R ECOGNITION AND M ANAGEMENT OF P ESTICIDE POISONINGS Fifth Edition, 1999 J. Routt Reigart, M.D. Professor of Pediatrics, Medical University of South Carolina James R. Roberts, M.D., M.P.H. Assistant Professor of Pediatrics, Medical University of South Carolina Support for this publication was provided by: Certification and Worker Protection Branch Field and External Affairs Division Office of Pesticide Programs U.S. Environmental Protection Agency 401 M Street SW (7506C) Washington, DC 20460 For additional copies or more information: Tel: 703-305-7666 Fax: 703-308-2962 The manual is available in electronic format on the Internet at: http://www.epa.gov/pesticides/safety/healthcare Acknowledgments We are grateful to the Office of Pesticide Programs, Environmental Protection Agency, for giving us the opportunity to collaborate on this new edition. Our thanks go to Kevin Keaney, Acting Branch Chief, for his support and vision, and for giving this publication priority attention. Particular mention should also be made of the efforts of Jerome M. Blondell, Ph.D., M.P.H., and Ameesha Mehta, M.P.H., whose oversight and constant assistance were invaluable in moving this project forward. Ana Maria Osorio, M.D., M.P.H., contributed Chapter 3, Environmental and Occupational History, to this manual. Experts in clinical toxicology conducted critical reviews of draft material. We are greatly appreciative of the time and effort of the following reviewers: Jeffery Lloyd Burgess, M.D., M.P.H. Assistant Professor Environmental Occupational Health Unit University of Arizona Prevention Center Matthew C. Keifer, M.D., M.P.H. Assistant Professor Department of Medicine/Environmental Health University of Washington Wayne R. Snodgrass, M.D., Ph.D. Professor and Head Clinical Pharmacology-Toxicology Texas Poison Center Sheldon L. Wagner, M.D. Professor of Clinical Toxicology Oregon State University Many other individuals contributed their time and skill to this publication. We are very appreciative of the tireless efforts of Patricia Clark, our administrative assistant, who spent endless hours in text review, securing references, communicating with reviewers, and otherwise making the revision process possible and easier than anticipated. Gilah Langner of Stretton Associates, Inc., provided editorial super- vision. Will Packard and Sarah Carter of Free Hand Press, Inc. were responsible for the format and layout of the manual. Cover photographs by Steve Delaney, EPA. CONTENTS Section I: General Information 1 Introduction ........................................................................................................... 2 2 General Principles in the Management of Acute Pesticide Poisonings .................... 10 3 Environmental and Occupational History.............................................................. 17 Section II: Insecticides 4 Organophosphate Insecticides ............................................................................... 34 5 N-Methyl Carbamate Insecticides ......................................................................... 48 6 Solid Organochlorine Insecticides ......................................................................... 55 7 Biologicals and Insecticides of Biological Origin ................................................... 63 8 Other Insecticides, Acaricides, and Repellents........................................................ 74 Section III: Herbicides 9 Chlorophenoxy Herbicides ................................................................................... 94 10 Pentachlorophenol ................................................................................................ 99 11 Nitrophenolic and Nitrocresolic Herbicides ........................................................ 104 12 Paraquat and Diquat ............................................................................................ 108 13 Other Herbicides ................................................................................................ 118 Section IV: Other Pesticides 14 Arsenical Pesticides ............................................................................................. 126 15 Fungicides .......................................................................................................... 137 16 Fumigants ........................................................................................................... 156 17 Rodenticides....................................................................................................... 169 18 Miscellaneous Pesticides, Solvents, and Adjuvants ................................................. 183 19 Disinfectants ....................................................................................................... 196 Section V Index of Signs and Symptoms ...................................................................................... 210 Index of Pesticide Products .......................................................................................... 223 List of Tables Dosage Tables Sorbitol................................................................................................................. 12 Activated Charcoal ................................................................................................ 13 Syrup of Ipecac ..................................................................................................... 14 Diazepam.............................................................................................................. 14 Lorazepam ............................................................................................................ 15 Atropine ............................................................................................................... 42 Pralidoxime .......................................................................................................... 43 Atropine ............................................................................................................... 51 Diazepam.............................................................................................................. 58 Atropine Sulfate ...............................................................................................68, 72 Calcium Gluconate ............................................................................................... 84 Lorazepam .......................................................................................................... 102 Bentonite and Fuller’s Earth ................................................................................ 113 Morphine Sulfate ................................................................................................ 115 BAL (Dimercaprol) ............................................................................................. 130 D-penicillamine .................................................................................................. 131 DMSA (Succimer) .............................................................................................. 131 DMPS ................................................................................................................ 131 Cyanide Antidotes ............................................................................................... 166 Supplemental Sodium Nitrite and Sodium Thiosulfate ........................................ 167 Phytonadione...................................................................................................... 171 Aquamephyton® .................................................................................................. 172 Calcium Gluconate ............................................................................................. 178 Tables Pesticides Most Often Implicated in Symptomatic Illnesses, 1996............................. 5 California Occupational Illnesses Due to Pesticides, 1991-1995 ............................... 6 Screening Questions for Occupational and Environmental Exposures .................... 18 Adult Interview for Occupational and Environmental Exposures ........................... 26 Steps in Investigating a Disease Outbreak .............................................................. 26 Approximate Lower Limits of Normal Plasma and Red Cell Cholinesterase Activities in Humans .............................................. 39 Toxicity of Common Herbicides ......................................................................... 119 Section I GENERAL INFORMATION CHAPTER 1 Introduction This fifth edition of Recognition and Management of Pesticide Poisonings is an up- date and expansion of the 1989 fourth edition. The Office of Pesticide Pro- grams of the United States Environmental Protection Agency has sponsored the series since 1973. The purpose of the manual is to provide health profes- sionals with recently available information on the health hazards of pesticides currently in use, and current consensus recommendations for management of poisonings and injuries caused by them. Pesticide poisoning is a commonly under-diagnosed illness in America to- day. Despite recommendations by the Institute of Medicine and others urging the integration of environmental medicine into medical education, health care providers generally receive a very limited amount of training in occupational and environmental health, and in pesticide-related illnesses, in particular.1 The updating of this manual is part of a larger initiative of the U.S. Environmental Protection Agency, in conjunction with numerous