Organophosphorus poisoning.

Acute poisoning by organophosphorus (OP) compounds is a major global clinical problem, with thousands of deaths occurring every year. Most of these pesticide poisoning and subsequent deaths occur in developing countries following a deliberate self ingestion of the poison. Metacid (Methyl parathion) and Nuvan (Dichlorovos) are commonly ingested OP pesticides; Dimethoate, Profenofos, and Chlorpyrifos are other less frequently ingested compounds in Nepal. The toxicity of these OP pesticides is due to the irreversible inhibition of acetylcholinesterase (AChE) enzyme leading to accumulation of acetylcholine and subsequent over-activation of cholinergic receptors in various parts of the body. Acutely, these patients present with cholinergic crisis; intermediate syndrome and delayed polyneuropathy are other sequel of this form of poisoning. The diagnosis depends on the history of exposure to these pesticides, characteristic manifestations of toxicity and improvements of the signs and symptoms after administration of atropine. The supportive treatment of OP poisoning includes the same basic principles of management of any acutely poisoned patient i.e., rapid initial management of airways, breathing, and circulation. Gastric lavage and activated charcoal are routinely used decontamination procedures, but their value has not been conclusively proven in this poisoning. Atropine is the mainstay of therapy, and can reverse the life threatening features of this acute poisoning. However, there are no clear cut guidelines on the dose and duration of atropine therapy in OP poisoning. Cholinesterase reactivators, by regenerating AChE, can reverse both the nicotinic and muscarinic effects; however, this benefit has not been translated well in clinical trials. All these facts highlight that there are many unanswered questions and controversies in the management of OP poisoning and there is an urgent need for research on this aspect of this common and deadly poisoning.