Lambda-cyhalothrin and pyrethrin poisoning: A case report

Goodluck Muneeswari V

Hospital Infection Control Nurse, Kauvery Hospital, Salem, Tamilnadu, India

*Correspondence: vgoodluckgoodluck@gmail.com

Abstract

The most common organophosphorus products are dimethoate and fenthion. Endosulfan is an organochlorine insecticide. They have been phased out globally due to their potential for acute toxicity, bioaccumulation and their role as an endocrine disruptor.

Synthetic pyrethroid insecticides (cypermethrin and lambda-cyhalothrin) are ubiquitous. Exposure to Lambda-cyhalothrin poses both acute and chronic risks. Acute effects include skin and eye irritation, non-cardiogenic pulmonary edema, cardiovascular toxicity, coma, convulsions, and severe muscle fasciculation. There is no antidote for pyrethrin or pyrethroid poisoning. However, quick and effective treatment with the decontamination, monitoring, and supportive care help to minimize the extent and severity of signs. Nursing care is of utmost importance. Noticing every new symptom and intimating the consultant is key to the recovery of the patient. The nurse plays a key role in preventing hospital-acquired infections, especially in patients requiring prolonged critical care.

Keywords: Lambda-cyhalothrin, Insecticide, Poisoning, Pyrethroid, Pseudomonas aeruginosa

Background

Lambda-cyhalothrin is a synthetic pyrethroid insecticide that is used in agriculture, home pest control, and disease vector control. Lambda-cyhalothrin may irritate the skin, throat, nose, and other body parts if exposed. Exposure to Lambda-cyhalothrin poses both acute and chronic risks. Acute effects include skin and eye irritation, non-cardiogenic pulmonary edema, cardiovascular toxicity, coma, convulsions, and severe muscle fasciculation. Other symptoms may include dizziness, headache, nausea, lack of appetite, and fatigue.

Case Presentation

A 19-year-old lady came to our ER with an alleged history of consumption of organophosphorus poisoning (Lamba Cyhalotherin 5% – Pyrethroid +/- 100 ml). Initially, she went to a nearby hospital where she was given multiple-dose-activated charcoal. She developed bradycardia and one episode of seizure in the ambulance, which was managed with Inj. Atropine and Inj. Lorazepam.

Her vitals in the ER were: HR – 50 beats/min, RR – 12 breaths/min, BP – 90/60 mmHg, SpO2 – 95 % RA. She gives a history of head injury 1 year back. She also gives a history of documented seizure disorder, with the last episode of seizure 45 days before admission.

On Admission

On admission, her Glasgow Coma Scale was E2V2M5, pupils dilated bilaterally 4 mm (Atropine effect), HR – 124/min, BP – 110/60 mmHg, RR – 18/min, SpO2 – 99% in room air, CVS – S1S2 heard, RS – breath sounds heard bilaterally, coarse sounds from the throat, PA – Soft. CXR and CT Brain were normal.

Lambda-cyhalothrin-and-pyrethrin-poisoning-1

Fig. 1. X-ray and CT shows normal study, later x-ray showed a fluid-filled cavity.

Day 1

She was conscious, afebrile, and obeyed commands, both pupils were dilated 4mm, fasciculations were present, Involuntary Speech was present, Muscle weakness was present. She went into bradycardia, breathlessness, and SpO2 70% with oxygen (face mask @ 6 L/min). She was treated with Inj. Dopamine 1 mg IV bolus followed by infusion 15 mL/min. Spikes of fever were treated with antipyretics. Cardiologist and neurologist opinions were obtained. The family was on condition of the patient on a poor prognosis.

Lambda-cyhalothrin-and-pyrethrin-poisoning-2

Day 2

She was conscious and obeyed commands. Symptoms of Sludge Syndrome (Cholinergic crisis- Salivation, Lacrimation, Urination, Defecation, Gastrointestinal distress, and Emesis, all characteristic of contamination with or exposure to certain chemicals) were present.

A neurology consult opinion was taken for two episodes of seizures (the last episode 45 days back), added Inj. Levitiracetam 250 mg-0-500 mg IV. RT feeding was started and Incentive Spirometry every 2nd hour was added to the patient care plan.

Day 3

She was electively put on a mechanical ventilator in volume control mode. She had continuous oral secretions. Inotrope supports were initiated. A cardiac consult was taken to rule out stress cardiomyopathy. Blood culture, Urine culture, and ET cultures were sent for analysis. 2D ECHO showed global hypokinesia of the left ventricle with EF – 37%, mild MR+, and mild TR+. The cardiologist advised them to continue noradrenaline infusion. Use of Carvedilol was considered. The antibiotic was changed to Inj. Piptaz 4.5 g IV BD. ABG showed metabolic acidosis. Low molecular weight heparin was given and a DVT bandage was applied to prevent DVT. Chest and limb physiotherapy was started in the patient care plan.

Day 4

She was on a mechanical ventilator, the mode was changed from Volume control to Pressure support/Continuous Positive Airway Pressure. BP – 110/70 with noradrenaline 1mg/h, HR – 90 /min with Inj. Atropine 8mg/h infusion, Pupils – B/L constricted, muscle power improved. Urine output 70 to 80 ml/h. ABG showed acidosis, which was corrected. ET culture showed Pseudomonas aeruginosa – (Heavy growth). Urine culture showed Escherichia coli -Colony Count >100000, and Blood culture was sterile.

Day 5

She was conscious and obeyed commands, and muscle weakness improved. She was on intermittent CPAP. Fasciculations were present. Increased frequency of a high protein RT feeding was advised. The patient was planned for tracheostomy the next day. Urine output 90 ml/h.

Day 6

Spontaneous opening of eyes, not obeying commands, fasciculations present. On ventilator support, the Patient was suspected to have Intermediate syndrome (Muscular weakness and paralysis that occurs 1-4 days after the resolution of acute cholinergic toxidrome due to organophosphate exposure) and OPIDN (Organophosphate-induced delayed neuropathy).

Day 7

Her sensorium was lower, basal crepitations present, CNS-Quadriparesis was present, The ET secretion was thick, and tracheostomy was done. Inj. Atropine was stopped. EF improved to 49 %. Plan to get a Medical Gastroenterologist’s opinion. CXR and Ultrasonogram abdomen and pelvis did show the normal study.

Day 10

The patient’s general condition, improved. she was conscious, oriented, and obeyed commands, with muscle power 3/5. Foot strength was noticed to have decreased which was treated with potassium supplements, aggressive chest and limb physiotherapy, and spirometry given via tracheostomy. Repeat 2D ECHO showed no RWMA, normal LV function, and LVEF -60 %.

Facial & limb present EPS ( Extrapyramidal symptoms – Drug-induced movement disorders). Added Tab. Pacitane, Plan for trail T-pieces.

Day 11

She was on intermittent CPAP/ T-pieces. Urine output 60-70 ml/h. The tracheal culture showed Acinetobacter baumanii Complex (Carbapenemase Producer) – Heavy growth. The blood culture was sterile. Inj. Piptaz was escalated to Inj. Colistin, nebulization, and Tab. Septran DS. CXR taken.

Lambda-cyhalothrin-and-pyrethrin-poisoning-3

Day 18

Tracheostomy decannulated. Hot water gargling was advised twice a day. She tolerated oral feeding.

Day 21

Psychiatric opinion obtained. She was successfully Discharged.

Infection Control and Prevention aspects

Her endotracheal tube cultures grew heavy growth of Pseudomonas aeruginosa on the day of intubation, her blood culture had no growth and her urine culture showed Escherichia coli. Pseudomonas aeruginosa infections are becoming more difficult to treat because of the increasing incidence of antibiotic resistance. Multidrug-resistant types of Pseudomonas aeruginosa are even more dangerous as the treatment options are limited.

Lambda-cyhalothrin-and-pyrethrin-poisoning-4

Hospital-acquired infections are becoming more complex in modern medicine. There are well known to prolong hospitalization in moribund patients as well as increase the cost of care to critical patients. Any deviation in the nursing care or during interventions can make a patient prone to infections. These infections can easily be transmitted to other patients in the critical care unit or the community. We can harbor the organisms and even transmit them to our family members. During routine duty, we often fail to understand the seriousness of being able to harbor or transmit these infections. Hand hygiene and barrier nursing remain to be the cornerstone in preventing hospital-acquired infections among patients requiring prolonged critical care support. The cost to the patient is not just a financial cost, but time, energy, livelihood, and disability.

Approach

  1. Hand Hygiene, hand hygiene, hand hygiene!
  2. Wear appropriate personal protective equipment (PPE)
  3. Advocate for barrier nursing
  4. Teach the patient, family, and caregivers, the proper technique for giving care to  patient care
  5. Multi-disciplinary teamwork; Starting from the Doctors to the ANMs are required to work as a team to prevent hospital-acquired infections
  6. If the patient is on antibiotics, instruct the patient to take the full course of antibiotics at the right dosage at the right time even if symptoms improve or disappear.

Preventing nosocomial infections:

  1. Meticulous use of medical and surgical asepsis is necessary to prevent the transmission of potentially infectious microorganisms;
  2. Hand hygiene: Both the caregiver’s hands need to be cleaned regularly. The need to adhere to and observe the 5 moments of hand hygiene with prescribed products
  3. Nutrition: A balanced diet enhances the health of all body tissues, helps keep the skin intact, and promotes the skin’s ability to repel microorganisms; adequate nutrition enables tissues to maintain and rebuild themselves and helps keep the immune system functioning well.
  4. Fluid: Fluid intake permits fluid output that flushes out the bladder and urethra, removing microorganisms that can cause an infection.
  5. Sleep: Adequate sleep is essential to health and to renewing energy.
  6. Stress: Excessive stress predisposes people to infections; nurses can assist clients to learn stress-reducing techniques.
  7. Immunizations: The use of immunizations has dramatically decreased the incidence of vaccine-preventable diseases.
  8. Disinfecting the environment: The first links in the chain of infection, the etiologic agent and the reservoir, are interrupted with the use of antiseptics (agents that inhibit the growth of some microorganisms) and disinfectants (agents that destroy pathogens other than spores) and by sterilization; both antiseptics and disinfectants are said to have bactericidal or bacteriostatic properties; a bactericidal preparation destroys bacteria, whereas a bacteriostatic preparation prevents the growth and reproduction of some bacteria.
  9. Sterilization: Sterilization is a process that destroys all microorganisms, including spores and viruses; four commonly used methods of sterilization are: moist heat (to sterilize with moist heat, steam under pressure is used because it attains temperatures higher than the boiling point); gas (ethylene oxide gas destroys microorganisms by interfering with their metabolic processes); boiling water (this is the most practical and inexpensive method for sterilizing in the home); and radiation (both ionizing and non-ionizing are used for disinfection and sterilization.

Nursing Outcome

  1. Maintain strict asepsis for patient care, dressing changes, wound care, intravenous therapy, and medical device care.
  2. Ensure that any articles used are properly disinfected or sterilized before use.
  3. Wash hands or perform hand hygiene before coming in contact with the patient.
  4. Educate clients and SO (significant other) about appropriate cleaning, disinfecting, and sterilizing items.
  5. Encourage intake of protein-rich and calorie-rich foods and encourage a balanced diet.
  6. Perform measures to break the chain of infection and prevent infection.
  7. Encourage increased fluid intake unless contraindicated (e.g., heart failure, kidney failure).
  8. Encourage coughing and deep breathing exercises; frequent position changes.
  9. Recommend the use of soft-bristled toothbrushes and stool softeners to protect mucous membranes.
  10. Promote nail care by keeping the client and the nurse‘s fingernails short and clean. Rough edges or hangnails can harbor microorganisms. Promote good grooming practices for our patients while they are hospitalized
  11. Encourage the patients to sleep and rest well. Adequate sleep is an essential modulator of immune responses.
  12. Place the patient in protective isolation if the patient is at high risk of infection.
    Protective isolation is set when the WBC indicates neutropenia.
  13. Demonstrate and allow return demonstration of all high-risk procedures that the patient and/or SO will do after discharge, such as dressing changes, peripheral or central IV site care, and so on.

Conclusion

Prolonged hospitalization in complex patients should have a multidisciplinary approach. In modern medicine, the diagnosis and care may be complex but the road to recovery for a patient lies in the nurse’s role. In the healthcare system, we spend the most time with a patient, and this reflects on the relationship we have with the patient. A relationship is recognized by the patient when we are committed to delivering the best to our patients. The basics are to be given utmost priority. We play a pivotal role in bringing down the incidence of hospital-acquired infections.

Reference

  1. Dawson SJ. The role of the infection control link nurse. J Hosp Infect. 2003.
  2. Pittet D. Infection control and quality health care in the new Millenium. Am J Infect Contr. 2005.
  3. Sopirala MM, et al. Infection control link nurse program: an interdisciplinary approach in targeting healthcare-acquired infection. Am J Infect Contr. 2014.
  4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4509214.
  5. https://www.easpublisher.com/get-articles/478.

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