Saudi Journal of Medicine and Medical Sciences

ORIGINAL ARTICLE
Year
: 2015  |  Volume : 3  |  Issue : 1  |  Page : 22--25

Organophosphate poisoning: A 10-year experience at a tertiary care hospital in the kingdom of saudi arabia


Mohammed A Al Jumaan, Mohammad S Al Shahrani, Mohey H Al Wahhas, Amal H Al Sulaibeakh 
 Department of Emergency Medicine, King Fahd Hospital of the University, University of Dammam, Dammam, Saudi Arabia

Correspondence Address:
Mohammed A Al Jumaan
P.O. Box 40331, Al-Khobar 31952
Saudi Arabia

Abstract

Introduction: Toxicity resulting from pesticides is an important global public health hazard concern, particularly in developing countries. The objectives of this retrospective study were to determine the presenting clinical features, complications and length of stay of patients poisoned with organophosphates (OP). Materials and Methods : The medical records of all OP poisoning patients admitted to King Fahd Hospital of the University in the period between 2000 and 2010 were reviewed. Results: There was a total of 50 patients: Thirty-four males (68%) and 16 females (32%), 39(78%) of whom were >18 years of age. The most common route of exposure was ingestion, which was observed in 20 patients; vomiting was the most common clinical presentation. Thirteen patients were intubated at the Emergency Department on account of respiratory failure. Thirty-two patients required admission to the Intensive Care Unit and the mean length of stay in the hospital was 5 days. Two patients had cardiac arrest. Conclusion: This relatively high prevalence of OP poisoning makes it necessary to have tighter governmental controls and awaken public awareness to this problem.



How to cite this article:
Al Jumaan MA, Al Shahrani MS, Al Wahhas MH, Al Sulaibeakh AH. Organophosphate poisoning: A 10-year experience at a tertiary care hospital in the kingdom of saudi arabia.Saudi J Med Med Sci 2015;3:22-25


How to cite this URL:
Al Jumaan MA, Al Shahrani MS, Al Wahhas MH, Al Sulaibeakh AH. Organophosphate poisoning: A 10-year experience at a tertiary care hospital in the kingdom of saudi arabia. Saudi J Med Med Sci [serial online] 2015 [cited 2023 Jan 31 ];3:22-25
Available from: https://www.sjmms.net/text.asp?2015/3/1/22/149663


Full Text

 INTRODUCTION



Organophosphate (OP) poisoning is a common problem particularly in developing countries, with one million serious unintentional poisonings and an additional two million hospital admissions for suicidal attempts every year. [1] In general, accidental poisoning is more common in children; whereas poisoning with suicidal intensions is more common in young adults. [2] OP compounds inhibit acetylcholinesterase, resulting in the accumulation of acetylcholine and overstimulation of cholinergic synapses. [3] Clinical symptoms and signs are variable depending on the nature of the OP compound, amount consumed, severity, time lapse between exposure and presentation to the hospital. [4],[5] The standard treatment of OP poisoning involves supportive measures, administration of the antimuscarinic agents atropine and acetylcholinesterase reactivation with pralidoxime. [6],[7],[8]

 Objectives



The aims of this retrospective analysis were to characterize acute OP poisonings at a single hospital, including the route of exposure, clinical characteristics, management and subsequent outcomes.

 MATERIALS AND METHODS



This is a review of the medical records of all patients presenting to King Fahd Hospital of the University's Emergency Department (ED) with OP poisoning from January 2000 to December 2010. The following variables were abstracted from patient files: Patient age, sex, occupation, poisoning agent, source of agent, route of poisoning, clinical symptoms, laboratory findings, hospital and Intensive Care Unit (ICU) admissions and final disposition.

 RESULTS



A total of 50 patients (34 males [68%] and 16 females [32%]), eleven of whom were below the age of 18 (22%) whereas 39 (78%) were 18 years and older. Twenty-two of them were Saudis (44%) and 28 non-Saudis (56%). The most common route of exposure was ingestion in 20 patients (39%) and the second was inhalation in 16 patients (31%). There were three cases (6%) of dermal exposure and in 12 patients (24%), the route of exposure was unknown. The majority of exposures: Twenty nine cases (58%) were accidental, nine cases (18%) were intentional and the reasons behind the rest were unknown (24%). In seven males (77) 6 (66) of whom were non-Saudis, ingestion was mainly intentional. The most common clinical presentation in 13 patients (26%) was vomiting; 11 cases (22%) had excessive salivation, 2 (4%) cases had cardiac arrest and 34 patients (68%) presented with non-specific symptoms relating to cholinergic crisis [Figure 1].{Figure 1}

Thirteen patients (26%), 8 (61%) of whom were males, were intubated in the ED because of respiratory failure. The most common route of exposure in 9 patients (69%) was ingestion [Table 1].{Table 1}

Forty-four (88%) of the patients received atropine within an average of 1.10 hour of arriving at the ED. Two patients had the highest dose of 1 gram and the lowest dose given was 0.1 mg. Twenty patients (40%) were given pralidoxime, and the mean stay of 32 patients (64%) admitted to ICU was 3 days. The mean length of stay in hospital was 5 days.

Two patients died. The first was a 26-year-old Bangladeshi male who presented to the ED with cardiac arrest after intentionally ingesting OP. He was intubated and given atropine to a total of 2 mg and 1 gram pralidoxime, after which, he was admitted to the ICU and he died 2 days later. The second case was a 15-year-old Saudi female who was brought by her family in cardiac arrest, thought to have ingested OP. She was intubated, given 2 mg atropine and admitted to ICU. Eight days later, she died. Forty-eight patients (96%) were discharged home without any neurological deficits. Only 13 patients have had regular follow-up within 30 days.

 DISCUSSION



Organophosphates poisoning has increased in frequency in recent years in Saudi Arabia. The most common chemical substance cited has been pesticide. This is in accordance with the findings of other studies, in which, OP compounds were the most repeatedly involved in both accidental and occupational poisonings. [9],[10],[11],[12],[13]

This increase is not accounted for by occupational hazards in agriculture or industry. It is rather a reflection on the ready availability of OP compounds to the public and their growing popularity as agents for committing suicide.

Intentional poisoning with OP was reported as 10-36.2% in developed countries, 40-60% in African countries and 65-79.2% in developing countries. During this study period, 9 patients (18%) were poisoned intentionally. [14],[15],[16]

It is argued that the easy availability and widespread use of highly hazardous OP compounds is the foremost reason for this high number of incidents. According to the report by Saadeh et al. from Jordan, [18] the lack of adequate regulation to control their sale and application has encouraged some people to prefer them as the means of committing suicide. Strict legislation for the sale, distribution and storage of agrochemicals could be of help in reducing mortality and perhaps the incidence of poisoning in developing countries. In the long term, promoting an alternative to agrochemicals might be the most important strategy of preventing OP poisoning.

The proportion of suicidal attempts by females according to different reports was 20-70.8%. [13],[17] However in our study, the majority of suicidal attempts was by males at 77%.

The study revealed that the 20-30 age group was significantly more prone to suicide than other age groups [Table 2]. This issue needs further research in order to discover the reasons behind it.{Table 2}

We found that nationality was an important factor for suicidal attempts; six of the total number of nine suicidal cases were non-Saudis.

Linden and Burns [19] reported that the main route of exposure to OP compound was ingestion (74%). In our study, 20 patients (39%) had ingested the OP.

Thirteen patients required intubation in the ED because of respiratory failure, which is the most common complication encountered in the literature. [20],[21]

The mean stay in hospital recorded in the report of the Emerson et al.[22] study of 69 patients between 1987 and 1996 in Western Australia was 7 days (1-25 days). [23] In our study, the mean stay in hospital was 5 days (1-25 days), which is in keeping with other reports. [22],[24]

 CONCLUSION



Stricter legislation on the sale and distribution of agrochemicals may reduce the incidence of OP poisoning with consequent reduction in mortality.

References

1Gunnell D, Eddleston M, Phillips MR, Konradsen F. The global distribution of fatal pesticide self-poisoning: Systematic review. BMC Public Health 2007;7:357.
2Das RK. Epidemiology of insecticide poisoning at A.I.I.M.S emergency services and role of its detection by gas liquid chromatography in diagnosis. Med Update 2007;7:49-60.
3Senanayake N, Karalliedde L. Neurotoxic effects of organophosphorus insecticides. An intermediate syndrome. N Engl J Med 1987;316:761-3.
4Eddleston M. The pathophysiology of organophosphorus pesticide self-poisoning is not so simple. Neth J Med 2008;66:146-8.
5Namba T, Nolte CT, Jackrel J, et al. Poisoning due to organophosphate insecticides. Acute and chronic manifestations.Am J Med 1971;50:475-92.
6Eddleston M, Dawson A, Karalliedde L, Dissanayake W, Hittarage A, Azher S, et al. Early management after self-poisoning with an organophosphorus or carbamate pesticide - A treatment protocol for junior doctors. Crit Care 2004;8:R391-7.
7Eddleston M, Szinicz L, Eyer P, Buckley N. Oximes in acute organophosphorus pesticide poisoning: A systematic review of clinical trials. QJM 2002;95:275-83.
8Buckley NA, Eddleston M, Szinicz L. Oximes for acute organophosphate pesticide poisoning. Cochrane Database Syst Rev 2005;CD005085.
9Moazzam M, Al-Saigul AM, Naguib M, Al Alfi MA. Pattern of acute poisoning in Al-Qassim region: A surveillance report from Saudi Arabia, 1999-2003. East Mediterr Health J 2009;15:1005-10.
10Al-Sharbati MM, El-Burghthy S, Sudani OH. Accidental poisoning in children. Saudi Med J 1998;19:423-8.
11Yang CC, Wu JF, Ong HC, Kuo YP, Deng JF, Ger J. Children poisoning in Taiwan. Indian J Pediatr 1997;64:469-83.
12Yamamoto I, et al. Prevalence of chemical poisoning and drug abuse in Japan. In: Annual report, Japanese National Research Institute of Police Science 1996. Japan, 1998.
13Jeyaratnam J. Acute pesticide poisoning: A major global health problem. World Health Stat Q 1990;43:139-44.
14Kara IH, Guloglu C, Karabulut A, Orak M. Socio-demographic clinical and laboratory features of cases of organic phosphorus intoxication who attended the emergency department in the southeast Anatolian, Australia, 1987/1996. J Emerg Med 1999;17:273.
15Martín Rubí JC, Yélamos Rodríguez F, Laynez Bretones F, Córdoba Escámez J, Díez García F, Lardelli Claret A, et al. Poisoning caused by organophosphate insecticides. Study of 506 cases. Rev Clin Esp 1996;196:145-9.
16Hayes MM, van der Westhuizen NG, Gelfand M. Organophosphate poisoning in Rhodesia. A study of the clinical features and management of 105 patients. S Afr Med J 1978;54:230-4.
17Blumenthal SJ. Youth suicide: Risk factors, assessment, and treatment of adolescent and young adult suicidal patients. Psychiatr Clin North Am 1990;13:511-56.
18Saadeh AM, al-Ali MK, Farsakh NA, Ghani MA. Clinical and sociodemographic features of acute carbamate and organophosphate poisoning: A study of 70 adult patients in north Jordan. J Toxicol Clin Toxicol 1996;34:45-51.
19Linden HL, Burns MJ. Illnesses due to poisons, drug over dosage, and envenomation. In Braunwald E, Fauci AS, Kasper DL et al. eds. Harrison's principles of Internal Medicine, 15 th ed. London: McGraw-Hill Co., 2001:2595-629.
20Sungur M, Güven M. Intensive care management of organophosphate insecticide poisoning. Crit Care 2001;5:211-5.
21Tsao TC, Juang YC, Lan RS, Shieh WB, Lee CH. Respiratory failure of acute organophosphate and carbamate poisoning. Chest 1990;98:631-6.
22Emerson GM, Gray NM, Jelinek GA, Mountain D, Mead HJ. Organophosphate poisoning in Perth, Western Australia, 1987-1996. J Emerg Med 1999;17:273-7.
23Sahin HA, Sahin I, Arabaci F. Sociodemographic factors in organophosphate poisonings: A prospective study. Hum Exp Toxicol 2003;22:349-53 [PubMed] 2.
24Lee MJ, Kwon WY, Park JS, Eo EK, Oh BJ, Lee SW, et al. Clinical characteristics of acute pure organophosphate compounds poisoning: 38 multi-centers survey in South Korea. J Korean Soc Clin Toxicol 2007;5:27-35.