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The relationship between electrocardiographic changes, cholinesterase levels and mortality in acute organophosphate poisoning

Year 2013, Volume: 38 Issue: 2, 181 - 188, 01.06.2013

Abstract

Aim: In our study we aimed to investigate the relationship between electrocardiographic (ECG) changes, cholinesterase levels and mortality due to acute organophosphate poisoning. Material and Methods: We planned to take patients who administered to emergency department with organic phosphorus poisoning randomized and prospectively for 2 years between 01.08.2009 - 31.08.2011 after approval by the Ethics Committee. The electrocardiograms of the patients were taken after admission to the emergency department, before the treatment (atropine and pralidoxime application). Blood samples were taken and studied in the laboratory of our hospital. ECG findings, cholinesterase values and the final situation of the patients were recorded at the standard data entry form. SPSS 18.0 package program was used for statistical analysis of data. The statistical significance level of all tests was p < 0.05. Results: The five of thirty nine patients (12.8 %) included in the study have died during the treatment. The electrocardiographic findings seen in patients in order of frequency; sinus tachycardia (48.7 %), prolonged QT interval (20.5 %), and right bundle branch block (20.5 %), ST-T wave changes (12.8 %), atrial fibrillation (7.7 %), right axis deviation (5.1 %), prolonged PR (2.5 %). There was no statistically significant difference between the ECG findings of the patient groups who died or discharged (p &#8805; 0.05). The mean serum cholinesterase levels of the patients who died were statistically lower than the discharged patients (p = 0.006). Conclusion: There is not a significant relationship between ECG findings and the severity of organophosphate poisoning.There is a statistically significant relationship between mortality and low levels of serum cholinesterase due to severe poisoning. ECG findings and their effects to the mortality in organophosphate poisoning can give an opinion to the emergency physicians and contribute to their clinical experiences. However, more detailed studies are needed in this matter.

References

  • Karalliedde L, Senanayake N. Organophosphorous poisoning. Br J Anaes. 1989; 63: 736-50.
  • Dutoit PW, Maller FO, Ventonder WM, Ungerer MJ. Experiencewith intensive care management of organophosphate insecticidepoisoning. S Afr Med J 1981; 60: 227-9.
  • Saadeh AM, Farsakh NA, Al-Ali MK. Cardiac manifestations of acute carbamate and organophosphate poisoning. Heart 1997; 77: 461-4.
  • Roth A, Zellinger I, Arad M, Atsmon J. Organophosphates and the heart. Chest 1993; 103: 576Karki P, Ansari JA, Bhandary S, Koirala S. Cardiac and electrocardiographical manifestations of acute organophosphate poisoning. Singapore Med J. 2004; 45: 385-90.
  • Van Sitterd NJ. Manual Spectrophotometric Method for The Measurement of Erythrocyte and Plasma Cholinesterase (Modified Ellman Method). WHO, Manual of Analytical Methods. Course on Analytical Procedures for Assesment of Exposure to Organophosphorous Pecticides, Cremona, İtaly, 2-6 September 1985.
  • Tağa S, Dikmen N. Kolinesterazın Plazma, eritrosit, amnion sıvısında incelenmesi ve nöral tüp defektlerinde uygulanması. Bilim Uzmanlığı Tezi. ÇukurovaÜniversitesi Tıp Fakültesi, Adana, 1997.
  • Costa LG. Basic toxicology of pesticides. Occup Med. 1997; 12: 251.
  • Robey WC, Meggs WJ. Insecticides, Herbicides and Rodenticides. Tintinalli JE, Kelen GD, Stapczynski JS, eds. Emergency Medicine: a Comprehensive Study Guide. 6 th Ed. New York: McGraw-Hill Co, 2004; 1134-43.
  • Worek F, Kirchner T, Backer M, Szinicz L. Reactivation by various oximes of human erythrocyte acetylcholinesterase inhibited by different organophosphorus compounds. Arch Toxicol 1996; 70: 497-503.
  • Weidler DJ. Myocardial damage and cardiac arrhythmias afterintracranial hemorrhage: a critical review. Stroke 1974; 5: 759-64.
  • Manning GW, Hall GE, Banting. Vagus stimulation and the production of myocardial damage. Can Med Assoc J 1937; 37: 314.
  • Hall GE, Ettinger GH, Banting FG. An experimental productionof coronary thrombosis and myocardial failure. Can MedAssoc J 1936; 34: 9-15.
  • Petroianu G, Toomes LM, Petroianu A, Bergler W, Rufer R. Control of blood pressure, heart rate and haematocrit during high-dose intravenous paraoxon exposure in mini pigs. J Appl. Toxicol. 1998; 18: 293
  • Ludomirsky A, Klein H, Sarelli P, Becker B, Hoffman S, Taitelman U et al. Q-T prolongation and polymorphous (torsade de pointes) ventricular arrhythmias associated with organophsphorus insecticide poisoning. Am J Cardiol 1982; 49: 1654
  • Lovejoy FH, Linden CH. Acute poison and drug over dosage. Harrison’s Principles of Internal Medicine. 12th ed. New York: Mc Graw-Hill 1991; 2178.
  • Khan IA, Gowda RM. Novel therapeutics for treatment of long-QT syndrome and torsade de pointes. Int J Cardiol. 2004; 95: 1-6.
  • Finkelstein Y, Kushnir A, Raikhlin-Eisenkraft B, Taitelman U. Antidotal therapy of severe acute organophosphate poisoning: A multihospital study. Neurotoxicol Teratol. 1989; 11: 593-6.
  • Kiss Z, Fazekas T. Arrhythmias in organophosphate poisonings. Acta Cardiol 1979; 34: 323-30.
  • Bardin PG, Van Eeden SF, Moolman JA, Foden AP, Joubert JR. Organophosphate and carbamate poisoning. Arch Intern Med. 1994; 154: 1433-41.
  • Aygun D, Doganay Z, Altintop L, Guven H, Onar M, Deniz T, Sunter T. Serum acetylcholinesterase and prognosis of acute organophosphate poisoning. J Toxicol Clin Toxicol. 2002; 40: 903-10.
  • Merill DG, Mihm FG. Prolonged toxicity of organophosphate poisoning. Crit Care Med. 1982; 10: 550–1.
  • Chuang FR, Jang SW, Lin JL, Chern MS, Chen JB, Hsu KT. QTc prolongation indicates a poor prognosis in patients with organophosphate poisoning. Am J Emerg Med. 1996; 14: 451-3.
  • Bissbort SH, Vermaak WJ, Elias J, Bester MJ, Dhatt GS, Pum JK. Novel test and its automation for the determination of erythrocyte acethylcholinesterase and its application to organophosphate exposure. Clin Chim Acta. 2001; 303: 139-45.
  • Lyzhnikov EA, Savina AS, Shepelev VM. Pathogenesis of disorders of cardiac rhythm and conductivity in acute organophosphate insecticide poisoning. Cardiologia. 1975; 15: 126-9.
  • Baydin A, Aygun D, Yazici M, Karatas A, Deniz T, Yardan T. Is there a relationship between the blood cholinesterase and QTc interval in the patients with acute organophosphate poisoning. International Journal of Clinical Practice. 2007; 61: 927-30.
  • Yazışma Adresi / Address for Correspondence: Dr. Mehmet Oğuzhan Ay Adana Numune Eğitim ve Araştırma Hastanesi Acil Tıp Kliniği 01170, ADANA e mail: droguzhan2006@mynet.com geliş tarihi/received :09.08.2012 kabul tarihi/accepted:05.10.2012

Akut Organofosfat Zehirlenmelerinde Elektrokardiyografik Değişiklikler Ile Kolinesteraz Düzeylerinin Mortaliteye Etkileri

Year 2013, Volume: 38 Issue: 2, 181 - 188, 01.06.2013

Abstract

Giriş: Çalışmamızda akut organofosfat zehirlenmesine bağlı elektrokardiyografik (EKG) değişiklikler ile kolinesteraz
düzeylerinin mortaliteye etkilerini araştırmayı amaçladık.
Materyal ve Metod: Prospektif, randomize olarak 2 yıl süresince, 01.08.2009 – 31.08.2011 tarihleri arasında acil tıp
kliniği’ne organik fosfat zehirlenmesi ile gelen hastaların alınmasının planlandığı çalışmaya Etik Kurul’dan onay
alındıktan sonra başlandı. Acile başvuru sonrası, tedavi (atropin ve pralidoksim uygulaması) öncesinde çalışmada
kullanılmak üzere EKG çekildi ve kan örneği alınarak, serum ve eritrosit kolinesteraz düzeyleri hastanemiz
laboratuvarı’nda çalışıldı. Hastaların EKG bulguları, kolinesteraz değerleri, sonlanım durumu standart veri giriş formuna
kayıt edildi. Verilerin istatistiksel analizinde SPSS 18.0 paket programı kullanıldı.
Bulgular: Çalışmaya alınan 39 hastanın 5’i (% 12.8) tedavileri sırasında eksitus oldu. Hastalarda görülen
elektrokardiyografik bulgular sıklık sırasına göre; sinüs taşikardisi (% 48.7), uzamış QT mesafesi (% 20.5) ve sağ dal
bloğu (% 20.5), ST-T dalga değişikliği (% 12.8), atriyal fibrilasyon (% 7.7), sağ aks sapması (% 5.1), uzamış PR
mesafesi (% 2.5) idi. Eksitus ve taburcu edilen hastaların acile ilk başvurusu sonrasında çekilen EKG bulguları
karşılaştırıldığında gruplar arasında istatistiksel olarak fark olmadığı tespit edildi (p ≥ 0.05). Eksitus olan hastaların ilk
geliş anında bakılan ortalama serum kolinesteraz düzeyleri ortalaması taburcu edilen hastalara göre düşüktü ve
aralarında istatistiksel olarak anlamlı bir fark mevcuttu (p=0.006). Ancak eksitus ve taburcu edilen hastaların eritrosit
kolinesteraz düzeyleri arasında anlamlı farklılık yoktu (p= 0.984).
Sonuç: Organofosfat zehirlenmesinin şiddeti ile EKG bulguları arasında mortalite açısından anlamlı bir ilişki olmadığı,
şiddetli zehirlenmelerde serum kolinesteraz düzeyi düşüklüğü ile mortalite arasında istatistiksel olarak anlamlı bir ilişki
olduğu belirlendi. Organofosfat zehirlenmelerinde görülebilecek EKG bulguları ve mortaliteye etkileri hakkında acil
hekimlerine fikir vermesi, klinik deneyimlerine katkıda bulunması açısından bu çalışmanın faydası olacaktır. Ancak bu
konuda yapılacak daha detaylı çalışmalara ihtiyaç vardır.

References

  • Karalliedde L, Senanayake N. Organophosphorous poisoning. Br J Anaes. 1989; 63: 736-50.
  • Dutoit PW, Maller FO, Ventonder WM, Ungerer MJ. Experiencewith intensive care management of organophosphate insecticidepoisoning. S Afr Med J 1981; 60: 227-9.
  • Saadeh AM, Farsakh NA, Al-Ali MK. Cardiac manifestations of acute carbamate and organophosphate poisoning. Heart 1997; 77: 461-4.
  • Roth A, Zellinger I, Arad M, Atsmon J. Organophosphates and the heart. Chest 1993; 103: 576Karki P, Ansari JA, Bhandary S, Koirala S. Cardiac and electrocardiographical manifestations of acute organophosphate poisoning. Singapore Med J. 2004; 45: 385-90.
  • Van Sitterd NJ. Manual Spectrophotometric Method for The Measurement of Erythrocyte and Plasma Cholinesterase (Modified Ellman Method). WHO, Manual of Analytical Methods. Course on Analytical Procedures for Assesment of Exposure to Organophosphorous Pecticides, Cremona, İtaly, 2-6 September 1985.
  • Tağa S, Dikmen N. Kolinesterazın Plazma, eritrosit, amnion sıvısında incelenmesi ve nöral tüp defektlerinde uygulanması. Bilim Uzmanlığı Tezi. ÇukurovaÜniversitesi Tıp Fakültesi, Adana, 1997.
  • Costa LG. Basic toxicology of pesticides. Occup Med. 1997; 12: 251.
  • Robey WC, Meggs WJ. Insecticides, Herbicides and Rodenticides. Tintinalli JE, Kelen GD, Stapczynski JS, eds. Emergency Medicine: a Comprehensive Study Guide. 6 th Ed. New York: McGraw-Hill Co, 2004; 1134-43.
  • Worek F, Kirchner T, Backer M, Szinicz L. Reactivation by various oximes of human erythrocyte acetylcholinesterase inhibited by different organophosphorus compounds. Arch Toxicol 1996; 70: 497-503.
  • Weidler DJ. Myocardial damage and cardiac arrhythmias afterintracranial hemorrhage: a critical review. Stroke 1974; 5: 759-64.
  • Manning GW, Hall GE, Banting. Vagus stimulation and the production of myocardial damage. Can Med Assoc J 1937; 37: 314.
  • Hall GE, Ettinger GH, Banting FG. An experimental productionof coronary thrombosis and myocardial failure. Can MedAssoc J 1936; 34: 9-15.
  • Petroianu G, Toomes LM, Petroianu A, Bergler W, Rufer R. Control of blood pressure, heart rate and haematocrit during high-dose intravenous paraoxon exposure in mini pigs. J Appl. Toxicol. 1998; 18: 293
  • Ludomirsky A, Klein H, Sarelli P, Becker B, Hoffman S, Taitelman U et al. Q-T prolongation and polymorphous (torsade de pointes) ventricular arrhythmias associated with organophsphorus insecticide poisoning. Am J Cardiol 1982; 49: 1654
  • Lovejoy FH, Linden CH. Acute poison and drug over dosage. Harrison’s Principles of Internal Medicine. 12th ed. New York: Mc Graw-Hill 1991; 2178.
  • Khan IA, Gowda RM. Novel therapeutics for treatment of long-QT syndrome and torsade de pointes. Int J Cardiol. 2004; 95: 1-6.
  • Finkelstein Y, Kushnir A, Raikhlin-Eisenkraft B, Taitelman U. Antidotal therapy of severe acute organophosphate poisoning: A multihospital study. Neurotoxicol Teratol. 1989; 11: 593-6.
  • Kiss Z, Fazekas T. Arrhythmias in organophosphate poisonings. Acta Cardiol 1979; 34: 323-30.
  • Bardin PG, Van Eeden SF, Moolman JA, Foden AP, Joubert JR. Organophosphate and carbamate poisoning. Arch Intern Med. 1994; 154: 1433-41.
  • Aygun D, Doganay Z, Altintop L, Guven H, Onar M, Deniz T, Sunter T. Serum acetylcholinesterase and prognosis of acute organophosphate poisoning. J Toxicol Clin Toxicol. 2002; 40: 903-10.
  • Merill DG, Mihm FG. Prolonged toxicity of organophosphate poisoning. Crit Care Med. 1982; 10: 550–1.
  • Chuang FR, Jang SW, Lin JL, Chern MS, Chen JB, Hsu KT. QTc prolongation indicates a poor prognosis in patients with organophosphate poisoning. Am J Emerg Med. 1996; 14: 451-3.
  • Bissbort SH, Vermaak WJ, Elias J, Bester MJ, Dhatt GS, Pum JK. Novel test and its automation for the determination of erythrocyte acethylcholinesterase and its application to organophosphate exposure. Clin Chim Acta. 2001; 303: 139-45.
  • Lyzhnikov EA, Savina AS, Shepelev VM. Pathogenesis of disorders of cardiac rhythm and conductivity in acute organophosphate insecticide poisoning. Cardiologia. 1975; 15: 126-9.
  • Baydin A, Aygun D, Yazici M, Karatas A, Deniz T, Yardan T. Is there a relationship between the blood cholinesterase and QTc interval in the patients with acute organophosphate poisoning. International Journal of Clinical Practice. 2007; 61: 927-30.
  • Yazışma Adresi / Address for Correspondence: Dr. Mehmet Oğuzhan Ay Adana Numune Eğitim ve Araştırma Hastanesi Acil Tıp Kliniği 01170, ADANA e mail: droguzhan2006@mynet.com geliş tarihi/received :09.08.2012 kabul tarihi/accepted:05.10.2012
There are 26 citations in total.

Details

Primary Language Turkish
Journal Section Research
Authors

Mesude Atlı This is me

Ahmet Sebe This is me

Mehmet Oğuzhan Ay This is me

Meryem Genç Karanlık This is me

Ayça Açıkalın This is me

Nalan Kozacı This is me

Mustafa Yılmaz This is me

Salim Satar This is me

Publication Date June 1, 2013
Published in Issue Year 2013 Volume: 38 Issue: 2

Cite

MLA Atlı, Mesude et al. “Akut Organofosfat Zehirlenmelerinde Elektrokardiyografik Değişiklikler Ile Kolinesteraz Düzeylerinin Mortaliteye Etkileri”. Cukurova Medical Journal, vol. 38, no. 2, 2013, pp. 181-8.