* Patients may present with varying degrees of clinical symptomatology, ranging from nausea, vomiting, hypersecretions (bronchorrhoea, urination, diarrhoea), headache, severe confusion, pinpoint pupils, bradycardia, tachypnoea/bradypnoea, and hypertension/hypotension to convulsions, coma and eventually death.
* The initial diagnosis may not be obvious; however, clinical signs of mental alteration (confusion, headaches, restlessness and possibly collapse), pinpoint pupils and hypersecretions (diarrhoea, urination, bronchorrhoea) with shortness of breath or respiratory distress should alert the clinician regarding the diagnosis of organophosphate poisoning.
% Diaphoresis 15 30 Salivation 14 28 Bronchorrhoea
10 20 Vomiting 6 12 Neck muscle weakness 22 44 Fasciculations 22 44 Respiratory distress 25 50 Miosis 20 40 Seizures 1 2 Table 4.
: a presenting feature of pulmonary tuberculosis," Chest, vol.
In addition, the use of anticholinesterases could be considered relatively contraindicated in patients with severe respiratory disease, because of the risks of precipitating bronchospasm and bronchorrhoea
. The alternative, suxamethonium, would expose patients to the risks of depolarising block as well as the possibility of a phase II block if repeated doses are required.
The symptoms of organophosphate poisoning are well known (miosis, bronchorrhoea
, sinus tachycardia, respiratory failure, salivation, depressed level of consciousness, seizures).4
The commonest presentation is the acute cholinergic crisis, usually diarrhoea, urinary frequency, miosis, bradycardia, bronchorrhoea
and bronchoconstriction, emesis, lacrimation, salivation (easily remembered by the mnemonic DUMBELS) and hypotension.
On arrival, he had a respiratory rate (RR) of 30 breaths per minute, oxygen saturation levels of 100%, heart rate (HR) of 137 bpm, and was drowsy with pinpoint pupils and bronchorrhoea. A diagnosis of presumed OPP was made.
During the acute cholinergic crisis, respiratory embarrassment is due to bronchorrhoea, bronchospasm, respiratory muscle weakness and central nervous system depression with loss of central respiratory drive.
was observed, with aspiration of a great amount of watery mucus through the endotracheal tube.
Summary of the various toxic syndromes Syndrome Examples Clinical clues Alpha adrenergic Phenylpropanolamine, Hypertension with phenylephrine reflex bradycardia; mydriasis Beta adrenergic Salbutamol, Hypotension, theophylline, caffeine tachycardia Mixed adrenergic Amphetamines, cocaine Hypertension with sympathomimetic) tachycardia; mydriasis; sweaty skin 3ympatholytic Methyldopa, opioids, Hypotension and phenothiazines bradycardia; miosis; decreased peristalsis Nicotinic Nicotine, Unpredictable; cholinergic succinylcholine fasciculations, paralysis 'Muscarinic None Bradycardia, miosis, cholinergic' sweating, hyperperistalsis, bronchorrhoea
, wheezing, excessive salivation, etc.
In a recent case report of an OP poisoned patient, profuse bronchorrhoea
that persisted despite clinical signs of 'adequate' atropinisation, resolved with glycopyrrolate (32).