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TRIBUTYL PHOSPHATE

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) Tributyl phosphate (TBP) is a liquid phosphate ester, most often used as a component in the production of airline hydraulic fluids. It is additionally used as an antifoaming agent and plasticizer, and as a solvent in uranium extraction and for cellulose esters, as a heat exchange medium, and as a dielectric material.

Specific Substances

    1) TBP
    2) Phosphoric acid tributyl ester
    3) Tri-n-butyl phosphate
    4) CAS 126-73-8
    5) Molecular Formula: C12-H27-O4
    1.2.1) MOLECULAR FORMULA
    1) C12-H27-O4-P (C4H9)3PO4 (CH3[CH2]3O)3PO (n-C(4)H(9)O)(3)PO

Available Forms Sources

    A) SOURCES
    1) It is produced by the reaction of phosphorus oxychloride with butyl alcohol (Ashford, 1994; Budavari, 1996).
    B) USES
    1) Tributyl phosphate is used as a fire-resistant hydraulic fluid; a solvent for cellulose esters, lacquers, and natural gums; a plasticizer; a heat exchange medium; an antifoaming agent; an extraction agent in the processing of rare earths, uranium, plutonium, and phosphoric acid; a pigment-grinding assistant; and a dielectric (ACGIH, 1991; Ashford, 1994; Hathaway et al, 1996; Lewis, 1997).

Overview

Life Support

    A) This overview assumes that basic life support measures have been instituted.

Clinical Effects

    0.2.1) SUMMARY OF EXPOSURE
    A) Tributyl phosphate is primarily an irritant. Large doses might produce muscle weakness, pulmonary edema, and cholinergic symptoms. The most likely route of significant occupational exposure is dermal.
    0.2.4) HEENT
    A) Vapors may cause headache, irritation to the eyes and mucous membranes of the nose. Hot vapor is more irritating than cold.
    0.2.6) RESPIRATORY
    A) This agent has caused pulmonary edema in animals.
    0.2.14) DERMATOLOGIC
    A) Skin irritation and dermatitis may be seen.
    0.2.15) MUSCULOSKELETAL
    A) Muscle twitching and weakness have been reported in animals poisoned with TBP.
    0.2.17) METABOLISM
    A) TBP has very weak cholinesterase inhibiting effect on erythrocytes in plasma. A dose of 100 mL orally or several mL parenterally would be needed to produce cholinergic symptoms in humans.

Laboratory Monitoring

    A) Monitor cholinesterase levels when large amounts have been ingested.

Treatment Overview

    0.4.2) ORAL/PARENTERAL EXPOSURE
    A) EMESIS - is not recommended because of the potential for gastrointestinal irritation.
    B) ACTIVATED CHARCOAL: Administer charcoal as a slurry (240 mL water/30 g charcoal). Usual dose: 25 to 100 g in adults/adolescents, 25 to 50 g in children (1 to 12 years), and 1 g/kg in infants less than 1 year old.
    C) DILUTION - Immediately administer milk or water (15 mg/kg up to 250 mL) to dilute this substance. Neutralization is not indicated.
    D) CHOLINESTERASE ACTIVITY - For amounts greater than 100 mL orally, consider measuring cholinesterase levels. If levels are depressed and the patient is symptomatic, consider atropine or protopam.
    E) SUCTION ORAL SECRETIONS until atropinization.
    F) ATROPINE THERAPY - If symptomatic from organophosphate poisoning, administer IV atropine until atropinization is achieved (See details in Treatment Section). ADULT: 2 to 5 mg every 10 to 15 minutes; CHILD: 0.05 mg/kg every 10 to 15 minutes. Atropinization may be required for hours to days depending on severity.
    G) Treat moderate to severe poisoning (fasciculations, muscle weakness, respiratory depression, coma, seizures) with pralidoxime in addition to atropine; most effective if given within 48 hours. Administer for 24 hours after cholinergic manifestations have resolved. May require prolonged administration.
    H) BOLUS DOSE: The WHO currently recommends an initial bolus of at least 30 mg/kg followed by a continuous infusion of more than 8 mg/kg/hour.
    1) ALTERNATIVE DOSE: ADULT: An alternative initial dose for adults is 1 to 2 grams diluted in 100 mL of normal saline infused over 15 to 30 minutes.
    2) ALTERNATIVE DOSE: CHILD: An alternate initial dose for children is 20 to 50 mg/kg (maximum: 2 grams/dose) infused over 30 minutes as a 5% solution in normal saline
    I) CONTINUOUS INFUSION: A continuous infusion of pralidoxime is generally preferred to intermittent bolus dosing. DOSE: ADULT: The WHO recommends an infusion of more than 8 mg/kg/hour following the initial loading dose. An alternative is an infusion of 500 mg/hour as a 2.5% solution OR a 5% solution may be used in patients with pulmonary edema. CHILD: Administer 10 to 20 mg/kg/hour of a solution containing 10 to 20 mg of pralidoxime/mL.
    J) MAXIMUM DOSE: ADULT: Maximum recommended dose is pralidoxime 12 grams in 24 hours.
    0.4.3) INHALATION EXPOSURE
    A) Move patients to fresh air. Administer oxygen, determine blood gases, and obtain a chest x-ray. Although pulmonary edema has been seen in animals, it has not been reported in humans. If pulmonary edema is present, consider PEEP therapy.
    0.4.4) EYE EXPOSURE
    A) DECONTAMINATION: Remove contact lenses and irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. If irritation, pain, swelling, lacrimation, or photophobia persist after 15 minutes of irrigation, the patient should be seen in a healthcare facility.
    0.4.5) DERMAL EXPOSURE
    A) OVERVIEW
    1) DECONTAMINATION: Remove contaminated clothing and jewelry and place them in plastic bags. Wash exposed areas with soap and water for 10 to 15 minutes with gentle sponging to avoid skin breakdown. A physician may need to examine the area if irritation or pain persists (Burgess et al, 1999).

Range Of Toxicity

    A) A dose of 100 mL orally or several mL parenterally would be necessary to produce cholinergic symptoms.

Clinical Effects

Summary Of Exposure

    A) Tributyl phosphate is primarily an irritant. Large doses might produce muscle weakness, pulmonary edema, and cholinergic symptoms. The most likely route of significant occupational exposure is dermal.

Heent

    3.4.1) SUMMARY
    A) Vapors may cause headache, irritation to the eyes and mucous membranes of the nose. Hot vapor is more irritating than cold.
    3.4.3) EYES
    A) IRRITATION - Workers exposed to the vapors complain of headache, irritation of the eyes, and irritation of the mucous membranes (Procter & Hughes, 1988). Hot vapor is severely irritating to the eyes and throat (Procter & Hughes, 1988). One drop of tributyl phosphate in a rabbit produced temporary epithelial damage and discomfort (Grant, 1974).
    1) Due to the low vapor pressure and high boiling point, the likelihood of significant exposure due to inhalation of TBP is reduced (Healy et al, 1995).

Respiratory

    3.6.1) SUMMARY
    A) This agent has caused pulmonary edema in animals.
    3.6.3) ANIMAL EFFECTS
    A) ANIMAL STUDIES
    1) PULMONARY EDEMA
    a) This agent has caused pulmonary edema in animals, and although not seen in humans, these symptoms may be expected (Procter & Hughes, 1988).
    2) ASPIRATION
    a) In a rat model of subchronic toxicity after oral ingestion 3 of 24 animals receiving 100 milligrams/kilogram/day and 7 of 24 animal receiving 325 milligrams/kilogram/day died prior to scheduled sacrifice, usually shortly after dosing (Healy et al, 1995). Pathologic examination suggested aspiration of TBP-contaminated saliva.

Neurologic

    3.7.2) CLINICAL EFFECTS
    A) HEADACHE
    1) Headache has been reported (Proctor et al, 1988).
    3.7.3) ANIMAL EFFECTS
    A) ANIMAL STUDIES
    1) NEUROPATHY
    a) Acute and subchronic oral doses were administered to rats in order to determine neurotoxicity because of the potential for occupational exposure. Only transient changes, related to forelimb grip strength and mean activity level, were noted during the first 24 hours after dosing for the maximum of 1000 mg/kg in the rats. No gross or neurohistopathological changes were found (Healy et al, 1995).

Gastrointestinal

    3.8.2) CLINICAL EFFECTS
    A) NAUSEA
    1) Nausea has been reported when workers have been industrially exposed to the vapors (Procter & Hughes, 1988).
    3.8.3) ANIMAL EFFECTS
    A) ANIMAL STUDIES
    1) SALIVA INCREASED
    a) Following acute oral dosing (100 to 1000 mg/kg) in rats, all of the females and 1/2 of the males demonstrated varying degrees of salivation, ranging from mild to severe. In subchronic oral dosing, doses of greater than 100 mg/kg/day produced varying degrees of salivation, which usually subsided within a few hours postdosing (Healy et al, 1995).

Dermatologic

    3.14.1) SUMMARY
    A) Skin irritation and dermatitis may be seen.
    3.14.2) CLINICAL EFFECTS
    A) DERMATITIS
    1) Skin irritation and dermatitis may be seen (Procter & Hughes, 1988).

Musculoskeletal

    3.15.1) SUMMARY
    A) Muscle twitching and weakness have been reported in animals poisoned with TBP.
    3.15.3) ANIMAL EFFECTS
    A) ANIMAL STUDIES
    1) TWITCHING
    a) Muscle twitching and weakness were reported in animals experimentally poisoned with TBP (Clayton & Clayton, 1981).
    b) Only transient changes, related to forelimb grip strength and mean activity level, were noted during the first 24 hours after acute oral dosing of a maximum of 1000 mg/kg in a rat study (Healy et al, 1995).

Carcinogenicity

    3.21.1) IARC CATEGORY
    A) IARC Carcinogenicity Ratings for CAS126-73-8 (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004):
    1) Not Listed

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) Monitor cholinesterase levels when large amounts have been ingested.
    4.1.2) SERUM/BLOOD
    A) BLOOD/SERUM CHEMISTRY
    1) Monitoring cholinesterase levels may be of some diagnostic value when large amounts have been ingested.
    B) ACID/BASE
    1) Monitor blood gases in patients with pulmonary symptoms.
    4.1.4) OTHER
    A) OTHER
    1) MONITORING
    a) If, cholinesterase levels are elevated, monitor for central nervous system effects.

Radiographic Studies

    A) CHEST RADIOGRAPH
    1) Obtain a chest xray in patients with pulmonary symptoms.

Treatment

Life Support

    A) Support respiratory and cardiovascular function.

Monitoring

    A) Monitor cholinesterase levels when large amounts have been ingested.

Oral Exposure

    6.5.1) PREVENTION OF ABSORPTION/PREHOSPITAL
    A) SUMMARY
    1) For amounts under 100 milliliters, gastric decontamination is not likely to be necessary.
    B) EMESIS/NOT RECOMMENDED
    1) Emesis is not recommended because of the potential for gastrointestinal irritation.
    C) ACTIVATED CHARCOAL
    1) Consider prehospital administration of activated charcoal as an aqueous slurry in patients who have ingested more than 100 milliliters and are awake and able to protect their airway.
    2) CHARCOAL DOSE
    a) Use a minimum of 240 milliliters of water per 30 grams charcoal (FDA, 1985). Optimum dose not established; usual dose is 25 to 100 grams in adults and adolescents; 25 to 50 grams in children aged 1 to 12 years (or 0.5 to 1 gram/kilogram body weight) ; and 0.5 to 1 gram/kilogram in infants up to 1 year old (Chyka et al, 2005).
    1) Routine use of a cathartic with activated charcoal is NOT recommended as there is no evidence that cathartics reduce drug absorption and cathartics are known to cause adverse effects such as nausea, vomiting, abdominal cramps, electrolyte imbalances and occasionally hypotension (None Listed, 2004).
    b) ADVERSE EFFECTS/CONTRAINDICATIONS
    1) Complications: emesis, aspiration (Chyka et al, 2005). Aspiration may be complicated by acute respiratory failure, ARDS, bronchiolitis obliterans or chronic lung disease (Golej et al, 2001; Graff et al, 2002; Pollack et al, 1981; Harris & Filandrinos, 1993; Elliot et al, 1989; Rau et al, 1988; Golej et al, 2001; Graff et al, 2002). Refer to the ACTIVATED CHARCOAL/TREATMENT management for further information.
    2) Contraindications: unprotected airway (increases risk/severity of aspiration) , nonfunctioning gastrointestinal tract, uncontrolled vomiting, and ingestion of most hydrocarbons (Chyka et al, 2005).
    D) DILUTION
    1) DILUTION: If no respiratory compromise is present, administer milk or water as soon as possible after ingestion. Dilution may only be helpful if performed in the first seconds to minutes after ingestion. The ideal amount is unknown; no more than 8 ounces (240 mL) in adults and 4 ounces (120 mL) in children is recommended to minimize the risk of vomiting (Caravati, 2004).
    6.5.2) PREVENTION OF ABSORPTION
    A) ACTIVATED CHARCOAL
    1) Charcoal should only be necessary if this agent was ingested in large amounts.
    2) CHARCOAL ADMINISTRATION
    a) Consider administration of activated charcoal after a potentially toxic ingestion (Chyka et al, 2005). Administer charcoal as an aqueous slurry; most effective when administered within one hour of ingestion.
    3) CHARCOAL DOSE
    a) Use a minimum of 240 milliliters of water per 30 grams charcoal (FDA, 1985). Optimum dose not established; usual dose is 25 to 100 grams in adults and adolescents; 25 to 50 grams in children aged 1 to 12 years (or 0.5 to 1 gram/kilogram body weight) ; and 0.5 to 1 gram/kilogram in infants up to 1 year old (Chyka et al, 2005).
    1) Routine use of a cathartic with activated charcoal is NOT recommended as there is no evidence that cathartics reduce drug absorption and cathartics are known to cause adverse effects such as nausea, vomiting, abdominal cramps, electrolyte imbalances and occasionally hypotension (None Listed, 2004).
    b) ADVERSE EFFECTS/CONTRAINDICATIONS
    1) Complications: emesis, aspiration (Chyka et al, 2005). Aspiration may be complicated by acute respiratory failure, ARDS, bronchiolitis obliterans or chronic lung disease (Golej et al, 2001; Graff et al, 2002; Pollack et al, 1981; Harris & Filandrinos, 1993; Elliot et al, 1989; Rau et al, 1988; Golej et al, 2001; Graff et al, 2002). Refer to the ACTIVATED CHARCOAL/TREATMENT management for further information.
    2) Contraindications: unprotected airway (increases risk/severity of aspiration) , nonfunctioning gastrointestinal tract, uncontrolled vomiting, and ingestion of most hydrocarbons (Chyka et al, 2005).
    B) DILUTION
    1) DILUTION: If no respiratory compromise is present, administer milk or water as soon as possible after ingestion. Dilution may only be helpful if performed in the first seconds to minutes after ingestion. The ideal amount is unknown; no more than 8 ounces (240 mL) in adults and 4 ounces (120 mL) in children is recommended to minimize the risk of vomiting (Caravati, 2004).
    6.5.3) TREATMENT
    A) DILUTION
    1) DILUTION: If no respiratory compromise is present, administer milk or water as soon as possible after ingestion. Dilution may only be helpful if performed in the first seconds to minutes after ingestion. The ideal amount is unknown; no more than 8 ounces (240 mL) in adults and 4 ounces (120 mL) in children is recommended to minimize the risk of vomiting (Caravati, 2004).
    B) MONITORING OF PATIENT
    1) For amounts greater than 100 milliliters, consider measuring CHOLINESTERASE LEVELS.
    C) AIRWAY MANAGEMENT
    1) Suction oral secretions until atropinization is achieved.
    D) ATROPINE
    1) Atropine is primarily effective for the treatment of muscarinic effects of organophosphate poisoning, and will not reverse nicotinic effects (muscular weakness, diaphragmatic weakness, etc).
    2) DIAGNOSTIC DOSE
    a) Organophosphate-poisoned patients are generally tolerant to the toxic effects of atropine (dry mouth, rapid pulse, dilated pupils, etc). If these findings occur following a diagnostic atropine dose, the patient is probably not seriously poisoned.
    1) DIAGNOSTIC DOSE - ADULT: 1 milligram intravenously or intramuscularly; CHILD: 0.25 milligram (about 0.01 milligram/kilogram) intravenously or intramuscularly.
    3) THERAPEUTIC DOSE
    a) Severely poisoned patients may require exceedingly large doses of atropine (even up to 100 milligrams over a few hours or several grams over several days) to achieve adequate atropinization (ie: drying of secretions, especially pulmonary) (Golsousidis & Kokkas, 1985). Early and prompt atropinization is of paramount importance in severe organophosphate poisoning.
    b) Organophosphate manufacturers and some medical references grossly underestimate the amount of atropine that may be required in severe poisonings. However, recent evidence suggests that low dosages of atropine may be preferable in some circumstances (De Kort et al, 1988). The dosage should be individualized in each case, depending on dose of the organophosphate and response of the patient to atropine.
    1) Inject atropine sulfate slowly intravenously. In cases where this is not possible, such as in the presence of seizures, atropine can be injected subcutaneously or given endotracheally or intraosseously (Prete et al, 1987).
    2) ADULT - 2 to 5 milligrams slowly intravenously
    3) CHILD - 0.05 milligram/kilogram slowly intravenously
    4) Repeat doses may be administered every 10 to 30 minutes as needed to achieve and maintain full atropinization, indicated by complete clearing of rales and drying of pulmonary secretions.
    a) Drying of excessive secretions is a preferable indicator for completeness of atropinization rather than heart rate or pupil size, because tachycardia and mydriasis can be signs of nicotinic effects of severe organophosphate poisoning (Ganendran, 1974; Hirschberg & Lerman, 1984) Worrel, 1975).
    b) In cases of severe poisoning where atropinization may be required for a period of several days, continuous atropine infusion may be preferable. Initial infusion rates of 0.02 to 0.08 milligram/hour have been recommended (Tafuri & Roberts, 1987). Note that infusion of atropine does not eliminate the need for an initial bolus dose if rapid atropinization is required (Heath, 1989).
    c) PRECAUTIONS
    1) Many parenteral atropine preparations contain benzyl alcohol or chlorobutanol as preservatives. High-dose therapy with these preparations MAY RESULT IN BENZYL ALCOHOL OR CHLOROBUTANOL TOXICITY.
    2) Preservative-free atropine preparations are available, and should be used if large doses are required.
    3) The half-life of atropine is significantly longer in children under 2 years of age and in adults over 60 (Kanto & Klotz, 1988); the rate of administration in these patients should be adjusted to compensate for this phenomenon.
    4) Effects of overdosing with atropine include fever, warm dry skin, inspiratory stridor, irritability, and dilated and unresponsive pupils, as seen in accidental poisonings in children (Meerstadt, 1982).
    d) Atropinization must be maintained until all of the absorbed organophosphate has been metabolized. Typically, this may require administration of 2 to 2,000 milligrams of atropine over several hours to weeks. One case of parathion overdose required the use of 19,590 milligrams of atropine over 24 days. In one 24 hour period, 2950 milligrams were administered (Golsousidis & Kokkas, 1985).
    1) Atropine therapy may need to be prolonged in severe cases, because AChE activity may regenerate slowly.
    2) Atropine therapy must be withdrawn slowly to prevent the recurrence or rebounding of symptoms, often in the form of pulmonary edema. This is especially true of poisonings from lipophilic organophosphates such as fenthion. If atropine has been given for several days, it should be maintained for at least 24 hours after resolution of acute symptoms (Bardin et al, 1987).
    e) INHALED NEBULIZED ATROPINE
    1) Atropine 2 milligrams was administered via hand-held nebulizer to a 39-year-old male with a history of a paranoid personality disorder who ingested one-half box of malathion. This was administered in addition to intravenous atropine. He had received 2 milligrams of intravenous atropine (time period not specified) without improvement in rhonchi and respiratory distress. Marked improvement in the bronchorrhea and respiratory distress were noted during administration of the inhaled nebulized atropine. The author could not attribute this improvement to the inhaled atropine alone since, the patient was also treated with intravenous atropine (Shockley, 1989)
    2) Additional clinical studies are needed before this treatment can be recommended as the standard of care.
    E) PRALIDOXIME
    1) INDICATIONS
    a) PRALIDOXIME/INDICATIONS
    1) Severe organophosphate poisoning with nicotinic (muscle and diaphragmatic weakness, respiratory depression, fasciculations, muscle cramps, etc) and/or central (coma, seizures) manifestations should be treated with pralidoxime in addition to atropine(Prod Info PROTOPAM(R) Chloride injection, 2010).
    b) PRALIDOXIME/CONTROVERSY
    1) Human studies have not substantiated the benefit of oxime therapy in acute organophosphate poisoning (Eddleston et al, 2002; de Silva et al, 1992); however oxime dosing in these studies was not optimized and methodology was unclear. Most authors advocate the continued use of pralidoxime in the clinical setting of severe organophosphate poisoning (Singh et al, 2001; Singh et al, 1998).
    2) It has been difficult to assess the value of pralidoxime in case studies because most of the patients have also received atropine therapy, or the pralidoxime was given late in the treatment or at a suboptimal dose (Peter et al, 2006; Rahimi et al, 2006).
    3) More recent observational studies have indicated that acetylcholinesterase inhibited by various organophosphate (OP) pesticides varies in its responsiveness to oximes; diethyl OPs (eg, parathion, quinalphos) appear to be effectively reactivated by oximes, while dimethyl OPs (eg, monocrotophos or oxydemeton-methyl) appear to respond poorly. Profenofos, an OP that is AChE inhibited by a S-alkyl link, was also found to not reactivate at all to oximes (Eddleston et al, 2008).
    2) ADMINISTRATION
    a) PRALIDOXIME/ADMINISTRATION
    1) Pralidoxime is best administered as soon as possible after exposure; ideally, within 36 hours of exposure (Prod Info PROTOPAM(R) CHLORIDE injection, 2006). However, patients presenting late (2 to 6 days after exposure) may still benefit (Borowitz, 1988; De Kort et al, 1988a; Namba et al, 1971; Amos & Hall, 1965) .
    2) Some mechanisms which may account for pralidoxime efficacy with delayed administration include:
    a) Poisoning with an agent such as parathion or quinalphos which produces "slow aging" of acetylcholinesterase (Eddleston et al, 2008).
    b) Slow absorption of the organophosphate compound from the lower bowel or exposure to large amounts (Prod Info PROTOPAM(R) CHLORIDE injection, 2006).
    c) Release of the organophosphate from fat stores (Borowitz, 1988).
    d) Other actions of pralidoxime.
    3) DOSE
    a) PRALIDOXIME DOSE
    1) ADULT: A loading dose of 30 mg/kg (maximum: 2 grams) over 30 minutes followed by a maintenance infusion of 8 to 10 mg/kg/hr (up to 650 mg/hr) (Howland, 2011). In vitro studies have recommended a target plasma concentration of close to 17 mcg/mL necessary for pralidoxime to be effective, which is higher than the previously suggested concentration of at least 4 mcg/mL (Howland, 2011; Eddleston et al, 2002). ALTERNATE ADULT: An alternate initial dose for adults is 1 to 2 grams diluted in 100 mL of 0.9% sodium chloride infused over 15 to 30 minutes. Repeat initial bolus dose in 1 hour and then every 3 to 8 hours if muscle weakness or fasciculations persist (continuous infusion preferred). In patients with serious cholinergic intoxication, a continuous infusion of 500 mg/hr should be considered. In patients with acute lung injury, a 5% solution may be administered by a slow IV injection over at least 5 minutes (Howland, 2006). Intravenous dosing is preferred; however, intramuscular administration may be considered using a 1-g vial of pralidoxime reconstituted with 3 mL of sterile water for injection or 0.9% sodium chloride for injection, producing a solution containing 300 mg/mL (Howland, 2011). An initial intramuscular pralidoxime dose of 1 gram or up to 2 grams in cases of very severe poisoning has also been recommended (Haddad, 1990; S Sweetman , 2002).
    2) CHILD: A loading dose of 20 to 40 mg/kg (maximum: 2 grams/dose) infused over 30 to 60 minutes in 0.9% sodium chloride (Howland, 2006; Schexnayder et al, 1998). Repeat initial bolus dose in 1 hour and then every 3 to 8 hours if muscle weakness or fasciculations persist (continuous infusion preferred). ALTERNATE CHILD: An alternate loading dose of 25 to 50 mg/kg (up to a maximum dose of 2 g), followed via continuous infusion of 10 to 20 mg/kg/hr. In patients with serious cholinergic intoxication, a continuous infusion of 10 to 20 mg/kg/hr up to 500 mg/hr should be considered (Howland, 2006).
    3) Presently, the ideal dose has NOT been established and dosing is likely based on several factors: type of OP agent (ie, diethyl OPs appear to respond more favorably to oximes, while dimethyl OPs seem to respond poorly) which may relate to a variation in the speed of ageing, time since exposure, body load, and pharmacogenetics (Eddleston et al, 2008)
    4) CONTINUOUS INFUSION
    a) A continuous infusion of pralidoxime is generally preferred to intermittent bolus dosing to maintain a target concentration with less variation (Howland, 2011; Eddleston et al, 2008; Roberts & Aaron, 2007; Gallagher et al, 1989; Thompson, 1987). In an open label, randomized study of moderately severe organophosphate poisoned patients treated with high dose continuous infusions required less atropine, were less likely to be intubated and had shorter duration of ventilatory support than patients treated with intermittent bolus doses. HIGH DOSE CONTINUOUS INFUSION: In this study, an initial 2 g bolus (pralidoxime chloride or iodide) was given, followed by 1 g over an hour every hour for 48 hours. Followed by 1 g every 4 hours until the patient could be weaned from mechanical ventilation. The response to therapy was beneficial in patients exposed to either a dimethyl or diethyl organophosphate pesticide (Pawar et al, 2006).
    b) Infusion over a period of several days may be necessary and is generally well tolerated (Namba et al, 1971).
    5) MAXIMUM DOSE
    a) The maximum recommended dose for pralidoxime is 12 grams in 24 hours for adults (S Sweetman , 2002); based on WHO, this dose may be exceeded in severely poisoned adults (Tang et al, 2013).
    6) DURATION OF INTRAVENOUS DOSING
    a) Dosing should be continued for at least 24 hours after cholinergic manifestations have resolved (Howland, 2006). Prolonged administration may be necessary in severe cases, especially in the case of poisoning by lipophilic organophosphates (Wadia & Amin, 1988). Observe patients carefully for recurrent cholinergic manifestations after pralidoxime is discontinued.
    4) ADVERSE EFFECTS
    a) SUMMARY
    1) Minimal toxicity when administered as directed; adverse effects may include: pain at injection site; transient elevations of CPK, SGOT, SGPT; dizziness, blurred vision, diplopia, drowsiness, nausea, tachycardia, hyperventilation, and muscular weakness (Prod Info PROTOPAM(R) CHLORIDE injection, 2006). Rapid injection may produce laryngospasm, muscle rigidity and tachycardia (Prod Info PROTOPAM(R) CHLORIDE injection, 2006).
    b) MINIMAL TOXICITY
    1) When administered as directed, pralidoxime has minimal toxicity (Prod Info PROTOPAM(R) CHLORIDE injection, 2006). Up to 40.5 grams have been administered over seven days (26 grams in the first 54 hours) without ill effects (Namba et al, 1971).
    2) One child developed delirium, visual hallucinations, tachycardia, mydriasis, and dry mucous membranes (Farrar et al, 1990). The authors were uncertain if these effects were related to 2-PAM or organophosphate poisoning per se.
    c) NEUROMUSCULAR BLOCKADE
    1) High doses have been reported to cause neuromuscular blockade, but this would not be expected to occur with recommended doses (Grob & Johns, 1958).
    d) VISUAL DISTURBANCES
    1) Oximes have produced visual disturbances (eg, blurred vision, diplopia) (Prod Info PROTOPAM(R) CHLORIDE injection, 2006).
    2) Transient increases in intraocular pressure may occur (Ballantyne B, 1987).
    e) ASYSTOLE
    1) Pralidoxime administered intravenously at an infusion rate of 2 grams over 10 minutes was associated with asystole in a single reported case, which occurred about 2 minutes after initiation of the infusion (Scott, 1986). A cause and effect relationship was not established.
    f) WEAKNESS
    1) Mild weakness, blurred vision, dizziness, headache, nausea, and tachycardia may occur if the rate of pralidoxime infusion exceeds 500 milligrams/minute (Jager & Stagg, 1958).
    g) ATROPINE SIDE EFFECTS
    1) Concomitant administration of pralidoxime may enhance the side effects of atropine administration (Hiraki et al, 1958). The signs of atropinization may occur earlier than anticipated when the agents are used together (Prod Info PROTOPAM(R) CHLORIDE injection, 2006).
    h) CARDIOVASCULAR
    1) Transient dose-dependent increases in blood pressure have occurred in adults receiving 15 to 30 milligrams/kilogram of 2-PAM (Calesnick et al, 1967). Increases in systolic and diastolic blood pressure have been observed in healthy volunteers given parenteral doses of pralidoxime (Prod Info PROTOPAM(R) CHLORIDE injection, 2006).
    2) Electrocardiographic changes and marked hypertension were observed at doses of 45 milligrams/kilogram (Calesnick et al, 1967).
    5) PHARMACOKINETICS
    a) HALF-LIFE: Pralidoxime is relatively short-acting with an estimated half-life of 75 minutes (Prod Info PROTOPAM(R) CHLORIDE injection, 2006). One report found that the effective half-life of pralidoxime chloride was longer in poisoned individuals than in healthy volunteers. This was attributed to a reduced renal blood flow in the poisoned patients (Jovanovic, 1989).
    6) AVAILABLE FORMS
    a) VIALS
    1) Each 20-mL vial contains 1 gram of pralidoxime chloride (Prod Info PROTOPAM(R) Chloride injection, 2010)
    b) SELF-INJECTOR
    1) Each auto-injector contains 600-mg of pralidoxime chloride in 2 mL of a sterile solution containing 20 mg/mL benzyl alcohol, 11.26 mg/mL glycine in water for injection (Prod Info PRALIDOXIME CHLORIDE intramuscular injection, 2003).
    c) CONVERSION FROM AUTOINJECTOR TO IV SOLUTION
    1) In one study, the conversion of intramuscular pralidoxime (from a MARK I Injector) to an IV solution resulted in a stable and sterile solution for up to 28 days. It is suggested that this conversion may be used in a mass casualty situation when additional IV doses of pralidoxime are needed. The following method may be used to transfer the syringe content: (Corvino et al, 2006).
    a) Avoid a shattered glass incident by using a biological safety cabinet.
    b) Double-glove and use a 30 mL empty sterile glass vial.
    c) Sterilize the vial diaphragm with alcohol.
    d) To vent the vial, insert a 1 1/2 inch 21 gauge IV needle bent to 90 degrees.
    e) Obtain the pralidoxime syringe from the kit and place it over the top of the vial diaphragm.
    f) Keep the syringe perpendicular to the vial and grasp the barrel of the syringe and press down firmly until the needle is deployed, and allow the syringe contents to enter into the vial.
    g) Use 5 pralidoxime injectors for one vial, which will be 10 mL in each vial.
    h) A 19 gauge 1.5 inch 5 micro filter needle is used with the 5 or 10 mL syringe to withdraw the pralidoxime solution from the 30 mL vial.
    i) Each vial (10 mL) is used to prepare either 250 mL, 0.9% sodium chloride injection IV bag at 8 mg/mL OR 100 mL, 0.9% sodium chloride injection IV bag to yield a final pralidoxime concentration of 10 mg/mL; 3.33 mL should be added into a 100 mL bag and 6.66 mL should be added into a 250 mL bag.
    d) OTHER SALTS
    1) Pralidoxime mesylate (P2S) in the United Kingdom (UK License holder, Department of Health).
    2) Pralidoxime methisulfate (Contrathion(R)) available in Greece (from IFET), Turkey (from Keymen), Brazil (from Sanofi-Aventis), Italy (from Sanofi-Aventis) and France (from SERB).
    F) OBIDOXIME CHLORIDE
    1) OBIDOXIME/INDICATIONS
    a) Obidoxime dichloride, Toxogonin(R), may be a less toxic and more efficacious alternative to pralidoxime in poisonings from organophosphates containing a dimethoxy or diethoxy moiety.
    b) Clinical experience with this compound is limited (Kassa, 2002; Willems, 1981; De Kort et al, 1988a; Barckow et al, 1969).
    c) It is apparently favored over pralidoxime in clinical practice in Belgium, Israel, The Netherlands, Scandinavia, and Germany and is the only oxime available in Portugal. It is currently not available in the US, but may be available through Merck in some countries.
    2) ADULT DOSE
    a) INITIAL: Obidoxime may be given as an intravenous bolus of 250 milligrams and may be repeated once or twice at 2 hour intervals (Prod Info TOXOGONIN(R) IV injection, 2007). It is more effective if given early, and the manufacturer recommends that it not be administered more than after 6 hours following organophosphate intoxication (Prod Info TOXOGONIN(R) IV injection, 2007), however in clinical practice it is often used in patients presenting more than 6 hours after poisoning (Thiermann et al, 1997).
    b) ALTERNATIVE DOSING: For the treatment of organophosphorous pesticide poisoning, administer 250 milligrams of obidoxime as an intravenous or intramuscular bolus, followed by a continuous intravenous infusion of 750 milligrams/day (Antonijevic & Stojiljkovic, 2007; Thiermann et al, 1997).
    c) CONTINUOUS INFUSION: To achieve a 4 microgram/milliliter threshold plasma level of obidoxime for the treatment of nerve agent intoxication, the following loading and maintenance doses are suggested: LOADING DOSE: 0.8 milligram/kilogram. INFUSION RATE: 0.5 milligram/kilogram/hour (Kassa, 2002).
    3) PEDIATRIC DOSE
    a) Children may be given single doses of 4 to 8 milligrams/kilogram, followed by an intravenous infusion of 0.45 milligrams/kilogram/hour (Prod Info TOXOGONIN(R) IV injection, 2007; Antonijevic & Stojiljkovic, 2007; Thiermann et al, 1997) not to exceed 250 milligrams, usual adult dose, in older children (Prod Info Toxogonin(R), obidoxime chloride, 1989).
    4) DURATION:
    a) More severely poisoned patients generally require a longer duration of infusion (Thiermann et al, 1997). If cholinergic signs or symptoms worsen or if cholinesterase concentrations decline after obidoxime is discontinued, therapy should be reinstituted.
    5) ADVERSE EFFECTS
    a) Mild, transient liver dysfunction has been noted with obidoxime use (Finkelstein et al, 1989).
    G) CONTRAINDICATED TREATMENT
    1) Succinylcholine is contraindicated.
    H) ACUTE LUNG INJURY
    1) ONSET: Onset of acute lung injury after toxic exposure may be delayed up to 24 to 72 hours after exposure in some cases.
    2) NON-PHARMACOLOGIC TREATMENT: The treatment of acute lung injury is primarily supportive (Cataletto, 2012). Maintain adequate ventilation and oxygenation with frequent monitoring of arterial blood gases and/or pulse oximetry. If a high FIO2 is required to maintain adequate oxygenation, mechanical ventilation and positive-end-expiratory pressure (PEEP) may be required; ventilation with small tidal volumes (6 mL/kg) is preferred if ARDS develops (Haas, 2011; Stolbach & Hoffman, 2011).
    a) To minimize barotrauma and other complications, use the lowest amount of PEEP possible while maintaining adequate oxygenation. Use of smaller tidal volumes (6 mL/kg) and lower plateau pressures (30 cm water or less) has been associated with decreased mortality and more rapid weaning from mechanical ventilation in patients with ARDS (Brower et al, 2000). More treatment information may be obtained from ARDS Clinical Network website, NIH NHLBI ARDS Clinical Network Mechanical Ventilation Protocol Summary, http://www.ardsnet.org/node/77791 (NHLBI ARDS Network, 2008)
    3) FLUIDS: Crystalloid solutions must be administered judiciously. Pulmonary artery monitoring may help. In general the pulmonary artery wedge pressure should be kept relatively low while still maintaining adequate cardiac output, blood pressure and urine output (Stolbach & Hoffman, 2011).
    4) ANTIBIOTICS: Indicated only when there is evidence of infection (Artigas et al, 1998).
    5) EXPERIMENTAL THERAPY: Partial liquid ventilation has shown promise in preliminary studies (Kollef & Schuster, 1995).
    6) CALFACTANT: In a multicenter, randomized, blinded trial, endotracheal instillation of 2 doses of 80 mL/m(2) calfactant (35 mg/mL of phospholipid suspension in saline) in infants, children, and adolescents with acute lung injury resulted in acute improvement in oxygenation and lower mortality; however, no significant decrease in the course of respiratory failure measured by duration of ventilator therapy, intensive care unit, or hospital stay was noted. Adverse effects (transient hypoxia and hypotension) were more frequent in calfactant patients, but these effects were mild and did not require withdrawal from the study (Wilson et al, 2005).
    7) However, in a multicenter, randomized, controlled, and masked trial, endotracheal instillation of up to 3 doses of calfactant (30 mg) in adults only with acute lung injury/ARDS due to direct lung injury was not associated with improved oxygenation and longer term benefits compared to the placebo group. It was also associated with significant increases in hypoxia and hypotension (Willson et al, 2015).

Inhalation Exposure

    6.7.1) DECONTAMINATION
    A) Move patient from the toxic environment to fresh air. Monitor for respiratory distress. If cough or difficulty in breathing develops, evaluate for hypoxia, respiratory tract irritation, bronchitis, or pneumonitis.
    B) OBSERVATION: Carefully observe patients with inhalation exposure for the development of any systemic signs or symptoms and administer symptomatic treatment as necessary.
    C) INITIAL TREATMENT: Administer 100% humidified supplemental oxygen, perform endotracheal intubation and provide assisted ventilation as required. Administer inhaled beta-2 adrenergic agonists, if bronchospasm develops. Consider systemic corticosteroids in patients with significant bronchospasm (National Heart,Lung,and Blood Institute, 2007). Exposed skin and eyes should be flushed with copious amounts of water.
    6.7.2) TREATMENT
    A) SUPPORT
    1) Move patient to fresh air. Administer oxygen, determine blood gases, and obtain a chest x-ray.
    B) ACUTE LUNG INJURY
    1) Although pulmonary edema has been seen in animals, it has not yet been reported in humans. If pulmonary edema is present, consider positive end expiratory pressure (PEEP), ventilation and steroids.
    C) Treatment should include recommendations listed in the ORAL EXPOSURE section when appropriate.

Eye Exposure

    6.8.1) DECONTAMINATION
    A) EYE IRRIGATION, ROUTINE: Remove contact lenses and irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. If irritation, pain, swelling, lacrimation, or photophobia persist after 15 minutes of irrigation, an ophthalmologic examination should be performed (Peate, 2007; Naradzay & Barish, 2006).
    6.8.2) TREATMENT
    A) GENERAL TREATMENT
    1) Permanent damage has not been seen in animal studies.
    B) Treatment should include recommendations listed in the ORAL EXPOSURE section when appropriate.

Dermal Exposure

    6.9.1) DECONTAMINATION
    A) DERMAL DECONTAMINATION
    1) DECONTAMINATION: Remove contaminated clothing and wash exposed area thoroughly with soap and water for 10 to 15 minutes. A physician may need to examine the area if irritation or pain persists (Burgess et al, 1999).
    6.9.2) TREATMENT
    A) GENERAL TREATMENT
    1) Actual burns are not anticipated.
    B) Treatment should include recommendations listed in the ORAL EXPOSURE section when appropriate.

Range Of Toxicity

Summary

    A) A dose of 100 mL orally or several mL parenterally would be necessary to produce cholinergic symptoms.

Minimum Lethal Exposure

    A) The minimum lethal human dose to this agent has not been delineated.
    B) The probable lethal oral dose in humans ranges from 0.5 to 5 g/kg; 1 oz to 1 pt (or 1 lb) for a 70 kg (150 lb) person (HSDB , 1998).

Maximum Tolerated Exposure

    A) The maximum tolerated human exposure to this agent has not been delineated.
    B) Headache and nausea have resulted from occupational exposure to an airborne concentration of 15 mg/m(3) of tributyl phosphate (ACGIH, 1991).
    C) ROUTE OF EXPOSURE
    1) A dose of 100 milliliters orally or several milliliters parenterally would be necessary to produce cholinergic symptoms (Sabine & Hayes, 1952).
    2) INHALATION - 123 parts per million for 6 hours produced respiratory irritation (Procter & Hughes, 1988).

Workplace Standards

    A) ACGIH TLV Values for CAS126-73-8 (American Conference of Governmental Industrial Hygienists, 2010):
    1) Editor's Note: The listed values are recommendations or guidelines developed by ACGIH(R) to assist in the control of health hazards. They should only be used, interpreted and applied by individuals trained in industrial hygiene. Before applying these values, it is imperative to read the introduction to each section in the current TLVs(R) and BEI(R) Book and become familiar with the constraints and limitations to their use. Always consult the Documentation of the TLVs(R) and BEIs(R) before applying these recommendations and guidelines.
    a) Under Study
    1) Tributyl phosphate
    a) TLV:
    1) TLV-TWA:
    2) TLV-STEL:
    3) TLV-Ceiling:
    b) Notations and Endnotes:
    1) Carcinogenicity Category: Not Listed
    2) Codes: Not Listed
    3) Definitions: Not Listed
    c) TLV Basis - Critical Effect(s):
    d) Molecular Weight:
    1) For gases and vapors, to convert the TLV from ppm to mg/m(3):
    a) [(TLV in ppm)(gram molecular weight of substance)]/24.45
    2) For gases and vapors, to convert the TLV from mg/m(3) to ppm:
    a) [(TLV in mg/m(3))(24.45)]/gram molecular weight of substance
    e) Additional information:
    b) Adopted Value
    1) Tributyl phosphate
    a) TLV:
    1) TLV-TWA: 0.2 ppm
    2) TLV-STEL:
    3) TLV-Ceiling:
    b) Notations and Endnotes:
    1) Carcinogenicity Category: Not Listed
    2) Codes: BEI(A)
    3) Definitions:
    a) BEI(A): The BEI notation is listed when a BEI is also recommended for the substance listed. Biological monitoring should be instituted for such substances to evaluate the total exposure from all sources, including dermal, ingestion, or non-occupational. Substances identified as Acetylcholinesterase Inhibiting Pesticides are part of this notation.
    c) TLV Basis - Critical Effect(s): Nausea; headache; eye and URT irr
    d) Molecular Weight: 266.32
    1) For gases and vapors, to convert the TLV from ppm to mg/m(3):
    a) [(TLV in ppm)(gram molecular weight of substance)]/24.45
    2) For gases and vapors, to convert the TLV from mg/m(3) to ppm:
    a) [(TLV in mg/m(3))(24.45)]/gram molecular weight of substance
    e) Additional information:

    B) NIOSH REL and IDLH Values for CAS126-73-8 (National Institute for Occupational Safety and Health, 2007):
    1) Listed as: Tributyl phosphate
    2) REL:
    a) TWA: 0.2 ppm (2.5 mg/m(3))
    b) STEL:
    c) Ceiling:
    d) Carcinogen Listing: (Not Listed) Not Listed
    e) Skin Designation: Not Listed
    f) Note(s):
    3) IDLH:
    a) IDLH: 30 ppm
    b) Note(s): Not Listed

    C) Carcinogenicity Ratings for CAS126-73-8 :
    1) ACGIH (American Conference of Governmental Industrial Hygienists, 2010): Not Listed ; Listed as: Tributyl phosphate
    2) ACGIH (American Conference of Governmental Industrial Hygienists, 2010): Not Listed ; Listed as: Tributyl phosphate
    3) EPA (U.S. Environmental Protection Agency, 2011): Not Listed
    4) IARC (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004): Not Listed
    5) NIOSH (National Institute for Occupational Safety and Health, 2007): Not Listed ; Listed as: Tributyl phosphate
    6) MAK (DFG, 2002): Category 4 ; Listed as: Tributyl phosphate
    a) Category 4 : Substances with carcinogenic potential for which genotoxicity plays no or at most a minor part. No significant contribution to human cancer risk is expected provided the MAK value is observed. The classification is supported especially by evidence that increases in cellular proliferation or changes in cellular differentiation are important in the mode of action. To characterize the cancer risk, the manifold mechanisms contributing to carcinogenesis and their characteristic dose-time-response relationships are taken into consideration.
    7) NTP (U.S. Department of Health and Human Services, Public Health Service, National Toxicology Project ): Not Listed

    D) OSHA PEL Values for CAS126-73-8 (U.S. Occupational Safety, and Health Administration (OSHA), 2010):
    1) Listed as: Tributyl phosphate
    2) Table Z-1 for Tributyl phosphate:
    a) 8-hour TWA:
    1) ppm:
    a) Parts of vapor or gas per million parts of contaminated air by volume at 25 degrees C and 760 torr.
    2) mg/m3: 5
    a) Milligrams of substances per cubic meter of air. When entry is in this column only, the value is exact; when listed with a ppm entry, it is approximate.
    3) Ceiling Value:
    4) Skin Designation: No
    5) Notation(s): Not Listed

Toxicity Information

    7.7.1) TOXICITY VALUES
    A) References: ACGIH, 1991 ITI, 1995 Lewis, 1996 RTECS, 1998 Note: All values are from RTECS (1998) unless otherwise noted.
    1) LD50- (INTRAPERITONEAL)MOUSE:
    a) 159 mg/kg
    b) 100-200 mg/kg (ACGIH, 1991)
    2) LD50- (ORAL)MOUSE:
    a) 1189 mg/kg
    b) 400-1240 mg/kg (ACGIH, 1991)
    3) LD50- (SUBCUTANEOUS)MOUSE:
    a) 764 mg/kg
    4) LD50- (INTRAPERITONEAL)RAT:
    a) 251 mg/kg
    b) 800-1600 mg/kg (ACGIH, 1991)
    5) LD50- (ORAL)RAT:
    a) 3 g/kg
    b) 1390 mg/kg (Lewis, 1996)
    c) 1390-3000 mg/kg (ACGIH, 1991)

Physicochemical

Physical Characteristics

    A) Tributyl phosphate is a stable, colorless to pale yellow, odorless liquid (Budavari, 1996; Lewis, 1997; NIOSH , 1998).

Molecular Weight

    A) 266.31

Other

    A) ODOR THRESHOLD
    1) Odorless (Budavari, 1996; Lewis, 1997)

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