Organophosphate Poisoning Case

[kbrown]

Last night 46 y/o Indian female in to Resusc Room for overdose. She became angry with her family and ingested a bottle of MALATHION. Brought to ER by son within 30 minutes. Immediately NG lavage with 6 litres was performed. As we watched her she started to sweat, then lacrimation, defecation, and bronchorrea with fasciculations. We started her on Atropine and Pralidoxime drip. Her symptoms improved slowly over the time.

Pretty sweeeeetttt case. She is doing well right now, got her set up and sent to ICU.

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[WallowaWanderer]

Wow, that's a great case. I thought that stuff only happened on board exams.

 

[BADMD]

Just an aside to you all: Please report any OD or poisoning to your local Poison Control Center, even if you don't want management advice.

These reports get uploaded to a national database every 6 minutes where automated filters review the data for changing trends and unusual occurrences. A few OP cases or a rash of deaths from say, heroin, will trigger an alert and it will get looked into.

 

[BKN]

Last night 46 y/o Indian female in to Resusc Room for overdose. She became angry with her family and ingested a bottle of MALATHION. Brought to ER by son within 30 minutes. Immediately NG lavage with 6 litres was performed. As we watched her she started to sweat, then lacrimation, defecation, and bronchorrea with fasciculations. We started her on Atropine and Pralidoxime drip. Her symptoms improved slowly over the time.

Pretty sweeeeetttt case. She is doing well right now, got her set up and sent to ICU.

I spent a month at CMC Vellore India in August. They've got 2-3 of these a week (preferred method for suicide attempt). They surprised me by not using the pralidoxime. They said it hadn't affected their results over atropine and support in a series.

 

[kbrown]

I spent a month at CMC Vellore India in August. They've got 2-3 of these a week (preferred method for suicide attempt). They surprised me by not using the pralidoxime. They said it hadn't affected their results over atropine and support in a series.

That is remarkable. So this appears to be cultural thing. I was surprised to see the malathion come in with the son. This was definitely a tox case that I will never forget. She read the textbook for sure.

Just as a teaching point that we learned last night. Give atropine, irrespective of heart rate, when you see bronchorrhea. She will become tachycardic and hypertensive, don't worry. You can stop the atropine once the bronchorrhea has stopped. When we started it her heart rate was 110 already. She went up to the 160s with it. The atropine is not supposed to help with the other symptoms (lacrimation, defecation, etc.) it is for the bronchorrhea only.

 

[BADMD]

I spent a month at CMC Vellore India in August. They've got 2-3 of these a week (preferred method for suicide attempt). They surprised me by not using the pralidoxime. They said it hadn't affected their results over atropine and support in a series.

It depends on who you ask. What I really think it comes down to is cost. Those whose hospitals can afford it, use it. Those whose hospital can't, don't.

If you think about the mechanism, it makes sense that an oxime would be necessary. While the atropine may fix the muscarinic symptoms, you aren't dealing with the nicotininc effects. Also, once the OP ages, you have to regenerated your cholinesterases...a process which takes weeks. So, if the oxime is able to pull the OP out of the Ach-estrase, then you should shorten or eliminate that intermediate period where the estrases are being regenerated.

 

[BADMD]

That is remarkable. So this appears to be cultural thing. I was surprised to see the malathion come in with the son. This was definitely a tox case that I will never forget. She read the textbook for sure.

Just as a teaching point that we learned last night. Give atropine, irrespective of heart rate, when you see bronchorrhea. She will become tachycardic and hypertensive, don't worry. You can stop the atropine once the bronchorrhea has stopped. When we started it her heart rate was 110 already. She went up to the 160s with it. The atropine is not supposed to help with the other symptoms (lacrimation, defecation, etc.) it is for the bronchorrhea only.

Did you happen to draw an RBC cholinesterase and/or a pseudocholinesterase level?

 

[southerndoc]

I saw several cases of organophosphate poisoning while in Zambia. Only one patient could be saved, and we depleted half the hospital's supply treating him. That supply we used was six month's of rationed atropine.

 

[kbrown]

Did you happen to draw an RBC cholinesterase and/or a pseudocholinesterase level?

No. Strangely, in speaking with the on call Toxicologist, that wasn't brought up. Is that just more useful in determine efficacy of treatment or does it represent severity?

 

[BADMD]

No. Strangely, in speaking with the on call Toxicologist, that wasn't brought up. Is that just more useful in determine efficacy of treatment or does it represent severity?

It give you an idea of how toxic the patient might be. It is a send out, so it isn't immediately useful. It is probably more useful for determining if someone has intermediate syndrome, but it would be academically interesting.

 

[bulgethetwine]

That is remarkable. So this appears to be cultural thing. I was surprised to see the malathion come in with the son. This was definitely a tox case that I will never forget. She read the textbook for sure.

Just as a teaching point that we learned last night. Give atropine, irrespective of heart rate, when you see bronchorrhea. She will become tachycardic and hypertensive, don't worry. You can stop the atropine once the bronchorrhea has stopped. When we started it her heart rate was 110 already. She went up to the 160s with it. The atropine is not supposed to help with the other symptoms (lacrimation, defecation, etc.) it is for the bronchorrhea only.

Great case -- and just to add to the 'teaching point' above, don't forget that the usual cardiac max doses of atropine don't apply to organophosphate poisoning. Titrate to affect as described in the teaching point above.

 

[Orthonut]

Random question:

We see alot of organophosphate intoxications. Do you guys induce vomiting with these, or do you just go right to the gastric lavage? General oral ingestion question: Do you place activated charcoal routinely when you are finished lavaging?

 

[WallowaWanderer]

Random question:

We see alot of organophosphate intoxications. Do you guys induce vomiting with these, or do you just go right to the gastric lavage? General oral ingestion question: Do you place activated charcoal routinely when you are finished lavaging?

I've been told in my tox lectures to never induce vomiting for anything in an ED setting. My impression is that if you have an ingestion that happened recently enough (i.e. 1 hr ago) that you have reason to believe it's still in the stomach then you would do gastric lavage. But gastric lavage has a lot of complications so it's falling out of favor. And I believe charcoal is given routinely when lavage is done.

 

[BADMD]

Random question:

We see alot of organophosphate intoxications. Do you guys induce vomiting with these, or do you just go right to the gastric lavage? General oral ingestion question: Do you place activated charcoal routinely when you are finished lavaging?

Where are you that you are seeing so much OP? They aren't used that much in the US. Canada has some. Typically the cases are more in the eastern world.

That being said, while induction of vomiting is pretty common in the Vet world, typically you expect to see a certain amount of it with the OP. Secondarily, if you manage to get the dog to vomit, there is going to be an uncontrolled spray of potentially toxic vomitus all over. I'm not even sure I'd want to lavage someone who was OP poisoned without a suit and charcoal air filter.

As for giving charcoal, OPs will absorb, however there is substantial risk of vomiting and resultant charcoal aspiration. So it is going to be very dependent on the patient...and they had better be stabilized with atropine before I consider it.

 

[Orthonut]

Where are you that you are seeing so much OP? They aren't used that much in the US. Canada has some. Typically the cases are more in the eastern world.

That being said, while induction of vomiting is pretty common in the Vet world, typically you expect to see a certain amount of it with the OP. Secondarily, if you manage to get the dog to vomit, there is going to be an uncontrolled spray of potentially toxic vomitus all over. I'm not even sure I'd want to lavage someone who was OP poisoned without a suit and charcoal air filter.

As for giving charcoal, OPs will absorb, however there is substantial risk of vomiting and resultant charcoal aspiration. So it is going to be very dependent on the patient...and they had better be stabilized with atropine before I consider it.

I'm going to SGU-Grenada. Plus, here in the US veterinary wise many of the intoxications we see are OPs. Just some weird thing I guess...maybe regional (west coast nursery land)

We're pretty good at vomiting the dogs and aiming them. Typically they don't spray like people do-they usually retch, open their mouth, and it kinda pours out.

It's common around here to rinse the apomorphine out of the SC sac when the vomiting is no longer productive/desired, then some give an antiemetic, THEN they give the charcoal (some omit the anti emetic step) and they repeat the charcoal q6h or so.

Maybe it's just a vet thing?

Thanks for indulging my cross species curiosity!

 

[Orthonut]

I've been told in my tox lectures to never induce vomiting for anything in an ED setting. My impression is that if you have an ingestion that happened recently enough (i.e. 1 hr ago) that you have reason to believe it's still in the stomach then you would do gastric lavage. But gastric lavage has a lot of complications so it's falling out of favor. And I believe charcoal is given routinely when lavage is done.

I think we prefer vomiting the animals instead of lavaging because the latter is so much more time consuming and cost prohibitive/too expensive for many people (requires GA for conscious patients) I mean, if it were candyland (if I were the Boss of the Universe) I'd love to lavage everything.