Title: Cardiac Effects associated with Pesticide Exposure
1Cardiac Effectsassociated withPesticide
Exposure
- Ana Maria Osorio, MD, MPH
- US Public Health Service, on detail to
- US Environmental Protection Agency
- Washington DC
- Tel 703.305.7666
- E-mail Osorio.AnaMaria_at_epa.gov
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3InsecticidesOrganophosphates
R - O
l R - O P S (or O)
l R
alkyl group O X
X leaving group Common mechanism of
cholinesterase inhibition
4Toxicology
- Absorbed via inhalation, ingestion and dermal
penetration - Phosphorylation of acetylcholinesterase enzyme
(AChE) ? ? Ach at nerve endings - Recovery when generation of new AChE
- Effects
- Muscarinic (involuntary smooth muscle and
exocrine gland cells) - Nicotinic (voluntary skeletal muscle)
- CNS (sensory behavioral abnormalities,
incoordination, decreased motor function and
respiratory depression)
5Toxicology - continued
- Metabolites alkyl phosphates and leaving
- groups
- Reactivation dephosphorylate AChE with
pralidoxime (1-2 days post exposure) - Aging later, lose alkyl group and P bond
stronger
6Signs and Symptoms (Sx)
7Dx If poisoning probable, dont wait for lab
confirmation!!!
- Blood samples
- plasma pseudoAChE (days to weeks)
- RBC AChE (1 3 months)
- Low plasma AChE hereditary, liver disease,
malnutrition, EtOH, certain drugs, BCPs and
pregnancy - Low RBC AChE hemolytic anemia
- Urine metabolites - alkyl phosphates, phenols (up
to 48 hrs post exposure)
8Rx
- Atropine sulfate
- Anti-muscarinic agent
- Atropinization flushing, dry mouth, mydriasis,
and tachycardia - Pralidoxime (2-PAM)
- Reactivates Ach, slows aging
- Within 48 hrs, anti-muscarinic nicotinic
- Hypertensive crisis, tachycardia, arrhythmias
- Cardiopulmonary monitoring
9OP Cardiac Manifestations46 patient case
series, Jordan
1031 cases (67) with cardiac effects 2 deaths
due to vent fib
Conclude that cardiac Sx early in severe
intoxication that aggressive Rx in ICU can
decrease mortality rate.
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12Additional literature re OP/Carb intoxications
- Case series of 168 persons ? 5 with transient MI
presentation - Necropsy series ? 2 malathion intoxication cases
showed myocardial damage - Case report of carbamate intoxication associated
with diffuse myocarditis - Extended case series of Jordan hospital ? 84
adults with similar results to earlier survey
8 with elevated cardiac enzymes
13Organochlorines
- Atropine and adrenergic amines contraindicated
because these agents may potentiate myocardial
irritability
14DipyridilsParaquate Diquat
- Primary pulmonary effects (edema fibrosis)
- Death from multi-organ failure including
myocardial necrosis has been reported
15Case ReportParaquat Suicide
- 59 yo man in Belgium ingested 50-60 ml of
Gramasone. - Production of free radicals ? tissue damage by
peroxidation of lipid in cell membranes - Death usually from caustic injury to GI tract
/or circulatory failure /or respiratory failure - Aggressive treatment of this patient ?
aspiration, gastric lavage, hemodialysis
prolonged anti-oxidant therapy - Outcome survived with minimal lung damage
16Chlorophenoxy Herbicides
- Reports of T-wave flattening and inversion
following large ingestion episodes
17Pentachlorophenol
- Tachycardia and other arrhythmias reported
18Aluminum phosphide
- Slow release of phosphine ? strong mucous
membrane and respiratory irritant - Report of cardiotoxicity
19Glyphosate-surfactant
- In Taiwan, 26 yo man presented with nausea and
vomiting 4 hours status post glyphosate suicide
ingestion. - Post admission ? cardiogenic shock with increased
ventricular rhythm on EKG. Echo showed diffuse
hypokinesis of left ventricle. - Over the next 16 hours with aggressive treatment,
normal rhythm returned. - Was clinical event due to circulatory collapse
or transient suppression of cardiac conduction
and contractibility or both?