3. DISCUSSION
OP is the common form of poisoning accounting for 0.9-1.0% of the patient admissions to hospital EDs in Nepal.2,4 The most prevalent symptoms of OP poisoning are SLUDGE (salivation, lacrimation, urination, defecation, gastric cramps, and emesis).9 Signs and symptoms of OP poisoning can be divided into acute cholinergic crisis, intermediate syndrome (IMS) and type 3 paralysis or organophosphate induced delayed polyneuropathy (OPIDP).10 IMS is muscle paralysis involving mainly bulbar, respiratory, and proximal muscles of limbs following the acute cholinergic phase, occurring 3-4 days after exposure. It usually resolves in 1–3 weeks but may require mechanical ventilation if indicated.9 Respiratory failure is the most common cause of death in IMS.8,11 OPIDP occurs about 2-4 weeks after exposure to large doses of OP insecticide. It is characterised by distal muscle weakness causing ataxia, foot drop and claw hand, and is due to inhibition of neuropathy target esterase. It may take weeks to months to recover. Rare complications of OP poisoning are cardiac arrhythmias, pancreatitis, and hepatic dysfunction.12 There have been cases of delayed myelopathy after insecticide CPS ingestion.10Diagnosis of OP poisoning is primarily based on the clinical history, the clinical signs and symptoms, smell of insecticides or solvents involved, and reduced levels of RBC or plasma AchE. The management of OP poisoning requires prompt identification of toxins and rapid administration of atropine to counteract the cholinergic crisis. Although psychotic symptoms such as restlessness, excitement, hallucinations, and delirium have been reported following atropine administration, atropine is an antidote for OP poisoning.3 Exposure with dermal contact needs immediate decontamination to reduce systemic absorption.13 Further management requires adequate supportive care including IV fluids, airway management, seizure control and 2-PAM to reactivate AchE.2 One of the studies shows atropine seemed to be as effective as atropine plus 2-PAM in the treatment of acute OP poisoning. 2-PAM if used should be given within 48 hrs of poisoning.8 Immediate decontamination, oxygen, ventilatory support and benzodiazepines for seizure control if required, IV atropine, IV 2-PAM and IV fluids are of utmost importance for saving a patient’s life.4 Also while dealing with cases of suspected poisoning, stomach wash, blood, stool, urine and if possible empty bottles of poison should be collected for medicolegal registry.14