The treatment of OP poisoning includes decontamination, supportive care, and the antidotes, atropine and oximes. Mortality due to OP poisoning is typically a result of respiratory failure. The “intermediate syndrome” (IMS) may occur from 24 to 96 h after resolution of the cholinergic toxidrome and is characterized by respiratory paralysis, cranial neuropathy, proximal limb weakness, and hyporeflexia. Acetylcholine then accumulates within the nervous system overstimulating both the muscarinic and nicotinic receptors leading to a wide range of clinical effects: (1) salivation, lacrimation, urination, diarrhea, gastrointestinal distress, emesis (SLUDGE) bronchorrhea, bronchoconstriction, and bradycardia (muscarinic) (2) muscle fasciculations, weakness, and diaphragmatic paralysis (nicotinic) and (3) restlessness, dysarthria, tremor, altered mentation, psychosis, and seizure (central nervous system). Organophosphates phosphorylate the serine hydroxyl group of acetylcholinesterase to inactivate the enzyme. It is crucial for clinicians to understand the optimal treatment for acute OP poisonings, not only because of the widespread use of OP in agriculture but also due to the potential threat of chemical warfare with OP-containing agents. These agents were also used in a terrorist attack in the Tokyo subway in 1995 and have been implicated more recently in the assassination of Kim Jung Nam, the half-brother of Kim Jung Un. Organophosphates were first developed for warfare in Nazi Germany and have since been deployed multiple times with devastating effects: Iran-Iraq war (1980–1988) by Saddam Hussein and Syrian conflicts in 20. Use of OP-containing nerve gas is also an ongoing concern in present-day conflicts. Intentional poisonings comprise approximately 60–70% of pesticide poisonings in Malaysia, Indonesia, and Thailand 4. Seventy percent of unintentional poisonings are related to occupational exposures in Sri Lanka. The World Health Organization estimates that about 3 million poisonings (1 million unintentional and 2 million intentional) involving OP pesticides occur annually worldwide resulting in 220,000 deaths. Organophosphates account for the majority of pesticide-related unintentional or intentional poisonings in lower- and middle-income countries. Organophosphate (OP) compounds are used primarily as pesticides in agricultural settings but have also been developed into nerve agents such as sarin and VX. Based on our meta-analysis of the available RCTs, 2-PAM was not shown to improve outcomes in patients with acute OP poisoning. The risk of death (RR = 1.5, 95% CI 0.9–2.5) intubation (RR = 1.3, 95% CI 1.0–1.6) intermediate syndrome (RR = 1.6, 95% CI 1.0–2.6) complications (RR = 1.2, 95% CI 0.8–1.8) and the duration of intubation (mean difference 0.0, 95% CI − 1.6–1.6) were not significantly different between the atropine plus 2-PAM and atropine alone. We found five studies comprising 586 patients with varying risks of bias. Data were abstracted and risk ratios (RR) were calculated for mortality, rate of intubation, duration of intubation, intermediate syndrome, and complications such as hospital-acquired infections, dysrhythmias, and pulmonary edema. The Cochrane review handbook was used to assess the risk of bias. We searched PubMed, EMBASE, and SCOPUS up to March 2017. We performed a systematic review and meta-analysis of available randomized controlled trials (RCT) to compare 2-PAM plus atropine in comparison to atropine alone for acute OP poisoning. The benefit of adding 2-pyridine aldoxime methyl chloride (2-PAM), however, is controversial. The therapeutic role of atropine is well-established for patients with acute OP poisoning. Organophosphates (OP) account for the majority of pesticide-related unintentional or intentional poisonings in lower- and middle-income countries.
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