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有机磷和氨基甲酸酯类中毒

Author
Steven Bird, MD, FACEP
Section Editor
Stephen J Traub, MD
Deputy Editor
Jonathan Grayzel, MD, FAAEM
Translators
邢玲玉, 主治医师

引言

有机磷(organophosphate, OP)和氨基甲酸酯类是强效胆碱酯酶抑制剂，可在皮肤接触、吸入或经口摄入后引起严重的胆碱能毒性。尽管有机磷和氨基甲酸酯类的结构不同(图 1)，但中毒后的临床表现相似，过量使用后的治疗也类似。

本专题将总结有机磷和氨基甲酸酯类中毒。附表中总结了紧急处理的相关问题(表 1)。疑似药物中毒的一般处理方法将单独讨论。 (参见“成人药物中毒的一般处理方法”)

流行病学和暴露源

有机磷50多年来都在世界各地被用作杀虫剂。其使用率在过去的10-20年间有所下降，部分原因是氨基甲酸酯类杀虫剂的出现，两者的毒性作用相似[1]。有机磷和氨基甲酸酯类的医疗用途包括逆转神经肌肉阻滞(新斯的明、吡斯的明、依酚氯铵)和治疗青光眼、重症肌无力和阿尔茨海默病(依可碘酯、吡斯的明、他克林和多奈哌齐)。

据估计，全球每年有3百万人暴露于有机磷或氨基甲酸酯类，其导致的死亡数多达30万[2,3]。2008年里，美国上报的有机磷或氨基甲酸酯类暴露超过8000例，暴露导致了不到15例的死亡[4]。中毒原因通常是有意或无意摄入或暴露于农业杀虫剂[2,5]。有机磷或氨基甲酸酯类中毒的其他潜在原因包括摄入被污染的水果、面粉或食用油，以及穿着被污染的衣物[5,6]。

引起人类中毒的制剂包括氨基甲酸酯杀虫剂(灭多威和涕灭威)和有机磷杀虫剂(对硫磷、倍硫磷、马拉硫磷、敌匹硫磷和毒死蜱)。毒死蜱的有机磷成分Chlorpyrifos存在于某些常见的家用除蟑螂和蚂蚁的喷雾，包括雷达牌(Raid)和Black Flag的产品(图 2)。美国环保局(Enviromantal Protection Agent, EPA)在2001年里禁止了毒死蜱的很多家庭用途，而且对其在某些农作物中的应用做出了限制，包括番茄、苹果和葡萄[7]。

                       

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Literature review current through: 2017-06 . | This topic last updated: 2017-01-23.
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References
Top
  1. Rotenberg M, Shefi M, Dany S, et al. Differentiation between organophosphate and carbamate poisoning. Clin Chim Acta 1995; 234:11.
  2. Eddleston M, Phillips MR. Self poisoning with pesticides. BMJ 2004; 328:42.
  3. Eyer P. The role of oximes in the management of organophosphorus pesticide poisoning. Toxicol Rev 2003; 22:165.
  4. Bronstein AC, Spyker DA, Cantilena LR Jr, et al. 2008 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 26th Annual Report. Clin Toxicol (Phila) 2009; 47:911.
  5. Watson WA, Litovitz TL, Rodgers GC Jr, et al. 2002 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 2003; 21:353.
  6. Wu ML, Deng JF, Tsai WJ, et al. Food poisoning due to methamidophos-contaminated vegetables. J Toxicol Clin Toxicol 2001; 39:333.
  7. United States Environmental Protection Agency. Organophosphate pesticide information. www.epa.gov/pesticides/op/chlorpyrifos/consumerqs.htm (Accessed on May 03, 2005).
  8. Buckley NA, Roberts D, Eddleston M. Overcoming apathy in research on organophosphate poisoning. BMJ 2004; 329:1231.
  9. Centers for Disease Control and Prevention (CDC). Recognition of illness associated with exposure to chemical agents--United States, 2003. MMWR Morb Mortal Wkly Rep 2003; 52:938.
  10. Okudera H, Morita H, Iwashita T, et al. Unexpected nerve gas exposure in the city of Matsumoto: report of rescue activity in the first sarin gas terrorism. Am J Emerg Med 1997; 15:527.
  11. Reutter S. Hazards of chemical weapons release during war: new perspectives. Environ Health Perspect 1999; 107:985.
  12. Tafuri J, Roberts J. Organophosphate poisoning. Ann Emerg Med 1987; 16:193.
  13. Khurana D, Prabhakar S. Organophosphorus intoxication. Arch Neurol 2000; 57:600.
  14. Eddleston M, Szinicz L, Eyer P, Buckley N. Oximes in acute organophosphorus pesticide poisoning: a systematic review of clinical trials. QJM 2002; 95:275.
  15. Morgan JP. The Jamaica ginger paralysis. JAMA 1982; 248:1864.
  16. Mutch E, Blain PG, Williams FM. Interindividual variations in enzymes controlling organophosphate toxicity in man. Hum Exp Toxicol 1992; 11:109.
  17. Eddleston M, Eyer P, Worek F, et al. Differences between organophosphorus insecticides in human self-poisoning: a prospective cohort study. Lancet 2005; 366:1452.
  18. Sidell FR. Soman and sarin: clinical manifestations and treatment of accidental poisoning by organophosphates. Clin Toxicol 1974; 7:1.
  19. Sidell FR. Clinical effects of organophosphorus cholinesterase inhibitors. J Appl Toxicol 1994; 14:111.
  20. Wang MH, Tseng CD, Bair SY. Q-T interval prolongation and pleomorphic ventricular tachyarrhythmia ('Torsade de pointes') in organophosphate poisoning: report of a case. Hum Exp Toxicol 1998; 17:587.
  21. Cha YS, Kim H, Go J, et al. Features of myocardial injury in severe organophosphate poisoning. Clin Toxicol (Phila) 2014; 52:873.
  22. Vijayakumar S, Fareedullah M, Ashok Kumar E, Mohan Rao K. A prospective study on electrocardiographic findings of patients with organophosphorus poisoning. Cardiovasc Toxicol 2011; 11:113.
  23. Asari Y, Kamijyo Y, Soma K. Changes in the hemodynamic state of patients with acute lethal organophosphate poisoning. Vet Hum Toxicol 2004; 46:5.
  24. Senanayake N, Karalliedde L. Neurotoxic effects of organophosphorus insecticides. An intermediate syndrome. N Engl J Med 1987; 316:761.
  25. Indira M, Andrews MA, Rakesh TP. Incidence, predictors, and outcome of intermediate syndrome in cholinergic insecticide poisoning: a prospective observational cohort study. Clin Toxicol (Phila) 2013; 51:838.
  26. Karalliedde L, Baker D, Marrs TC. Organophosphate-induced intermediate syndrome: aetiology and relationships with myopathy. Toxicol Rev 2006; 25:1.
  27. Groszek B, Pach J, Kłys M. Intermediate syndrome in acute fenitrothion poisoning. Przegl Lek 1995; 52:271.
  28. De Bleecker J, Van den Neucker K, Colardyn F. Intermediate syndrome in organophosphorus poisoning: a prospective study. Crit Care Med 1993; 21:1706.
  29. Moretto A, Lotti M. Poisoning by organophosphorus insecticides and sensory neuropathy. J Neurol Neurosurg Psychiatry 1998; 64:463.
  30. Sevim S, Aktekin M, Dogu O, et al. Late onset polyneuropathy due to organophosphate (DDVP) intoxication. Can J Neurol Sci 2003; 30:75.
  31. Yang PY, Tsao TC, Lin JL, et al. Carbofuran-induced delayed neuropathy. J Toxicol Clin Toxicol 2000; 38:43.
  32. Dickoff DJ, Gerber O, Turovsky Z. Delayed neurotoxicity after ingestion of carbamate pesticide. Neurology 1987; 37:1229.
  33. Glynn P. Neuropathy target esterase. Biochem J 1999; 344 Pt 3:625.
  34. Abou-Donia MB. Organophosphorus ester-induced chronic neurotoxicity. Arch Environ Health 2003; 58:484.
  35. Aygun D, Onar MK, Altintop BL. The clinical and electrophysiological features of a delayed polyneuropathy developing subsequently after acute organophosphate poisoning and it's correlation with the serum acetylcholinesterase. Electromyogr Clin Neurophysiol 2003; 43:421.
  36. Johnson MK. Organophosphorus esters causing delayed neurotoxic effects: mechanism of action and structure activity studies. Arch Toxicol 1975; 34:259.
  37. Craig PH, Barth ML. Evaluation of the hazards of industrial exposure to tricresyl phosphate: a review and interpretation of the literature. J Toxicol Environ Health B Crit Rev 1999; 2:281.
  38. Arima H, Sobue K, So M, et al. Transient and reversible parkinsonism after acute organophosphate poisoning. J Toxicol Clin Toxicol 2003; 41:67.
  39. Cavari Y, Landau D, Sofer S, et al. Organophosphate poisoning-induced acute renal failure. Pediatr Emerg Care 2013; 29:646.
  40. Agostini M, Bianchin A. Acute renal failure from organophospate poisoning: a case of success with haemofiltration. Hum Exp Toxicol 2003; 22:165.
  41. Sahin I, Onbasi K, Sahin H, et al. The prevalence of pancreatitis in organophosphate poisonings. Hum Exp Toxicol 2002; 21:175.
  42. Johnson, MK. Mechanisms of and biomarkers for acute and delayed neuropathic effects of organophosphorus esters. In: Use of Biomarkers in Assessing Health and Environmental Impact of Chemical Pollutants. NATO Advanced Study Workshop. June 1-5, 1992, Amaral-Mendes, J, Traviseds, CC (Eds), Plenum Press, Luso, Portugal 1993. p.169.
  43. Konickx LA, Bingham K, Eddleston M. Is oxygen required before atropine administration in organophosphorus or carbamate pesticide poisoning? - A cohort study. Clin Toxicol (Phila) 2014; 52:531.
  44. Eddleston M, Roberts D, Buckley N. Management of severe organophosphorus pesticide poisoning. Crit Care 2002; 6:259.
  45. Abedin MJ, Sayeed AA, Basher A, et al. Open-label randomized clinical trial of atropine bolus injection versus incremental boluses plus infusion for organophosphate poisoning in Bangladesh. J Med Toxicol 2012; 8:108.
  46. United States Food and Drug Administration. FDA approves pediatric doses of Atropen. FDA Talk Paper, www.fda.gov/bbs/topics/ANSWERS/2003/ANS01232.html (Accessed on May 03, 2005).
  47. Newmark J. Therapy for nerve agent poisoning. Arch Neurol 2004; 61:649.
  48. Johnson, MK, Jacobsen, D, Meredith, TJ, et, al. Evaluation of antidotes for poisoning by organophosphorus pesticides. Emerg Med 2000; 12:22.
  49. World Health Organization. Environmental Health Criteria No 63. Organophosphorus Pesticides: A General Introduction. World Health Organization, Geneva 1986.
  50. Holstege CP, Baer AB. Insecticides. Curr Treat Options Neurol 2004; 6:17.
  51. Schier JG, Hoffman RS. Treatment of sarin exposure. JAMA 2004; 291:182; author reply 182.
  52. Pawar KS, Bhoite RR, Pillay CP, et al. Continuous pralidoxime infusion versus repeated bolus injection to treat organophosphorus pesticide poisoning: a randomised controlled trial. Lancet 2006; 368:2136.
  53. Schexnayder S, James LP, Kearns GL, Farrar HC. The pharmacokinetics of continuous infusion pralidoxime in children with organophosphate poisoning. J Toxicol Clin Toxicol 1998; 36:549.
  54. Buckley NA, Eddleston M, Li Y, et al. Oximes for acute organophosphate pesticide poisoning. Cochrane Database Syst Rev 2011; :CD005085.
  55. Eddleston M, Eyer P, Worek F, et al. Pralidoxime in acute organophosphorus insecticide poisoning--a randomised controlled trial. PLoS Med 2009; 6:e1000104.
  56. McDonough JH Jr, Zoeffel LD, McMonagle J, et al. Anticonvulsant treatment of nerve agent seizures: anticholinergics versus diazepam in soman-intoxicated guinea pigs. Epilepsy Res 2000; 38:1.
  57. Tuovinen K. Organophosphate-induced convulsions and prevention of neuropathological damages. Toxicology 2004; 196:31.
  58. Office of the U.S. Surgeon General. Army's Diazepam Auto-Injector Package Insert. U.S. Army Medical Research and Development Command (MCMR-RCQ-HR) Fort Detrick, Detrick, MD 1997.
  59. Capacio BR, Byers CE, Merk KA, et al. Pharmacokinetic studies of intramuscular midazolam in guinea pigs challenged with soman. Drug Chem Toxicol 2004; 27:95.
  60. Stacey R, Morfey D, Payne S. Secondary contamination in organophosphate poisoning: analysis of an incident. QJM 2004; 97:75.
  61. Geller RJ, Singleton KL, Tarantino ML, et al. Nosocomial poisoning associated with emergency department treatment of organophosphate toxicity--Georgia, 2000. J Toxicol Clin Toxicol 2001; 39:109.
  62. Eddleston M, Juszczak E, Buckley NA, et al. Multiple-dose activated charcoal in acute self-poisoning: a randomised controlled trial. Lancet 2008; 371:579.
  63. Roberts D, Buckley NA. Alkalinisation for organophosphorus pesticide poisoning. Cochrane Database Syst Rev 2005; :CD004897.
  64. Davies JO, Eddleston M, Buckley NA. Predicting outcome in acute organophosphorus poisoning with a poison severity score or the Glasgow coma scale. QJM 2008; 101:371.
  65. Peter JV, Thomas L, Graham PL, et al. Performance of clinical scoring systems in acute organophosphate poisoning. Clin Toxicol (Phila) 2013; 51:850.