Atnaa

Organophosphate Insecticide or Nerve Agent Poisoning Symptom Criteria

Mild symptoms: Bradycardia, chest tightness, breathing difficulties, blurred vision, drooling miosis, vomiting, runny nose, stomach cramps (acute onset), salivation, teary eyes, wheezing/coughing, tremors/muscular twitching, airway secretions increased

Severe symptoms: Confused/strange behavior, involuntary urination/defecatioin, muscular twitching/generalized weakness (severe), severe breathing difficulties, convulsions, copious secretion from lung or airway

Organophosphate, Insecticide or Nerve Agent Poisoning

2.1 mg atropine/0.7 mL + 600 mg pralidoxime/2 mL IM into outer thigh or buttocks

Mild symptoms: 1 injection; if after 10-15 min there are no severe symptoms experienced, no further injections are necessary; if severe symptoms experienced following initial injection, give 2 additional injections in rapid succession

Severe symptoms (>1 severe symptom): 3 injections in rapid succession

Maximum dose: Not to exceed 3 injections unless medical care support available

Renal Impairment

Caution; parlidoxime is renally eliminated

Safety and efficacy not established

No absolute contraindications

• It is used to treat poisoning from nerve gas or chemicals that kill insects.

Use this medicine as ordered by your doctor. Read all information given to you. Follow all instructions closely.

• It is given as a shot into a muscle.

What do I do if I miss a dose?

• Call your doctor to find out what to do.

WARNING/CAUTION: Even though it may be rare, some people may have very bad and sometimes deadly side effects when taking a drug. Tell your doctor or get medical help right away if you have any of the following signs or symptoms that may be related to a very bad side effect:

• Signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat.
• Very bad dizziness or passing out.
• Chest pain or pressure or a fast heartbeat.
• A heartbeat that does not feel normal.
• Very bad headache.
• Feeling confused.
• Trouble passing urine.
• Lowered interest in sex.
• Change in sex ability.
• Fast breathing.
• Not able to pass urine or change in how much urine is passed.

All drugs may cause side effects. However, many people have no side effects or only have minor side effects. Call your doctor or get medical help if any of these side effects or any other side effects bother you or do not go away:

• Muscle stiffness.
• Pain where the shot was given.
• Dry mouth.
• Dry nose.
• Change in eyesight.
• Dry eyes.
• If bright lights bother your eyes.
• Larger pupils.
• Headache.
• Dizziness.
• Flushing.
• Hard stools (constipation).
• Belly pain.
• Swelling of belly.
• Upset stomach or throwing up.
• Less sweating.
• Feeling sleepy.
• Muscle weakness.
• Dry skin.

These are not all of the side effects that may occur. If you have questions about side effects, call your doctor. Call your doctor for medical advice about side effects.

You may report side effects to the FDA at 1-800-FDA-1088. You may also report side effects at http://www.fda.gov/medwatch.

FOR USE IN NERVE AGENT POISONING ONLY STERILE SOLUTIONS FOR INTRAMUSCULAR USE ONLY

Symptoms:

Serious overdosage with atropine is characterized by widespread paralysis of parasympathetically innervated organs. Dry mucous membranes, widely dilated and nonresponsive pupils, tachycardia, fever, and cutaneous flush are especially prominent, as are mental and neurological symptoms. Disorientation, mania, hallucinations, gait disturbances, and symptoms may last 48 hours or longer. In instances of severe intoxication, respiratory depression, coma, circulatory collapse, and death may occur.

The fatal dose of atropine is not known. In the treatment of organophosphorous poisoning, 200 mg doses have been used and doses as high as 1000 mg have been given.

In children, 10 mg or less may be fatal. With a dose as low as 0.5 mg, undesirable minimal symptoms or responses of overdosage may occur. These increase in severity and extent with larger doses of the drug (excitement, hallucinations, delerium, and coma with a dose of 10 mg or more). However, in the presence of organophosphate poisoning, higher doses of atropine may be tolerated.

Pralidoxime Chloride

Symptoms of pralidoxime chloride overdose have been observed in normal subjects only: dizziness, blurred vision, diplopia, headache, impaired accommodation, nausea, slight tachycardia. In therapy it has been difficult to differentiate side effects due to the drug from those due to effects of the poison.

Treatment:

Supportive treatment should be administered as indicated. If respiration is depressed, artificial respiration with oxygen is necessary. Ice bags, alcohol sponges or a hypothermia blanket may be required to reduce fever, especially in children. Catheterization may be necessary if urinary retention occurs. Since atropine elimination takes place through the kidney, urinary output must be maintained and increased if possible; intravenous fluids may be indicated. Because of the affected person's photophobia, the room should be darkened.

In the event of toxic overdosage, a short acting barbiturate or diazepam may be given as needed to control marked excitement and convulsions. Large doses for sedation should be avoided because central depressant action may coincide with the depression occurring late in atropine poisoning. Central stimulants are not recommended. Physostigmine, given as an atropine antidote by slow intravenous injection of 1 to 4 mg (0.5 to 1.0 mg in children), rapidly abolishes delirium and coma caused by large doses of atropine. Since physostigmine has a short duration of action, the patient may again lapse into coma after one or two hours and repeated doses are likely to be required. Neostigmine, pilocarpine, and methacholine are of little real benefit, since they do not penetrate the blood-brain barrier.

1. Landauer, W: Cholinomimetic teratogens. V. The effect of oximes and related cholinesterase reactivators. Teratology 15: 33 (Feb) 1977.
2. Moller, K.O., Jensen-Holm, J. and Lausen, H.H.: Ugeskr Laeg. 123: 501,1961.
3. Namba, T, Nolte, C.T., Jackrel, J. and Grob, D: Poisoning due to organophosphate insecticides. Acute and chronic manifestations. Amer. J. Med. 50: 475 (Apr), 1971.
4. Arena, J.M.: Poisoning, Toxicology Symptoms, Treatments, ed. 4, Springfield, IL, Charles C.Thomas, 1979, p. 133.
5. Brachfeld, J., and Zavon, M.R.: Organic phosphate (Phosdrin®) intoxication. Report of a case and the results of treatment with 2-PAM, Arch. Environ. Health 11: 859, 1965.
6. Hayes, W.J., Jr.: Toxicology of Pesticides. Baltimore, The Williams &Wilkins Company, 1975, p. 416.

– Patient Information