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Pesticide Dr. Suda Vannaprasaht Department of Pharmacology Faculty of Medicine Khon Kaen University, Thailand

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Presentation on theme: "Pesticide Dr. Suda Vannaprasaht Department of Pharmacology Faculty of Medicine Khon Kaen University, Thailand"— Presentation transcript:

1 Pesticide Dr. Suda Vannaprasaht Department of Pharmacology Faculty of Medicine Khon Kaen University, Thailand

2 Pesticides Insecticide: organophosphates, carbamates, organochlorines, pyrethrins Rodenticide: coumarin, thallium, zinc phosphine Herbicide: paraquat, glyphosate

3 Organophosphate Insecticide Parathion Malathion Fenthion Dimethoate Monocrotophos Metamidophos

4 Carbamate Insecticide Carbaryl Carbofuran Propanocarb Thiodicarb

5 Route of exposure Inhalation: unlikely at ordinary temperatures, low volatility : sprays or dusts : hydrocarbon solvent (toluene or xylene) Skin/eye contact: not irritate skin or eye : rapidly absorbed through intact skin and eyes, contributing to systemic toxicity Ingestion: acute toxicity and rapidly fatal systemic poisoning

6 Organophosphate Chemical warfare Nerve agents Tabun Sarin Soman VX

7 Sarin Gas Attack in Japan June 1994, Matsumoto (614) March 1995, Tokyo subway (5510)

8 Sarin toxicology Isopropyl methylphosphonofluoridate High potency organophosphate ester Clear, colorless liquid with a vapor pressure of 2.1 mm Hg Liquid: rapidly penetrate skin and clothing Vapor: rapidly penetrate mucous membranes of the eye or inhaled in to the lung

9 Mechanism of Intoxication

10

11 = Defecation = Urination = Miosis = Bradycardia = Emesis = Lacrimation = Secretion DUMBELSDUMBELS Muscarinic Receptor

12 JAMA 2003;290:661

13 Intensive Care Med 1997;23:1006 Relationship between pupil size and AChE activity in patient exposed to sarin vapor

14 Intensive Care Med 1997;23:1006

15 True Cholinesterase (RBC) Investigation Cholinesterase level Plasma Cholinesterase

16 Comparison between RBC and plasma AchE

17 Management 1. Basic life support Airway Breathing Circulation

18 2. Early mangement c Prevent absorption: gastric lavage activated charcoal skin decontamination c Enhance Elimination

19 End point:HR> 60/min or <150/min pupil size > 3 mm secretion decrease Dose: 1- 4 mg IV push every 5-15 min Antidote 1. Atropine antimuscarinic

20 Clinical response: Motor power - tidal volume - muscle power Dose: 1-2 gm IV push > 10 min every 2-4 hr. or IV continuos drip Max: 1/2 gm/ hr. Pralidoxime (2-PAM)

21 Pre-hospital management Hot zone  Rescuer Protection: Highly toxic systemic poison absorbed well by all routes of exposure - Respiratory protection: Positive pressure, self contained breathing apparatus (SCBA) - Skin protection: Chemical protective clothing  ABC Reminder  Victim removal Parathion

22 Pre-hospital management Decontamination zone  Rescuer Protection: lower level of protection than that worn in Hot Zone  ABC Reminders  Basic Decontamination: - Rapid and thorough decontamination is critical, but must proceed concurrently with supportive and antidotal measure - Quickly remove and double- bag contaminated clothing and personal belonging

23 Pre-hospital management  Wash repeatedly with copious amounts of soap and water  Rescuers wear rubber gloves as vinyl groves  Clean hair, fingernails and skin folds  Irrigate exposed or irritated eyes with plain water or saline for 15 min  Activated charcoal  Not induce emesis  Transfer to support zone

24 Pre-hospital management Support zone  Support zone team wear disposable aprons or gowns and rubber gloves for protection  ABC reminder  Additional decontamination  Advance treatment  Antidotes  Transport to medical facility

25 Emergency Department Management  Decontamination area: - Butyl rubber aprons and butyl rubber gloves - Two layers of latex gloves and waterproof apron or chemical resistant jumpsuit - Wash hand - ABC reminder - Basic decontamination

26 Emergency Department Management  Critical Care area - ABC reminder - GI decontamination – gastric lavage, activated charcoal - Antidotes - Laboratory test: RBC cholinesterase activity

27 Emergency Department Management  Disposition and Follow- up - Life threatening illness, serious exposure and symptomatic - Delay effect: skin absorption : aspiration of chemical (hydrocarbon)  chemical pneumonitis : Chronic neurologic symptoms

28 Intermediate Syndrome 1- 4 days after acute poisoning Sign: cranial nerve palsy paralysis of proximal limb muscle, neck muscle & respiratory Fenthion, monocrotophos, dimethoate, methamidophos etc. DDx: redistribution of organophosphate Treatment: supportive

29 Emergency Department Management - Patient release: asymptomatic for 4-6 hours after exposure - Follow up: primary care physician : persistant CNS sequelae and delayed peripheral neuropathy - Report

30 Organophosphate induce delayed neuropathy (OPIDN) ` After 2- 4 wks after acute poisoning ` Delay neuropathy: cramping muscle pain distal numbness & paresthesia progressive leg weakness and gait disturbance depressed deep tendon reflexes lower then upper extremeties

31 Nerve agent Prehospital Management Hot zone  Rescuer Protection: rapidly absorbed by inhalation and ocular contact : rapid local and systemic effect : liquid is readily absorbed thorough skin (delay for minutes to up to 18 hours) - Respiratory protection: Pressure demand, self- contained breathing apparatus - Skin protection: chemical-protective clothing and butyl rubber gloves

32  ABC reminders  There are 4 triage categories  Antidote: difficult to achieve in Hot Zone  Victim removal: decontamination zone Decontamination zone  Rapid decontamination is critical to prevent further absorption  Rescuer protection: wear the same level of protection as required in the Hot Zone Prehospital Management

33 Triage for nerve agent casualties

34  ABC reminder  Antidotes  Basic decontamination: Liquid - eyes decontamination within minutes of exposure - flush eyes with water for 5-10 minutes - remove all clothing and wash skin with soap and water - 0.5% sodium hypochlorite - absorbent powder such as flour, talcum powder or Fuller’s earth Prehospital Management

35 - Place contaminated clothes and personal belonging in a sealed double bag Vapor - no need to flush eyes following exposure Ingestion – activated charcoal  Transfer to support zone Prehospital Management Support zone  Victims must be decontamination properly before entering the Support Zone

36 Prehospital Management  ABC reminder  Antidotes  Additional decontamintion  Transport to medical facility

37 Emergency Department Management  Decontamination Area: - ABC reminder - Personal protection: - before enter the facility - inside the hospital: negative air pressure and floor drain to contain contamination - personal wear the same level of protection require in Hot Zone - Basic decontamination

38  Treatment area - ABC reminder - Triage – conscious and full muscular control need minimal care - exposed to liquid observe at least 18 hours - only exposure to vapor: no sign of exposure by the time reach the hospital  discharge Emergency Department Management

39 - Antidotes Vapor exposure - Miosis and rhinorrhea need no care a) eye pain or head pain or nausea and vomiting  topic atropine b) rhinorrhea is very severe  atropin IM 2 mg

40 Emergency Department Management - Laboratory test: RBC AChE  Disposition and Follow up - Vapor agent: miosis and/or mild rhinorrhea  do not need to admit - All other patients: hospitalized and observed closely - Delay effect: - skin exposure: 18 hours - inhalation: 12 hours ( bronchitis, pneumonia, pulmonary edema, respiratory failure

41 Emergency Department Management - Follow up - severe exposure: CNS sequelae  Report

42

43 Organochlorine poisoning

44 Organochlorine DDTBenzene HC Cyclodienes Toxaphene Lindane ** Aldrin *** Endrin *** Chlordane ** Chlordeco ne ** InhalationIngestionDermal

45 Clinical Manifestation Acute toxicity Seizure threshold & CNS stimulant  Respiratory failure  1-2 hr. postingestion

46 Ca2+- ATPase neuronal membrane Increase Na+ Channel opening time tremorparesthesiamyoclonusocular movement weakness

47 Chronic toxicity Chlordecone: factory workers who prolong exposured pseudotumor cerebri oligospermia & decrease sperm motility wt loss, tremor weakness, ataxia metal status change, abn liver function test Carcinogen

48 Management Basic life support Early management Prevent absorption: gastric lavage activated Charcoal skin decontamination Support treatment: seizure

49 Pre-hospital management Hot zone  Rescuer Protection: Moderate toxic systemic poison absorbed well by all routes of exposure - Respiratory protection: Positive pressure, self contained breathing apparatus (SCBA) - Skin protection: Chemical protective clothing  ABC Reminder  Victim removal Chlordane

50 Pre-hospital management Decontamination zone  Rescuer Protection: lower level of protection than that worn in Hot Zone  ABC Reminders  Basic Decontamination: - Quickly remove and double- bag contaminated clothing and personal belonging

51 Pre-hospital management  Flush with water 20 min then wash with soap twice  Do not scrub  Irrigate exposed or irritated eyes with water or saline for 20 min  Activated charcoal  Not induce emesis  Transfer to support zone

52 Pre-hospital management Support zone  ABC reminder  Additional decontamination  Advance treatment  Cardiac life support  Transport to medical facility

53 Emergency Department Management  Decontamination area: - Telfon gloves and suits before treating patient - Flush with water 20 min then wash with soap twice - ABC reminder - Basic decontamination

54 Emergency Department Management  Critical Care area - ABC reminder - GI decontamination – gastric lavage, activated charcoal - No antidotes - Laboratory

55 Emergency Department Management  Disposition and Follow- up - history of serious exposure : admit - Delay effect: pulmonary edema (Vapor) - Discharge: asymptomatic

56

57 Herbicides Paraquat Diquat 2,4dichlorophenoxyacetic acid Color : Blue-green emetic agent

58 Paraquat Lung O2O2 O2O2. OH. Lipid peroxidation Type I and II pneumocyte cell death & alveolitis Lung fibrosis GSHGSSG

59 Paraquat Lung O2O2 O2O2. OH. Lipid peroxidation Type I and II pneumocyte cell death & alveolitis Lung fibrosis A C D B GSHGSSG E F G Fuller’s earth, GI decontamination, HD Paraquat Ab Low FiO 2 Fe 2+ H

60 การดูแลผู้ป่วยที่ได้รับพิษจาก paraquat 2. Prevent absorption 2.1 Gastric lavage 2.2 Fuller’s earth 2.3 MOM 30 ml q 6 hrs 2.4 Skin decontamination O2O2 1. Basic life support

61 3. Increase elimination 3.1 Hemodialysis/ Hemoperfusion 4. Modification of tissue toxicities 4.1 Modulate inflammatory responses - Cyclophosphamide 5mg/kg/day IV divided to every 8 hr - Dexamethazone 10 mg IV q 8 hr - Chlorpheniramine 4 mg 1 tab po qid

62 4.2 Prevent oxidation - Vit C (500mg/amp) 6 g/day IV - Vit E (400 i.u./ tab) 2 tabs qid - N-acetylcysteine (300mg/amp) 50mg/kg every 8 hr

63 “ ขอบคุณค่ะ ”


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