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Comparison of Current Recommended Regimens of Atropinization in Organophosphate Poisoning

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Abstract

Atropine is the mainstay of therapy in organophosphate (OP) toxicity, though research and consensus on dosing is lacking. In 2004, as reported by Eddleston et al. (J Toxicol Clin Toxicol 42(6):865-75, 2004), they noted variation in recommended regimens. We assessed revisions of original references, additional citations, and electronic sources to determine the current variability in atropine dosing recommendations. Updated editions of references from Eddleston et al.’s work, texts of Internal and Emergency Medicine, and electronic resources were reviewed for atropine dosing recommendations. For comparison, recommendations were assessed using the same mean dose (23.4 mg) and the highest dose (75 mg) of atropine as used in the original paper. Recommendations were also compared with the dosing regimen from the World Health Organization (WHO). Thirteen of the original recommendations were updated and 15 additional references were added giving a convenience sample of 28. Sufficient information to calculate time to targeted dose was provided by 24 of these samples. Compared to 2004, current recommendations have greatly increased the speed of atropinization with 13/24 able to reach the mean and high atropine dose within 30 min compared to 1/36 in 2004. In 2004, there were 13 regimens where the maximum time to reach 75 mg was over 18 h, whereas now, there are 2. While only one recommendation called for doubling the dose for faster escalation in 2004, 15 of the 24 current works include dose doubling. In 2004, Eddleston et al. called for an evidence-based guideline for the treatment of OP poisoning that could be disseminated worldwide. Many current recommendations can adequately treat patients within 1 h. While the WHO recommendations remain slow to treat patients with OP poisoning, other authorities are close to a consensus on rapid atropinization.

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References

  1. Eddleston M, Buckley NA, Eyer P et al (2008) Management of acute organophosphorus pesticide poisoning. Lancet 371(9612):597–607

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  2. Eddleston M, Buckley NA, Checketts H et al (2004) Speed of initial atropinisation in significant organophosphorus pesticide poisoning—a systematic comparison of recommended regimens. J Toxicol Clin Toxicol 42(6):865–875

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  3. Ford MD (2012) Acute poisoning. In: Goldman L, Schafer AI (eds) Goldman’s Cecil medicine. Elsevier/Saunders, Philadelphia, pp 670–84

    Chapter  Google Scholar 

  4. Robey WC III, Meggs WJ (2011) Pesticides. In: Tintinalli JE, Stapczynski JS (eds) Tintinalli’s emergency medicine: a comprehensive study guide. McGraw-Hill, New York

    Google Scholar 

  5. Aaron CK, Rhee JW, Dolcourt BA (2010) Pesticides. In: Marx JA, Hockberger RS, Walls RM et al (eds) Rosen’s emergency medicine: concepts and clinical practice. Mosby Elsevier, Philadelphia, pp 2052–2060

    Google Scholar 

  6. Taylor P (2011) Anticholinesterase Agents. In: Brunton LL, Blumenthal DK, Murri N, Hilal-Dandan R, Knollman BC (eds) Goodman & Gilman’s The pharmacological basis of therapeutics, online edition. McGraw-Hill Medical, New York

    Google Scholar 

  7. Costa LG (2013) Toxic Effects of Pesticides. In: Klaassen CD (ed) Casarett & Doull’s toxicology: the basic science of poisons. McGraw-Hill Medical, New York

    Google Scholar 

  8. Ehrich M (2005) Organophosphates. In: Wexler P (ed) Encyclopedia of toxicology. Elsevier, Oxford

    Google Scholar 

  9. Rothrock SG (2012) Tarascon’s adult emergency pocketbook. Jones & Bartlett Learning, Sudbury, Massachusetts, p 176

    Google Scholar 

  10. Rivers CS, Howell J, Barkin R (2006) Toxicologic emergencies. In: Preparing for the written board exam in emergency medicine. Emergency Medicine Educational Enterprises, Milford, pp 733–800

    Google Scholar 

  11. Wyatt JP, Illingworth RN, Graham CA, Hogg K (2012) Toxicology. In: Oxford handbook of emergency medicine. Oxford University Press, Oxford

    Chapter  Google Scholar 

  12. Stone CK, Humphries R (2011) Current diagnosis and treatment emergency medicine, 7th edn. McGraw Hill, New York

    Google Scholar 

  13. Bird, S. Organophosphate and carbamate poisoning. In: Basow D, editor. UpToDate. Waltham, Massachusetts: UpToDate.com; 2012. Accessed August 2012

  14. Katz KD. Organophosphate toxicity treatment and management. In: Pinsky MR, editor. eMedicine emergency medicine : an on-line medical reference. Medscape Reference; 2012. Accessed August 2012.

  15. Lexicomp. Lexi-Drugs: Atropine. Lexicomp American Pharmacists Association Hudson, Ohio; 2012. Accessed August 2012.

  16. Drug monographs: Atropine. Access Emergency Medicine; 2012. Available from: www.accessemergencymedicine.com. Accessed August 2012.

  17. Epocrates. Atropine. Epocrates online. Available from: https://online.epocrates.com. Accessed August 2012.

  18. Barile FA (2010) Clinical toxicology: principles and mechanisms, 2nd edn. Informa HealthCare, London

    Book  Google Scholar 

  19. Vohra R (2012) Organophosphorous and carbamate insecticides. In: Olson K (ed) Poisoning and drug overdose. McGraw-Hill Companies, USA

    Google Scholar 

  20. Organophosphorus poisoning. In: ToxiNZ; 2012. Available from: toxinz.co.nz. Accessed August 2012.

  21. Howland MA (2011) Antidotes in depth: atropine. In: Nelson LS, Lewin NA, Howland MA, Hoffman RS, Goldfrank LR, Flomenbaum NE (eds) Goldfrank’s toxicologic emergencies. McGraw-Hill, New York, pp 1473–1476

    Google Scholar 

  22. Aaron CK (2007) Organophosphates and carbamates. In: Shannon MW, Borron SW, Burns MJ (eds) Haddad and Winchester’s clinical management of poisoning and drug overdose. Saunders/Elsevier, Philadelphia, pp 1171–1184

    Chapter  Google Scholar 

  23. Wiki Tox. 2.2.7.4.5 organophosphates. Wiki Tox: open source clinical toxicology curriculum; 2012. Available from http://curriculum.toxicology.wikispaces.net/2.2.7.4.5+Organophosphates Accessed August 2012.

  24. Hurst CG, Newmark J, Romano JA. Chemical terrorism. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson L, Loscalzo J, editors. Harrison’s Online. Access Medicine; 2012

  25. Joint Formulary Committee (2011) British National Formulary. 62nd ed. London: British Medical Association and Royal Pharmaceutical Society of Great Britain

  26. Stuart MC, Kouimtzi M, Hill SR, (eds) (2008) Antidotes and other substances used in poisonings. In: WHO model formulary 2008. World Health Organization, Geneva, p. 55–66

  27. Lotti M (2010) Clinical toxicology of anticholinesterase agents in humans. In: Krieger RI (ed) Hayes’ handbook of pesticide toxicology. Elsevier, London, pp 1543–1589

    Chapter  Google Scholar 

  28. Leikin JB, Paloucek FP (eds) (2008) Antidotes and drugs used in toxicology. In: Poisoning and toxicology handbook. Informa Healthcare, New York, pp. 965–1013

  29. Poisindex System. Organophosphorous poisoning. Thomson Reuters (Healthcare) Inc. Greenwood Village, Colorado. Accessed June 2013.

  30. National Poisons Information Service UK. Organophosphorus insecticides. TOXBASE. Accessed June 2013.

  31. Bird SB, Gaspari RJ, Dickson EW (2003) Early death due to severe organophosphate poisoning is a centrally mediated process. Acad Emerg Med 10:295–298

    Article  PubMed  Google Scholar 

  32. Perera PM, Shahmy S, Gawarammana I, Dawson AH (2008) Comparison of two commonly practiced atropinization regimens in acute organophosphorus and carbamate poisoning, doubling doses vs. ad hoc: a prospective observational study. Hum Exp Toxicol 27:513–518

    Article  CAS  PubMed Central  PubMed  Google Scholar 

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Conflicts of Interest

This study received no funding. The authors report no conflicts of interest.

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Authors and Affiliations

  1. NYU/Bellevue Hospital Center, 455 First Ave, New York, NY, USA

    Nicholas J. Connors & Robert S. Hoffman

  2. New York City Poison Control Center, 455 First Ave, New York, NY, USA

    Nicholas J. Connors & Robert S. Hoffman

  3. New York University School of Medicine, 455 First Ave, New York, NY, USA

    Zachary H. Harnett

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  1. Nicholas J. Connors
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  2. Zachary H. Harnett
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  3. Robert S. Hoffman
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Correspondence to Nicholas J. Connors.

Electronic supplementary material

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Supplementary Table

A: The sources used in this analysis updated since 2004, B: those in Eddleston et al.’s paper that were not updated, C: those that were not located, and D: new sources accessed for atropine dosing recommendations (DOCX 25 kb).

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Connors, N.J., Harnett, Z.H. & Hoffman, R.S. Comparison of Current Recommended Regimens of Atropinization in Organophosphate Poisoning. J. Med. Toxicol. 10, 143–147 (2014). https://doi.org/10.1007/s13181-013-0324-9

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