الفهرس 
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Abstract
Acute cholinesterase enzyme inhibitor poisoning is considered as a major health problem by WHO with estimate mortality 250,000 per year, cholinesterase enzyme inhibitors poisoning causes accumulation of acetylcholine. ACh accumulation at muscarinic and nicotinic receptors leads to various manifestation of cholinergic toxidrome (SLUDGE and DUMBLE).
Currently, diagnosis of acute ChEI poisoning depends on clinical toxidrome and BuChE level aid in diagnosis. Atropine and oximes are considered the mainstay treatment of acute ChEI poisoning. Oxime has a doubtful efficacy.
The aim of the present work is to assess the efficacy of magnesium sulfate, sodium bicarbonate or N-Acetylcysteine as adjuvant therapies in cases of acute poisoning by cholinesterase enzyme inhibitor insecticides.
The current study included 80 patients equally distributed on four groups, all four groups are subjected to routine lab, ECG and buytryl cholinesterase level (BuChE) on admission and 24 hours later. All patients received usual treatment in the form of atropine and oximes. All patients were subjected to poisoning severity score (PSS) and Glasgow coma score (GCS).
group I was considered control group receive usual treatment only. group II receive magnesium sulphate (MgSO4) four grams divided on 2 dose in 12 hours schedule. group 3 received 50 meq. Sodium bicarbonate (NaHCO3) on three doses and was subjected to arterial blood gas on admission and after treatment. group IV received N acetyl cysteine 600 mg triple daily dose for 3 days.
Outcome was assessed on bases of mortality, hospital stay, ICU stay and mechanical ventilation period added to appearance of any serious side effects and BuChE level after 24 hours from start of start of treatment.
The current study was conducted on 80 patients; 57 females and 23 males, 90% (72) was intentional while 10 % (n=8) was accidental, and all patients was between age of 18 and 48 years old.
The current study, showed that 92.5% (n=74) presented with nausea and vomiting, 90% (n=72) miosis, 60% (n=48) breathing difficulty, 33% (n=26) fasciculation, 30% (n=24) bradycardia, 30% (n=24) prolonged Qtc interval, 25% (n=20) confusion, 17.5% (n=14) tachycardia and 11.25% (n=9) hypotension.
Patients was randomly distributed between four groups. There was no statistical difference between them on admission as regards respiratory rate, temperature, fasciculation, PH, Po2, HCO3, oxygen saturation, creatinine, haemoglobin, sodium, potassium, magnesium, cholinesterase level and poisoning severity score and Glasgow coma scale.
There was significant difference between four groups as regards heart rate this was because bradycardia and prolonged Qtc was exclusion criteria for group II. Also, hypotension was another exclusion criteria in group II. While group III significant difference was a matter of coincidence. Hypoventilation was an exclusion criteria for group III which was responsible for significant difference in PCO2 between four groups.
There was no significant difference in serum magnesium level between group I and II on admission or post treatment with MgSO4or group I pre and post treatment. Although, there was significant difference in magnesium level in group II between pre-treatment with mean 1.81 and post treatment with mean 1.97.
PH mean value post treatment between group I and III and between pre-treatment and post treatment with NaHCO3 in group III was significant. Sodium bicarbonate infusion caused rise to PH to a mean 7.49.
Serum cholinesterase level post treatment was significantly higher in four groups except group I. Where, mean pre-treatment was 88.70 ± 45.27, 104.8 ± 63.33, 75.05 ± 37.07 and 98.50 ± 56.92 in group I, II, III and IV respectively. While post treatment was 114.0 ± 56.86, 194.8 ± 138.0, 119.6 ± 54.74 and 179.7 ± 103.9 in group I, II, III and IV respectively.
Serum cholinesterase level post treatment was significantly higher in group II and IV than group I.
In the current study, atropine dose was significantly lower in group II, III and IV than group I. Mean atropine level was 44.1 ± 24.3, 24.2 ± 22.8, 25.6 ± 22.7 and 24.1 ± 13.3 in four groups, respectively.
In the present study, there was no significant difference between oxime use in four groups where P equals 0.768.
In the present study, there was no significant difference between four groups in ICU admission where P equals 0.479, although, there was lower hospital length of stay in group II and III relative to group I where P was 0.001 and 0.011, respectively. While no significant difference was detected between group I and IV as regard hospital length of stay where P equals 0.275.
In the current study, there was no significant difference between four groups in mechanical ventilation where P equals 0.674.
In the present study, sever poisoning severity score was related to longer hospital length of stay and lower cholinesterase level. Also it was related to higher incidence of ICU admission but did not reflect length of ICU stay.
In the current study, patients admitted to intensive care unit had a lower cholinesterase level than patients who had not been admitted where, p equals 0.001.
In the present study, there was significant negative correlation between Glasgow coma scale and ward length of stay where, p equals 0.006.