Diagnosis & Management

of
Insecticide Poisoning
Winai Wananukul, M.D.
Ramathibodi Poison Center & Department of Medicine
Ramathibodi Hospital

Epidemiology of Toxic Exposure

(May 2000 - April 2001)

Household
Products
21.7%

Medical
Products
22.4%

Occupational
Products
6.3%
Others
8.0%

Pesticide
41.6%

Winai Wananukul,
Ramathibodi Poison

Classification of Pesticide Exposure

Synergist
1%

Rodenticides
17%

Plant growth
regulator
Mollusticide
1%
Fungicide
1%
Miticide
1%
6%
Miscellaneous
1%

Herbicides
22%

Insecticides

50%

Winai Wananukul,
Ramathibodi Poison

Classification of Insecticide Exposure

Repellant
2.0%
Organochlorine
7.5%

Unknown
6.9%

Fumigant
1.1%

Carbamate
24.4%

Combined
18.1%

Pyrethroid
17.8%

Others
2.0%

Organophosphate
20.1%

Winai Wananukul,
Ramathibodi Poison

Classification of Herbicide Exposure

Chloroacetanilide Others
12.6%
6.0%
Chlorophenoxy

Unknown
2.6%

6.0%

Paraquat
20.5%

Glycine
52.3%

Winai Wananukul,
Ramathibodi Poison

Classification of Rodenticide Exposure

Superwarfarin Unknown
6.8%
3.4%
Zinc Phospide
41.0%

Warfarin
48.7%

Winai Wananukul,
Ramathibodi Poison

Ratio of Exposure with and without clinical manifestation of

poisoning at the time consult to the Poison Center

Without Clinical
Manifestation of
Poisoning
46.7%

Clinical
Poisoning
53.3%

Winai Wananukul,
Ramathibodi Poison

Medical Outcome of the Risk Group

Clinical
Poisoning
53.3%
No S/S
46.7%

Death Unable to FU
10.8%
8.7%
Major Effect
8.0%

Moderate
Effect
6.1%

Minor Effects
32.2%

Winai Wananukul,
Ramathibodi Poison

No Effects
34.3%

Medical Outcome of the Poisoned Group

Clinical
Poisoning
53.3%
No S/S
46.7%

Death
19.4%

Unable to FU
6.7%
Minor Effects
48.6%

Major Effect
Moderate
14.4%
Effect
10.8%

Winai Wananukul,
Ramathibodi Poison

Medical Outcome of Selected Toxic Exposure

250
200
150
100
50
0

Pesticides
Death

Medical
Products
Major

Household
Products

Moderate

Minor

Winai Wananukul,
Ramathibodi Poison

Occupational
Products
No Effect

Survival & Death Rate of Selected Pesticide Exposure

(from high to low mortality rate)
4.2%

2.5%

1.6%

100%
80%

22.9% 20.0%
61.3% 42.3%

60%
40%
20%
0%

PQ

OC

OP

CB

ZnP

Gly

Survive

Winai Wananukul,
Ramathibodi Poison

Death

Pyr

Organophosphate
and
Carbamate Poisoning

What is Acute Organophosphate & Carbamate

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

Winai Wananukul,
Ramathibodi Poison

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)

Winai Wananukul,
Ramathibodi Poison

Clinical course after acute poisoning

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

Winai Wananukul,
Ramathibodi Poison

Diagnosis of Organophosphate or Carbamate

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

Winai Wananukul,
Ramathibodi Poison

Management of OP & CB Poisoning

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

Winai Wananukul,
Ramathibodi Poison

Decontamination

Increase
Elimination

Antidotes

Airway

Circulation

Skin
Parenteral

GI.
Ion Trapping

Tissues
&
Organs

RAC.

Hemodialysis, Hemoperfusion
Winai Wananukul, Ramathibodi Poison Center

ANTIDOTES
TOXIC

Winai Wananukul, Ramathibodi Poison Center

Atropine
Muscarinic Effects
Heart rate
Sweating
Secretion
Pupils

Winai Wananukul, Ramathibodi Poison Center

2 PAM
AChE Inhibitions
Nicotinic
Muscarinic

Winai Wananukul, Ramathibodi Poison Center

2 PAM
Nicotinic Effects

Motor Power

+ (Muscarinic Effects)

Winai Wananukul, Ramathibodi Poison Center

Intermediate Syndrome
Develop only after some acute organophosphate

poisoning
Mechanism: unknown
not directly relate to acetylcholine excess

Clinical Manifestation:
Proximal muscle weakness
Bulbar palsy

Winai Wananukul,
Ramathibodi Poison

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

Winai Wananukul,
Ramathibodi Poison

Chronic Organophosphate Poisoning

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

Winai Wananukul,
Ramathibodi Poison

 31
1/2
Egodan

. ER
: HR 140/min, BP 160/110,
RR 22/min

generalized tonic and clonic

seizure
ET tube
intubation iv Winai
fluid Wananukul,
diazepam
Ramathibodi Poison

 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.

Winai Wananukul,
Ramathibodi Poison

Organochlorine Poisoning

Classification of Organochlorine
Dichlorodiphenylethanes
DDT

Methoxychlor

Hexachlorocyclohexane
Lindane

Cyclodienes
Aldrin
Endrin

Chlordane
Dieldrin
Endosulphan Hepatochlor

Chlordecone (kepone)
Mirex

Winai Wananukul,
Ramathibodi Poison

Acute Organochlorine Poisoning

Prodomal symptoms:

tremor, ataxia, quick involuntary jerk (myoclonus)

dizziness, confusion
Paresthesia of month,
nausea, vomiting

Winai Wananukul,
Ramathibodi Poison

Acute Organochlorine Poisoning

The typical presentation: Status epilepticus
Followed by:

Respiratory failure
Cardiac arrhythmias
Rhabdomyolysis & acute renal failure

Winai Wananukul,
Ramathibodi Poison

Acute Organochlorine Poisoning

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

Winai Wananukul,
Ramathibodi Poison

Diagnosis of Organocholine Poisoning

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

Winai Wananukul,
Ramathibodi Poison

Subacute Organochlorine Poisoning

Hyperexcitability stage:

Tachycardia
Tremor
Hyperreflexia
Treatment
Symptomatic Px: Anxiolytic
Enhance Elimination : Cholestyramine

Winai Wananukul,
Ramathibodi Poison

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.

Winai Wananukul,
Ramathibodi Poison

Pyrethroid Poisoning

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
Deltamethrin

Type II Pyrethroids
Cyhalothrin

Cypermethrin

Cyphenothrin

Fenpropenthrin

Fenvalerate

Fluvalinate

Winai Wananukul,
Ramathibodi Poison

Pyrethroids Exposure
Direct Toxic
Hypersensitivity
Allergic rhinitis
Bronchitis
Bronchial asthma
Anaphylactic shock
Local Irritation
Contact dermatitis
Corneal abrasion
Winai Wananukul,
Ramathibodi Poison

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

Winai Wananukul,
Ramathibodi Poison

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.

Winai Wananukul,
Ramathibodi Poison

Diagnosis of Pyrethroid Poisoning

Clinical Diagnosis
Laboratory Test
None

Winai Wananukul,
Ramathibodi Poison

Management of Pyrethroid Poisoning

Hypersensitivity:
Adrenaline
Corticosteroids
Bronchodilators
Antihistamine
Direct Toxic:
Supportive treatment

Winai Wananukul,
Ramathibodi Poison