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Organophosphorus and carbamate insecticides (organophosphates: parathion, malathion, etc; carbamates: carbaryl, aldicarb, etc) are widely used in commercial agriculture and home gardening and have largely replaced older, more environmentally persistent organochlorine compounds such as DDT and chlordane. The organophosphates and carbamates—also called anticholinesterases because they inhibit the enzyme acetylcholinesterase—cause an increase in acetylcholine activity at nicotinic and muscarinic receptors and in the peripheral and CNS. There are a variety of chemical agents in this group, with widely varying potencies. Most of them are poorly water-soluble, are often formulated with an aromatic hydrocarbon solvent such as xylene and are well absorbed through intact skin. Most chemical warfare “nerve agents” (such as GA [tabun], GB [sarin], GD [soman], and VX) are organophosphates.


Inhibition of cholinesterase results in abdominal cramps, diarrhea, vomiting, excessive salivation, sweating, lacrimation, miosis, wheezing and bronchorrhea, seizures, and skeletal muscle weakness. Initial tachycardia is usually followed by bradycardia. Profound skeletal muscle weakness, aggravated by excessive bronchial secretions and wheezing, may result in respiratory arrest and death. Symptoms and signs of poisoning may persist or recur over several days, especially with highly lipid-soluble agents such as fenthion or dimethoate.

The diagnosis should be suspected in patients who present with miosis, sweating, and diarrhea. Serum and RBC cholinesterase activity is usually depressed at least 50% below baseline in those patients who have severe intoxication.


A. Emergency and Supportive Measures

If the agent was recently ingested, consider gut decontamination by aspiration of the liquid using a nasogastric tube followed by administration of activated charcoal. If the agent is on the person’s skin or hair, wash repeatedly with soap or shampoo and water. Providers should take care to avoid skin exposure by wearing gloves and waterproof aprons. Dilute hypochlorite solution (eg, household bleach diluted 1:10) is reported to help break down organophosphate pesticides and nerve agents on equipment or clothing.

B. Specific Treatment

Atropine reverses excessive muscarinic stimulation and is effective for treatment of salivation, bronchial hypersecretion, wheezing, abdominal cramping, and sweating. However, it does not interact with nicotinic receptors at autonomic ganglia and at the neuromuscular junction and has no direct effect on muscle weakness. Administer 2 mg intravenously, and if there is no response after 5 minutes, give repeated boluses in rapidly escalating doses (eg, doubling the dose each time) as needed to dry bronchial secretions and decrease wheezing; as much as several hundred milligrams of atropine have been given to treat severe poisoning.

Pralidoxime (2-PAM, Protopam) is a more specific antidote that reverses organophosphate binding to the cholinesterase enzyme; therefore, it should be effective at the neuromuscular junction as well as other nicotinic and muscarinic sites. It is most likely to be clinically effective if started very soon after poisoning, to prevent permanent binding of the organophosphate to cholinesterase. However, ...

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