Organophosphorus pesticide toxicity to humans and animals is mainly the inhibition of acetylcholinesterase (AChE), causing the accumulation of acetylcholine (ACh), so that cholinergic nerves are subject to continuous impulses, resulting in a series of muscarinic-like, nicotinic-like and central nervous system symptoms such as excitement and then failure; severe patients can die of respiratory failure. The common ways of acute poisoning are: suicide or misuse, improper use of pesticides at work or inadequate protection to make pesticides enter through the respiratory tract and skin. Acute organophosphorus pesticide poisoning (AOPP) is more common in the majority of primary hospitals, especially in township health centers. This paper hopes to improve the treatment level of primary care physicians and reduce the death rate of patients by describing new AOPP first aid techniques. Pre-hospital first aid Pre-hospital first aid refers to the first aid measures that medical and nursing personnel (and even non-medical personnel) should try to perform on patients before they arrive at the hospital, for example, in rural areas, village doctors are more likely to be exposed to pre-hospital first aid. Stop pesticides continue to enter the body, such as lifting the patient immediately out of the workshop overflowing with pesticide gas due to leakage, pesticide mist difficult to disperse farmland or orchards; for oral intake, immediately seize the bottle, using hands or chopsticks to stimulate the patient’s throat, so that they spit out the pesticide. For pesticide contaminated clothing, the situation allows, should try to change. As soon as the diagnosis is established, immediately give antidotes Immediately give the antidotes available on hand intramuscularly, for example: for those with severe AOPP immediately inject 3 intramuscularly (compound) solution of phosphorus injection, 3 chlorophosphamide (500 mg/stem). If there is no condition to save, immediately send to a hospital with condition to save. Maintain respiration, circulation and other vital indicators either at the scene, or on the way to the hospital, if found in respiratory arrest, or even cardiac arrest, to immediately give oxygen and freehand extrasystole artificial respiration or chest compressions until admission. Halfway must not give up freehand resuscitation, while giving appropriate respiratory and circulatory stimulants. If the condition is not good, you can repeat 1/2 the first amount of antivenom at an interval of 0.5 hours or more from the first amount. Pre-hospital conditions should be recorded briefly including: changes in condition, resuscitation measures and type and dose of toxicants. Post-hospital treatment Identification or re-identification of organophosphorus pesticide poisoning and its extent ① For patients without pre-hospital emergency care, make the first diagnosis and differential diagnosis. For example, carefully question the patient or by asking the family about the medical history, whether the patient has been exposed to or self-administered pesticides, and carefully examine the body for important clinical manifestations of AOPP (garlic smell, pupil narrowing, etc.). Care should be taken to differentiate from heat stroke, other pesticide poisoning and other diseases. ② For those who have been given pre-hospital emergency treatment, it is important to understand the history of poisoning, initial symptoms and signs, degree of poisoning, history of anti-toxic and sedative medication, how the condition has changed, and how the degree of poisoning has changed. ③After comprehensive analysis, confirming the diagnosis and grading, immediately administer the corresponding first or repeated medication. ④Grading of the degree of acute poisoning: mild poisoning: M-like symptoms predominate, cholinesterase activity 70% to 50%. Dizziness, headache, nausea, vomiting, sweating, chest tightness, blurred vision, weakness, etc. Pupils may be narrowed; moderate poisoning: M-like symptoms are aggravated, N-like symptoms appear, and cholinesterase activity is 50% to 30%. In addition to the above poisoning symptoms, there are muscle bundle tremor, pupil narrowing, mild dyspnea, sweating, salivation, abdominal pain, diarrhea, staggering gait, clear or blurred consciousness, and blood pressure may be increased; severe poisoning: in addition to M and N-like symptoms, combined pulmonary edema, coma, respiratory muscle paralysis and cerebral edema, and cholinesterase activity of 30% or less. In addition to the symptoms of moderate poisoning, confusion, coma, pupils such as pinpoint size, pulmonary edema, generalized muscle bundle tremor, urinary and fecal incontinence, and respiratory failure. Remove residual pesticide from skin or stomach ① Remove all contaminated clothes (including underwear) and put them in plastic garbage bags to be processed; wash and change clothes with soapy water for the whole body. ② All those who are poisoned through the digestive tract are given thorough gastric lavage. Precautions for gastric lavage 1. For those who are awake, the first thing to do is to explore vomiting (stimulate the laryngopharynx with tongue depressor, etc., and reflexively induce vomiting). 2. For those who are in deep coma and have poor respiratory condition, gastric lavage should not be performed for the time being, but once the respiratory condition improves, gastric lavage should be performed immediately. In general, water (20~25℃) is sufficient. 3, pay attention to the amount of in and out, each injection of 300 ~ 400 ml is appropriate; the total amount of about 20 000 ~ 30 000 ml; gastric lavage at the end, you can add 30 ~ 50 g of activated charcoal in the water into the stomach. 4. For those who take a large amount of poison, the gastric tube can be kept for 24 hours. (6) Gastric lavage can be massaged in the stomach and change position to facilitate multi-directional gastric lavage. Anti-toxic treatment The principle of anti-toxic application: after the diagnosis is confirmed, give the first amount as early as possible and in sufficient quantity. In the case of rescue, restorative agents are the mainstay and anticholinergics are supplementary. Note: * indicates irregular administration to maintain mild atropinization for 24-48 hours; ** indicates applicable for transdigestive poisoning; for transdermal poisoning, depending on myofibrillation and AChE vitality; low limit is suitable for transdermal poisoning, high limit is suitable for oral poisoning; intramuscular injection; qlh×1: 1 time in 1 hour, shared 1 time Here also the application methods of new anticholinergic drugs are introduced: Hydrochloric acid As a new anticholinergic drug, pentoxifylline (long tonic) has comprehensive central anti-M and anti-N receptor effects and symptoms of central nervous system poisoning with few adverse reactions, its usage: the first dosage is 1~2 mg (mild), 2~4 mg (moderate) and 4~6 mg (severe) respectively. If the symptoms of poisoning do not disappear 1 to 2 hours after the first dose, half the first dose is given again. If the cholinesterase activity is lower than 50%, 1 to 2 mg can be applied and administered every 6 to 12 hours until the symptoms of intoxication or cholinesterase activity is restored to more than 60%. It is not advocated to combine with other anticholinergic drugs such as atropine to avoid confusing the dosage. Notes on the application of antitoxic drugs 1. The time of stopping the use of reenergizing agents is not necessarily 3 days, and it should be ensured that the blood cholinesterase (ChE) activity is steadily restored to more than 50%, and the view that poisoning enzyme aging is not easily revived after 3 days of poisoning should not be emphasized. 2, pay attention to the early (within 2 hours) after the acute poisoning of the “golden” time of the full amount of drugs, because in this time with a sufficient amount of reenergizer can not only reduce the amount of atropine, but also effectively prevent the occurrence of respiratory muscle paralysis, when the enzyme is also the easiest to revive. 3. The use of compounding agents should not be ignored because of the type of pesticide. For example, in the past, it was thought that the poisoning enzyme was not easily revived, but now it is thought that the poisoning enzyme can still be revived by the reenergizer and the use of it should be emphasized. 4.After the patient is awake, no compounding agent (compounded phosphorus relief injection) is used, and individual drugs such as atropine or chlorophosphoric acid are used for symptomatic treatment. 5. Repeat the medication according to the condition. Atropine drugs, to be given temporarily depending on the condition, observe cardiac monitoring, after atropinization, if the heart rate < 90 beats / min, then give 1 to 3 mg each time, it is not necessary to emphasize too many indicators; for those who are poisoned by mouth, compounding agents can be given under long-term medical advice, to maintain a period of effective blood concentration. 6, when the patient's whole blood ChE vitality is stable at 50% to 60% or more, you can try to stop the drug for observation. Sedative-hypnotic drugs Valium has been used as a routine drug for organophosphorus poisoning in foreign countries. The mechanism of action of Valium is different from that of reenergizer and atropine, and it has a relieving effect on heart damage, muscle tension and tremor, convulsions, and sedation of the central nervous system in severe organophosphorus pesticide poisoning. Therefore, Valium is very necessary as an adjunct to organophosphorus pesticide poisoning. However, the use of Valium requires correct timing and dosage: when the patient is agitated and convulsing, Valium 5-10mg can be used intramuscularly or intravenously, and 10% chloral hydrate 15-20ml enema. If the dosage is too large will cause respiratory distress and affect the observation of symptoms and signs. For general irritability, in principle, sedative drugs should not be abused and used more often, and the main symptom should be rescued at this time. Comprehensive symptomatic treatment ① Keep the airway unobstructed. In case of respiratory distress and cyanosis, immediately administer oxygen. In case of respiratory failure, perform artificial ventilation. ②Maintain circulatory function, prevent and control shock, and correct cardiac arrhythmia. ③Prevent and control cerebral edema. For patients with severe poisoning, it is recommended to routinely give diuretic and dehydrating agents, commonly 25% mannitol 250 ml rapid sedative drip, 15-30 minutes, once every 6-8 hours. Dexamethasone high dose short course treatment, 30-60 mg/day, divided into several intravenous doses. ④Sedation and anti-stunning, diazepam 10-20 mg intramuscularly or intravenously, repeated if necessary. ⑤ Maintain fluid, electrolyte, acid-base balance. ⑥Prevent and control pulmonary infection, hepatoprotective therapy, and enhance nursing care. ⑦In order to deal with the toxic effects of solvents such as benzene, toluene and xylene in organophosphorus pesticides on the body, it is recommended that hepatoprotective and detoxifying drugs such as hepatocyte be used as regular medication for AOPP rescue treatment. ⑧ to take a large amount of poisonous severe patients, rescue the initial segment, you can transfuse fresh blood 400 ~ 600 ml, the purpose is to let the blood cholinesterase (ChE) and free pesticide specific binding in the body, so that the pesticide can not go to the target organs to play a toxic role. In a sense, it can play a "blood washing" role. Case presentation Patient, female, 45 years old. After being admitted to the local health center, the patient's family called the 120 emergency number, and the author arrived 25 minutes later by emergency vehicle. On examination, BP was 90/60 mmHg, exhaled breath smelled like garlic, pale, dyspnea, sweating, salivation, coma, bilateral pupils were like the size of a pinpoint, and both lungs were covered with vesicular sounds. The heart rate was 62 beats/min, and the rhythm was uniform. Local cholinesterase activity was measured at 0 U (test paper method). Diagnosis Acute organophosphorus pesticide poisoning (severe); cerebral edema; pulmonary edema. Treatment and transfer The author arrived by emergency vehicle with drugs, and the local doctor was performing gastric lavage for resuscitation. Upon examination, intramuscular chlorophosphamide 2.0 g and atropine 10 mg intravenously were immediately administered. Intravenous access was established and 25% mannitol was rapidly given intravenously. After 30 minutes, the gastric lavage solution was clear, so gastric lavage was stopped and additional atropine 10 mg was administered. About 30 minutes later, he was admitted to our hospital with cardiac monitoring. The patient's pupils were dilated to 5 mm bilaterally, his face was red, and his consciousness turned clear. Body temperature was 37.6°C, heart rate was 100 beats/min, and rhythm was uniform. Repeatedly, chlorophosphamide 1.0 g was administered intramuscularly. Subsequently, chlorophosphamide was administered according to the rescue protocol for poisoning: q1h×2→q4h×3d (1 injection of 1.0 g every hour for 2 consecutive injections followed by 1 injection of 1.0 g every 4 hours for 3 days). The cholinesterase was measured at 2000 U/L by enzymatic method on the 3rd day after admission, so the reenergizer and atropine were stopped. The patient was discharged on the 7th day of admission. The key to the success of the patient's resuscitation: ① The rural hospital did not send the patient to a higher hospital after a long journey, but used the limited local conditions to provide reasonable treatment, because time is life. ②Gastric lavage, establishment of intravenous access, application of emergency drugs, and symptomatic treatment should be carried out simultaneously (or in sequence). ③ Implement treatment in strict accordance with the aforementioned treatment plan for severe sexual organophosphorus pesticide poisoning.