{"id":10579,"date":"2023-09-04T14:14:12","date_gmt":"2023-09-04T14:14:12","guid":{"rendered":"https:\/\/testv45.demowebsitelinks.com\/VirtualDoctorsUSA\/?p=10579"},"modified":"2023-09-04T14:14:12","modified_gmt":"2023-09-04T14:14:12","slug":"organophosphate-poisoning","status":"publish","type":"post","link":"https:\/\/testv45.demowebsitelinks.com\/VirtualDoctorsUSA\/organophosphate-poisoning\/","title":{"rendered":"ORGANOPHOSPHATE POISONING"},"content":{"rendered":"<div id=\"block-77266b87c85d3caa8a45\" class=\"sqs-block html-block sqs-block-html\" data-block-type=\"2\">\n<div class=\"sqs-block-content\">\n<div class=\"sqs-html-content\">\n<p class=\"\">Introduction<\/p>\n<p class=\"\">Case fatality for self-poisoning in the developing world is around 10-20% according to some estimates; but for certain pesticides it may be several times higher.\u00a0 Such pesticides often contain organophosphates, which are highly toxic compounds.\u00a0They cause problems by leading to an imbalance of chemical transmitters at nerve endings.\u00a0 This in turn can result in severe or even fatal symptoms for the patient.\u00a0 Organophosphate poisoning is now rarely seen in the UK; the use of these compounds is restricted to agricultural rather than residential pesticides.\u00a0But in parts of the developing world, where much of the population lives in rural agricultural areas, it is seen more frequently.\u00a0Many of the patients at the Clinics we serve in Zambia live and work in farming communities.\u00a0The Virtual Doctors team has consulted on a number of cases of deliberate self-poisoning with organophosphate containing pesticides; with a further three incidents in the last quarter alone.<\/p>\n<\/div>\n<\/div>\n<\/div>\n<div id=\"block-yui_3_17_2_1_1603275301006_42093\" class=\"sqs-block image-block sqs-block-image sqs-text-ready\" data-block-type=\"5\">\n<div id=\"yui_3_17_2_1_1693836628284_97\" class=\"sqs-block-content\">\n<div id=\"yui_3_17_2_1_1693836628284_96\" class=\"\n          image-block-outer-wrapper\n          layout-caption-below\n          design-layout-inline\n          combination-animation-none\n          individual-animation-none\n          individual-text-animation-none\n        \" data-test=\"image-block-inline-outer-wrapper\"><\/p>\n<figure id=\"yui_3_17_2_1_1693836628284_95\" class=\"\n              sqs-block-image-figure\n              intrinsic\n            \"><\/p>\n<div id=\"yui_3_17_2_1_1693836628284_94\" class=\"image-block-wrapper\" data-animation-role=\"image\">\n<div id=\"yui_3_17_2_1_1693836628284_93\" class=\"sqs-image-shape-container-element\n\n              has-aspect-ratio\n            \"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/images.squarespace-cdn.com\/content\/v1\/5501a6c4e4b0fda45131b71f\/1603275891565-XLO6FOHE8XQ7AAYGOSYL\/Picture2.jpg\" sizes=\"auto, 100vw\" srcset=\"https:\/\/images.squarespace-cdn.com\/content\/v1\/5501a6c4e4b0fda45131b71f\/1603275891565-XLO6FOHE8XQ7AAYGOSYL\/Picture2.jpg?format=100w 100w, https:\/\/images.squarespace-cdn.com\/content\/v1\/5501a6c4e4b0fda45131b71f\/1603275891565-XLO6FOHE8XQ7AAYGOSYL\/Picture2.jpg?format=300w 300w, https:\/\/images.squarespace-cdn.com\/content\/v1\/5501a6c4e4b0fda45131b71f\/1603275891565-XLO6FOHE8XQ7AAYGOSYL\/Picture2.jpg?format=500w 500w, https:\/\/images.squarespace-cdn.com\/content\/v1\/5501a6c4e4b0fda45131b71f\/1603275891565-XLO6FOHE8XQ7AAYGOSYL\/Picture2.jpg?format=750w 750w, https:\/\/images.squarespace-cdn.com\/content\/v1\/5501a6c4e4b0fda45131b71f\/1603275891565-XLO6FOHE8XQ7AAYGOSYL\/Picture2.jpg?format=1000w 1000w, https:\/\/images.squarespace-cdn.com\/content\/v1\/5501a6c4e4b0fda45131b71f\/1603275891565-XLO6FOHE8XQ7AAYGOSYL\/Picture2.jpg?format=1500w 1500w, https:\/\/images.squarespace-cdn.com\/content\/v1\/5501a6c4e4b0fda45131b71f\/1603275891565-XLO6FOHE8XQ7AAYGOSYL\/Picture2.jpg?format=2500w 2500w\" alt=\"Credit: Adwo-Shutterstock.com\" width=\"800\" height=\"531\" data-stretch=\"false\" data-src=\"https:\/\/images.squarespace-cdn.com\/content\/v1\/5501a6c4e4b0fda45131b71f\/1603275891565-XLO6FOHE8XQ7AAYGOSYL\/Picture2.jpg\" data-image=\"https:\/\/images.squarespace-cdn.com\/content\/v1\/5501a6c4e4b0fda45131b71f\/1603275891565-XLO6FOHE8XQ7AAYGOSYL\/Picture2.jpg\" data-image-dimensions=\"800x531\" data-image-focal-point=\"0.5,0.5\" data-load=\"false\" data-loader=\"sqs\" \/><\/div>\n<\/div><figcaption class=\"image-caption-wrapper\">\n<div class=\"image-caption\">\n<p class=\"\">Credit: Adwo-Shutterstock.com<\/p>\n<\/div>\n<\/figcaption><\/figure>\n<\/div>\n<\/div>\n<\/div>\n<div id=\"block-yui_3_17_2_1_1603275301006_42393\" class=\"sqs-block html-block sqs-block-html\" data-block-type=\"2\">\n<div class=\"sqs-block-content\">\n<div class=\"sqs-html-content\">\n<p class=\"\">The onset of symptoms following ingestion of an organophosphate will vary between people (and between pesticides), but it is usually within minutes to hours.\u00a0Mild exposure may lead to a syndrome rather like flu (runny nose, fatigue, dizziness etc).\u00a0More significant exposure may cause vomiting, diarrhoea and cramping abdominal pain.\u00a0The patient may complain of burning of the mouth or throat and may describe chest tightness.\u00a0Subsequently there may be fasciculation (muscle twitching) then weakness, fits and confusion followed by organ failure and even death.<\/p>\n<p class=\"\">Even if the patient survives the acute effects of the poisoning, there may be further complications afterwards:<\/p>\n<ul data-rte-list=\"default\">\n<li>\n<p class=\"\">Muscle weakness (1-5 days after poisoning)<\/p>\n<\/li>\n<li>\n<p class=\"\">Organophosphate-induced nerve injury (1-5 weeks after ingestion)<\/p>\n<\/li>\n<li>\n<p class=\"\">Chronic organophosphate induced neuropsychiatric disorder<\/p>\n<\/li>\n<\/ul>\n<p class=\"\">Given the severity of the condition, many patients will need transfer to a Hospital for ongoing management.\u00a0Nevertheless, the early identification of potential cases in the community and swift emergency management at the Clinic can help to save lives<\/p>\n<p class=\"\">The Case<\/p>\n<p class=\"\">We present a case of deliberate self-poisoning, trying to outline the steps where the Virtual Doctors can offer help and support.<\/p>\n<p class=\"\"><strong><em>A 47-year old man is brought to the clinic after taking an unknown substance in an attempt to kill himself.\u00a0He is extremely unwell on arrival with noisy breathing and a slow weak pulse.\u00a0His blood pressure is dangerously low, and he is only semi-conscious.\u00a0 <\/em><\/strong><\/p>\n<p class=\"\">When managing the sick patient, it is sensible to use a structured approach.\u00a0The \u2018ABC\u2019 assessment of emergencies is helpful: the clinician checks and manages problems relating to:<\/p>\n<p class=\"\">\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <strong>A<\/strong>irway<\/p>\n<p class=\"\">\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <strong>B<\/strong>reathing<\/p>\n<p class=\"\">\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <strong>C<\/strong>irculation<\/p>\n<p class=\"\">\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <strong>D<\/strong>isability (the patient\u2019s conscious level)<\/p>\n<p class=\"\">And then moves on to:<\/p>\n<p class=\"\">\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <strong>E<\/strong>xposure (looking at everything else)<\/p>\n<p class=\"\">This checklist forms part of an ongoing continuous assessment, as the response to immediate therapy is monitored.<\/p>\n<p class=\"\">In our Case responses to the Clinical Officers we try to emphasise and encourage this approach. In addition, we have recommended various educational resources covering the ABC assessment of the sick patient and produced our own <a href=\"https:\/\/anchor.fm\/the-virtual-doctors\">podcast<\/a> on the topic.\u00a0 We hope to help them incorporate this into their own practice, for every emergency they see.\u00a0It helps clinicians address the most life-threatening problems first and makes sure nothing is overlooked.\u00a0It helps to prepare them to deal with challenging cases even before contacting us.<\/p>\n<p class=\"\"><strong><em>The Clinical Officer begins her initial ABC management.\u00a0The patient has copious secretions around his mouth, but his airway is not obstructed.\u00a0There is no oxygen immediately available, but the CO has been successful in putting in an IV line and giving fluid to support the circulation.\u00a0She gives him a dose of atropine in view of his low heart rate.\u00a0 She has also given some dextrose intravenously in case a low sugar level was making the patient drowsy.\u00a0 \u00a0<\/em><\/strong><\/p>\n<p class=\"\">The management of poisoning mostly centres around optimal supportive care.\u00a0We have provided a <a href=\"https:\/\/vdrforums.org.uk\/wp-content\/uploads\/2019\/10\/POISONING.pdf\">checklist<\/a> to the clinical officers on the forum relating specifically to generic supportive care of the poisoned patient.<\/p>\n<p class=\"\"><strong><em>The Clinical Officer is concerned that, despite her initial management, the patient remains gravely unwell.\u00a0She contacts the Virtual Doctors via the App for further support. <\/em><\/strong><\/p>\n<p class=\"\">The Volunteer emphasises the need for \u201cABC\u201d management initially. They recognise from the patient\u2019s presentation that it is highly likely that this patient has taken an organophosphate compound (the slow heart rate and excessive salivation in this drowsy and unstable patient are clues).\u00a0This is important because in cases of organophosphate poisoning there is a specific antidote: atropine.\u00a0 It is one of only 4 antidotes listed on the Zambian Essential Medicine Formulary.\u00a0The volunteer explains the specific management to the Clinical Officer: in such severe cases of poisoning a single dose of atropine will not be sufficient; repeated doses (often followed by an infusion) are required.\u00a0 This can be life-saving.\u00a0The Volunteer gives a clear description for the targets of treatment (and also highlights the side effects of <em>too much<\/em> atropine). The Volunteer recommends giving another medication, pralidoxime, to avoid further complications, if it is available.\u00a0They stress the importance of re-assessing \u201cABC\u201d at each step and highlight that the patient needs close observations.<\/p>\n<p class=\"\"><strong><em>The Clinical Officer follows this advice and the patient\u2019s vital signs improve.\u00a0She contacts the team again to let us know things are beginning to stabilise.<\/em><\/strong><\/p>\n<p class=\"\">Even if there is not a specific antidote available, it is always helpful in cases of poisoning to know what problems to look out for; in the UK we have an online resource called Toxbase run by the National Poisons Information Service.\u00a0Our volunteers can refer to this when advising on a case (in the meantime, we have made our COs aware of other reliable resources that they can access locally online to provide them with basic information about specific poisons).\u00a0Such databases highlight what complications to expect not only at the time of the acute poisoning but also subsequently.\u00a0In the case of organophosphate poisoning there is an ongoing danger period and the Volunteer ensured that the CO knew what symptoms and signs to be vigilant for; specifically, weakness of the neck and breathing muscles, that can be life-threatening.<\/p>\n<p class=\"\"><strong><em>The following day a further message told us that the patient was much better; he was awake and alert with a normal blood pressure and pulse rate.<\/em><\/strong><\/p>\n<p class=\"\">We are not able to measure the benefit our service offers in terms of sense of teamwork or even moral support, but there is no doubt it is important.\u00a0The Clinical Officer was relieved to have someone to discuss the progress of the patient with and the Volunteer was extremely encouraging about all her inputs and efforts so far.<\/p>\n<p class=\"\">It is likely that the patient with organophosphate poisoning will need transfer to a hospital where continuous monitoring and ventilatory support is possible.\u00a0But initial prompt resuscitation and atropine administration, along with optimal supportive care prior to transfer, probably saves many lives.\u00a0So, the early management at the local facility is still of vital importance and the Virtual Doctors team tries to support that at every step.<\/p>\n<p class=\"\">But our input does not always end at the time of transfer.\u00a0It is not unusual for our team to be contacted <em>after <\/em>the patient has been moved to hospital.\u00a0Dealing with a case of severe self-poisoning can be quite challenging both clinically and emotionally and we have been sent referrals following transfer asking, \u201cCould I have done anything else?\u201d\u00a0 Our main role then is as a mentor and to debrief.\u00a0We can also share available educational resources with them (in this case there is a topic relating specifically to <a href=\"https:\/\/vdrforums.org.uk\/wp-content\/uploads\/2019\/10\/ORGANOPHOSPHATE-POISONING.pdf\">organophosphate poisoning<\/a> on the forum).\u00a0Reflecting and learning from cases like this is really important.\u00a0We have recently started posting weekly <a href=\"https:\/\/vdrforums.org.uk\/category\/case-based-scenarios\/\">Case-based problems<\/a> on the forum so that we can share learning from these episodes with all the Clinical Officers.\u00a0 Over time we hope to build a significant case series for the whole team.<\/p>\n<p class=\"\">In this way the Virtual Doctors Charity aims to improve knowledge and skills which will empower the Clinical Officers to manage the cases themselves, as well as providing clinical advice and mentoring during and after a case encounter.<\/p>\n<\/div>\n<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Worldwide around 3 million deaths per year result from the harmful use of alcohol. The Clinical Officers in the Facilities we support in Sub-Saharan Africa face similar challenges: they often have to deal with conditions where alcohol is a causal or contributing factor.<\/p>\n","protected":false},"author":1,"featured_media":10580,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"categories":[1],"tags":[],"class_list":["post-10579","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-cases-from-the-field"],"_links":{"self":[{"href":"https:\/\/testv45.demowebsitelinks.com\/VirtualDoctorsUSA\/wp-json\/wp\/v2\/posts\/10579","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/testv45.demowebsitelinks.com\/VirtualDoctorsUSA\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/testv45.demowebsitelinks.com\/VirtualDoctorsUSA\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/testv45.demowebsitelinks.com\/VirtualDoctorsUSA\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/testv45.demowebsitelinks.com\/VirtualDoctorsUSA\/wp-json\/wp\/v2\/comments?post=10579"}],"version-history":[{"count":1,"href":"https:\/\/testv45.demowebsitelinks.com\/VirtualDoctorsUSA\/wp-json\/wp\/v2\/posts\/10579\/revisions"}],"predecessor-version":[{"id":10581,"href":"https:\/\/testv45.demowebsitelinks.com\/VirtualDoctorsUSA\/wp-json\/wp\/v2\/posts\/10579\/revisions\/10581"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/testv45.demowebsitelinks.com\/VirtualDoctorsUSA\/wp-json\/wp\/v2\/media\/10580"}],"wp:attachment":[{"href":"https:\/\/testv45.demowebsitelinks.com\/VirtualDoctorsUSA\/wp-json\/wp\/v2\/media?parent=10579"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/testv45.demowebsitelinks.com\/VirtualDoctorsUSA\/wp-json\/wp\/v2\/categories?post=10579"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/testv45.demowebsitelinks.com\/VirtualDoctorsUSA\/wp-json\/wp\/v2\/tags?post=10579"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}