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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA BANGALORE ANNEXURE – II PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION 1. NAME OF THE CANDIDATE AND ADDRESS (IN BLOCK LETTERS) Dr. NAGENDER SHARMA DEPT.OF MEDICINE, M.R.MEDICAL COLLEGE, GULBARGA. PERMANENT ADDRESS 44A, OLD HOUSING BOARD COLONY, NEAR KAMLA BHAWAN, BHIWANI (HARYANA) 127021 2. NAME OF THE INSTITUTION H.K.E.SOCIETY’S MAHADEVAPPA RAMPURE MEDICAL COLLEGE, GULBARGA-585105 3. COURSE OF STUDY AND SUBJECT DATE OF ADMISSION TO COURSE TITLE OF TOPIC 4. 5. M.D. (GENERAL MEDICINE) 1st JUNE 2008 STUDY OF CLINICAL PROFILE OF ORGANOPHOSPHATE COMPOUND POISONING WITH SPECIAL REFERENCE TO ELECTROCARDIOGRAPHIC CHANGES AND ELECTROLYTE DERANGEMENTS 6. Brief resume of the intended work 6.1 Need for the study The widespread use of organophosphates and carbamates as agricultural insecticides has increased the likelihood of poisoning with these compounds. Cardiac complications often accompany poisoning with these compounds, which may be serious and often fatal. These complications are potentially preventable if they are recognised early and treated adequately. Organophosphate poisoning has been postulated both in animal and human studies to cause myocardiotoxic damage (myocardial necrosis). Electrocardiographic changes in organophosphate compound poisoning have been reported along with the associated structural myocardial damage. Organophosphate compound poisoning itself causes diarrhoea and vomiting which can lead to electrolyte derangements. Thus, this study is undertaken to study the clinical profile of organophosphate poisoning and evaluate the importance of electrocardiographic changes and electrolyte derangements in organophosphate compound poisoning. 6.2 Review of literature Dalvi CP, Abraham PP, Iyer SS et al stated that Abnormal ST-T wave changes and progressive fall in voltage or low voltage were the commonest ECG changes encountered. Other ECG abnormalities, like prolongation of QIT interval, Ectopic Beats, conduction defects and peaked P waves were seen less frequently. The dose of atropine required was highest and the rate of normalization of ECG and clinical recovery slowest, in the group with severe poisoning. The mortality was higher in moderate and severe groups, death was sudden and clinically unexpected in patient who were appearing to be recovering normally clinically. Abnormal ECG changes were present in 40% of mild cases, 87% of moderate cases, 100% of severe organophosphate poisoning cases .Patient with ECG changes should be monitored carefully till these changes revert back to normal because even after transient apparent clinical recovery, these patients are prone for sudden death1. A M Saadeh, N A Farsakh, M K Al-Ali et al studied the frequency, extent and pathogenesis of cardiac complications accompanying organophosphate and carbamate poisoning. They concluded that cardiac complications often accompany poisoning with these compounds particularly during first few hours. 46 cases records (24 females and 22 males) were reviewed. ECG manifestations were, prolonged QTc interval (67%), Elevated ST segment (24%), inverted T waves (17%) Prolonged PR interval (9%), Atrial fibrillation (9%), Ventricular tachycardia (9%), Extrasystoles (6%), Venticular fibrillation (4%). Other cardiac manifestations were noncardiogenic pulmonary oedema (43%), sinus tachycardia (35%), Sinus Bradycardia (28%), Hypertension (22%) and hypotension (17%). Hypoximea, Acidosis and electrolyte derangements are major predisposing factors2. S.B Agarwal, V.K Bhatnagar, Amol Agarwal, Usha Agarwal ,K.Venkaiah, S.K Nigam , S.K Kashyap et al studied complete clinical profile of organophosphate compound poisoning. In there study, sinus tachycardia, ST Segment depression and T wave Inversion followed by sinus bradycardia were the most common ECG abnormalities3. P. Karki, J.A Ansari, S.Bhandary, S Koirala studied extent, frequency and pathogenesis of cardiac and electrocardiographic manifestation of acute organophosphate poisoning. They also studied clinical profile of organophosphate poisoning in terms of age, sex, intension, symptoms and signs, time interval between compound consumption and hospitalization, total dose of atropine given, duration of treatment with atropine, cardiac and electrocardiographic manifestations. Cardiac manifestations and electrcardiographic changes were recorded before administration of any medications ECG manifestations in there study were prolonged QTc interval (37.8%), ST/T changes i.e. , Elevated ST segment (16.2%), inverted T waves (13.5%), Prolonged PR Interval (5.4%) Atrial fibrillation (5.4%), Ventricular tachycardia (10.8%), Extrasystole (5.4%). Other cardiac manifestations were sinus tachycardiac (40.5%), Sinus bradycardiac (18.9%), non cardio genic pulmonary edema (21.6%), hypertension (13.5%), hypotension (10.8%). In there study cardiac complications developed in 62.2% of patients, most common were Sinus tachycardia (40.5%), Prolonged QTc interval (37.8%)4. Ismail Hamdi kara, Cahfer Guloglu, Aziz Karabulut, Murat Orak et al studied sociodemographic, clinical and laboratory features of cases of organophosphorus intoxication and found mean age of cases24+/_11years, M/F ratio 1/3.8, mostly from low socioeconomical class and of suicidal intension, most common ECG changes were sinus tachycardia in 58.3%, ST changes in 54.2 % and T changes in 12.5%. Hypokalemia followed by hyponatremia were the most common Electrolyte Derangements seen in there study5. Kumiko Taira,Yoshiko Aoyama and Miwako Kawamata studied relationship between ECG manifestations and subjective symptoms accompanying organophosphate pesticide exposure caused by aerial spray was investigated6. Yurumez Y, Yavuz Y, Saglam H, Durukan P, Ozkan S, Akdur O, Yucel M evaluated 85 patients who presented to emergency department with Organophosphate poisoning and found QTc prolongation(55.5%) followed by sinus tachycardia (31.8%) were the most common Elecrocardiographic changes7. 6.3 Objective(s) of the study 1. To study the clinical profile of organophosphate compound poisoning. 2. To evaluate the importance of electrocardiographic changes and electrolyte derangements in organophosphate poisoning. 7. Material and methods 7.1 Source of Data Patients admitted with history of organophosphate poisoning in Basaveshwar Teaching and General Hospital, attached to Mahadeveppa Rampure Medical College, Gulbarga. 7.2 Methods of collection of data(including sampling procedures, if any) By using simple random method,100 cases of organophosphate poisoning admitted over a period of 2 years in Basaveshwar teaching and General Hospital, Gulbarga will be studied. The patients will be divided into mild, moderate & severe cases on the basis of modified criteria of V.N Kabaravala, S.V Solanki &S.C Charterji (1967). a. Mild cases: Giddiness, headache, vomiting, diarrhoea, excessive sweating, salivation, abdominal pain, mild to moderate constriction of pupils. Pulse rate <110/min, normal BP & no abnormal CVS, RS & CNS findings. b. Moderate cases: Drowsiness, Bradycardia or tachycardia, hypo or hypertention &mild pulmonary edema, general weakness, difficulty in talking, Irritability, fasciculation Or combination of these. c. Severe cases: Coma, Cyanosis, Respiratory paralysis, extensive Fasciculation, pin point pupils, bladder &bowel incontinence, convulsions Or combination of these. Under any circumstances. Treatment will not be withheld for the purpose of study. Inclusion criteria: • All adults with history of consumption &/or exposure to OPC of either sex, admitted in hospital within 12 hrs of ingestion and not having been treated outside. Exclusion criteria: • • • • All patients with poisoning due to compounds other than OPC. Patients with prior H/o consumption of OPC. Patients who received partial treatment outside and referred later to this hospital. Patients having H/o cardiac diseases. ECG will be recorded in 100 cases before administering atropine, pralidoxime or any other medications in casuality and ECG will be repeated in all cases before discharge following recovery from poisoning to study the possible abnormalities which could have been from organophosphate compound poisoning. Blood samples will be drawn for electrolyte estimation (Na+, K+, Ca+2) before starting treatment for poisoning in all cases and same investigation will be repeated after recovery before discharge Or before expiry of those expired. 7.3 Does the study require any investigation or intervention to be conducted on patients or other humans or animals? if so please describe briefly Yes, the study requires investigation like ECG and serum electrolytes (Na+, K+, Ca+2) serum cholinesterase. 7.4 Has ethical clearance been obtained from your institution in case of 7.3? Yes. Ethical clearance has been obtained from “Ethical clearance committee” of the institution. 8 List of References 1. Dalvi CP, Abraham PP, Iyer SS. Correlation of Electrocardiographic changes with prognosis of Organophosphate poisoning.JPGM1986; Vol.32/3 :115-119 2. Saadeh AM, Farsakh NA, Al-Al MK. Cardiac manifestations of acute carbamate and Organophosphate poisoning. Heart 1997;77:461-464 3. Agarwal SB, Bhatnagar VK et al. Impairment in Clinical Indices in Acute Organophosphate Insecticide poisoning Patients in India. The Internet Journal of Toxicology. 2007; Vol 4: No.1 4. P Karki, JA Ansari et al. Cardiac and Electrocardiographical manifestations of Acute Organophosphate poisoning. Singapore Med J 2004 Vol 45(8);385-389 5. Ismail Hamdi Kara, Cahfer Gulog LU et al. Sociodemographic, Clinical, and laboratory features of cases of organic phosphorus Intoxication who attended the Emergency Department in the Southeast Anatolialian Region of Turkey. Environment Research. Feb 2002; Vol 88 Issue2: 82-88. 6. Kumiko Taira, Yoshiko Aoyama, Miwako Kawamata. Long QT and ST-T Change Associated With Organophosphate Exposure By Aerial Spray. Environmental Toxicology and Pharmacology July 2006; Vol 22: Issue1:40-45. 7. Yurumez Y, Yavuz Y et al. Electrocardiographic findings of Acute Organophosphate Poisoning. J Emergency Med. 2008 Feb23; Doi: 10.1016/j.jemer,Med.2007; 08.063. 8. Singh S, Balkrishnan S, and Malhotra V. Parathion Poisoning in Punjab (A clinical and electrocardiographic study of 20 cases) J. Assoc Phys. India 1969; 17: 181-187. 9. Kiss Z and Fazekas, T. Organophosphate poisoning and complete heart block (letter). K. Roy. Soc Med. 1982; 75: 85-86, 138-139. 10. Kabrawala VN and Solanki SV. Pralidoxime chloride as an adjuvant in the treatment of diazinon poisoning. JAPI, 1971; 19: 278. 11. DE and SC Chatterjee. Poisoning with organophosphorus compounds. JIMA, 1967; 48: 153. 12. Ludomirsky A, Klein H, Sarelli P, Becker B, Hottman S, Taitelman U et al. Q.T prolongation and polymorphous (torsades de pointes) ventricular arrhythmias associated with organophosphorus insecticide poisoning. Am J Cardiol 1982; 49: 1654-8. 9 Signature of Candidate 10 Remarks of guide 11 11.1 Name and designation of the Guide A good study helps in treatment and outcome of the patient Dr. B. MANGSHETTY M.D. ASSOCIATE PROFESSOR DEPARTMENT OF MEDICINE, M.R. MEDICAL COLLEGE, GULBARGA 11.2 Signature 11.3 Co- guide (if any) Dr. JAGADISH B. INGIN M.D (Biochemistry) PROFESSOR & HOD DEPARTMENT OF BIOCHEMISTRY , M.R. MEDICAL COLLEGE, GULBARGA 11.4 Signature 11.5 Head of the Department 11.6 Signature 12 12.1 Remarks of the Chairman and Principal 12.2 Signature Dr. G. VEERANNA M.D., DM (Cardiology) PROFESSOR AND HOD DEPARTMENT OF MEDICINE M.R.MEDICAL COLLEGE, GULBARGA