diagnosis & management of insecticide poisoning winai wananukul, m.d. ramathibodi poison center...
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Diagnosis & Management Diagnosis & Management of of
Insecticide PoisoningInsecticide Poisoning
Winai Wananukul, M.D.
Ramathibodi Poison Center & Department of Medicine
Ramathibodi Hospital
Winai Wananukul, Ramathibodi Poison Center
Epidemiology of Toxic ExposureEpidemiology of Toxic Exposure(May 2000 - April 2001)(May 2000 - April 2001)
Occupational Products
6.3%
Others8.0%
Medical Products
22.4%
Pesticide41.6%
Household Products
21.7%
Winai Wananukul, Ramathibodi Poison Center
Classification of Pesticide ExposureClassification of Pesticide Exposure
Insecticides50%
Herbicides22%
Rodenticides17%
Miticide6%
Synergist1%
Mollusticide1% Fungicide
1%Miscellaneous
1%
Plant growth regulator
1%
Winai Wananukul, Ramathibodi Poison Center
Classification of Insecticide ExposureClassification of Insecticide Exposure
Carbamate24.4%
Organophosphate20.1%
Pyrethroid17.8%
Combined18.1%
Unknown6.9%
Repellant2.0%
Fumigant1.1% Others
2.0%Organochlorine7.5%
Winai Wananukul, Ramathibodi Poison Center
Classification of Herbicide ExposureClassification of Herbicide Exposure
Glycine52.3%
Paraquat20.5%
Chlorophenoxy6.0%
Chloroacetanilide6.0%
Unknown2.6%
Others12.6%
Winai Wananukul, Ramathibodi Poison Center
Classification of Rodenticide ExposureClassification of Rodenticide Exposure
Zinc Phospide41.0%
Superwarfarin3.4%
Unknown6.8%
Warfarin48.7%
Winai Wananukul, Ramathibodi Poison Center
Ratio of Exposure with and without clinical manifestation of Ratio of Exposure with and without clinical manifestation of poisoning at the time consult to the Poison Centerpoisoning at the time consult to the Poison Center
Without Clinical Manifestation of
Poisoning46.7%
Clinical Poisoning
53.3%
Winai Wananukul, Ramathibodi Poison Center
Medical Outcome of the Risk GroupMedical Outcome of the Risk Group
No S/S46.7%
Clinical Poisoning
53.3%
No Effects34.3%
Minor Effects32.2%
Unable to FU8.7%
Moderate Effect6.1%
Major Effect8.0%
Death10.8%
Winai Wananukul, Ramathibodi Poison Center
Medical Outcome of the Poisoned GroupMedical Outcome of the Poisoned Group
Clinical Poisoning
53.3%
No S/S46.7%
Minor Effects48.6%
Moderate Effect10.8%
Major Effect14.4%
Death19.4%
Unable to FU6.7%
Winai Wananukul, Ramathibodi Poison Center
Medical Outcome of Selected Toxic ExposureMedical Outcome of Selected Toxic Exposure
0
50
100
150
200
250
Pesticides MedicalProducts
HouseholdProducts
Occupational Products
Death Major Moderate Minor No Effect
Winai Wananukul, Ramathibodi Poison Center
0%
20%
40%
60%
80%
100%
PQ OC OP CB ZnP Gly Pyr
Survive Death
Survival & Death Rate of Selected Pesticide Exposure Survival & Death Rate of Selected Pesticide Exposure (from high to low mortality rate(from high to low mortality rate))
61.3%61.3% 42.3%42.3%
22.9%22.9% 20.0%20.0%
4.2%4.2% 2.5%2.5% 1.6%1.6%
Organophosphate Organophosphate andand
Carbamate PoisoningCarbamate Poisoning
Winai Wananukul, Ramathibodi Poison Center
What is Acute Organophosphate & Carbamate PoWhat is Acute Organophosphate & Carbamate Poisoning ?isoning ?
State of Acetylcholine Excess It is a combination of
– Muscarinic receptor
– Nicotinic receptor
– CNS (unspecified)
Winai Wananukul, Ramathibodi Poison Center
Organophosphate VS. Carbamate PoisoningOrganophosphate VS. Carbamate Poisoning
Reversible vs. Irreversible Inhibition
– Reversible vs. Irreversible clinical poisoning
– Time of clinical course
Blood brain barrier penetration
– CNS symptoms (after exclude hypoxic effects)
Winai Wananukul, Ramathibodi Poison Center
Clinical course after acute poisoningClinical course after acute poisoning
Cholinergic Excess Others (than cholinergic excess)
– Intermediate syndrome
– Delayed neuropathy
– Arrthymias
Winai Wananukul, Ramathibodi Poison Center
Diagnosis of Organophosphate or Carbamate PoDiagnosis of Organophosphate or Carbamate Poisoning:isoning:
Clinical Diagnosis
Laboratory
– Red cell cholinesterase
– Plasma (Pseudo, Butyryl (Bu)) cholinesterase
Winai Wananukul, Ramathibodi Poison Center
Management of OP & CB PoisoningManagement of OP & CB Poisoning
Supportive Care– Vital signs
– Respiration:
• secretion block and airway obstruction
• respiratory motor weakness
– Seizure
Specific Treatment
Winai Wananukul, Ramathibodi Poison Center
Airway
Skin
Parenteral
GI. Cir
cula
tion Tissues
&Organs
Ion Trapping RAC.
DecontaminationDecontamination Increase Increase EliminationElimination
AntidotesAntidotes
Hemodialysis, Hemoperfusion
Winai Wananukul, Ramathibodi Poison Center
TOXICTOXIC
ANTIDOTESANTIDOTES
Winai Wananukul, Ramathibodi Poison Center
Muscarinic EffectsMuscarinic EffectsHeart rateHeart rateSweating Sweating SecretionSecretionPupilsPupils
AtropineAtropine
Winai Wananukul, Ramathibodi Poison Center
AChE InhibitionsAChE InhibitionsNicotinicNicotinicMuscarinicMuscarinic
2 PAM2 PAM
Winai Wananukul, Ramathibodi Poison Center
Nicotinic EffectsNicotinic EffectsMotor Power Motor Power
++ (Muscarinic Effects) (Muscarinic Effects)
2 PAM2 PAM
Winai Wananukul, Ramathibodi Poison Center
Intermediate SyndromeIntermediate Syndrome
Develop only after some acute organophosphate poisoning
Mechanism: unknown– not directly relate to acetylcholine excess
Clinical Manifestation:– Proximal muscle weakness
– Bulbar palsy
Winai Wananukul, Ramathibodi Poison Center
Intermediate SyndromeIntermediate Syndrome
Spontaneous recover in 2 -3 weeks after develop Treatment
– Supportive care, especially respiratory care Note: this condition must be differentiated from
“Aged Acetylcholinesterase”
Winai Wananukul, Ramathibodi Poison Center
Chronic Organophosphate PoisoningChronic Organophosphate Poisoning
Clinical Features:– Delay polyneuropathy
– Neuropsychiatric disorder
Diagnosis– Clinical diagnosis, by suspicious & exclusion
Investigation– ?? Plasmacholinesterase
Treatment– Not established
Winai Wananukul, Ramathibodi Poison Center
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ตรวจร�างกาย : HR 140/min, BP 160/110, RR 22/min
ผู้*+ปี,วยม generalized tonic and clonic seizure ตลอดเวลา ได+ ET tube intubation ให+ iv fluid แล+วฉีด diazepam
Winai Wananukul, Ramathibodi Poison Center
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ตรีวจัรี�างก่ายเพ��มเต�ม : unconsciousPupil 4 mm, react to light bilateralLung : clearAbdomen : soft, normal bowel soundNeurological signs: no stiff neck, motor power grossly intact, absent of Babinsk’s sign.
Organochlorine PoisoningOrganochlorine Poisoning
Winai Wananukul, Ramathibodi Poison Center
Classification of OrganochlorineClassification of Organochlorine
DichlorodiphenylethanesDichlorodiphenylethanesDDT Methoxychlor
HexachlorocyclohexaneHexachlorocyclohexaneLindane
CyclodienesCyclodienesAldrin Chlordane Dieldrin
Endrin Endosulphan Hepatochlor
Chlordecone (kepone)Chlordecone (kepone)Mirex
Winai Wananukul, Ramathibodi Poison Center
Acute Organochlorine PoisoningAcute Organochlorine Poisoning
Prodomal symptoms: – tremor, ataxia, quick involuntary jerk (myoclonus) – dizziness, confusion – Paresthesia of month, – nausea, vomiting
Winai Wananukul, Ramathibodi Poison Center
Acute Organochlorine PoisoningAcute Organochlorine Poisoning
The typical presentation: Status epilepticus
Followed by:
– Respiratory failure
– Cardiac arrhythmias
– Rhabdomyolysis & acute renal failure
Winai Wananukul, Ramathibodi Poison Center
Acute Organochlorine PoisoningAcute Organochlorine Poisoning
Treatment:
– Control seizure as the same way as “Status epilepticus”
• Benzodiazepines
• Phenobarbital
• Phenytoin
– Prevent complications
Winai Wananukul, Ramathibodi Poison Center
Diagnosis of Organocholine PoisoningDiagnosis of Organocholine Poisoning
Clinical Diagnosis– History of exposure
– Clinical features of repeated seizure
Laboratory Test– Plasma level
– Subcutaneous fat level
Winai Wananukul, Ramathibodi Poison Center
Subacute Organochlorine PoisoningSubacute Organochlorine Poisoning
Hyperexcitability stage:
– Tachycardia
– Tremor
– Hyperreflexia Treatment
– Symptomatic Px: Anxiolytic
– Enhance Elimination : Cholestyramine
Winai Wananukul, Ramathibodi Poison Center
Chronic Organochlorine PoisoningChronic Organochlorine Poisoning
– Organochlorine insecticides interfere with endocrine
and reproductive systems.
– People who working with the insecticides have low
sperm count and motility, infertility and abortion.
– The insecticides have also been reported to be
carcinogenic to animals.
Pyrethroid PoisoningPyrethroid Poisoning
Winai Wananukul, Ramathibodi Poison Center
Classification of Pyrethrins & PyrethroidsClassification of Pyrethrins & Pyrethroids
PyrethrinsCinerin I Cinerin II Justmolin I Jusmolin II
Pyrethrin I Pyrethrin II Pyrethrum extract
Type I PyrethroidsAllethrin Bioallethrin Cismethrin Kadethrin
Permethrin Phenothrin Resmethrin Tetramethrin
Type II PyrethroidsCyhalothrinCypermethrin Cyphenothrin Deltamethrin
Fenpropenthrin Fenvalerate Fluvalinate
Winai Wananukul, Ramathibodi Poison Center
Pyrethroids ExposurePyrethroids Exposure
Direct Toxic Hypersensitivity
– Allergic rhinitis
– Bronchitis
– Bronchial asthma
– Anaphylactic shock
Local Irritation– Contact dermatitis
– Corneal abrasion
Winai Wananukul, Ramathibodi Poison Center
Pyrethroid Poisoning: InsectPyrethroid Poisoning: Insect
The type I syndrome (caused by type I pyrethroids): • fine tremor
• reflex hyperexcitability
• sympathetic activation
The type II syndrome (caused by type II pyrethroids):• salivation
• coarse tremor
• choreoathetosia
• reflex hyperexcitability
• sympathetic activation, and seizure
Winai Wananukul, Ramathibodi Poison Center
Pyrethroid Poisoning: HumanPyrethroid Poisoning: Human
Usually mild
Common:
nausea and vomiting after ingestion of pyrethroids.
Sever Cases: drowsiness, seizure and coma
( In patient exposed to large amount of pyrethroids, especially the product used in agriculture in higher concentration)
Death from pyrethroid poisoning is rare.
Winai Wananukul, Ramathibodi Poison Center
Diagnosis of Pyrethroid PoisoningDiagnosis of Pyrethroid Poisoning
Clinical Diagnosis Laboratory Test
– None
Winai Wananukul, Ramathibodi Poison Center
Management of Pyrethroid PoisoningManagement of Pyrethroid Poisoning
Hypersensitivity: – Adrenaline
– Corticosteroids
– Bronchodilators
– Antihistamine
Direct Toxic:– Supportive treatment