QJM Advance Access originally published online on April 25, 2008
QJM 2008 101(6):507-508; doi:10.1093/qjmed/hcn053
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A comment on ‘Predicting outcome in acute organophosphorus poisoning with a poison severity score or the Glasgow coma scale’
Sir,We read with interest the article ‘Predicting outcome in acute organophosphorus poisoning with a poison severity score or the Glasgow coma scale’.1 Organophosphate (OP) poisoning is a major global health problem and a high mortality is seen in resource poor settings.2 A clinically based scoring system to predict outcome is of utmost importance in these setting where the patients are managed with minimal resources and we agree that the clinical utility of a simple measure such as Glasgow Coma Scale (GCS) is valuable. However, as this study analysed the GCS on admission some further information regarding confounders of pre-admission alcohol use and atropine treatment would be helpful both in interpreting this study and in forming treatment guidelines.
Alcohol ingestion is a common co-ingestant in poisonings and clearly can directly decrease the GCS, which may have additive or synergistic effects with OP induced CNS depression. In addition, it is possible that amount of OP ingested by someone who is intoxicated and disinhibited by alcohol may be greater. In this context, it would be useful to know what number of patients had co-ingested alcohol and whether their outcome was worse than ingestion of OP alone.
While these patients’ atropine treatment was directed by a standard protocol once they arrived in hospital, the authors suggest a large percentage of patients were transferred from peripheral hospitals. Analysis of the extent and adequacy of pre-hospital atropinisation would be informative for primary hospital treatment guidelines as there is a large variation in clinical practice.3 Adequate early atropinisation may protect from CNS depression,4 conversely excess atropine may cause central nervous system effect (confusion, delirium) which might affect the assessment of the GCS.3
1Department of Pharmacology
Faculty of Medical Sciences
University of Sri Jayewardenepura
Nugegoda
Sri Lanka
2South Asian Clinical Toxicology Research
Collaboration
Faculty of Medicine
University of Peradeniya
Sri Lanka
email: Pradeepa{at}sactrc.org
References
1. Davies JO, Eddleston M, Buckley NA. Predicting outcome in acute organophosphorus poisoning with a poison severity score or the Glasgow coma scale. QJM (2008) Mar 4; [Epub ahead of print].
2. Eddleston M, Phillips MR. Self poisoning with pesticides. BMJ (2004) 328(7430):42–4.
3. Perera PMS, Shahmy I, Gawarammana I, Dawson AH. Comparison of two commonly practiced atropinisation regimens in acute organophosphorus and carbamate poisoning, doubling doses vs ‘ad hoc’ — a prospective observational study. Hum Exp Toxicol (2008) (In press).
4. Dickson EW, Bird SB, Gaspari RJ, Boyer EW, Ferris CF. Diazepam inhibits organophosphate-induced central respiratory depression. Acad Emerg Med (2003) 10(12):1303–06.[CrossRef][Web of Science][Medline]
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