RECENT ADVANCES in CLINICAL MEDICINE

Intensive Care Managament of Acute Organophosphate Poisoning: Clinical Experience and the Review of the Literature

VUČINIĆ SLAVICA1, ANTONIJEVIĆ BILJANA2, BOŠKOVIĆ BOGDAN1, ĆURČIC MARIJANA2 National Poison Control Centre, Crnotravska 17, 11000 Belgrade1 Faculty of Pharmacy, University of Belgrade, Vojvode Stepe 450, 11221 Belgrade 2 SERBIA [email protected]

Abstract: Current therapeutic scheme for management of acute poisoning with anticholinesterase pesticides includes general supportive measures (decontamination, respiratory support) and specific pharmacological treatment (, , ). therapy is aimed to competitively antagonise overstimulation of muscarinic receptors with atropine and to reactivate inhibited AChE with . Rectivation and clinical improvement of neuromuscular function are limited by aging of and high concentrations of organophosphates. Results of our longitudinal clinical experience confirm benefitial effect of oxime administration in OP poisoning.

Key words: acute organophosphate poisoning, oxime, intensive care management

1 Introduction endogenous effect in normal Organophosphate (OP) insectide poisoning doses. While these effects have been results from occupational, accidental and conclusively demonstrated in experimental intentional exposure. According to the World settings the general clinical benefit in OP Health Organization, about 1 million accidental poisoning is not clear yet, and the mortality is and 2 million suicidal poisonings with high despite the use of atropine and oxime. organophosphorus insecticides are reported per There are several reasons for the contradictory year, with more than 300 000 fatalities [1]. reports: 1) The type and dose of poison are The greatest share of poisonings comes often unknown and may vary widely. 2) The from the developing countries of the Asia extent of decontamination may greatly differ. Pacific region, but OP insecticide poisonings 3) Different oxime regimen. 4) Patients may are also a problem for countries in the differ with respect to enzyme polymorphisms developed world, although their primary in toxifying phosphorothioates (CYP concern is defense against terrorist use of these superfamily) and hydrolytic detoxication chemicals [2]. (PON1) [3]. In this paper we present our experience related to clinical management of 2 Problem formulation acute poisoning with OPs at National Poison Besides general supportive therapy, curent Control Centre (NPCC), Belgrade, that were therapeutic protocols include atropine, oxime collected during the 10 years period (1998 and benzodiazepine. Atropine is the mainstay 2007). Treatment of acute poisoning caused by of treatment of muscarinic effects in OP this class of substances will be considered poisoning worldwide. This physiologic antidote through a correlation of our experience and the effectively antagonizes muscarinic receptor review of the literature. mediated effects of excessive , it is somewhat effective at central mreceptors, 2.1 Mechanisms of acute toxicity of but it fails at nicotine sensitive synapses. Here, organophosphate insecticides reactivating oximes can act as specific The primary molecular mechanism of action of . Three actions have been attributed to the OP ompounds is inhibition of oximes: 1) rectivation of by acetylcholinesterase (EC 3.1.1.7, AChE) cleavage of phosphorylated active sites; 2) producing excessive acetylcholine (ACh) direct reaction and detoxification of unbounded accumulation and overstimulation of organophosphorus molecules, and 3)

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neurons. The variations in the acute registered in 83 (26.2%) and acute toxicity of OP are the result of their different cardiocirculatory failure in 15 (4.7%) patients. chemical structures and rates of spontaneous This is consistent with the results of other reactivation and aging. Even though aging studies with acute organophosphate occurs slowly and reactivation relatively poisoning[13]. rapidly in the case of OP insecticides, early Clinical diagnosis is relatively simple oxime administration is clinically important in and is based on medical history, circumstances patients poisoned with these agents. In addition of exposure, clinical presentation, and to reaction with AChE, OPs also react with laboratory tests. Confirmation of diagnosis can serum cholinesterase (EC 3.1.1.8, ChE), a be made by measurement of erythrocyte AChE circulating plasma glycoprotein synthetized in or serum ChE [14]. Many OP insecticides (e.g. the liver, in the same manner as with AChE , demethon, , , [3,4]. , trichlorphon) appear to be more potent inhibitors of ChE than AChE and, as the 3 Results consequence, ChE inhibition might occur to a During the ten year period, 29723 patients were greater extent than AChE inhibition. treated at the NPCC, 11174 were hospitalized, Erythrocyte AChE is identical to the enzyme and among them 526 patients were poisoned present in the target synapses, thus, it is with pesticides. OP compounds were detected regarded as biomarker of toxicity of these in 296 patients. Poisoning with dimethyl OP compounds [35]. was confirmed in 246 patients (malathion 153, The majority of patients exposed to OP 69, dichlorvos 4, 6, pesticides (46.6%) had their AChE activity 8), with diethyl OP in 38 between 20 and 50% (compared to mean patients (diazinon 21, 9, 1, population controls) indicating mild poisoning, 1, 3, chlorpyriphos 2, about 9% patients had 1020% of AChE quinalphos 1) and in 12 patients OP could not activity (moderate poisoning), and there were be fully identified. Majority of poisonings only 2.7% patients with AChE activity lower (92%) were due to deliberate ingestion of than 10% (severe poisoning). Additional cholinesterase inhibitors. confirmation of OP poisoning was obtained after detection of these compounds and/or their metabolites in biological samples (blood, urine, 3.1 Clinical features and diagnosis of lavate) by gas chromatography in 161 poisoned acute anticholinesterase poisoning patients. The highest registered concentration Acute cholinergic crisis is a medical emergency of malathion in blood was 61.0 mg/L in a that often requires treatment in Intensive Care severely poisoned patient who had AChE Unit. It consists of muscarinic, nicotinic and activity lower than 10%. central nervous system effects. Muscarinic features include bronchorrhoea, broncho 3.2 Assessment of the poisoning severity constriction, miotic pupils, abdominal cramps, The assessment of the severity of poisoning is involuntary defecation and urination, essential for adequate management of patients bradycardia, QT prolongation, hypotension. with anticholinesterase poisonings. At the Nicotinic features include twiching of fine NPCC for many years for this purpose we use muscles, fasciculation and hyperreflexia which the Poisoning Severity Score (PSS) [6]. PSS may progressively lead to flaccid paralysis. The considers the overall clinical course where PSS most prominent CNS symptoms are: headache, 0 designates no symptoms of poisoning, PSS 1 dizziness, drowsiness, nausea, confusion, minor (mild) poisoning, PSS 2 moderate anxiety, slurred speech, ataxia, tremor, poisoning, PSS 3 severe poisoning and PSS 4 psychosis, convulsions, coma and respiratory fatal poisoning. In addition, we take into depression [14]. consideration other relevant data available such The most common clinical signs of as the activity of AChE in erythrocytes and poisoning in patients exposed to OPs observed ChE in serum as well as good tolerance of high at Clinic of Toxicology of the NPCC were atropine doses. miosis (61.8%), bronchorrhoea (51.7%), OP were the cause of severe and fatal vomiting and diarrhea (50.8%), hypotension poisoning (PSS 3 and 4) in 129 (43.5%), and (27.8%). Acute respiratory insufficiency was mild poisoning (PSS 1) in 70 (23.7 %) patients.

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The majority of clinical manifestations resolve includes careful titration of atropine until within a few days or weeks, but appearance of signs of hyperatropinization, and neurophysiological symptoms may remain for individualization of dosage. The highest total months. Fourty seven patients (15.9%) died. administered dose of atropine at NPCC was This is consistent with the findings of other 6400 mg. However, the most patients received authors who reported case fatality generally total doses of atropine up to 500 mg (32%), more than 15%. Acute respiratory while about 13% patients received atropine insufficiency, due to weakness of respiratory 5001000 mg or up to 50 mg. muscles and central respiratory depression, was the major cause of lethal outcome in OP 3.3.3 Oxime therapy poisoning. Another cause of death was Oximes reactivate phosphorylated AChE by cardiocirculatory insufficiency which was even displacing the phosphoryl moiety from the more difficult do cope with since it is often enzyme by virtue of their high affinity for the refractory to treatment [7]. enzyme and their powerful nucleophilicity. The rate of reactivation depends on the structure of 3.3 Management of acute poisoning with the phosphoryl moiety bound to the enzyme, OP pesticides the source of the enzyme, the structure and concentration of oxime which is present at the 3.3.1 General supportive measures and active site, and the rate of postinhibitory decontamination dealkylation known as aging [27]. In our patients, respiratory support by It has been over five decades since mechanical ventilation was necessary in 97 Wilson and Ginsburg in the USA and Childs et patients (32.7%) with OP poisoning. Gastric al. in England published independently on the lavage was the most commonly used (22.7%) efficacy of the compound 2PAMiodide as a form of decontamination in OP poisoning. reactivator of phosphorylate , Administration of oral activated but this chapter has not come to a closure yet. charcoal, in conventional doses, may be Since then several salts of have considered for reducing further absorption of been used: pralidoxime chloride, pralidoxime some OP pesticides [7]. This recommendation methanesulfonate and pralidoxime methyl was supported by Peng et al. who conducted a sulfate [3]. TMB4 Cl2 [1,3Bis (4

randomized controlled clinical trial involving hydroxyiminomethyl1pyridinio) propane 108 patients, aimed to assess the efficacy of dichloride] was synthesized in the United hemoperfusion with charcoal in treatment of States. Lüttringhaus and Hagedorn synthesised acute severe dichlorvos poisoning [8]. another compound, (Toxogonin®), Eddleston et al. conducted an openlabel, in 1964 and introduced into the medical parallel group, randomized, controlled trial in practice. Hagedorn’s group in Freiburg,

three Sri Lankan hospitals and found no benefit Germany also synthesised an oxime named HI of multipledose activated charcoal [7]. 6 Cl2 [1(2hydroxyiminomethyl1pyridinio) 3(4carbamoyl1pyridinio)2oxapropanedi 3.3.2 Atropine chloride] and their most recent oxime of Atropine, an alkaloid isolated from importance was HLö7. Many attempts had Atropa belladonna L. by Main in 1835, was been made so far to improve the antidotal

used against a cholinesteraseinhibiting agent properties of the conventional mono and bis

for the first time by Fraser in 1863. It has pyridinium mono(di)oximes by modifying remained the cornerstone of the therapy of OP their structure [3,10]. Despite intensive pesticide intoxication ever since. There is a research activities on this topic, PAM2, TMB general agreement to use atropine in OP 4, LüH6, HI6 and HLö7 have remained poisoning, and the only dilemma is related to dominant among oximes in experimental work

the dosing regimen. Grob recommended 46 [10]. mg atropine, followed by 2 mg doses at 5 min intervals, until bronchial secretion was stopped [9]. Other authors found continuous infusions with atropine 12 mg/h, after initial 3.3.4 Clinical Use of Oximes atropinization, efficient as well [3,7]. The A particular problem in interpreting the atropine dosing regimen applied in NPCC beneficial role and efficacy of oximes in

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clinical practice is a deficiency of published of AChE inhibited by the majority of data, especially those evaluated in controlled organophosphorus pesticides. clinical trials with the proper stratification of The efficacy of pyridinium oximes has patients with OP poisoning. also been demonstrated in many cases of Willems et al. reported on the effects of patients poisoned with OP insecticides who PAM2 methylsulphate (4.42 mg/kg as a bolus were treated in European clinics. In those cases injection followed by continuous infusion 2.14 the recommendations for pralidoxime dosing mg/kg/h) in nine patients intoxicated with proposed by World Health Organization were organophosphorus insecticides. The therapeutic followed (30 mg/kg body weight bolus effect of the oxime seemed to depend on the intravenously followed by 8 mg/kg/h IV) [3, plasma concentrations of ethylparathion and 1013]. methylparathion [11] . Contrary to these findings, the reports In a series of five case reports, LüH6 from Asia indicated that pralidoxime treatment (Toxogonin) 250 mg was given as an was not effective in their patients. These intravenous bolus followed by continuous studies were apparently poorly designed due to infusion of 750 mg/24 hours in cases of life suboptimal dose, short duration of treatment, threatening parathion poisoning. This dose was delay between patient exposure and effective, especially when the dose of parathion pralidoxime administration, and the fact that absorbed was relatively low [12]. the chemical structure of OP pesticides was not In a clinical study of 63 patients taken in account [14]. poisoned with organophosphorus insecticides, one group of patients was treated with atropine 3.3.6 Clinical experience with HI-6 only, while the other two groups received During the different phases of development of atropine and either PAM2 or LüH6. Loading the NPCC in Belgrade, many pyridinium and maintenance intravenous doses for PAM2 oximes were used in experimental and clinical were 30 mg/kg and 8 mg/kg/h, respectively and studies, as well as in routine clinical practice, 8 mg/kg and 2 mg/kg/h, respectively, for LüH such as pralidoxime chloride, pralidoxime 6. Although the severity of intoxications (based methylsulphate, obidoxime, and HI6. Oxime on respiratory complications and duration of HI6 was introduced in clinical practice in hospitalization) was higher in the atropine plus Serbia in early 1980s. Its development was oxime groups, no mortality was found in the initiated by Military Establishments in order to PAM2 plus atropine group, whereas 12% and improve the treatment of chemical warfare 50% of patients in the atropine and atropine agent poisoning. plus LüH6 groups died, respectively[13]. The clinical development of HI6 (asoxime chloride, Bosnalijek, Drug Company, 3.3.5 Drawbacks and Limitations of Oxime Sarajevo) started in the Clinic of toxicology Therapy Military Medical Academy in 1985 and its Experimental results have demonstrated that antidotal efficacy in quinalfos poisoning was different oximes are not equally effective reported by Boškovic and coworkers [15]. against poisonings caused by structurally The effects of HI6 and PAM2 were different organophosphorus compounds. compared in a study of Kušić et al [16]. Sixty Pralidoxime (PAM2), trimedoxime (TMB4), patients acutely poisoned with various OPs obidoxime (LüH6), HI6 and HLö7 have all were treated with atropine, diazepam and HI6 been demonstrated to be very effective in (500 mg every 6 hours intramuscularly) for 2 to experimental poisonings with and VX. 7 days, depending on the severity of the TMB4 and LüH6 may reactivate organophosphate poisoning. In addition, in nine inhibited AChE, whereas HI6 possesses the patients, PAM2 was administered (1g/6h) over ability to reactivate the inhibited the same period of time. The recovery of enzyme. An oxime HLö7 seems to be an erythrocyte AChE was rapid in patients efficient reactivator of AChE inhibited by any suffering from severe phorate, quinalphos, of the four organophosphorus warfare agents. dichlorvos and pyridafenthion poisonings with According to the available literature, the reactivation halflives ranging from 0.5 to 3.5 oximes LüH6 and TMB4, although relatively hours. Malathioninhibited enzyme was toxic, are the most potent to induce reactivation reactivated much more slowly (reactivation halflife=10.1 hours), while HI6 was

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ineffective against AChE inhibition caused by other studies suggest that oximes significantly dimethoate and phosphoramidon. While nearly reduce atropine consumption in OP poisoning, 100% reactivation of the enzyme was obtained and signs of atropinization might occur earlier after only 2 days of HI6 treatment, PAM2 when oximes were given [3,17]. Length of could reactivate only 40% of the enzyme hospitalisation was the lowest in the group on activity by the end of the eighth day. The most atropine and oxime therapy (p<0,001), and reasonable explanation for this difference in the when bicarbonate was added to oxime and activity of HI6 lies in the chemical structure of atropine, the duration of mechanical ventilation the OP insecticide, considering that diethoxy was significantly reduced (p<0.001). type inhibited ChE in contrast to dimethoxy Reactivation of AChE was the highest inhibited enzyme, ages slowly. Slower (p<0.001) in this group but bicarbonate reactivation of malathioninhibited eChE administration did not show any benefit to could be explained in part by the effects of its reactivation of AChE. impurities – isomalathion. The lack of undesirable effect even under conditions of 3.3.8 Diazepam maintaining HI6 levels far above "the minimal Diazepam is used for prophylaxis and treatment effective concentrations" for oximes and being of convulsions. It improves atropine tolerance, much lower for the more effective reduces CNS damage and central respiratory bispyridinium reactivators, for up to 7 days, weakness [13, 1012]. confirms its exceptional tolerance in humans. In conclusion, the therapeutic use of HI6 3.3.9 Sodium bicarbonate therapy against poisoning by various OP insecticides Experimental and clinical studies have shown showed it to be as effective as, or superior to beneficial therapeutic effect of sodium the other oximes clinically available. bicarbonate, when added to standard treatment Exceptional tolerance, the reactivation of for acute organophosphate poisoning, but the acetylcholinesterase and its direct mechanism is unclear [1819]. We have pharmacological effect make HI6 the main administered sodium bicarbonate as a loading contributory drug to the standard atropine dose of 4 mEq/kg/h followed by 4 mEq/kg/24 diazepam treatment of OP poisoning. hours as long as OP was detected in blood in 26 (8.2 %) of patients. 3.3.7 Experience with pralidoxime methylsulphate 4 Problem solution Due to economic crisis in Serbia, NPCC did not There is currently insufficient evidence have any oxime available for several years, but regarding the efficacy of oximes, however, during the past ten years pralidoxime ® experimental studies and limited clinical methylsulphate (Contrathion ) was applied experience emphasize the need for further with a loading dose of 400 mg (two bottles) by development of universally suitable oxime and slow intravenous infusion: subsequently 200 alternative adjunct in treatment of OP mg/h continuous intravenous infusion was poisoning. administered during the first day, and continued as long as clinical signs of poisoning and pesticide in urine and blood were present. In 5 Conclusions moderate poisoning 400 mg of Contrathion® Acute poisoning with OP esticides is not followed by 400 mg/3 h were used. In our frequent in Serbia, however, it represent group of patients 74 (23.3 %) were treated with important clinical feature due to severity, pralidoxime. Retrospectively four therapeutic possible complications and their impact on patients' groups were analyzed: I atropine, II duration and costs of hospitalization. atropine and oxime, III atropine, oxime and Management consists of prompt resuscitation, bicarbonate and IV atropine and bicarbonate. antidotes as required and selective There were no differences in mortality between decontamination. Oxime administration is the groups. The atropine consumption was recommended for moderate and severe lower in the group of patients treated with an poisoning. High quality medical care and oxime, but the difference was significant only ongoing monitoring in ICU are essential. in the group of severely poisoned patients where it was reduced for 30%. The results of

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