning.

Multiple Small Intestine Perforations after Organophosphorous Poisoning: A Case Report

Organophosphate poisoning has significant gastrointestinal manifestations including vomiting, diarrhea, cramps and increased salivation. We report an uncommon gastrointestinal complication of multiple small intestinal perforations following organophosphorus poisoning. A 28-year old male presented after ingesting dichlorvos mixed with alcohol. Following the initial cholinergic symptoms, the patient developed severe shock with fever, attributed to aspiration pneumonia. Despite appropriate antibiotics, shock was persistent. Over the next 24-hours, he developed abdominal distension, loose stools and high nasogastric aspirates. Computed tomography showed pneumoperitonium. Exploratory laparotomy revealed six perforations in the jejunum and ileum. The involved portion of the bowel was resected and re-anastomosed, following which only 80-cm of small bowel was left. Postoperatively, shock resolved over 72-hours. However, over the next few days, patient developed features of anastomotic leak. Since only a small portion of the small bowel was preserved, a conservative approach was adopted. He deteriorated further and finally succumbed to the illness.

Chemical and biological weapons. Implications for anaesthesia and intensive care

In the wake of recent atrocities there has been renewed apprehension regarding the possibility of chemical and biological weapon (CBW) deployment by terrorists. Despite various international agreements that proscribe their use, certain states continue to develop chemical and biological weapons of mass destruction. Of greater concern, recent historical examples support the prospect that state-independent organizations have the capability to produce such weapons. Indeed, the deliberate deployment of anthrax has claimed several lives in the USA since September 11, 2001. In the event of a significant CBW attack, medical services would be stretched. However, victim survival may be improved by the prompt, coordinated response of military and civil authorities, in conjunction with appropriate medical care. In comparison with most other specialties, anaesthetists have the professional academic background in physiology and pharmacology to be able to understand the nature of the injuries caused by CBWs. Anaesthetists, therefore, play a vital role both in the initial resuscitation of casualties and in their continued treatment in an intensive care setting. This article assesses the current risk of CBW deployment by terrorists, considers factors which would affect the severity of an attack, and discusses the pathophysiology of those CBWs most likely to be used. The specific roles of the anaesthetist and intensivist in treatment are highlighted.