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    Acute and Late Complications of Organophosphate Poisoning: Original Article

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    Gokull Shautri
    This study examined 300 cases of organophosphate poisoning admitted to the hospital. The most common acute complications within 4 weeks included seizures in 16.66% of patients, bradycardia in 10%, and hyperglycemia in 5%. The mortality rate from acute complications was 16.66%. Late complications after 4 weeks occurred less frequently and included monoplegia in 2.66% and paraplegia in 0.66% of patients. The study found that acute complications of organophosphate poisoning were more frequent and associated with higher mortality compared to late complications, which were less common and less life-threatening.

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    Acute and Late Complications of Organophosphate Poisoning: Original Article

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    Gokull Shautri
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    This study examined 300 cases of organophosphate poisoning admitted to the hospital. The most common acute complications within 4 weeks included seizures in 16.66% of patients, bradycardia in 10%, and hyperglycemia in 5%. The mortality rate from acute complications was 16.66%. Late complications after 4 weeks occurred less frequently and included monoplegia in 2.66% and paraplegia in 0.66% of patients. The study found that acute complications of organophosphate poisoning were more frequent and associated with higher mortality compared to late complications, which were less common and less life-threatening.

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    This study examined 300 cases of organophosphate poisoning admitted to the hospital. The most common acute complications within 4 weeks included seizures in 16.66% of patients, bradycardia in 10%, and hyperglycemia in 5%. The mortality rate from acute complications was 16.66%. Late complications after 4 weeks occurred less frequently and included monoplegia in 2.66% and paraplegia in 0.66% of patients. The study found that acute complications of organophosphate poisoning were more frequent and associated with higher mortality compared to late complications, which were less common and less life-threatening.

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    11 views3 pages

    Acute and Late Complications of Organophosphate Poisoning: Original Article

    Uploaded by

    Gokull Shautri
    This study examined 300 cases of organophosphate poisoning admitted to the hospital. The most common acute complications within 4 weeks included seizures in 16.66% of patients, bradycardia in 10%, and hyperglycemia in 5%. The mortality rate from acute complications was 16.66%. Late complications after 4 weeks occurred less frequently and included monoplegia in 2.66% and paraplegia in 0.66% of patients. The study found that acute complications of organophosphate poisoning were more frequent and associated with higher mortality compared to late complications, which were less common and less life-threatening.

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    of 3

    ORIGINAL ARTICLE

    Acute and Late Complications of Organophosphate Poisoning


    Muhammad Saleem Faiz1, Shaheen Mughal2 and Abdul Qayoom Memon3

    ABSTRACT
    Objective: To describe the acute and late complications of organophosphate (OP) poisoning.
    Study Design: Case series.
    Place and Duration of Study: Medicine Department at Peoples Medical College Hospital, Nawabshah, from June 2008
    to December 2009.
    Methodology: A total of 300 patients with organophosphate poisoning admitted to the Medical ICU were included.
    Baseline investigations included blood complete picture, urea, creatinine, arterial blood gas values, and serum
    cholinesterase levels. Data was retrieved from the files on a structured proforma. Studied variables included gender, mode
    of exposure, acute (occuring within 4 weeks) and delayed (occuring after 4 weeks onwards) complications
    Results: There were 50 (16.66%) males and 250 (83.33%) females with ratio of 1:5. Two hundred and forty eight (82.6%)
    had ingested while 18 (6%) had inhaled the poison. Acute complications included fits in 50 (16.66) bradycardia in 30 (10%)
    and hyperglycemia in 15 (5%) patients. Delayed complications (after 4 weeks and later) included monoplegia and mild
    sensory loss of lower limbs in 4 (2.66) and paraplegia and weakness of upper limbs in 2 (0.66%) patients each. A total of
    50 patients died due to different complications in acute period making a mortality rate of 16.66%.
    Conclusion: Frequency of acute organophosphate (OP) poisoning complications is much higher and related with high
    mortality and morbidity and where as late complications are less frequent and less life threatening.
    Key words:

    Organophosphate (OP) poisoning. Acute complications. Late complications. Seizures. Bradycardia. Monoplegia.

    INTRODUCTION
    Organophosphate (OP) is the general term for esters of
    phosphoric acid.1,2 In 1932, German chemist Willy Lange
    and his graduate student, Gerde von Krueger, first
    described the cholinergic nervous system effects of
    organophosphates, noting a choking sensation and a
    diminution of vision after exposure.3 This discovery later
    inspired the German chemist Gerhard Schrader in 1930s
    to experiment with these compounds as insecticides.4
    OP is the commonest suicidal agent in Pakistan. The
    American Association of Poison Control Centre reported
    102,705 cases of the incidence of organophosphate
    annually;6 the highest incidence is seen in India.5,6 The
    incidence in Sri Lanka is 10,000 20,000 hospital
    admissions annually.7 According to WHO estimation
    around 10,000 hospital deaths annually occur from OP
    poisoning world-wide.8 Signs and symptoms are divided
    into muscarinic effects, nicotinic effects and central
    nervous system effects.9 Morbidity and mortality are due
    to insufficient respiratory management, delayed
    intubation, cardiac complications, aspiration pneumonia,
    weakness and neuropathy.10
    Department of Medicine, Medical Unit I1, Department of
    Neurology2, Department of Medicine, Medical Unit II3,
    Peoples Medical College, Nawabshah.
    Correspondence: Dr. Muhammad Saleem Faiz, Associate
    Professor, Department of Medicine, Medical Unit-I, Peoples
    Medical College, Nawabshah.
    E-mail: [email protected]
    Received April 12, 2010; accepted March 29, 2011.

    288

    Despite its common occurrence, there is not much


    awareness. The current study was aimed to determine
    acute and late complications of organophosphate
    poisoning.

    METHODOLOGY
    This case series was conducted at the ICU of Medicine
    Department at Peoples Medical College Hospital,
    Nawabshah, from June 2008 to December 2009. All
    patients of OP poisoning were included in this study.
    Detailed history was taken from all the patients relatives
    about the circumstances of poisoning. Detailed clinical
    examination of the patients was done. Diagnosis of OP
    poisoning was based on clinical features that included
    bronchorrhoea, bronchospasm, miosis, salivation,
    defecation, urination and hypotension, history of
    exposure to a known OP compound and low serum
    pseudocholiesterase activity (level < 4500 IU). Patients
    were treated according to the standard protocol of
    organophosphates poisoning with respiratory support,
    atropine and prollidoxime. All patients were dealt upto
    recovery or death from poisoning and follow-up of all
    recovered patients was done to assess any delayed
    complication. The acute complications were defined as
    those which occur after 4 weeks of onset of poisoning
    and late complications were those which occur after
    4 weeks and later.
    Studied variables included gender, mode of exposure,
    acute (occurring within 4 weeks) and delayed (occurring
    after 4 weeks onwards) complications.

    Journal of the College of Physicians and Surgeons Pakistan 2011, Vol. 21 (5): 288-290

    Complications of organophosphate poisoning

    Results were compiled for descriptive statistics through


    SPSS software version 16.

    RESULTS

    were received unconscious. Four (1.33%) patients


    developed monoplegia with mild sensory loss of lower
    limb and 2 (0.66%) patients each developed paraplegia
    and weakness of both upper limbs (Table I).

    Three hundred cases of OP poisoning were admitted


    during the study period. Two hundred and forty eight
    (82.66%) patients ingested the compound, 23 (7.6%)
    patients had dermal exposure, 18 (6%) patients had
    inhaled while 11 (3.6%) patients had other types of
    exposure. Fifty (16.66%) were male and 250 (83.33%)
    female with ratio of 1:5. There was wide variation of age
    ranging from a minimum of 14-50 years with mean age
    of 32 + 5.2 years.

    Organophosphate (OP) compounds are widely used as


    pesticides in agricultural parts of the world. Insufficient
    control on the importation, production, storage and
    unsafe use of OP pesticides are the common reasons of
    poisoning.11

    The most common complications were respiratory


    distress and mental confusion in almost all cases. One
    hundred and fifty patients out of 300 were stable after
    gastric lavage. They were kept under observation for
    the next 3 days and finally discharged. The remaining
    150 patients were in coma and developed acute
    complications. Fifty (16.66%) patients developed episodic
    convulsions. Twenty (6.66%) patients developed
    profuse diarrhea. Severe bradycardia was seen in 30
    (10%) patients. Hypotension was seen in 30 (10%)
    patients, 15 (5%) patients developed hyperglycemia
    and 5 (1.66%) patients developed acute renal failure
    with anuria. Fifty (16.66%) patients died in different
    complications of organophosphate poisoning (Table I).

    The male to female ratio in this study was 1:5. However,


    the male to female ratio given by Ather,12 is 1:1 and Tall
    et al.,10 is 1:1.8 which is quite different from present
    study. The age ranged from 14 to 50 years with mean
    age was 32 + 5.2 years. The prime age for presentation
    in this study was between 25-40 years which is
    comparable to other study where age ranged between
    14-60 years.11 However, Hayden et al. showed age
    range from 13 to 47 years with a mean age of 23
    years.13

    Delayed complications i.e. those which occured after


    4 weeks and later were seen in 8 (2.66%) patients who
    Table I: A summary of gender, mode of exposure, complications
    and mortality in organ.
    Variable

    Number of
    patients

    Percentage

    Gender
    Male
    Female

    50

    16.66%

    250

    83.33%

    Mode of exposure
    Ingestion

    248

    82.66%

    Dermal exposure

    23

    7.6%

    Inhalation

    18

    6%

    others

    11

    3.6%

    Fits

    50

    16.66%

    Bradycardia

    30

    10%

    Diarrhea

    20

    Hypotension

    30

    10%

    Hyperglycemia

    15

    5%

    Acute complications (within 4 weeks)

    Renal failure

    6.66%

    1.66%

    Monoplegia with mild sensory loss of lower limb

    2.66%

    Paraplegia

    0.66%

    Weakness limbs

    0.66%

    10

    3.33%

    Delayed complications (after 4 weeks and later)

    Mortality
    ARDS
    Arrhythmias

    1.66%

    Deep coma

    32

    10.66%

    Renal failure

    1%

    DISCUSSION

    Suicidal and non-suicidal organophosphate poisoning is


    a major problem in rural areas of Pakistan and the
    incidence are increasing rapidly due to increasing
    sentimental situations.5

    In this study, majority of complications were found to be


    more frequent in acute stage i.e. within 4 weeks of
    poisoning as compared to late complications i.e. after
    4 weeks and onwards. In this study, respiratory distress
    and mental confusion were observed in almost all cases
    and similar reported by Tall et al.10
    In the present study there were 16.66% cases of deep
    coma which developed 4-7 days after hospital
    admission with pulmonary complication. A study
    conducted by Sequeira showed the frequency of deep
    coma to be 21%.14
    Acute complications seen in this study were episodic
    convulsions developed in 50 (16.66%) patients, 20
    (6.66%) patients developed profuse diarrhea, severe
    bradycardia was seen in 30 (10%) patients, hypotension
    was seen in 30 (10%) patients, 15 (5%) patients
    developed hyperglycemia and 5 (1.66%) patients
    developed acute renal failure. Acute complications as
    given by Malik were bradycardia in 29 (93.5%), change
    in mental status in 10 (32.2%), low oxygen saturations
    (less than 90%) in 21 (67.8%) and subsequent
    convulsions in 3 (9.6%).17
    Delayed complications were seen in those patients
    who were received late and unconscious. All were
    neurological and predominantly motor deficits. Jamal
    et al. found neuropathy and sensory motor distal axonopathy especially distal paresis in lower limb in 1.5%
    patients ingesting large doses of organophosphates.15
    In the present study, it was observed that the 16.66%

    Journal of the College of Physicians and Surgeons Pakistan 2011, Vol. 21 (5): 288-290

    289

    Muhammad Saleem Faiz, Shaheen Mughal and Abdul Qayoom Memon

    mortality, in different acute complications of organophosphate poisoning was due to central respiratory
    depression, bronchospasm, excessive bronchosecretion,
    severe bradycardia, and hypotension. Later it was a
    result of acute renal failure and complications of
    aspiration and long-term ventilation. However,
    frequency of mortality due to OP given by Yamashita
    varied between 4% and 30%,16 5.5% in a study by
    Malik17 and 8% in the study by Aziza et al.18

    5.

    CONCLUSION

    2.

    Kasper DL, Braunwald E, Hauser S, Longo D, Jameson JL,


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    16th ed. New York: McGraw Hill; 2005.

    3.
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    8.

    Ghosh PG, Sawant NA, Patil SN, Aglav BA. Microbial


    biodegradation of organophosphate pesticides. Int J Biotechnol
    Biochem 2010; 6:871-6.

    9.

    Karczmar AG. Story of muscarinic receptors, alkaloids with


    muscarinic significance and of muscarinic functions and
    behaviors. Annual Rev Biomed Sci 2009; 11:T1-50.

    13. Hayden K, Norton M, Darcey D, Ostbye T, Zandi P, Breitner J,


    et al. Occupational exposure to pesticides increases the risk of
    incident AD: the Cache County study. Neurology 2010; 74:1524-30.
    14. Sequeira JF, Andre P, Miranda, Sa J. Intoxication by organophosphates: prognostic evaluation on 143 patients. Med Intern
    1994; 1:4-10.
    15. Jamal G. A neurological syndrome of organophosphates.
    Toxicol Rev 1997; 16:133-70.
    16. Yamashita M, Yamashita M, Tanaka J, Ando Y. Human mortality
    in organophosphate poisoning. Veter Hum Toxicol 1997; 39:84-5.
    17. Malik GM, Mubarik M, Romshoo GJ. Organophosphorus
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    Taylor P. Anticholinesterase agents. In: Goodman LS, Gilman A,


    editors. The pharmacological basis of therapeutics. 6th ed. New
    York: MacMillan Publishing Co; 1980. p. 428.

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    Khurana D, Prabhakar S. Organophosphorus intoxication.


    Arch Neurol 2000; 57:600-2.

    12. Ather NA, Ara J, Khan EA, Sattar RA, Durrani R. Acute
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    Reddy KS. The essentials of forensic medicine and toxicology.


    25th ed. India: Medical Book Co.; 2006.

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    11. Suleman MI, Jibran R, Rai M. The analysis of organophosphate


    poisoning case treated at Bhawal Victoria Hospital, Bahawalpur
    in 2000-2003. Pak J Med Sci 2006; 22:244-9.

    REFERENCES
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    10. Tall A, Ly AB, Nabeth P, Sall AA, Sarr FD, Faye J, et al.
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    Frequency of acute organophosphate (OP) poisoning


    complications is much greater and related with high
    mortality and morbidity and where as late complications
    are rare and less life threating. These patients are to be
    shifted to a well-equipped ICU as soon as possible.
    Good supportive care and observation can help reduce
    the acute complications like episodic convulsions,
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    Journal of the College of Physicians and Surgeons Pakistan 2011, Vol. 21 (5): 288-290

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