Abstract:
-Early deaths from organophosphorus (OP) pesticide selfpoisoning result from respiratory failure and cardiovascular collapse. Therapy
requires the urgent use of atropine to reverse cholinergic excess, thereby
improving respiratory function, heart rate, and blood pressure. We aimed to assess
variation in textbook recommendations for early atropinisation and to see whether
this variation affected time to stabilisation using model data from 22 severely
poisoned patients seen in a Sri Lankan clinical trial. Methods-We extracted
prospectively recorded data on atropine requirements for 22 OP poisoned patients
who required intubation but survived to discharge. We did a systematic search for
textbook recommendations for initial atropinisation regimens. These regimens
were then applied to data from the Sri Lankan patients. Results-The patients
required a mean of 23.4 mg (standard deviation 22.0, range 1-75 mg) atropine to
clear the lungs, raise the pulse above 80bpm, and restore systolic blood pressure to
more than 80 mmHg. Textbook recommendations varied markedly -atropinisation
of an average patient, requiring the mean dose of 23.4mg, would have taken 8 to
1380 mins; atropinisation of a very ill patient, requiring 75mg, would have taken
25 to 4440 mins. Atropinisation was attained most rapidly with a regimen of
increasing bolus doses after failure to respond to the previous bolus. ConclusionsThere is great variation in recommendations for atropinisation, with some
regimens taking hours and even days to stabilise a patient. The guidelines are very
flexible - possibly appropriate for experienced emergency physicians or clinical
toxicologists, but completely inappropriate for the inexperienced junior doctors
who see most cases worldwide. We recommend that a consensus guideline be
developed by appropriate organisations to bring order to this important part of OP
therapy, while acknowledging the paucity of data to drive the guidelines.
