الفهرس 
ACKNOWLEDGEMENTOnly 14 pages are availabe for public view
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Abstract
Organophosphorus compounds insecticides (OPC) are the most widely used group of insecticides worldwide (Halstead et al., 2015).
The present study aimed to study how extent we are sticking to guidelines of management of organophosphorus poisoning in the emergency unit , intermediate care unit and intensive care unit at Assiut university children hospital from October 2018 to March 2019.
The study included 40 patients with organophosphrus poisoning. Their ages ranged from 1-18 years, 20 cases were males and 20 cases were females.
Demographic data about age and sex were done according to the audit in 100% of cases, and about residence and place of exposure were done in 80 % of cases. It was more common in the age group from 1-5 years by 27 cases (67.5%), group from 5-10 years by 5 cases (12.5%) and a group more than 10 years by 8 cases (20%). This study showed that the most common age presentation was from (1-5) years. There was no significant difference in gender distribution . 20 cases (50%) were males and 20 cases (50%) were females.
Demographic data about residence and place of exposure were done in 80 % of cases. 21 cases (52.5%) were from rural areas and 11 cases (27.5%) were from urban areas. It may be because in our country, agriculture dependent pesticides are readily available at home and children are prone to accidental intake. And 26 cases (65%) were exposed to poison indoor and 6 cases (15%) were exposed outdoor. This may be related to that exposures are more commonly occurred in the home after it has been sprayed or fogged with pesticides. Children may be exposed when pesticides are stored in unlabeled containers or beverage bottles.
All cases(100%) were asked about the type of exposure, 38 cases (95%) were exposed by ingestion route and two cases (5%) were exposed by inhalation route.
Regarding cause of exposure in our study, 100% of cases were asked about it . 32 cases (80%) were accidental and 8 cases (20%) were suicidal to cause self-harm. All of them were above 10 years old , out of which 4 cases were females (50%) and 4 cases were males (50%) . This was related to the activity of children and having the habit of put things in their mouth. So accidental poisoning is common in small children. Adolescents are emotionally labile and this may be reason behind suicidal tendencies in our study group.
As Assiut university hospital children is a tertiary referral center, 85% of cases were asked about referral from other health care center . About (65%) of cases were referred, of which 42.5% were managed before referral by decontamination and gastric lavage and atropine.
According to the guidelines, the following symptoms were asked about: abdominal cramp in 23 cases (57.5%), anorexia in 24 cases (60%), lacrimation in 32 cases (80%), salivation in 32 cases (80%), vomiting in 40 cases (100%), diarrhea in 33 cases (82.5%), dyspnea in 32 cases (80%), cough in 28 cases (70%), incontinence in 29 cases (72.5%), involuntary defecation in 32 cases (80%), confusion in 36 cases (90%), convulsion in 34 cases (85%).
The clinical presentation of the cases were: abdominal cramp in 15 cases (65.2%), anorexia in 16 cases (66.7%), lacrimation in 20 cases (62.5%), salivation in 22 cases (68.8%), vomiting in 30 cases (75%), diarrhea in 24 cases (72.7%), dyspnea in 18 cases (56.2%), cough in 17 cases (60.7%), incontinence in 14 cases (48.3%), involuntary defecation in 9 cases (28.1%), confusion in 29 cases (80.6%), convulsion in 11 cases (32.4%).
According to the guidelines, the following signs were examined : level of conscious in 40 cases (100%), pupil examination in 39 cases (97.5), pallor in 34 cases (85%), cyanosis in 37cases (92.5%), sweating in 35 cases (87.5%), rhinorrhea in 31 cases (77.5%), special odour in 24 cases (60%).
The clinical presentation of the cases were: disturbed conscious level in 23 cases (57.5%), pin point pupil in 32 cases (82.05), pallor in 14 cases (41.2%), cyanosis in 11cases (29.7%), sweating in 25 cases (71.4%), rhinorrhea in 19 cases (61.3%), characteristic odor in 6 cases (25%) .
Temperature was recorded in 77.5 (48.5% were normal, 41.9 % were hypothermia and 9.7% were hyperthermia). Blood pressure was recorded in 97.5% of cases (58.97 % were normal, 41.03 % were hypotensive and 3% were hypertensive). Heart rate was recorded in 95% of cases (52.6% of cases were normal, 15.8% were bradycardic and 31.6% of cases were tachycardic). Respiratory rate was recorded in 97.5% of cases (33.33% of cases were normal, 17.95% were bradypnea and 48.72 % of cases were tachypnea).
Clinical examination of respiratory system retraction was examined in 35 cases (85%) [ 30 cases (88.2%) had retraction]. Grunting was examined in 32 cases (80%) [19 cases (59.4%) were presented with grunting]. Chest auscultation were done in 100% of cases [ 90% of cases were equal air entry, wheezes was present in 13 cases (32.5%), crepitation was present in 33 cases (82.5%), pulmonary edema was present in 3 cases (7.5%)] .
Regarding cardiac examination signs of heart failure was examined in 62.5 % of cases. Sign of arrhythmia was examined in 38 cases (95%) [52.6% of cases had normal rhythm and 47.4 % of cases had abnormal rhythm]. Cardiac examination was done for other sign in 26 cases (65%).
Neurological examination which twitches of fecial muscle was examined in 32 cases (80%) [20 cases (62.5%) had twitches in their faces]. Tremor was examined in 26 cases (65%) [12 cases (46.2%) presented with tremor]. Gait was examined in 18 cases (45%) [17 cases (94.4%) had normal gait, one case (5.6%) had abnormal gait]. Muscle tone was examined in 39 cases (97.5%) [20 cases (53.3%) had normal tone , 19 cases (48.7%) were hypotonia]. Reflexes were examined in 36 cases (90%) [22 cases (61.1%) had normal reflexes, 14 cases (38.9%) were hyporeflexia]. Cranial nerves was examined in 19 cases ( 47.5%), which all of them were intact. Hallucination was examined in 25 cases (62.5%) [3 cases (12%) were presented with hallucination]. Abnormal movement was examined in 24 cases (60%) [3cases (12.5%) had abnormal movement].
Urine output was recorded in 18 cases (45%) [13cases (72.2%) had normal urine output, 5 cases (27.8%) abnormal urine output].
Abdominal examination intestinal sound was examined in 38 cases (95%) [33cases (86.8%) had normal intestinal sound, 5cases (13.2%) had absent intestinal sound]. Abdominal distention was examined in 37 cases (92.5%) which was present in 7cases (18.9%).
The diagnosis was confirmed by measuring plasma cholinesterase levels. Low plasma ChE levels support the diagnosis of organophosphorus poisoning (Eddleston et al, 2006).
Random blood glucose was done in 30 cases (75%) [18 cases (60%) were normal, 9 cases (30%) were hyperglycemic, 3 cases (10%) were hypoglycemic]. White blood cells count was done in 33cases (82.5%) [18cases (54.5%) had normal count and 15 cases (45.5) had leucocytosis]. Haemoglobin level was done in 33cases (82.5%) [24 cases (72.7%) were normal and 9 cases (27.3) had low haemoglobin level].
Platelet count was done in 33cases (82.5%) [29 cases (87.9%) had normal count and 4 cases (12.1) had thrombocytosis]. Serum electrolyte and kidney function test were done in 33cases (82.5%) which in serum creatinine examination [32 cases (96.97%) had normal result, 1 case (3.03) had increased level]. BUN examination [32 cases (96.97%) had normal result, 1 case (3.03) had increased level]. Serum sodium examination [31 cases ( 93.94%) were normal and 2 cases(6.06) were hypernatremic]. Serum potassium examination [33 cases (100%) were normal]. Plasma cholinesterase enzyme was done in 4 cases ( 10%) which all of them were decreased.
ECG was done in 18 cases (45%) [12 cases(66.7%) had normal finding, 6 cases (33.3%) had abnormal finding]. Chest x-ray done in 30 cases (75%) [25 cases (83.3%) had normal finding and 5 cases (16.7%) had abnormal finding]. Arterial blood gases was done in 26 cases (65%) of which 13 cases (50%) were normal.
Management of organophosphorus poisoning has two components; general management which include immediate assessment and management of disturbances in airway, breathing, and circulation and decontamination (skin and gastric), further steps are based on risk assessment and observations during continuous monitoring. Antidotes are muscarinic antagonists (usually atropine), oximes (usually pralidoxime) and benzodiazepines (Eddleston et al., 2005).
The present study showed that decontamination was done in 35 cases (87.5%). Secure airway was done in 100 % of cases. Circulatory support was done in 55 % of cases. Atropine was given in adjusted dose in 100% of cases with frequency of repetition [once in 12 cases (30%), twice 13 cases (32.5%), three times in 6 cases(15%), four times in 5 cases (12.5%), five times in 3cases (7.5%) and six times in one cases (2.5%)].
Benzodiazepines was given in adjusted dose in 22.5% of cases which was needed. Mechanical ventilation was needed in 15% of cases. Anticonvulsive drugs were needed in 22.5% of cases. Inotropic drugs were needed in 22.5 % of cases. Cardiovertion was needed in 12.5% of cases. Diuretic were needed in 2.5 % of cases .
In the present study, the detected complications were: coma was present in 9 cases (22.5%), seizure was present in 11 cases (27.5%), respiratory failure was present in 6 cases(15%), respiratory acidosis was present in 13 cases (32.5%), cardiogenic shock was present in 4 cases (10%) and hypovolemic shock was present in 13 cases (32.5%).
Regarding the duration of hospital stay, 80% of cases had early recovery ( stayed for 1:5 days), 15% of cases stayed for 5:10 days and 5% of cases had delayed recovery (stayed for more than 10 days). The longest duration of hospital stay was 28 days. This was related to development of complications as coma, shock and respiratory failure.
Outcome of the studied cases with organophosphorus poisoning showed that 4 cases died (10%) and 36 cases improved (90%).