Summary
Definition
History and exam
Key diagnostic factors
- presence of risk factors
- increased secretions
- fasciculations
- pinpoint pupils
- distinctive odour
- chest crackles and rhonchi
- semi-conscious/coma
Other diagnostic factors
- visual disturbances
- vomiting
- influenza-like syndrome
- urinary or faecal incontinence
- proximal muscle weakness
- abnormal deep tendon reflexes
- abnormal heart rate
- abnormal blood pressure
- decreased respiration
- hypothermia
- seizures
- delayed-onset central nervous system and peripheral (predominantly motor) neuropathy
Risk factors
- pesticide availability
- history of self-harm or recent interpersonal conflict
- mental illness
- alcohol or drug abuse
Diagnostic investigations
1st investigations to order
- atropine therapeutic trial
- plasma cholinesterase
- red blood cell cholinesterase
Investigations to consider
- chest x-ray
- ECG
- blood gases
Treatment algorithm
suspected poisoning
occupational or accidental poisoning
deliberate ingestion or terrorism/warfare with nerve agent
intermediate syndrome
organophosphate-induced delayed neuropathy
Contributors
Authors
Nicholas Buckley, MD, FRACP
Professor of Clinical Pharmacology
Pharmacology Department
Sydney Medical School
University of Sydney
Sydney
New South Wales
Australia
Disclosures
NB is an author of a number of references cited in this topic.
Peer reviewers
Steven B. Bird, MD, FACEP
Assistant Professor of Emergency Medicine
Division of Medical Toxicology
University of Massachusetts Medical School
North Worcester
MA
Disclosures
SBB declares that he has no competing interests.
Cynthia K. Aaron, MD, FACMT, FACEP
Program Director
Medical Toxicology
Regional Poison Center
Children's Hospital of Michigan
Detroit
MI
Disclosures
CKA holds stock in Merck Pharmaceuticals and is a paid consultant for ToxEd. She was briefly a paid consultant for Lexi-Comp.
Kent R. Olson, MD
Professor Medical Director
San Francisco Division
California Poison Control System
San Francisco
CA
Disclosures
KRO declares that he has no competing interests.
Ruben Thanacoody, MD, FRCP(Edin)
Consultant Physician and Clinical Toxicologist
National Poisons Information Service (Newcastle)
Newcastle-upon-Tyne
UK
Disclosures
RT declares that he has no competing interests.
References
Key articles
Eddleston M, Buckley NA, Eyer P, et al. Management of acute organophosphorus pesticide poisoning. Lancet. 2008 Feb 16;371(9612):597-607.Full text Abstract
Lavonas EJ, Akpunonu PD, Arens AM, et al. 2023 American Heart Association focused update on the management of patients with cardiac arrest or life-threatening toxicity due to poisoning: an update to the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2023 Oct 17;148(16):e149-84.Full text Abstract
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
Differentials
- Carbamate poisoning
- Chlorophenoxy herbicide poisoning
- Opioid overdose
More DifferentialsGuidelines
- 2023 American Heart Association focused update on the management of patients with cardiac arrest or life-threatening toxicity due to poisoning: an update to the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care
- Clinical management of acute pesticide intoxication: prevention of suicidal behaviours
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