Efficacy of hemoperfusion in the treatment of severe organophosphorus poisoning in patients and its effects on diaphragm function / 中国基层医药

Objective:To investigate the clinical efficacy of hemoperfusion in the treatment of severe organophosphorus poisoning and its effect on diaphragm function.Methods:Eighty-five patients with severe organophosphorus poisoning who received treatment in Affiliated Huxi Hospital of Jining Medical University (Shanxian Central Hospital), China between January 2018 and January 2020 were included in this study. They were randomly divided into treatment ( n = 43)and control ( n = 42) groups. The control group was given conventional treatment including gastric lavage, catharsis, and application of reactivators and anticholinergic drugs. The treatment group was subjected to three times of hemoperfusion, with an interval of 24 hours between two hemoperfusion interventions based on the conventional treatment used in the control group. Before and after three times of hemoperfusion, serum levels of cholinesterase (CHE), interleukin-6 (IL-6), arterial partial pressure of oxygen (PaO 2), and arterial partial pressure of carbon dioxide (PaCO 2) were measured. The Acute Physiology and Chronic Health Evaluation (APACHE) II score and oxygenation index (OI) in each group were calculated. Right diaphragmatic activity, diaphragmatic thickness at the end of inspiration (DTei) and diaphragmatic thickness at the end of expiration were measured by bedside ultrasound. The diaphragmatic thickening rate (DTF) and diaphragmatic rapid shallow breathing index (D-RSBI) were calculated. Serum CHE and IL-6 levels, OI, diaphragmatic activity, DTF and D-RSBI were compared between the treatment and control groups. The incidence of intermediate syndrome, tracheal intubation rate, 28-day mortality rate, and hospital stay were compared between the two groups. Results:Before hemoperfusion, there were no significant differences in serum levels of CHE and IL-6, OI, right diaphragmatic activity, DTF, and D-RSBI between the treatment and control groups (all P > 0.05). After three times of hemoperfusion, serum IL-6 level and D-RSBI in the treatment group were (37.9 ± 6.2) ng/L and (0.77 ± 0.20) times /min/mm, which were significantly lower than those in the control group [(45.9 ± 5.3) ng/L, (0.90 ± 0.16) times/min/mm ( t = -6.295, -3.382, P < 0.001, P = 0.001)]. Serum CHE level, OI, DE and DTF in the treatment group were (2.29 ± 0.52) kU/L, (264.5 ± 24.3) mmHg, (16.5 ± 1.9) mm, (27.2 ± 4.7) %, respectively, which were significantly higher than those in the control group [(1.96 ± 0.39) kU/L, (252.6 ± 27.2) mmHg, (14.3 ± 1.6) mm, (23.5 ± 4.1) %, t = 3.258, 2.141, 5.598, 3.877, all P < 0.05]. The incidence of intermediate syndrome, tracheal intubation rate, hospital stay in the treatment group were [4.7% (2/43)], [2.3% (1/43)] and [(11.8 ± 1.8) days], respectively, which were significantly lower than those in the control group [23.8% (10/42), 19.0% (8/42) and (12.9 ± 1.8) days, χ2 = 6.432, P = 0.011; χ2 = 6.276, P = 0.012; t = -2.932, P = 0.004]. There was no significant difference in 28-day mortality rate between the two groups ( P > 0.05). Conclusion:Hemoperfusion can improve diaphragmatic function, reduce inflammatory reaction and shorten hospital stay in patients with severe organophosphorus poisoning.

Clinical correlates of hypotension in patients with acute organophosphorus poisoning / 世界急诊医学杂志（英文）

@#BACKGROUND: The aim of the present study is to describe the clinical correlates of hypotension and its associated outcomes in patients with acute organophosphorus poisoning (AOPP). METHODS: In this retrospective cohort study, we analyzed data pertaining to 871 patients with AOPP who were treated at two hospitals. Data from hypotensive and non-hypotensive patients were compared to identify clinical correlates of hypotension. We also evaluated the association between clinical parameters (including hypotension) and in-hospital mortality. RESULTS: The incidence of hypotension in AOPP patients was 16.4%. Hypotensive patients showed significantly higher in-hospital mortality (1.1% vs. 39.9%, P<0.001). Advanced age (odds ratio [OR] 1.25, 95% confidence interval [CI] 1.08-1.44), history of diabetes (OR 2.65, 95% CI 1.14-5.96), and increased white blood cell count (OR 1.06, 95% CI 1.03-1.09), plasma cholinesterase (OR 0.91, 95% CI 0.84-0.94), plasma albumin (OR 0.88, 95% CI 0.85-0.92), serum amylase (OR 1.01, 95% CI 1.01-1.02), and blood pH (OR 0.64, 95% CI 0.54-0.75) were significantly associated with hypotension. After adjusting for potential confounders, hypotension was associated with increased in-hospital mortality (hazard ratio 8.77-37.06, depending on the controlled variables). CONCLUSIONS: Hypotension is a common complication of AOPP and is associated with increased in-hospital mortality. Advanced age, history of diabetes, and changes in laboratory parameters were associated with hypotension in AOPP patients.

A prospective study on the predictors of mechanical ventilation in organophosphate poisoning

Background: Organophosphorus poisoning is one of the most common poisonings often requiring ICU care and ventilatory support. The objective and aim of this study are to identify the factors which predict the need for ventilation in these patients.Methods: 50 patients who were diagnosed to have consumed organophosphorus compound poison admitted in Konaseema Institute of Medical Sciences and Research Foundation who presented within 24 hours of consumption are included in the study. Patients with double poisonings, concomitant illnesses, chronic lung diseases and those treated outside are excluded from the study.Results: A total number of 50 patients were studied. 18(36%) patients required ventilation. Generalized fasciculations was a discernible feature in 66% of cases in this study. 69.2% of patients with a fasciculation score of ≥4 required ventilation. Ventilation was needed by 55% of patients who had a Glasgow Coma Scale score of ≤10.Conclusions: Patients who presented with higher fasciculation scores and/or lower GCS scores were more likely to require ventilation. Using GCS scores as a predictor for the requirement of ventilatory support in organophosphate poisoning, a GCS score ten or less was significantly associated with an increased need for ventilatory support.

Correlation of serum creatine phosphokinase and serum cholinesterase in organophosphate poisoning in children

Background: Organophosphate (OP) poisoning is one of the most common pesticide poisoning in India in adolescents because of its easy availability. Serum pseudocholinesterase levels are commonly used to assess the severity and to know the prognosis in OP compound poisoning. Serum creatine phosphokinase (CPK) levels is another lab parameter which gets deranged in OP poisoning and has been tried in adults to assess the severity and to know the prognosis.'Authors objective was to study the correlation of serum pseudocholinesterase and serum CPK in organophosphate poisoning at admission and to compare outcome with serum CPK levels.Methods: All the children in the age group of 1 month to 18 yrs, who were admitted with the history of suspected OP compound poisoning were enrolled for the study. Estimation of cholinesterase and CPK levels were done at admission and after 1 week. Patients were categorised in to latent, mild, moderate and severe cases based on the S. Cholinesterase levels. These values were analysed to see the correlation.Results: Among 34 OP poisoning cases,13(38%) were males and 21(62%) were females. Mean age of study population was12.6+4.25 yrs. The median CPK values in latent, mild, moderate and severe cases were 121.5 IU/L,276.5 IU/L, 308IU/L and 467IU/L respectively (p=0.015). Spearman's rho Correlation coefficient was -0.522 between S. Cholinesterase and S CPK at admission which was significant. The median serum CPK level after 1week in non survivors was 2498.0IU/L and in survivors was 201.0IU/L (p0.014).Conclusions: There was a strong negative relationship between serum cholinesterase and serum CPK at admission in OP poisoning. Follow up values at 1 week showed that significantly high serum CPK and low cholinesterase, which was also significant and was associated with mortality.

Study on awareness regarding hazards of organophosphorus poisoning among agricultural workers who are at risk of exposure to organophosphate pesticides in Kurnool District, Andhra Pradesh

Background: Agricultural workers are at high risk of exposure to organophosphate pesticides (OPs). Farmers are using OPs frequently without having any safe handling practices. Improving their knowledge and perception regarding organophosphate poisoning can give rise to a drastic reduction in morbidity and mortality due to OP poisoning. Objectives: The objectives of this study were (i) to assess the awareness about hazards of organophosphorus poisoning, (ii) to educate about the protective measures while handling pesticides, and (iii) to educate about first aid measures after accidental exposure to pesticides. Materials and Methods: A community-based longitudinal study was carried out from September 1, 2015, to January 31, 2016, among agricultural workers using pesticides in their farm of seven villages of Kurnool District. All study subjects were interviewed using a pre-tested semi-structured questionnaire. Health education was given in two sessions with a gap of 2 weeks using audiovisual aids, posters, and flip charts. Each session lasted for 3 h in each village. Post-test was conducted 1 week after the last session. Results: A total of 230 subjects were using pesticides in their farm. Their knowledge levels regarding route of entry through contact 0%, inhalation 20 (8.69%) and ingestion 74 (32.17%) respectively in baseline study; which significantly improved to 82 (35.65%), 132 (57.39%) and 230 (100%) respectively in Post-test. Before educational intervention 52% were aware about usage of personal protective equipment during application of pesticides which was significantly improved to 100% in post-test. In pre and Post-test the habit of storage of partially used and un used pesticide tins in households were 28% & 0% respectively. Awareness about the proper disposal of empty tins was (0) less in baseline study which increased significantly to (76%) after educational intervention. Conclusions: Overall awareness of agricultural workers regarding usage and toxicity of OPs was inadequate, which was significantly improved after health education. Frequent educational sessions are needed to improve their awareness regarding safe handling procedures.

Sudden death caused by trichlorfon poisoning in Korean native cattle / 대한수의학회지

Two 12-month-old cattle with anthelmintics containing trichlorfon the day before death presented to the Animal and Plant Quarantine Agency for diagnosis. In necropsy, they revealed enlargement of the spleens, redness of mucosa and serosa in stomachs and intestines, and friable kidneys. Histopathologically, hemorrhages in the spleens, omasums, abomasums, and intestines as well as renal tubular necrosis were observed. Trichlorfon was detected at above the lethal dose in the ruminal contents. Based on these findings, we diagnosed this case as death caused by trichlorfon poisoning.

Methidathion Poisoning / 대한구급학회지

Although methidathion is an organophosphate insecticide, it is different from the other organophosphates in terms of toxicity. Because of its relatively high fat solubility, the apparent volume of methidathion distribution throughout the body is very high, indicating that hemoperfusion is not effective in removing this organophosphate from the body. Redistribution of methidathion from fat to blood can also occur when plasma levels diminish. Additionally, acetylcholinesterase aging, which is the loss of an alkyl side chain that prevents reactivation by oximes, is very rapid so that the effective reactivation by oximes is thwarted. Thus, methidathion's effect on acetylcholinesterase inhibition is long lasting, particularly with a high dose. In addition to its parasympatholytic effect and ability to induce muscle paralysis, methidathion poisoning is associated with a profound and long-lasting circulatory collapse due to sympathetic ganglion blockade. This report presents the case of a 55-year-old man who accidentally ingested a high dose of methidathion. He later developed enteroinvasive aspergillosis infection-induced multiple bowel perforations on two separate occasions while on mechanical ventilator support, resulting in a fatal outcome. The renin-angiotensin axis activated by sympathetic ganglion blockade may have reduced the patient's splanchnic blood flow, contributing to translocation of endotoxin. Also, the effect of excessive acetylcholine on non-neuronal acetylcholine receptors may have contributed to the development of fatal enteroinvasive aspergillosis in this patient.

Methidathion Poisoning / 대한중환자의학회지

Although methidathion is an organophosphate insecticide, it is different from the other organophosphates in terms of toxicity. Because of its relatively high fat solubility, the apparent volume of methidathion distribution throughout the body is very high, indicating that hemoperfusion is not effective in removing this organophosphate from the body. Redistribution of methidathion from fat to blood can also occur when plasma levels diminish. Additionally, acetylcholinesterase aging, which is the loss of an alkyl side chain that prevents reactivation by oximes, is very rapid so that the effective reactivation by oximes is thwarted. Thus, methidathion's effect on acetylcholinesterase inhibition is long lasting, particularly with a high dose. In addition to its parasympatholytic effect and ability to induce muscle paralysis, methidathion poisoning is associated with a profound and long-lasting circulatory collapse due to sympathetic ganglion blockade. This report presents the case of a 55-year-old man who accidentally ingested a high dose of methidathion. He later developed enteroinvasive aspergillosis infection-induced multiple bowel perforations on two separate occasions while on mechanical ventilator support, resulting in a fatal outcome. The renin-angiotensin axis activated by sympathetic ganglion blockade may have reduced the patient's splanchnic blood flow, contributing to translocation of endotoxin. Also, the effect of excessive acetylcholine on non-neuronal acetylcholine receptors may have contributed to the development of fatal enteroinvasive aspergillosis in this patient.

Implementing Best Practice in Critically Ill Organophosphate Poisoned Patient Through Simulation-Based Learning Program

PURPOSE: Despite the clinical and socio-economic impact of acute poisoned patients, many of the treatments are not standardized in Korea. Moreover, no formal training that is specifically focused on clinical toxicology exists. Rather, training and education are conducted case by case in various institutions. This study was conducted to develop a standardized simulation-based clinical toxicology training curriculum for healthcare providers. This program will focus on specific assessment and treatment of critical toxicology patients, specifically those who have been poisoned with organophosphate. METHODS: The study was performed using a pre- and post-design to determine the effects of implementation of this program. The study was conducted at eight different urban teaching hospitals in a simulated room in the clinical area. The study was targeted to 19 groups composed of emergency residents and nurses. Simulation-based learning was conducted for each group. RESULTS: All 19 groups achieved the minimum passing score of 75%. Implementation of the program led to improved performance rates for overall management and cooperative moods competency (p<0.01). Inter-rater agreement between the two evaluators was excellent. In general, the participants thought the program was realistic and were able to recognize and improve the competencies needed to care for organophosphate poisoned patients. CONCLUSION: Simulation-based learning is an effective educational strategy that can be applied to improving and understanding proper care for rare but critical patients. This program was effective at improving team performance and cooperative moods when managing an organophosphate poisoned patient in the Emergency Department.

760 ampollas de atropina utilizadas para tratar a un paciente con intoxicación grave por plaguicidas en un entorno de bajos recursos / 760 ampollas de atropina utilizadas 760 atropine ampules used to treat a patient with severe pesticide intoxication in a low resources setting

We reported the case of a 24-year-old male patient that arrived unconscious; with no identifable vital signs, a complete lack of response to pain stimuli and presented an extremely myotic pupils. Due to the report of his relatives we diagnosed an acute self-induced organophosphate (OP) intoxication through the ingestion of a full bottle of malathion. Endotracheal intubation, chest compressions, and manual ventilation were performed until the heart monitor showed slow myocardial activity. The patient was treated with atropine in the absence of specifc antidote (pralidoxime). A continuous peripheral IV infusion of atropine was started at a rate of 2 mg IV every 3 min. Given the constant decline in the patient's heart rate, the dose was constantly increased according to the vital sign chart until complete atropinization was achieved (heart rate over 120'). After administering a total of 760, 1 mg/ml ampules within 12 hours, a signifcant improvement was observed. The patient was discharged from the hospital 8 days later with no further complications

Blood Lipid Profile as a Prognostic Factor in Patients with Organophosphate Poisoning

PURPOSE: The purpose of this study is to compare clinical outcomes with blood lipids level and lipid solubility of organophosphate-poisoned patients. METHODS: Data from 88 patients who visited the emergency room from January 2008 to July 2014 were analyzed. This study was conducted retrospectively using blood test results and progress notes. The contents of data included the type of organophosphate herbicide, ingesting dose, vital signs on emergency room, blood lipids level, electrocardiographic finding, and hospital course. For lipid solubility, octanol/water coefficient was used. RESULTS: Among a total of 88 patients with organophosphate herbicide intoxication, 48 patients ingested high lipophilic organophosphate. There were statistically significant between cholesterol and duration of ventilator care. And there was a trend toward significance between cholesterol and intensive care unit, total admission stay, between triglyceride and total admission stay. As cholesterol and triglyceride level of patient was higher, the prognosis was worse. CONCLUSION: In this study, blood cholesterol and triglyceride levels in high lipophilic organophosphate herbicide intoxicated patients are useful predictable factors for prognosis.

Comparison of therapeutic effect of two types of blood purification on patients with severe acute organophosphate poisoning combined with myocardial injury / 中华急诊医学杂志

Objective To compare therapeutic effect of single hemoperfusion and hemoperfusion combined with continuous veno-venous hemofiltration ( sequential continuous blood purification) on patients with severe acute organophosphate poisoning combined with myocardial injury.Methods A total of 80 patients with severe acute organophosphate poisoning combined with myocardial injury admitted to EICU of Beijing Chaoyang Hospital from Jan.2004 to Dec.2013 were respectively analyzed and divided into two groups: hemoperfusion group (patients collected from Jan.2004 to Dec.2008, n=41) and sequential continuous blood purification (patients collected from Jan.2009 to Dec.2013, n =39).The average cholinesterase recovery time, the average consciousness recovery time, the average doses of atropine, the average hospital time, the change of cardiac troponin I levels on days 1, 2, 3, 5 and 7 after admission, and the change of left ventricular ejection fraction within 24 h after admission and after 24 h following blood purification treatment were compared between the two groups.Results Patients in the sequential continuous blood purification group had less average cholinesterase recovery time, average consciousness recovery time, average doses of atropine and average hospital time compared with patients in the hemoperfusion group [ ( 87.6 ±8.8 ) h vs.( 113.8 ±13.3 ) h;(57.3 ±11.7) h vs.(100.5 ±10.8) h;(284.5 ±61.4) mg vs.(476.6 ±93.1) mg and (10.2 ±2.3) vs. (14.6 ±3.9) , all P<0.01].The levels of cardiac troponin I on days 2, 3, 5 and 7, and ejection fraction of left ventricule after 24 h following blood purification treatment in the sequential continuous blood purification group were significantly decreased compared with patients in the hemoperfusion group ( all P <0.05 ) . Conclusion Therapeutic effect of sequential continuous blood purification on patients with severe acute organophosphate poisoning combined with myocardial injury is superior to single hemoperfusion.It suggests that sequential continuous blood purification could be used as a preferred choice in treatment of patients with severe acute organophosphate poisoning combined with myocardial injury.

Effects of Glutamine Dipeptide on Neurological and Gastrointestinal Function of Severe Organophosphate Poisoning Patients / 中国药房

OBJECTIVE:To investigate the effects of glutamine on neurological and gastrointestinal function of severe organo-phosphate poisoning patients. METHODS:46 patients with severe organic phosphorus poisoning in our hospital were enrolled and ran-domly divided into control group and observation group,with 23 cases in each group. Control group was given antidote atropine,en-ergy recovery agent pralidoxime chloride,blood perfusion and other symptomatic treatment. Observation group was additionally given Glutamine dipeptide injection 0.5 g/kg,ivgtt,qd,on the basis of control group. Both groups received the treatment for consecutive 3 d. The time of poisoning symptom disappearance,the time of blood cholinesterase recovery,hospitalization time,neurological and gastrointestinal function indexes were compared between 2 groups. RESULTS:The time of poisoning symptom disappearance,the time of blood cholinesterase recovery and hospitalization time of observation group were significantly shorter than those of control group,with statistical significance (P<0.05). After treatment,serum diamine oxidase and lactulose/mannitol of observation group were significantly lower than those of control group,while the serum content of citrulline was higher than in control group,with sta-tistical significance (P<0.05). After treatment,MCV and SCV of observation group were significantly higher than those of control group,while F wave latency was significantly shorter than control group,with statistical significance(P<0.05). CONCLUSIONS:Glutamine dipeptide is helpful to promote remission,improve gastrointestinal and neurological function.

Effect of Alcohol on Death Rate in Organophosphate Poisoned Patients

PURPOSE: Many patients who are acutely poisoned with organophosphorus pesticides have co-ingested alcohol. The purpose of this study was to identify the factors that influence mortality in organophosphate intoxication and the differences between alcohol coingested patients and non-coingested patients, looking at vital signs, length of admission, cholinesterase activity, complications, and mortality. METHODS: All patients visiting one Emergency Department (ED) with organophosphate intoxication between January 2000 and December 2012 were reviewed retrospectively. The patients were divided into two groups, alcohol coingested group and non-coingested group. RESULTS: During the study period, 136 patients (alcohol coingested group, 95 patients; non-coingested group, 41 patients) presented to the ED with organophosphate intoxication. Seventy-one alcohol coingested patients (74.1%) vs. 16 non-coingested patients (39.0%) received endotracheal intubation, with results of the analysis showing a clear distinction between the two groups (p=0.001). Twenty-three alcohol coingested patients (24.2%) vs. 1 non-coingested patient (2.4%) required inotropics, indicating a significant gap (p=0.002). Twenty-eight alcohol coingested patients (29.5%) vs. 2 non-coingested patients (4.9%) died, with results of the analysis showing a clear distinction between the two groups (p=0.002). CONCLUSION: In cases of organophosphate intoxication, alcohol coingested patients tended to receive endotracheal intubation, went into shock, developed central nervous system complications, and more died.

Intoxicação aguda por agrotóxicos anticolinesterásicos na cidade do Recife, Pernambuco, 2007-2010 / Acute anticholinesterase pesticide poisoning in Recife, Pernambuco State, Brazil, 2007-2010 / Intoxicación aguda por agrotóxicos anticolinesterásicos en la ciudad de Recife, Pernambuco, 2007-2010

Objetivo: descrever as características epidemiológicas e a distribuição espacial dos casos de intoxicações agudas por agrotóxicos anticolinesterásicos na cidade do Recife, estado de Pernambuco, Brasil, no período 2007-2010. Métodos: estudo descritivo das notificações registradas no Sistema de Informação de Agravos de Notificação (Sinan), para levantamento do perfil epidemiológico e geoprocessamento. Resultados: foram identificados 549 casos de intoxicações agudas por agrotóxicos anticolinesterásicos, sendo as maiores frequências observadas no sexo feminino (60,3 por cento), na faixa etária de 15 a 29 anos (42,3 por cento) e naqueles de cor ou raça parda (95,3 por cento); o "chumbinho" representou o principal agente tóxico envolvido (92,2 por cento) e o principal motivo das intoxicações foi a tentativa de suicídio (79,4 por cento). Conclusão: a intoxicação por agrotóxicos anticolinesterásicos acometeu principalmente mulheres, jovens e pardos; o achado de que a grande maioria dos casos estava relacionada a tentativa de suicídio indica a necessidade de ações de prevenção focadas na população detectada como vulnerável.

Objective: to describe the epidemiological characteristics and spatial distribution of acute anticholinesterase pesticide poisoning cases in the city of Recife Pernambuco State, Brazil, 2007-2010. Methods: this was a descriptive study of cases reported on the Notifiable Diseases Database (Sinan) to obtain their epidemiologic profile and perform geoprocessing. Results: 549 cases were identified. The highest frequencies occurred among females (60.3 percent), the 15-29 age group (42.3 percent) and brown-skinned individuals (95.3 percent). "Rat poison" was the main poisoning agent found (92.2 percent) and attempted suicide was the main reason for poisoning (79.4 percent). Conclusion: anticholinesterase pesticide poisoning is a serious public health problem with a high proportion of cases concentrated in youth, women and brown-skinned people. The finding that the vast majority of cases were related to attempted suicide indicates the need for prevention actions focusing vulnerable populations.

Objetivo: describir las características epidemiológicas y la distribución espacial de los casos de intoxicaciones agudas por agrotóxicos anticolinesterásicos en la ciudad de Recife, estado de Pernambuco, Brasil, en el período 2007-2010.Métodos: estudio descriptivo de las notificaciones registradas en el Sistema de Información de Agravamientos de Notificación (Sinan), para analizar el perfil epidemiológico y el geoprocesamiento.Resultados: se identificaron 549 casos de intoxicaciones agudas por agrotóxicos anticolinesterásicos, siendo observadas las mayores frecuencias en el sexo femenino (60,3%), en la franja de edad de 15 a 29 años (42,3%) y en las personas de color o raza parda (95,3%); el rodenticida ("chumbinho") fue el principal agente tóxico involucrado (92,2%) y el principal motivo de las intoxicaciones fue el intento de suicidio (79,4%). Conclusion: la intoxicación por agrotóxicos anticolinesterásicos acometió principalmente a mujeres, jóvenes y a pardos; el hallazgo de que en la gran mayoría de los casos estaba relacionada al intento de suicidio indica la necesidad de acciones de prevención dirigidas a la población detectada como vulnerable.

Organophosphate induced delayed polyneuropathy: An unusual presentation.

Organophosphate poisoning is an important cause of suicides in hospital admission. The present case is of a female presenting with loss of power in all four limbs two weeks following a suicidal attempt. Nerve conduction velocity test revealed axonal type of motor neuropathy in bilateral median and ulnar nerve and peroneal and tibial nerves were unexcitable bilaterally. Therefore, in all cases of neuropathy, ingestion of organophosphate, either accidental or suicidal should be looked for even if the initial phases of intoxication are not clinically well defined.

The Features and Prognoses in Organophosphate Intoxication according to Age

BACKGROUND: The purpose of this study was to identify the factors that influence mortality in organophosphate intoxication and the differences between the elderly (> or =65 years) and younger adults (18-64 years) looking at vital sign, length of admission, cholinesterase activity, complications, and prognosis. METHODS: All patients visiting one Emergency Department (ED) with organophophate intoxication between January 2000 and December 2011 were reviewed retrospectively. We divided the patients into two groups, geriatric adults (> or = 65 years) and nongeriatric adults (18-64 years). RESULTS: During the study period, 155 patients (45 patients, > or =65 years; 110 patients, 18-64 years) presented to the ED with organophosphate intoxication. Thirty-six elderly patients (80.0%) vs. 63 younger adult patients (57.3%) were intubated endotracheally, with the analysis showing a clear distinction between the two groups (p=0.026). Twenty-two elderly patients (48.9%) vs. 23 younger adult patients (20.9%) went into shock, displaying a significant gap (p=0.008). Thirtyfive elderly patients (81.4%) vs. 62 younger adult patients (59.0%) developed respiratory complications and 20 elderly patients (46.5%) vs. 19 younger adult patients (18.1%) developed central nervous system complications, with obvious differences seen in each of the comparison at (p=0.031) and (p=0.005), respectively. Comparing plasma cholinesterase levels at 1st, 3rd, 5th, 10th, 15th, and 20th days, the rate of increase was faster in the younger adults (p=0.022). CONCLUSION: With organophosphate intoxication, elderly patients tended to be intubated endotracheally, went into shock, developed central nervous system complications, were more severe, and showed a slower increase in cholinesterase level.

Initial Laboratory Parameters and its Correlation to Intermediate Syndrome in Patients with Acute Organophosphate Poisoning

PURPOSE: The association of serial serum cholinesterase (SChE) activity and the occurrence of intermediate syndrome (IMS) in patients orally poisoned with organophosphate (OP) were investigated. In addition, other clinical and laboratory factors were assessed for their ability to predict the subsequent development of IMS. METHODS: A total of 114 patients presented to our emergency department with acute OP ingestion between 2007 and 2012 were enrolled in this prospective study. Of these patients, 67 who needed mechanical ventilation (MV) over five days were divided into the IMS group. The 47 patients weaned from MV within four days after admission, or who did not receive the assistance of MV, were placed in the non-IMS group. The level of SChE at admission, 48 hours, and 96 hours, at discharge after admission were checked. The APACHE II (Acute Physiology, Age, Chronic Health Evaluation II) score, the amount ingested, exposure route, gender, age, and the laboratory test results were collected. All statistical analyses were performed using the Statistical Package for the Social Sciences (version 20.0). RESULTS: The mean age of total enrolled patients was 53.7+/-17.9 years and 73 patients (64.0% of total patients) were male. There were 102(89.5%) patients who intentionally ingested the OP and the mean amount ingested was 102.5+/-64.9 mL. The mean time after patients sought medical care was 5.4+/-10.5 hours after ingestion. The level of SChE at admission was 1,586+/-796 U/L and the APACHE II score was 28.81+/-19.7. The arterial pH, bicarbonate and carbon dioxide pressure, and serum protein and albumin were significantly lower in the IMS group than the non-IMS group (p<0.001). In contrast, the serum amylase, lipase, and glucose were higher in the IMS group. The APACHE II score, serum albumin and amylase, arterial bicarbonate, and the SChE at 48 and 96 hours after ingestion were independent factors that predicted the occurrence of IMS in patients with OP poisoning. The rate of recovery was 86.6% in the IMS group and 100% in the non-IMS group (p<0.001). CONCLUSION: Patients with a higher APACHE II score and levels of serum amylase, and lower levels of serum albumin and arterial bicarbonate, may be associated with the occurrence of IMS. Furthermore, when SChE levels after 48 hours and 96 hours did not increase, compared with the level of SChE at admission, patients tended to show IMS.

Initial Laboratory Parameters and its Correlation to Intermediate Syndrome in Patients with Acute Organophosphate Poisoning

PURPOSE: The association of serial serum cholinesterase (SChE) activity and the occurrence of intermediate syndrome (IMS) in patients orally poisoned with organophosphate (OP) were investigated. In addition, other clinical and laboratory factors were assessed for their ability to predict the subsequent development of IMS. METHODS: A total of 114 patients presented to our emergency department with acute OP ingestion between 2007 and 2012 were enrolled in this prospective study. Of these patients, 67 who needed mechanical ventilation (MV) over five days were divided into the IMS group. The 47 patients weaned from MV within four days after admission, or who did not receive the assistance of MV, were placed in the non-IMS group. The level of SChE at admission, 48 hours, and 96 hours, at discharge after admission were checked. The APACHE II (Acute Physiology, Age, Chronic Health Evaluation II) score, the amount ingested, exposure route, gender, age, and the laboratory test results were collected. All statistical analyses were performed using the Statistical Package for the Social Sciences (version 20.0). RESULTS: The mean age of total enrolled patients was 53.7+/-17.9 years and 73 patients (64.0% of total patients) were male. There were 102(89.5%) patients who intentionally ingested the OP and the mean amount ingested was 102.5+/-64.9 mL. The mean time after patients sought medical care was 5.4+/-10.5 hours after ingestion. The level of SChE at admission was 1,586+/-796 U/L and the APACHE II score was 28.81+/-19.7. The arterial pH, bicarbonate and carbon dioxide pressure, and serum protein and albumin were significantly lower in the IMS group than the non-IMS group (p<0.001). In contrast, the serum amylase, lipase, and glucose were higher in the IMS group. The APACHE II score, serum albumin and amylase, arterial bicarbonate, and the SChE at 48 and 96 hours after ingestion were independent factors that predicted the occurrence of IMS in patients with OP poisoning. The rate of recovery was 86.6% in the IMS group and 100% in the non-IMS group (p<0.001). CONCLUSION: Patients with a higher APACHE II score and levels of serum amylase, and lower levels of serum albumin and arterial bicarbonate, may be associated with the occurrence of IMS. Furthermore, when SChE levels after 48 hours and 96 hours did not increase, compared with the level of SChE at admission, patients tended to show IMS.

A Case of Central Nervous System (CNS) Toxicity in Acute Organophosphate Intoxication

Acute organophosphate intoxication is important because of its high morbidity and mortality. The mortality is still high despite the use of atropine as specific antidotal therapy and oximes for reactivation of acetylcholinesterase. Inhibition of acetylcholinesterase by organophosphate can cause acute parasympathetic system dysfunction, muscle weakness, seizure, coma, and respiratory failure. Acute alteration in conscious state or a coma, which may occur following organophosphate intoxication, is an indication of severe intoxication and poorer prognosis. This acute decline in conscious state often reverses when the cholinergic crisis settles; however, it may be prolonged in some patients. We report on a case of a 60-year-old male who showed prolonged decline in conscious state due to of Central Nervous System (CNS) toxicity after a suicide attempt with organophosphate.