The use of glycopyrrolate in a case of intermediate syndrome following acute organophosphate poisoning

Abstract

The use of glycopyrrolate in a case of intermediate syndrome following acute organophosphate poisoningPurpose: This report describes a case of organophosphate intoxication refractory to atropine in which glycopyrrolate was used to reduce cholinergic symptoms, and describes the development of intermediate syndrome, an uncommon subacute complication of organophosphate poisoning. Clinical features: A 44-yr-old woman presented in cholinergic crisis following malathion ingestion. Treatment was initiated with atropine and pralidoxime. Despite clinical signs of adequate atropinisation, the patient continued to have profuse bronchorrhoea, which resolved with glycopyrrolate. During her course in the intensive care unit, she displayed a subacute deterioration in neuromuscular and mental status with decrement-increment phenomenon on electromyography consistent with intermediate syndrome. The patient eventually made a complete recovery. Conclusion: This case report describes the successful use of glycopyrrolate in organophosphate intoxication and the development of the intermediate syndrome, characterised by onset of weakness of neck flexors, proximal limb muscles, and respiratory muscles within one to four clays after poisoning. Recognition of the syndrome is important in light of the potential for respiratory depression requiring ventilatory support.Objectif : Cette observation d&rit un cas d'intoxication aux organophosphor& r6fractaire ~ ratropine o6 le glycopyrrolate a ~t~ utilis~ pour diminuer les sympt6mes cholinengiques, et d&rit aussi le d~veloppement d'un syndrome interm~diaire, une complication subaigu~ non fr~quente de I'empoisonnement aux organophosphor~s. l~,l~ments cliniques : Une femme de 44 ans se pr&ente en crise cholinergique suite ~ I'ingestion de malathion. On d~bute le traitement ~. ratropine et ~ la pralidoxime. Malgr~ des signes cliniques d'atropinisation adequate, la patiente continue ~ pr&enter une bronchorrh~e profuse, qui rentre dans I'ordre avec le glycopyrrolate. Durant son s~jour aux soins intensifs, elle pr&ente une d&&ioration subaigua de la fonction neuromusculaire et mentale avec ph~nom~ne incr~mentiel-d&r~mentiel ~ I'~lectromyographie, compatible avec un syndrome interm~-diaire. Cette patiente va &entuellement r&up&er compl&ement. Conclusion : Cette observation ~ propos d'un cas d&rit I'utilisation avec succ& du g!ycopyrrolate dans I'intoxication aux organophosphor& et la survenue d'un syndrome interm~diaire caract&is~ par rapparition de faiblesse au niveau des fl&hisseurs du cou, des muscles proximaux des membres et des muscles respiratoires survenant dans un d~lai de un ~ quatre jours apr& I'intoxication. Lidentification de ce syndrome est importante ~ cause de son potentiel d'insuffisance respiratoire n&essitant un support ventilatoire.

Early Death Due to Severe Organophosphate Poisoning Is a Centrally Mediated Process

“…Although atropine injection remains the standard treatment for acute OP poisoning, other anticholinergic agents have also been suggested and used in this setting. Bardin and Eeden 11 found that glycopyrrolate-a highly polar quaternary ammonium compound that does not cross the blood-brain barrier, [11][12][13] was equally effective in treating OP poisoning when compared with atropine, in patients who survived to hospital arrival. Ipratropium bromide (also a quaternary ammonium chemical) has also been used effectively in the setting of acute OP poisoning.…”

Organophosphate and Carbamate Poisoning

“…Despite limited evidence, glycopyrrolate is not inferior to atropine, and should be considered an appropriate alternative to atropine if atropine supply is limited. 86 Finally, if bronchorrhea and bronchoconstriction are the primary forms of toxicity, ipratropium can be administered by inhalation with direct effects on the target end organ. 87,88 Indications for antimuscarinic pharmacologic therapy are provided in Table 4.…”

Organophosphorus poisoning and anaesthesia

“…It has been shown that a smaller than traditional dose of atropine used over a shorter duration at a hospital in China was associated with lower complication and mortality rates [131]. A case of OP poisoning refractory to atropine, and in which glycopyrrolate was used to reduce cholinergic symptoms, was reported recently [9].…”

“…Organophosphorusbased pesticides are widely used globally and have emerged as the major pesticide contributor to ill health [2]. Ill health related to these irreversible inhibitors of acetylcholinesterase has been reported recently in studies from China [3], India [4][5][6], Brazil [7], Mexico [8], Canada [9], Costa Rica [10], Columbia [11], Puerto Rico [12], France [13], Spain [14,15], Poland [16], Italy [17,18], Belgium [19], Romania [20], Portugal [21], Greece [22], Germany [23], Japan [24], Jordan [25], South Africa [26], Turkey [27], Taiwan [28] and Sri Lanka [29,30]. In 1996, the American Association of Poison Control Centers reported 86 914 human exposures to pesticides in the US [31].…”