Carbamate poisoning, as well as poisoning with organophosphorus compounds (OP), have indistinguishable clinical presentation. Both are the same class of molecules that inhibit acetylcholinesterase causing accumulation of acetylcholine, consequently overstimulating the neural transmission [1].

Patient history may reveal occupational exposure to pesticides containing carbamates (farming, agriculture etc.). One study confirmed that out of 1100 patients presenting with carbamate poisoning, 93.8% had tried to attempt suicide [2]. Hence, non-occupational exposure can be due to an intent to self-harm. In these cases, observation of the patient and inquiry about negative life situations and overall psychological well-being is advisable to document. Evidence of self-harm or acute occupational exposure may be indicated by the presence of pesticide or solvent smells [3].

Clinical manifestation of carbamate poisoning is highly dependent on the dose, type of carbamate, route of exposure, and concomitant diseases [4].

Excessive stimulation of the sympathetic and parasympathetic system with carbamates is responsible for deleterious effects on the respiratory system ranging from difficulty breathing to respiratory failure [5]. The muscular system is also dependent on acetylcholine (Ach) activation and so signs of fasciculation or brief contractures of muscles, and incoordination of movements can be observed in some cases. Additionally, excessive sweating, headache, miosis, cramping in the abdominal cavity, changes in the cardiovascular system are all signs of possible carbamate poisoning [4]. Cardiovascular system symptoms include palpitations and changes in pulse rate, more commonly demonstrating as tachycardias [3].

Fortunately, spontaneous recovery is possible within 4 hours of poisoning if the patient presents only with nausea, vomiting, headache and excessive salivation [6].

• Gastric Lavage

  On the other hand, gastric lavage was not a statistically significant conduct (p=0.07), with regard to therapy. This finding is in agreement with the work of Vale,2020 Vale JA. Position statement: gastric lavage. [scielo.br]

  Special Considerations: Special Considerations O rganophosphates are usually dissolved in hydrocarbon bases; thus, the clinician should consider hydrocarbon pneumonitis and not to do gastric lavage. Slide 21: Thanks For Listening [authorstream.com]

  Once the patient is stable and atropinised, consider careful brief gastric lavage using a NG tube. Never perform lavage until the patient is stable/atropinised. [aic.cuhk.edu.hk]

  Gastric decontamination by lavage is indicated if ingestion of the poisoning has occurred within 60 minutes of patient presentation. [aafp.org]

  lavage ) Washing of the skin (irrigation), perhaps every few hours for several days Surgery to remove burned skin Breathing support, including tube through the mouth into the lungs and connected to a breathing machine (ventilator) How well someone does [medlineplus.gov]

• Fatigue

  All three family members developed symptoms that were compatible with cholinesterase inhibition: headache, lightheadedness, wheezing, shortness of breath, nausea, and fatigue. [nap.edu]

  Muscle weakness, fatigue. Vomiting, diarrhoea, urination. Severe Pinpoint pupils. Confusion and agitation. Convulsions. Copious excess secretions. Cardiac arrhythmias. Collapse, respiratory depression or respiratory arrest. Coma. Death. [patient.info]

• Bronchorrhea

  Bronchorrhea and bronchospasm are treated with titrated high-dose atropine. Neuromuscular toxicity is treated with IV pralidoxime. Organophosphates and carbamates, although different structurally, both inhibit cholinesterase activity. [merckmanuals.com]

  Less than 30 min after tracheal extubation, the patient’s respiratory status worsened because of major bronchorrhea and inefficient cough. [link.springer.com]

  Organophosphates and carbamates are common insecticides that inhibit cholinesterase activity, causing acute muscarinic manifestations (salivation, lacrimation, urination, diarrhea, emesis, bronchorrhea, bronchospasm, bradycardia, miosis) and some nicotinic [gii.co.jp]

  Rev Gaúcha Enferm. 2009; 30(4):648-55.It should be highlighted the appearance of bronchorrhea, sialorrhea, miosis, diarrhea, muscular fasciculation, seizures and cyanosis, which may evolve, in severe cases, to coma or death.1010 Oliveira MLF, Buriola [scielo.br]

• Respiratory Insufficiency

  Miosis (73%), excessive salivation (70%), muscle weakness (68%), and lethargy (54%) were the most common abnormal signs; 49% and 22% of patients had tachycardia and seizures, respectively, and 38% of children had respiratory insufficiency that required [utexas.influuent.utsystem.edu]

  Clinical Features (Acute Toxicity): Clinical Features (Acute Toxicity) Respiratory insufficiency can result from muscle weakness, decreased central drive, increased secretions, and bronchospasm and it is the lead cause of death. [authorstream.com]

• Dyspnea

  Dyspnea and vomiting were the most common symptom and miosis and cyanosis were the most frequently observed signs. Plasma and red cell cholinesterase levels were lowest in the mixed poison group and highest in the carbamate group. [ncbi.nlm.nih.gov]

• Vomiting

  The clinical manifestations of occupational carbofuran poisoning recorded were nausea and vomiting (82.3%), headaches (56.3%) and miosis (19.8%). [ncbi.nlm.nih.gov]

  Fortunately, spontaneous recovery is possible within 4 hours of poisoning if the patient presents only with nausea, vomiting, headache and excessive salivation. [symptoma.com]

  Symptoms of paradichlorobenzene poisoning: STOMACH AND INTESTINES Diarrhea Abdominal pain Nausea and vomiting MUSCLES Muscle spasms Note: Paradichlorobenzene mothballs are not very toxic. [medlineplus.gov]

  抄録 A 50-year-old man was admitted to the emergency room complaining oppression on his chest, sweating and vomiting. He had drunk a 30 ml volume nutrition supplement 60 minutes before. [ci.nii.ac.jp]

• Nausea

  The clinical manifestations of occupational carbofuran poisoning recorded were nausea and vomiting (82.3%), headaches (56.3%) and miosis (19.8%). [ncbi.nlm.nih.gov]

  It was verified that nausea (p=0.0041), emesis (p=0.0006) and tachycardia (p=0.006) were symptoms that prolonged the hospitalization, as shown inFigure 1. [scielo.br]

  Fortunately, spontaneous recovery is possible within 4 hours of poisoning if the patient presents only with nausea, vomiting, headache and excessive salivation. [symptoma.com]

  Symptoms of paradichlorobenzene poisoning: STOMACH AND INTESTINES Diarrhea Abdominal pain Nausea and vomiting MUSCLES Muscle spasms Note: Paradichlorobenzene mothballs are not very toxic. [medlineplus.gov]

  Adverse effects of pralidoxime: dizziness, headache, nausea, blurred vision, muscle weakness. Patient Disposition: Admit for observation (for 36-72hrs?) [ozemedicine.com]

• Abdominal Cramps

  cramps Diarrhea Loss of appetite Nausea and vomiting SKIN Blue-colored lips and fingernails Note: Serious poisoning can occur if an organophosphate gets on your bare skin or if you don't wash your skin soon after it gets on you. [medlineplus.gov]

  The mother additionally noted abdominal cramping and loose stools. The father went to work for 8 h, while the others stayed in the apartment. [nap.edu]

  Receptor type Location Effect Muscarinic (stimulation) Pupils Miosis Ciliary body Blurred vision Exocrine glands Increased secretions Heart Decreased heart rate Bronchial smooth muscle Bronchoconstriction GI smooth muscle Nausea, vomiting, abdominal cramps [aic.cuhk.edu.hk]

  cramps, urinating, diarrhea, muscular tremors, staggering gait, pinpoint pupils, hypotension (abnormally low blood pressure), slow heartbeat, breathing difficulty, and possibly death, if not promptly treated by a physician. [pmep.cce.cornell.edu]

• Abdominal Pain

  Symptoms of paradichlorobenzene poisoning: STOMACH AND INTESTINES Diarrhea Abdominal pain Nausea and vomiting MUSCLES Muscle spasms Note: Paradichlorobenzene mothballs are not very toxic. [medlineplus.gov]

• Loss of Appetite

  […] of appetite Nausea and vomiting SKIN Blue-colored lips and fingernails Note: Serious poisoning can occur if an organophosphate gets on your bare skin or if you don't wash your skin soon after it gets on you. [medlineplus.gov]

• Hypotension

  These insecticides inhibit the enzyme acetylcholinesterase (AChE), producing an 'acute cholinergic crisis' with reduced consciousness, bradycardia, hypotension, and acute respiratory failure. [clinicaltrials.gov]

  Consider volume resuscitation with normal saline or ringer to treat Bradycardia and hypotension. Use activated charcoal within one hour of an ingestion. [authorstream.com]

  Numerous contraindications: absent bowel sounds, abdominal trauma or surgery, intestinal perforation or obstruction, volume depletion, hypotension, or ingestion of a corrosive substance. [aafp.org]

  Stimulation of muscarinic parasymp. receptors: miosis, bronchoconstriction, wheezing, SOB, nausea, vomiting, diarrhoea, tenesmus, fecal incontinence, urinary frequency & incontinence, excessive lacrimation, salivation, broncorrhoea, sweating, bradycardia, hypotension [ozemedicine.com]

  Some muscarinic causes of cardio-respiratory failure (bronchorrhoea, bronchospasm, bradycardia, hypotension) generally respond well to atropine. Rapid atropinisation of patients on admission should reduce the number of early deaths. [aic.cuhk.edu.hk]

• Sialorrhea

  Atropine administration was an effective therapeutic approach for treating signs and symptoms, which included sialorrhea (p=0.0006), nausea (p=0. 0029) and emesis (p lt0.0001). [scielo.br]

• Sweating

  Additionally, excessive sweating, headache, miosis, cramping in the abdominal cavity, changes in the cardiovascular system are all signs of possible carbamate poisoning. [symptoma.com]

  The data made it possible to observe that symptoms such as sweating (n=21), miosis (n=26), sialorrhea (n=26) and nausea (n=32) were always presented simultaneously with other symptoms: nine for sweating, and eight for the others. [scielo.br]

  抄録 A 50-year-old man was admitted to the emergency room complaining oppression on his chest, sweating and vomiting. He had drunk a 30 ml volume nutrition supplement 60 minutes before. [ci.nii.ac.jp]

  However, we use five in routine assessment: miosis, excessive sweating, poor air entry into the lungs due to bronchorrhoea and bronchospasm, bradycardia, and hypotension. [ccforum.biomedcentral.com]

  Check for increase in heart rate and blood pressure, reduction in wheeze and crepitations in the chest, and reduced sweating. Set up fluid � give 500-1000ml over 20-30 min. The patient is normally intravascularly fluid depleted. [aic.cuhk.edu.hk]

• Muscle Twitch

  Marked muscle twitching or tremors. Muscle weakness, fatigue. Vomiting, diarrhoea, urination. Severe Pinpoint pupils. Confusion and agitation. Convulsions. Copious excess secretions. Cardiac arrhythmias. [patient.info]

  twitching/fasciculations, weakness CNS effects if penetrate BBB: emotional lability, restlessness, tremors, headaches, withdrawal & depression, drowsiness, lethargy If highly toxic exposure, pts can quickly (min-hrs) progress to: ataxia, generalised [ozemedicine.com]

  twitching; {01} {02} {06} tachycardia—if bradycardia was an earlier sign; {16} {18} {22} warm, dry, and flushed skin {08} {16} {18} {22} ) appear or until secretions are inhibited. {08} {22} Atropine should not be given in the presence of hypoxia because [drugs.com]

• Muscle Cramp

  cramps, altered gait, drowsiness, emotional lability, depression, irritability. [ozemedicine.com]

• Muscle Spasm

  Symptoms of paradichlorobenzene poisoning: STOMACH AND INTESTINES Diarrhea Abdominal pain Nausea and vomiting MUSCLES Muscle spasms Note: Paradichlorobenzene mothballs are not very toxic. [medlineplus.gov]

• Lacrimation

  Physician, Department of Emergency Medicine, Einstein Medical Center Click here for Patient Education Organophosphates and carbamates are common insecticides that inhibit cholinesterase activity, causing acute muscarinic manifestations (eg, salivation, lacrimation [merckmanuals.com]

  Clinical effects of anticholinesterase poisoning: Classically, symptoms develop over a few hours (less if massive exposures or up to 2days if lipophilic) and present as the “SLUDGE” syndrome : Salivation, Lacrimation, Urination, Diarrhoea, GIT effects [ozemedicine.com]

  She had the following symptoms of severe carbamate poisoning: coma, fasciculations, salivation, lacrimation, myosis, bronchorrhea, and difficult breathing. Her arterial blood pressure was normal and her heart rate was 56 beats · min −1. [link.springer.com]

  Organophosphates and carbamates are common insecticides that inhibit cholinesterase activity, causing acute muscarinic manifestations (salivation, lacrimation, urination, diarrhea, emesis, bronchorrhea, bronchospasm, bradycardia, miosis) and some nicotinic [gii.co.jp]

• Blurred Vision

  Painful, blurred vision. Runny nose and eyes. Excess saliva. Eyes looking 'glassy'. Headache. Nausea. Mild muscle weakness. Localised muscle twitching. Mild agitation. Moderate Pinpoint pupils, conjunctival injection. Dizziness, disorientation. [patient.info]

  Adverse effects of pralidoxime: dizziness, headache, nausea, blurred vision, muscle weakness. Patient Disposition: Admit for observation (for 36-72hrs?) [ozemedicine.com]

  Receptor type Location Effect Muscarinic (stimulation) Pupils Miosis Ciliary body Blurred vision Exocrine glands Increased secretions Heart Decreased heart rate Bronchial smooth muscle Bronchoconstriction GI smooth muscle Nausea, vomiting, abdominal cramps [aic.cuhk.edu.hk]

  Signs and symptoms of cholinesterase inhibition from exposure to CMs or OPs include the following: In mild cases (within 4 - 24 hours of contact): tiredness, weakness, dizziness, nausea and blurred vision; In moderate cases (within 4 - 24 hours of contact [pmep.cce.cornell.edu]

• Seizure

  Miosis (73%), excessive salivation (70%), muscle weakness (68%), and lethargy (54%) were the most common abnormal signs; 49% and 22% of patients had tachycardia and seizures, respectively, and 38% of children had respiratory insufficiency that required [utexas.influuent.utsystem.edu]

  Diazepam 0.1-0.2 mg/kg IV, repeat as necessary if seizures occur. phenytoin has no effect on organophosphate agent-induced seizures. [authorstream.com]

  Seizures controlled with benzodiazepines. Standard antiallergy therapy for hypersensitivity reactions. [aafp.org]

  YOU MIGHT ALSO LIKE... 41 terms Clinical Toxicology Exam 2: Quiz Questions 46 terms Approach to the Dog & Cat with Epileptic Seizures OTHER SETS BY THIS CREATOR 8 terms Chi Institute Master Points 28 terms Chi Institute Back shu/Front mu points 41 terms [quizlet.com]

• Headache

  The clinical manifestations of occupational carbofuran poisoning recorded were nausea and vomiting (82.3%), headaches (56.3%) and miosis (19.8%). [ncbi.nlm.nih.gov]

  Fortunately, spontaneous recovery is possible within 4 hours of poisoning if the patient presents only with nausea, vomiting, headache and excessive salivation. [symptoma.com]

  The daughter’s symptoms had also decreased but she still experienced nausea, headache, sore throat, and some wheezing when in the apartment. [nap.edu]

  Adverse effects of pralidoxime: dizziness, headache, nausea, blurred vision, muscle weakness. Patient Disposition: Admit for observation (for 36-72hrs?) [ozemedicine.com]

  These solvents can lead to symptoms too, including headache and nausea. Lipophilic compounds can cause delayed or persistent toxicity as they slowly move out of the tissues. Remember that accurate, contemporaneous notes are essential. [patient.info]

• Tremor

  The most severe symptoms are seizures, though highly uncommon unless highly exposed (usually through ingestion of large quantities); tremor, incoordination, salivation, vomiting; topical exposure can produce short-term paresthesias, especially of the [aafp.org]

  […] hypotension, ventricular tachycardia; Stimulation of nicotinic motor & sympathetic receptors: tachycardia, palor, hypertension, hyperglycaemia, muscle twitching/fasciculations, weakness CNS effects if penetrate BBB: emotional lability, restlessness, tremors [ozemedicine.com]

  Marked muscle twitching or tremors. Muscle weakness, fatigue. Vomiting, diarrhoea, urination. Severe Pinpoint pupils. Confusion and agitation. Convulsions. Copious excess secretions. Cardiac arrhythmias. [patient.info]

  […] and blurred vision; In moderate cases (within 4 - 24 hours of contact): headache, sweating, tearing, drooling, vomiting, tunnel vision, and twitching; In severe cases (after continued daily absorption): abdominal cramps, urinating, diarrhea, muscular tremors [pmep.cce.cornell.edu]

• Ataxia

  We report the case of a 4-year-old boy who was admitted to the Pediatric Department of the Second University of Naples for evaluation of stupor, lethargy, severe hypotonia, generalized weakness of his arms and legs, ataxia, dysmetria, miosis, excessive [ncbi.nlm.nih.gov]

  […] hyperglycaemia, muscle twitching/fasciculations, weakness CNS effects if penetrate BBB: emotional lability, restlessness, tremors, headaches, withdrawal & depression, drowsiness, lethargy If highly toxic exposure, pts can quickly (min-hrs) progress to: ataxia [ozemedicine.com]

Carbamate poisoning can be diagnosed if there is a suspicion of exposure and a typical clinical presentation.

Objective evidence of acetylcholinesterase (AchE) inhibition can be sought with butyrylcholinesterase (BChE) assay. This assay reveals information about the amount and activity of butyrylcholinesterase (a cholinesterase molecule related to acetylcholinesterase) in the blood. The activity of BChE correlates with the severity of poisoning and is a good tool to elucidate a prognosis [7]. This type of blood analysis is inexpensive [8] but inconvenient in terms of time taken to obtain the results. This delay can interfere with the management of patients if prompt intervention is necessary [7].

Cardiovascular effects of AchE inhibitors can lead to death. Thus, it is important to document the electrical potentials of the heart on electrocardiogram (ECG). ECG may reveal tachycardia or rarely bradycardia. Arrhythmias such as ventricular extrasystoles, atrial fibrillation, and ventricular fibrillation are evidence of abnormal cardiac rhythm. A presence of prolonged QT interval should be investigated as it is pathognomic for carbamate poisoning [3].

A study analyzed 115 patients exposed to organophosphate poisoning and compared their clinical presentation and findings on ECG. About 50% of the patients developed sinus tachycardia and only 3 of the subjects had sinus bradycardia. More serious findings included prolonged QT interval, polymorphic ventricular tachycardia (VT) which manifested in five patients and ventricular fibrillation (VF) that was found in 3 patients. Those who developed ventricular tachycardia died regardless of appropriate medical management. This study emphasizes the importance of rapid diagnosis and significance of monitoring in the patients throughout their inpatient stay [3].

The toxic agent was determined to be a carbamate insecticide, for which treatment with pralidoxime is considered controversial. [ncbi.nlm.nih.gov]

Administering atropine treatment for respiratory poisoning and pralidoxime treatment for skin inflammations are widely implemented for curing organophosphates and carbamates poisoning. [transparencymarketresearch.com]

The activity of BChE correlates with the severity of poisoning and is a good tool to elucidate a prognosis. This type of blood analysis is inexpensive but inconvenient in terms of time taken to obtain the results. [symptoma.com]

RBC cholinesterase level correlates better with severity and prognosis or a mixed cholinesterase ratio is best for determining if sufficient pralidoxime is being given. [patient.info]

There is little evidence of risk to healthcare workers from managing OP poisoned patients as long as universal precautions are followed � see refs 5, 6 below Prognosis Varies markedly. [aic.cuhk.edu.hk]

Serum acetylcholinesterase and prognosis of acute organophosphate poisoning. J Toxicol Clin Toxicol. 2002; 40:903-10.,44 Van Heel W, Hachimi-Idrissi S. Accidental organophosphate insecticide intoxication in children: a reminder. [scielo.br]

Although most patients with OPC and carbamate poisoning have a good prognosis, severe poisoning is potentially lethal. Early diagnosis and initiation of treatment are important. [emedicine.medscape.com]

The exact etiology of this is unclear but in the light of recent literature, it is likely that oxidative stress at the renal tubular level leading to renal tubular damage may be the most likely explanation. [ncbi.nlm.nih.gov]

Organophosphate and carbamate poisonings in the northwest of Paraná state, Brazil from 1994 to 2005: clinical and epidemiological aspects. [scielo.br]

[…] pesticides can lead both to depressive and anxiety disorders and also to cognitive defects (unrelated to psychiatric disorders). [ 4 ] This is a significant problem which may also affect children and further research in this field is necessary. [ 5 ] Epidemiology [patient.info]

Epidemiology Frequency United States In the United States, more than 18,000 products are licensed for use, and each year more than 2 billion pounds of pesticides are applied to crops, homes, schools, parks, and forests. [4] Occupational exposure is known [emedicine.medscape.com]

Pesticide Unit, Epidemiological Studies Laboratory, California Department of Health, 2151 Berkeley Way, Berkeley, CA. 94704. Telephone: (415)-540-3063. [pmep.cce.cornell.edu]

Epidemiological Studies Laboratory. Medical Supervision of Pesticide Workers: Guidelines for Physicians. Berkeley, California, 1988. 12. Augustinsson K. The normal variation of human blood cholinesterase activity. [nap.edu]

[…] odacheis Acetylcholinesterase inhibitor poisoning Organophosphate & Carbamate Insecticide Poisoning: Pathophysiology: Both organophosphate & carbamate insecticides are acetylcholinesterase inhibitors which are readily absorbed through intact skin or mucosa [ozemedicine.com]

Pathophysiology OPCs and carbamates bind to an active site of acetylcholinesterase (AChE) and inhibit the functionality of this enzyme by means of steric inhibition. [emedicine.medscape.com]

Aggressive treatment and prevention of the above three factors will reduce the incidence of RF, or in other words, reduce the mortality. [ncbi.nlm.nih.gov]

An indispensable handbook to the entire suite of toxicology lab tests, as well as all the possible sources of testing error, Resolving Erroneous Reports in Toxicology and Therapeutic Drug Monitoring offers clear remedies for eliminating and preventing [books.google.com]

Within seconds, a strong trismus, or spasm of the masseter muscles, was observed, preventing mouth opening and orotracheal intubation. [link.springer.com]

You should call if you have any questions about poisoning or poison prevention. It does NOT need to be an emergency. You can call for any reason, 24 hours a day, 7 days a week. Take the container with you to the hospital, if possible. [medlineplus.gov]

ABC's, Oxygen if needed Decontaminate skin, eyes to prevent ongoing absorption: remove clothes thoroughly cleanse skin - at least 2 separate water & detergent washes will remove up to 94% of residual organoP, even if done up to 6hrs after exposure; consider [ozemedicine.com]

1. Čolović MB, Krstić DZ, Lazarević-Pašti TD, Bondžić AM, Vasić VM. Acetylcholinesterase Inhibitors: Pharmacology and Toxicology. Curr Neuropharmacol. 2013;11(3):315-335.
2. Eddleston M, Juszczak E, Buckley NA, et al. Multiple-dose activated charcoal in acute self-poisoning: a randomised controlled trial. Lancet. 2008;371:579–586.
3. Laudari S, Patowary BS, Sharma SK, Dhungel S, Subedi K, Bhattacharya R, et al. Cardiovascular Effects of Acute Organophosphate Poisoning. Asia Pac J Med Toxicol 2014;3:64-7.
4. Rosman Y, Makarovsky I, Bentur Y, Shrot S, Dushnistky T, Krivoy A. Carbamate poisoning: treatment recommendations in the setting of a mass casualties event. Am J Emerg Med. 2009; 27: 1117-1124.
5. Eddleston M, Sudarshan K, Senthilkumaran M, et al. Patterns of hospital transfer for self-poisoned patients in rural SriLanka: implications for estimating the incidence of self-poisoning in the developing world. Bull World Health Organ. 2006;84:276–282.
6. Morais S, Dias E, de Lourdes Pereira M. Carbamates: Human Exposure and Health Effects. In: The Impact of Pesticides. 1st ed. AcademyPublish.org. January 2012;21-38.
7. Eddleston M, Buckley NA, Eyer P, Dawson AH. Management of acute organophosphorus pesticide poisoning. Lancet. 2008;371(9612):597-607.
8. Dhananjayan V, Ravichandran B, Anitha N, Rajmohan HR. Assessment of acetylcholinesterase and butyrylcholinesterase activities in blood plasma of agriculture workers. Indian J Occup Environ Med. 2012;16(3):127-130.