the emergency and intensive care management of op poisoning
TRANSCRIPT
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
Dr Bishan Rajapakse PhD Candidate Australia National University,
Advanced Trainee, Emergency Medicine, Wollongong Hospital South Asian Clinical Toxicology Research Collaboration
(SACTRC)
ICU Registrar Teaching – Thu 11th December 2014
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
• Background of topic (5 mins) – References/source
• OP Poisoning (25 mins) – Epidemiology/Pathophysiology
– Clinical Cases/Management
– Controversies of therapy
• Knowledge translation (5 mins) with surprise ending?
• Discussion (15mins)
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
• OPP High case fatality and global mortality
• ALS for OPP: concurrent atropine – High (doubling) doses
• Pralidoxime controversial
• Nosocomial poisoning (minimal risk to health workers)
• New research is constantly unfolding in OP management!
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
• Started as a bright spark 1st Year Advanced Trainee EM taking a year out… (and the rest is history)
• MPhil (in Tox) ! to PhD in medical education & knowledge translation – Measurement of AChE in acute
OP poisoning management – Rural doctor resuscitation training
• Worked with the “South Asian Clinical Toxicology Research Collaboration” (SACTRC) – 5 Hospitals in Sri Lanka
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
• PhD thesis related reading/research – Primary published research – Discussion with toxicologist supervisors/colleagues – Original research – Clinical experience Thesis contents
Ch1 – Management of OP poisoning (text book chapter: Lippincott, Williams and Wilkins)
Ch2 – Review : recommendations for use of AChE in OP Mx
Ch 3 – Review : ALS for OP poisoning
Ch 4 – POC testing for AChE (Annals of EM 2011)
Ch 5 – Knowledge attitudes and practice (BMC-HSR 2014)
Ch 6 - Rurual ALS training (Plos One 2013)
Ch 7 – Knowledge translation in OP Mx
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
“The only thing I know is that I don’t know anything”
'The more you know, the more you know you don't know.'
'The more I learn, the more I realize how much I don't know.'
- Socrates
- Aristotle
- Albert Einstein
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
“Sharing something is better than sharing nothing”
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
A global health problem of massive proportion….
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
• Prevalent in developing world – 300,000 deaths /year – Self–poisoning
predominates
• 15-30% mortality – (0.3% for all poisoning in
the west)
• Also affects developed world nations – Occupational exposure &
HAZMAT incidents – Nerve gas attacks
Eddleston M, Buckley NA, Eyer P, Dawson AH. Management of acute organophosphorus pesticide poisoning. Lancet. Feb 16 2008;371(9612):597-607.
Vale A. What lessons can we learn from the Japanese sarin attacks? Przegl Lek. 2005;62(6):528-532.
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
0
200
400
600
800
1000
1200
1400
1600
Death Cases
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
Men
Women
68%
Konradsen et al, 2004
Use of alcohol during self-harm in Uda Walawe
?
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
• High toxicity of agents
• Lack of 100% effective antidote
• Accessibility to healthcare – emergency and intensive care resource
limitations in rural setting
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014) Image accessed from CNSForum.com
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014) Figure from Chapter: “Organophosphorus and Carbamate Agents (Anti-cholinesterase pesticide poisoning)” – B.Rajapakse, N. Buckley - “Emergency Medicine Textbook” Ed S David, WoltersKluwer
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
Cholinergic Effects on
Central (CNS)
Peripheral (PNS)
Somatic
Autonomic P
S
Life threatening features
+ Death
Neuro: - " GCS - Seizure
Resp:
CVS:
- # Lung Secretions
- " HR - " BP
- Respiratory muscle weakness
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
• Acute cholinergic syndrome – Immediate onset
• Intermediate Syndrome – Delayed respiratory failure (24-96hrs)
– Nerve conduction can predict weakness
• OP induced delayed peripheral neuropathy
Jayawardane P, Dawson AH, Weerasinghe V, Karalliedde L, Buckley NA, Senanayake N. The spectrum of intermediate syndrome following acute organophosphate poisoning: a prospective cohort study from Sri Lanka. PLoS Med. Jul 15 2008;5(7):e147.
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
CASE
36 yo female Ingestion of Dimethoate
(Severely Toxic OP)
Village
• Drunk 100mls after dispute
• Found by family vomiting
• Taken to nearest peripheral hospital (1 doctor, 2 nurses)
• Sent by Ambulance (no paramedics) to nearest General hospital
0930 hrs
1000 hrs
0900 hrs (village)
1115 hrs
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
Hazmat incident involving OP – ICU called to help down in the ED…
Things are steaming in unit but still the pager rings….
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
• 27 yo female – A: Audible crackles, excessive salivation and
frothing at mouth
– B: Crackles through both lung fields, RR 40, O2 sats 86% on 15L/min
– C: P40, sBP 70-80, paradoxical breathing
– D: GCS 11/14, fasiculations, clonus
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
• x2 large bore cannula
• 1.5L crystalloid
• IV atropine by ED, total dose 30mg given in increments. – Last dose 16mg, given 5 mins ago
– Minimal improvement in Resp and CVS systems
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
a) atropine 5mg; + further 5mg every 5mins
b) atropine 32mg; doubling dose of atropine every 5 mins
c) Pralidoxime 2g IV
d) Pralidoxime 0.5g IV
e) Intubation is more immediately important than antidote therapy at this point
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
• Resuscitation! – A, B, C, D – Consider early intubation
• IV Atropine – Stops lung secretions – Increases blood pressure
Eddleston M, Buckley NA, Eyer P, Dawson AH. Management of acute organophosphorus pesticide poisoning. Lancet. Feb 16 2008;371(9612):597-607.
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
A B C D
• Acute Cholinergic Syndrome:
• Neuro: Low GCS, Coma, Seizure
• Resp: Lung Secretions
Respiratory Muscle Weakness
• CVS: Bradycardia and Hypotension
ATROPINE
DIAZEPAM
Roberts DM, Aaron CK. Management of acute organophosphorus pesticide poisoning. Bmj. Mar 24 2007;334(7594):629-634.
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
• Large doses of Atropine are required – Mean dose in severe OP poisoning 23.4mg (range
1-75mg)
• Text book recommendations vary – Upto 1,380 minutes to administer 23.4mg
• Doubling IV bolus doses most effective – Eg. 2mg, then 4mg, then 8mg etc every 5 minutes
until “clinical response” – Continue with 10-20% of loading dose/hour
Eddleston et al. Speed of initial atropinisation in significant organophosphorus pesticide poisoning--a systematic comparison of recommended regimens. J.Toxicol.Clin.Toxicol 2004;42(6):
865-75.
Connors et al. J Med Toxicol. 2013 Jul 31
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
Lung Secretions
Hypotension
Bradycardia
Sweating
(Miosis)
Clear Chest
sBP > 80mmHg
HR > 80/min
Dry Axillae
(Pupils no longer pinpoint)
ATROPINE
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
a) atropine 5mg; + further 5mg every 5mins
b) atropine 32mg; doubling dose of atropine every 5 mins
c) Pralidoxime 2g IV
d) Pralidoxime 0.5g IV
e) Intubation is more immediately important than antidote therapy at this point
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
• Oximes reverse the inhibition of AChE
– " mucarinic & nicotinic symptoms
– Potential to prevent delayed respiratory failure.. if given early enough?
• Neuro: Low GCS, Coma, Seizure
• Resp: Lung Secretions
Respiratory Muscle Weakness
• CVS: Bradycardia and Hypotension
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
• 2 important factors – kinetics of ageing
– achieving therapeutic dose
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
• t 1/2 inhibition – Milliseconds for both
diMethyl and diEthyl OPs
Eddleston M, Eyer P, Worek F, Mohamed F, et al Differences between organophosphorus insecticides in human self-poisoning: a prospective cohort study. Lancet. 2005 Oct 22-28;366(9495):1452-9
• t1/2 Spontaneous reactivation – 0.7 hr for diMethyl – 31 hrs for diEthyl
• t1/2 of Ageing – 3.7 hrs for diMethyl – 33 hrs for diEthyl
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
Rate of “Ageing”
t ½ 3.7 hrs
t ½ 33 hrs
0 1 0 2 0 3 0 4 0
chlorpyrifos
fenthion
dimethoate
C a s e f a t a l i t y r a t i o ( 9 5 % C I )
Eddleston M et al Differences between organophosphorus insecticides in human self-poisoning: a prospective cohort study. Lancet. 2005
Die
thyl
D
imet
hyl
Eddleston M, Szinicz L, Eyer P, Buckley N. Oximes in acute organophosphorus pesticide poisoning: a systematic review of clinical trials. Qjm. May 2002;95(5):275-283.
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
Reproduced from - Eyer P, Buckley NA “Pralidoxime for organophosphate poisoning”.Comment in the Lancet 2006: 368:2110-2111
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
• Double blind RCT, n= 235
• No significant difference between mortality in treatment arm and control (saline)
• #Biomarkers but not clinical improvement
Eddleston M, Eyer P, Worek F, et al. Pralidoxime in acute organophosphorus insecticide poisoning--a randomised controlled trial. PLoS Med. Jun 30 2009;6(6):e1000104.
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
Improvement in Biomarkers
• D
Non significant worsening of mortality
24.8%
15.8%
Eddleston M, Eyer P, Worek F, et al. Pralidoxime in acute organophosphorus insecticide poisoning--a randomised controlled trial. PLoS Med. Jun 30 2009;6(6):e1000104.
[HR] 1.69 (95% CI 0.88–3.26), p = 0.12
Dimethyl OP Diethyl OP
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
• No consistent clinical trial evidence of benefit
• Cochrane (Buckley et al 2011) – insufficient evidence to suggest if harmful
or beneficial
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
“The only thing I know is that I don’t know anything”
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
Three factors:
– The Evidence
– Clinical Expertise
– The Patient
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
What would I do – symptomatic OP pt?
• Patient responding to atropine - would use this alone and not use pralidoxime.
• If they are not getting better or decompensating with atropine, then treat with pralidoxime
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
• 2 commonly monitored “Biomarkers of Exposure” – Plasmacholinesterase (PChE)
• Large variation in normal population
– Red cell acetylcholinestersase (RBC-AChE) • Correlates better with neuronal AChE and clinical picture • Reactivation by oximes
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
• Potential Uses of RBC-AChE – Confirmation of diagnosis – Guidance of Oxime therapy – Early discharge of low acuity patients
• Biomarkers do not replace clinical judgment
Eddleston M et al. Management of acute organophosphorus pesticide poisoning. Lancet. Feb 16 2008;371(9612):597-607.
Eyer P, Worek F, Thiermann H, Eddleston M. Paradox findings may challenge orthodox reasoning in acute organophosphate poisoning. Chem Biol Interact. Oct 31 2009.
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014) Rajapakse BN, Thiermann H, Eyer P, Worek F, Bowe SJ, et al. (2011) Evaluation of the Test-mate ChE (cholinesterase) field kit in acute organophosphorus poisoning. Ann Emerg Med 58: 559-564 e556.
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
35 yo male – ingested 200mls chlorpyrifos, 2hrs prior to presentation Rx – ABCDE, Atropine 16mg, Pralidoxime1g 6hrly
10%
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
Improvement in Biomarkers
• D
Non significant worsening of mortality
24.8%
15.8%
Eddleston M, Eyer P, Worek F, et al. Pralidoxime in acute organophosphorus insecticide poisoning--a randomised controlled trial. PLoS Med. Jun 30 2009;6(6):e1000104.
[HR] 1.69 (95% CI 0.88–3.26), p = 0.12
Dimethyl OP Diethyl OP
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
• May have a role in predicting delayed respiratory failure – Proximal muscle weakness
– Nicotinic, motor endplate
– 24-96 after initial cholinergic crisis
Jayawardane P, Dawson AH, Weerasinghe V, Karalliedde L, Buckley NA, Senanayake N. The spectrum of intermediate syndrome following acute organophosphate poisoning: a prospective cohort study from Sri Lanka. PLoS Med. 2008 Jul 15;5(7):e147
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
• Prospective cohort study (n=78) – 10 diagnosed with IMS
– Characteristic changes observed in RNS
– Decrement- increment at lower frequencies
Jayawardane P, Dawson AH, Weerasinghe V, Karalliedde L, Buckley NA, Senanayake N. The spectrum of intermediate syndrome following acute organophosphate poisoning: a prospective cohort study from Sri Lanka. PLoS Med. 2008 Jul 15;5(7):e147
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
Jayawardane P, Dawson AH, Weerasinghe V, Karalliedde L, Buckley NA, Senanayake N. The spectrum of intermediate syndrome following acute organophosphate poisoning: a prospective cohort study from Sri Lanka. PLoS Med. 2008 Jul 15;5(7):e147
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
a) atropine 5mg; + further 5mg every 5mins
b) atropine 32mg; doubling dose of atropine every 5 mins
c) Pralidoxime 2g IV
d) Pralidoxime 0.5g IV
e) Intubation is more immediately important than antidote therapy at this point
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
ALS in OP poisoning
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
• 27 texts reviewed – 15 book chapters (Tox and EM)
– 6 monographs (online – eg Upto date, emedicine)
– 6 Review articles
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
0 10 20
BuChE scavengersHaemodialysis
NaHCO3Alpha 2 blockers (clonidine)
Magenesium sulphatelower priority than standard treatment
Titrate to RBC-AChE endpoints?Titrate to provided clincal endpoint?
Alternative dose PAMWHO dose PAM (2g bolus, 0.5-1g/h infusion)
Specifies obidoximeSpecifies pralidoxime (PAM)
Indication clearly providedControversy of efficacy discussed
Linked to resuscitationOxime therapy mentioned
Describe management of toxicityDescribe symptoms of toxicity
No need for oxygen before atropineAtropoine endpoints (>2/4) mentioned
Review frequently (every 5 mins)Doubling dose recommendedIdentified as core treatment
Linked to resuscitationAtropine therapy mentioned
Number of texts covering topic
General recommendations for antidote therapy in OP poisoning
evidence citedNo citation
Atropine
Oximes
Other Treatments
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
For acute severe OP poisoning
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
• Remove contaminated clothes
• Soap and water • Limited evidence for
GI decontamination – No gastric lavage
unless airway is protected
• Aspiration
• Trauma – Oesphageal Injury
– Nasopharyngeal injury 1. Eddleston et al. The hazards of gastric lavage for intentional self-poisoning in a resource poor location. Clin Toxicol (Phila) 2007;45(2):136-43.
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
0 10 20
Recommends specific ionotropes
Inotropic support indication
Arrhythmia management
Rate specfied to target physiologic endpoint
IV fluids
x2 IV cannulae
IV access
Avoid suxamethonium
Indication to intubation provided
Monitor ventilation volume
Monitor neck flexors
Left lateral position, neck extended
Open airway
Oxygen
Respiratory support is management priority
Number of texts covering topic
Airway, Breathing and Circulation ALS recommendations in OP resuscitation
evidence citedNo citation
Airway/ Breathing
Circulation & IV therapy
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014) Eddleston et al. Respiratory failure in acute organophosphorus pesticide self-poisoning. QJM. 2006;99(8):513-22.
Fenthion
<2hours
All OP’s
2-24hours
>24hours
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
• Open label RCT, n=4629 – 2338 ingested pesticides
– 1310 ingested OP or carbamates
• Limited evidence for routine use of multiple dose activated charcoal
Eddleston et al. Lancet. 2008 Feb 16;371(9612):579-87
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
• Consensus Statement – Little evidence of secondary poisoning in
staff caring for OP poisoned patients
– Hydrocarbon vapours • Mild self limiting symptoms
• Well ventilated areas recommended
– Recommend universal precautions to avoid dermal exposure to OP agents
Little et al. Emerg Med Australas. 2004 Oct-Dec;16(5-6):456-8
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
• OPP High case fatality and global mortality
• ALS for OPP: concurrent atropine – High (doubling) doses
• Pralidoxime controversial – On expert advice of if non responsive to
atropine
• Nosocomial poisoning (minimal risk to health workers) – Universal precautions enough (eye/mask/gown/gloves)
• New research is constantly unfolding!
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
amongst friends and colleagues..
Discussion time
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
SACTRC I would like to acknowledge all the staff at the South Asian clinical toxicology research collaboration, and in particular:-
Professor Nick Buckley, Professor Andrew Dawson, Dr Indika Gawarmanna, Dr Michael Eddleston, Dr Darren Roberts & Mr Lalith Senarathna
Sri Lanka Hospital Staff I would like to thank and acknowledge the patients and the hospital staff of Sri Lankan hospitals for their support in my research
Funders & University Welcome Trust (GR071669) & Australia National University
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
• OPP High case fatality and global mortality
• ALS for OPP: concurrent atropine – High (doubling) doses
• Pralidoxime controversial – On expert advice of if non responsive to
atropine
• Nosocomial poisoning (minimal risk to health workers) – Universal precautions enough (eye/mask/gown/gloves)
• New research is constantly unfolding!
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014) Buckley N, Kenyon R, Robertson A – “A review of emergency first-aid treatment of anticholinesterase pesticide poisoning in Australia” – Australian Government – Department of Health and Ageing. Office of Chemical Safety
Figure 1. Trends in the reporting of OP and carbamate exposure made to the NSW and Victorian Poisons Information Centres.
Figure 4.1.a Figure 4.1.b
0
100
200
300
400
500
600
Number of incidents
reported to the NSW Poisons Information
Centre
NSW: OP exposure 596 475 469 408
NSW carbamateexposure
119 113 70 63
2003 2004 2005 2006
0
20
40
60
80
100
120
140
160
Number of incidents
reported to the Victorian Poisons
Information Centre
VIC: OP exposure 152 85 89
VIC: carbamateexposure
61 15 8
2004 2006 2007
The above figures have been generated by the OCS. Data is incorporated from Tables 2a and 2b, which contain the number of calls regarding OP and Carbamate exposure recorded at both PIC’s. The figures demonstrate a downwards trend in reported OP and carbamate exposure from 2003 to 2007. Tables 2a and 2b indicate that the drop in reports of OP and carbamate exposure is not associated with a reduced number in the total number of calls made to either Centre.
Table 2a. OP and Carbamate exposure reports made to the NSW Poisons Information Centre Annual Report year No of Carbamate exposure
reported No of OP exposure
reported Total number of calls
to NSW 2003 119 596 108,727 2004 113 475 108,708 2005 70 469 110,874 2006 63 408 113,982
Data acquired from the NSW PIC annual reports
Table 2b. OP and Carbamate exposure reports made to the Victorian Poisons Information Centre Annual Report year No of Carbamate exposure
reported No of OP exposure
reported Total number of calls
to Victoria 2004 61 152 40,303 2006 15 85 37,668 2007 8 89 40,050
Data acquired from the Victorian PIC annual reports
9
Figure 1. Trends in the reporting of OP and carbamate exposure made to the NSW and Victorian Poisons Information Centres.
Figure 4.1.a Figure 4.1.b
0
100
200
300
400
500
600
Number of incidents
reported to the NSW Poisons Information
Centre
NSW: OP exposure 596 475 469 408
NSW carbamateexposure
119 113 70 63
2003 2004 2005 2006
0
20
40
60
80
100
120
140
160
Number of incidents
reported to the Victorian Poisons
Information Centre
VIC: OP exposure 152 85 89
VIC: carbamateexposure
61 15 8
2004 2006 2007
The above figures have been generated by the OCS. Data is incorporated from Tables 2a and 2b, which contain the number of calls regarding OP and Carbamate exposure recorded at both PIC’s. The figures demonstrate a downwards trend in reported OP and carbamate exposure from 2003 to 2007. Tables 2a and 2b indicate that the drop in reports of OP and carbamate exposure is not associated with a reduced number in the total number of calls made to either Centre.
Table 2a. OP and Carbamate exposure reports made to the NSW Poisons Information Centre Annual Report year No of Carbamate exposure
reported No of OP exposure
reported Total number of calls
to NSW 2003 119 596 108,727 2004 113 475 108,708 2005 70 469 110,874 2006 63 408 113,982
Data acquired from the NSW PIC annual reports
Table 2b. OP and Carbamate exposure reports made to the Victorian Poisons Information Centre Annual Report year No of Carbamate exposure
reported No of OP exposure
reported Total number of calls
to Victoria 2004 61 152 40,303 2006 15 85 37,668 2007 8 89 40,050
Data acquired from the Victorian PIC annual reports
9
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
Evidence delivery systems
Systematic reviews and syntheses
Studies
2. Bedside Evidence based medicine - validated instruments
3. Continuous quality improvement - monitoring adherence to initiatives
4. Decision aids / decision support
Education (lectures/workshops/ courses)
Evidence
Practice
Ch 2 Ch 3 Ch 4 Ch 5 Ch 6
1. Evidence
knowledge, attitudes and practice of treating physicians on AChE
Validation of AChE POC test
AChE
Resuscitation
Study description
workshop based resuscitation education
Systematic review of ALS guidelines
Systematic review of AChE recommendations
Dr Bishan Rajapakse - Management of OP Poisoning (TWH ICU 2014)
• Retrospective study 1990-2003 – Royal Brisbane hospital
• 40 presentations – 8 (20%) severe poisoning; tachycardia,
fasciculations, weaknesss, and metabolic acidosis
– AChE measured in 49%
– 1 death (2.4%, or 12.5% of severe poisonings)
D. M. ROBERTS*, J. F. FRASER†, N. A. BUCKLEY, B. VENKATESH Experiences of Anticholinesterase Pesticide Poisonings in an Australian Tertiary Hospital, Anaesth Intensive Care 2005; 33: 469-476