diagnosis & management of insecticide poisoning winai wananukul, m.d. ramathibodi poison center...

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%


Classification of Pesticide ExposureClassification of Pesticide Exposure

Insecticides50%

Herbicides22%

Rodenticides17%

Miticide6%

Synergist1%

Mollusticide1% Fungicide

1%Miscellaneous

1%

Plant growth regulator

1%


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%


Classification of Herbicide ExposureClassification of Herbicide Exposure

Glycine52.3%

Paraquat20.5%

Chlorophenoxy6.0%

Chloroacetanilide6.0%

Unknown2.6%

Others12.6%


Classification of Rodenticide ExposureClassification of Rodenticide Exposure

Zinc Phospide41.0%

Superwarfarin3.4%

Unknown6.8%

Warfarin48.7%


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%


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%


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%


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


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


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)


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)


Clinical course after acute poisoningClinical course after acute poisoning

Cholinergic Excess Others (than cholinergic excess)

– Intermediate syndrome

– Delayed neuropathy

– Arrthymias


Diagnosis of Organophosphate or Carbamate PoDiagnosis of Organophosphate or Carbamate Poisoning:isoning:

Clinical Diagnosis

Laboratory

– Red cell cholinesterase

– Plasma (Pseudo, Butyryl (Bu)) cholinesterase


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


Airway

Skin

Parenteral

GI. Cir

cula

tion Tissues

&Organs

Ion Trapping RAC.

DecontaminationDecontamination Increase Increase EliminationElimination

AntidotesAntidotes

Hemodialysis, Hemoperfusion


TOXICTOXIC

ANTIDOTESANTIDOTES


Muscarinic EffectsMuscarinic EffectsHeart rateHeart rateSweating Sweating SecretionSecretionPupilsPupils

AtropineAtropine


AChE InhibitionsAChE InhibitionsNicotinicNicotinicMuscarinicMuscarinic

2 PAM2 PAM


Nicotinic EffectsNicotinic EffectsMotor Power Motor Power

++ (Muscarinic Effects) (Muscarinic Effects)

2 PAM2 PAM


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


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”


Chronic Organophosphate PoisoningChronic Organophosphate Poisoning

Clinical Features:– Delay polyneuropathy

– Neuropsychiatric disorder

Diagnosis– Clinical diagnosis, by suspicious & exclusion

Investigation– ?? Plasmacholinesterase

Treatment– Not established


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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


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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


Classification of OrganochlorineClassification of Organochlorine

DichlorodiphenylethanesDichlorodiphenylethanesDDT Methoxychlor

HexachlorocyclohexaneHexachlorocyclohexaneLindane

CyclodienesCyclodienesAldrin Chlordane Dieldrin

Endrin Endosulphan Hepatochlor

Chlordecone (kepone)Chlordecone (kepone)Mirex


Acute Organochlorine PoisoningAcute Organochlorine Poisoning

Prodomal symptoms: – tremor, ataxia, quick involuntary jerk (myoclonus) – dizziness, confusion – Paresthesia of month, – nausea, vomiting



The typical presentation: Status epilepticus

Followed by:

– Respiratory failure

– Cardiac arrhythmias

– Rhabdomyolysis & acute renal failure



Treatment:

– Control seizure as the same way as “Status epilepticus”

• Benzodiazepines

• Phenobarbital

• Phenytoin

– Prevent complications


Diagnosis of Organocholine PoisoningDiagnosis of Organocholine Poisoning

Clinical Diagnosis– History of exposure

– Clinical features of repeated seizure

Laboratory Test– Plasma level

– Subcutaneous fat level


Subacute Organochlorine PoisoningSubacute Organochlorine Poisoning

Hyperexcitability stage:

– Tachycardia

– Tremor

– Hyperreflexia Treatment

– Symptomatic Px: Anxiolytic

– Enhance Elimination : Cholestyramine


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


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


Pyrethroids ExposurePyrethroids Exposure

Direct Toxic Hypersensitivity

– Allergic rhinitis

– Bronchitis

– Bronchial asthma

– Anaphylactic shock

Local Irritation– Contact dermatitis

– Corneal abrasion


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


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.


Diagnosis of Pyrethroid PoisoningDiagnosis of Pyrethroid Poisoning

Clinical Diagnosis Laboratory Test

– None


Management of Pyrethroid PoisoningManagement of Pyrethroid Poisoning

Hypersensitivity: – Adrenaline

– Corticosteroids

– Bronchodilators

– Antihistamine

Direct Toxic:– Supportive treatment

diagnosis & management of insecticide poisoning winai wananukul, m.d. ramathibodi poison center...

Documents

poison center slide

pam slide

hemoperfusion slide

carbamate poisoning

hypoxic effects slide

specific treatment slide

risk group slide

poisoned group slide