Diagnosis & Management of Insecticide Poisoning

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Diagnosis Management of Insecticide Poisoning

• Winai Wananukul, M.D.
• Ramathibodi Poison Center Department of
  Medicine
• Ramathibodi Hospital

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Epidemiology of Toxic Exposure(May 2000 - April
2001)
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Classification of Pesticide Exposure
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Classification of Insecticide Exposure
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Classification of Herbicide Exposure
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Classification of Rodenticide Exposure
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Ratio of Exposure with and without clinical
manifestation of poisoning at the time consult
to the Poison Center
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Medical Outcome of the Risk Group
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Medical Outcome of the Poisoned Group
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Medical Outcome of Selected Toxic Exposure
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Survival Death Rate of Selected Pesticide
Exposure (from high to low mortality rate)
4.2
2.5
1.6
22.9
20.0
42.3
61.3
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Organophosphate andCarbamate Poisoning
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What is Acute Organophosphate Carbamate
Poisoning ?

• State of Acetylcholine Excess
• It is a combination of
• Muscarinic receptor
• Nicotinic receptor
• CNS (unspecified)

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Organophosphate 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)

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Clinical course after acute poisoning

• Cholinergic Excess
• Others (than cholinergic excess)
• Intermediate syndrome
• Delayed neuropathy
• Arrthymias

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Diagnosis of Organophosphate or Carbamate
Poisoning

• Clinical Diagnosis
• Laboratory
• Red cell cholinesterase
• Plasma (Pseudo, Butyryl (Bu)) cholinesterase

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Management of OP CB Poisoning

• Supportive Care
• Vital signs
• Respiration
• secretion block and airway obstruction
• respiratory motor weakness
• Seizure
• Specific Treatment

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Increase Elimination
Decontamination
Antidotes
Airway
Skin
Tissues Organs
Circulation
Parenteral
GI.
Ion Trapping
RAC.
Hemodialysis, Hemoperfusion
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ANTIDOTES
TOXIC
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Atropine
Muscarinic Effects Heart rate Sweating
Secretion Pupils
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2 PAM
AChE Inhibitions Nicotinic Muscarinic
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2 PAM
Nicotinic Effects Motor Power (Muscarinic
Effects)
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Intermediate Syndrome

• Develop only after some acute organophosphate
  poisoning
• Mechanism unknown
• not directly relate to acetylcholine excess
• Clinical Manifestation
• Proximal muscle weakness
• Bulbar palsy

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Intermediate Syndrome

• Spontaneous recover in 2 -3 weeks after develop
• Treatment
• Supportive care, especially respiratory care
• Note this condition must be differentiated from
  Aged Acetylcholinesterase

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Chronic Organophosphate Poisoning

• Clinical Features
• Delay polyneuropathy
• Neuropsychiatric disorder
• Diagnosis
• Clinical diagnosis, by suspicious exclusion
• Investigation
• ?? Plasmacholinesterase
• Treatment
• Not established

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1/2 ??????????????????? ???????? Egodan ??????
½ ??? ?????????????????????????????????
??????????????. ??? ER ??????????? HR 140/min,
BP 160/110, RR 22/min ????????? generalized
tonic and clonic seizure ???????? ??? ET tube
intubation ??? iv fluid ??????? diazepam

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??????? 31 ?? ?????????? ?????????????

• ???????????????????? unconscious
• Pupil 4 mm, react to light bilateral
• Lung clear
• Abdomen soft, normal bowel sound
• Neurological signs no stiff neck,
• motor power grossly intact,
• absent of Babinsks sign.

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Organochlorine Poisoning
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Classification of Organochlorine

• Dichlorodiphenylethanes
• DDT Methoxychlor
• Hexachlorocyclohexane
• Lindane
• Cyclodienes
• Aldrin Chlordane Dieldrin
• Endrin Endosulphan Hepatochlor
• Chlordecone (kepone)
• Mirex

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Acute Organochlorine Poisoning

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

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Acute Organochlorine Poisoning

• The typical presentation Status epilepticus
• Followed by
• Respiratory failure
• Cardiac arrhythmias
• Rhabdomyolysis acute renal failure

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Acute Organochlorine Poisoning

• Treatment
• Control seizure as the same way as Status
  epilepticus
• Benzodiazepines
• Phenobarbital
• Phenytoin
• Prevent complications

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Diagnosis of Organocholine Poisoning

• Clinical Diagnosis
• History of exposure
• Clinical features of repeated seizure
• Laboratory Test
• Plasma level
• Subcutaneous fat level

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Subacute Organochlorine Poisoning

• Hyperexcitability stage
• Tachycardia
• Tremor
• Hyperreflexia
• Treatment
• Symptomatic Px Anxiolytic
• Enhance Elimination Cholestyramine

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Chronic 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.

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Pyrethroid Poisoning
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Classification of Pyrethrins Pyrethroids

• Pyrethrins
• Cinerin I Cinerin II Justmolin I Jusmolin II
• Pyrethrin I Pyrethrin II Pyrethrum extract
• Type I Pyrethroids
• Allethrin Bioallethrin Cismethrin Kadethrin
• Permethrin Phenothrin Resmethrin Tetramethrin
• Type II Pyrethroids
• Cyhalothrin Cypermethrin Cyphenothrin Deltamethrin
  
• Fenpropenthrin Fenvalerate Fluvalinate

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Pyrethroids Exposure

• Direct Toxic
• Hypersensitivity
• Allergic rhinitis
• Bronchitis
• Bronchial asthma
• Anaphylactic shock
• Local Irritation
• Contact dermatitis
• Corneal abrasion

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Pyrethroid 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

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Pyrethroid 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.

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Diagnosis of Pyrethroid Poisoning

• Clinical Diagnosis
• Laboratory Test
• None

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Management of Pyrethroid Poisoning

• Hypersensitivity
• Adrenaline
• Corticosteroids
• Bronchodilators
• Antihistamine
• Direct Toxic
• Supportive treatment