Updated: 7/24/2020

Organophosphate Poisoning

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Snapshot
  • A 60-year-old military officer presents after being attacked with nerve gas. He has increased salivation, lacrimation, and shortness of breath. He also reports involuntary urination and diarrhea. Physical exam reveals wheezing and constricted pupils. His clothes are removed and any remnant nerve gas is washed off his body. Atropine is given.
Introduction
  • Clinical definition
    • organophosphate poisoning that results in increased acetylcholine activity
  • Epidemiology
    • demographics
      • farmers or other workers who are exposed to insecticides
      • industrial workers
    • risk factors
      • occupational exposure
  • Etiology
    • insecticides
      • e.g., malathion, parathion, and fenthion
    • nerve gas
      • most rapid and most severe
    • ophthalmic agents
      • e.g., echothiophate and isofluophate
    • herbicide
      • e.g., merphos and tribufos
    • industrial chemicals
      • e.g., tricresyl phosphate
  • Pathogenesis
    • organophosphates irreversibly inhibit acetylcholinesterase and block the metabolism of acetylcholine, resulting in increased acetylcholine activity
    • this causes overstimulation of the muscarinic and nicotinic receptors
  • Prognosis
    • good with treatment, though patients may require intubation before stabilization
Presentation
  • Symptoms 
    • salivation, sweating, rhinorrhea, and lacrimation
    • involuntary urination or defecation
    • nausea, diarrhea, and vomiting
    • anxiety
  • Physical exam
    • wheezing
      • from bronchospasm
    • miosis and blurred vision
    • bradycardia and hypotension
    • fasciculations
    • seizures
  • DUMBBELSS
    • Diarrhea, Urination, Miosis, Bronchospasm, Bradycardia, Excitation of systems, Lacrimation, Sweating, and Salivation
Studies
  • Labs
    • typically not indicated but can be confirmed by measurement of
      • red blood cell cholinesterase levels
      • plasma cholinesterase levels
  • Making the diagnosis
    • most cases are clinically diagnosed
Differential
  • Viral gastroenteritis
    • distinguishing factor
      • primarily gastrointestinal upset without other muscarinic and nicotinic effects
Treatment
  • Conservative
    • remove clothes and wash the patient
      • indications
        • for all patients
        • for the protection of caregivers and other patients, as organophosphates can be absorbed through the skin
  • Medical 
    • atropine
      • indication
        • antidote for all patients as initial therapy
          • competitive inhibitor
    • pralidoxime 
      • indication
        • antidote for all patients shortly after atropine is given
          • reactivates acetylcholinesterase
    • benzodiazepines
      • indication
        • for patients with seizures or fasciculations
Complications
  • Respiratory failure
  • Seizures

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