農藥中毒

楊振昌醫師
國立陽明大學醫學系內科暨
臺北榮民總醫院內科部臨床毒物科
 農藥 (Pesticides)
• 保護農作物及其生產物或改良作物目的
所用之化學藥品
• 農藥之種類：
• 殺菌劑 (Fungicide)
• 殺蟲劑 (Insecticide)
• 除草劑 (Herbicide)
• 殺蹣劑 (Acaricide, Miticide)
 農藥 (Pesticides)
• 殺線蟲劑 (Nematocide)
• 殺鼠劑 (Rodenticide)
• 引誘劑 (Attractant)
• 忌避劑 (Repellent)
• 植物生長調節劑 (Plant growth regulator)
• 補助劑 (Supplemental agent)
 農藥之沿革
• 歐洲及中國於公元前即有使用硫黃、 東蕓草
(Hellebore) 及 紅海蔥 (red squill) 之記錄
• 十九世紀後，農藥使用日益增加 (CS2 、 除蟲菊
精、 硫酸銅、 砷酸鉛等 )
• 1939 年： DDT 被發現具良好殺蟲效果
• 1944 年：發現巴拉松 (Parathion)
• 1950 年：殺菌劑保米黴素 (Blasticidin-S)
• 其後各種除草劑、 殺蟲劑陸續被製造
 殺蟲劑 (Insecticides)
• 植物性殺蟲劑：如除蟲菊
• 有機氯劑：如安殺番
• 有機磷劑：如大滅松
• 氨基甲酸鹽：如安丹
• 有機氮劑：如培丹
• 有機氟素劑：如 Fussol
• 其他及雜類：如溴化甲烷
 除草劑 / 殺菌劑
• 選擇性除草劑：如 2-4-D 、 草滅淨、嘉磷塞
異丙胺鹽
• 非選擇性除草劑：如巴拉刈、五氯酚鈉
• 撒佈用殺菌劑：如波爾多、 錳乃浦、三苯醋
錫、快得寧
• 種子消毒劑：如免賴得
• 土壤消毒劑：如福馬林
• 果實保護劑：如硫尿素
 其他農藥
• 殺蹣劑：如克氯苯
• 殺線蟲劑：如巴拉松、二溴氯丙烷
• 殺鼠劑：如殺鼠靈 ( 短效 ) 或得伐鼠
• 植物生長調節劑：植物荷爾蒙
• 補助劑：包括展著劑 (spreader) 、增量劑
(diluent) 、溶劑 (solvent) 、乳化劑
(emulsifier) 、協力劑 (synergist) 、固著劑
(sticker) 、分解防止劑 (stabilizer)
 農藥型態
• 液劑： (1) 液體狀： 溶液、乳劑、水懸：粉
； (2) 粉狀：可濕性粉劑、可溶性粉劑
• 粉劑
• 粒劑
• 煙霧劑
• 燻蒸劑
• 錠劑
• 油劑… ...
 農藥 (Pesticides)
• 理想的農藥
• 低毒性
• 效力大
• 無藥害
• 品質安定
• 價格低廉
• 物理性質好
• 使用簡單，可混用… .
 農藥毒性的分級
• 可依據半致死劑量 (LD50) 作簡單之分類
∀ ≥ 5,000mg/kg ：無毒性
• 500-5,000 mg/kg ：低毒性
• 50-500 mg/kg ：中毒性
• 5-50 mg/kg ：強毒性
• < 5 mg/kg ：劇毒性
農藥中毒之流行病學：臺灣
 質分類(1985-1993)
表一、臺灣地區導致中毒之毒性物
毒性物質 ≤ 18歲 > 19歲 全部
N % N % N %
農藥 633 10.9 6,239 35.4 6,872 29.3
藥物 1,886 32.4 4,874 27.7 6,760 28.8
清潔劑 410 7.1 1,196 6.7 1,606 6.9
溶劑 285 4.9 736 4.2 1,021 4.4
動物螫咬 172 3.0 781 4.4 953 4.1
殺鼠劑 148 2.5 658 3.7 806 3.4
化粧美容用品 246 4.2 383 2.2 629 2.7
防蟲劑 251 4.3 257 1.5 508 2.2
中藥 111 1.9 319 1.8 430 1.8
一氧化碳及有毒氣體 93 1.6 331 1.9 424 1.8
食物性毒素 89 1.5 190 1.1 279 1.2
碳氫化合物 49 0.8 168 1.0 217 0.9
資料來源：Yang CC, et al. Taiwan National Poison Control Center:
Epidemiologic Data 1985-1993. Journal of Toxicology-Clinical
Toxicology 1996;34:651-663.
 Acute Pesticide Poisonings in Taiwan
60.0%
Percentage of all pesticide poisonings

Insecticides
50.0%
Herbicid
40.0% Fungicid
Others
30.0%

20.0%

10.0%

0.0%
1985-1988 1989-1991 1992-1994 1995-1997 1998-2001
n= 2,013) (n= 1,718) (n= 2,264) (n= 2,389) (n= 2,885)

Figure 1. Distribution of poisoning substance by calendar time among

11,269 patients with acute pesticide poisonings in Taiwan
 台灣地區的農藥中毒
• 中毒物質以有機磷殺蟲劑 (23.3%) 、嘉磷
塞異丙胺鹽除草劑 (15.4%) 、巴拉刈除草
劑 (11.9%) 、除蟲菊精殺蟲劑 (11.6%) 、
及氨基甲酸鹽殺蟲劑 (6.7%) 為主
• 中毒者以 30-39 歲者最多 (19.5%) ，其次
為 19-29 歲 (18.2%)
• 中毒途徑以口服為主 (79.2%) ，其次為吸
入 (13.3%)
 台灣地區的農藥中毒
• 中毒原因以自殺 (66.7%) 為主，職業相關
者佔 13.6%
• 中毒之死亡率為 14.5% ，以巴拉刈居首
(61.5%) ，其次為有機磷殺蟲劑
(13.1%) 、氨基甲酸鹽殺蟲劑 (8.2%) 等
• 中毒死亡與暴露途徑、中毒物質、中毒原
因、其他中毒物質、及年齡等因素有關
表十一 、口服暴露中毒死亡與非死亡組間 ，基本資料之差異及相對之 OR
No. of fatal cases No. of non-fatal Adjusted OR*
(n= 1,552) (%) cases (n= 7,378) (%) (95%CI)
Substances
Paraquat 789 (66.5) 397 (33.5) 108.7 (75.9, 155.7)
Glyphosates 111 (7.0) 1,480 (93.0) 3.0 (2.0, 4.3)
Other herbicides 38 (5.9) 609 (94.1) 2.1 (1.3, 3.4)
Organophosphates 320 (16.1) 1,668 (83.9) 7.2 (5.1, 10.2)
Carbamates 59 (13.5) 379 (86.5) 7.3 (4.7, 11.3)
Pyrethrin & 39 (3.4) 1,115 (96.6) 1.0
pyrethroids
Mixed insecticides 46 (33.6) 91 (66.4) 21.0 (12.8, 34.5)
Other insecticides 14 (5.3) 250 (94.7) 2.2 (1.1, 4.1)
Fungicides 32 (5.8) 519 (94.2) 2.2 (1.3, 3.5)
Others 104 (10.7) 870 (89.3) 5.1 (3.5, 7.5)
Calendar year
1985-1988 391 (23.4) 1,280 (76.6) 1.0
1989-1991 220 (16.4) 1,125 (83.6) 0.7 (0.6, 0.9)
1992-1994 297 (16.1) 1,553 (84.0) 0.7 (0.6, 0.9)
1995-1997 295 (16.3) 1,511 (83.7) 0.8 (0.6, 1.0)
1998-2001 349 (15.5) 1,909 (84.5) 0.7 (0.6, 0.9)
表十一 、口服暴露中毒死亡與非死亡組間 ，基本資料之差異及相對之 OR
No. of fatal cases No. of non-fatal cases (n= Adjusted OR*
(n= 1,552) (%) 7,378) (%) (95% CI)
Intent of exposure
Accidental 104 (7.9) 1,211 (92.1) 1.0
Occupational 7 (5.6) 118 (94.4) 0.7 (0.3, 1.8)
Suicide 1,414 (19.3) 5,909 (80.7) 3.8 (3.0, 5.0)
Unknown 27 (15.8) 144 (84.2) 3.3 (1.9, 5.6)
Other toxins
No 1,415 (17.4) 6,733 (82.6) 1.0
Pesticides 71 (19.9) 286 (80.1) 1.7 (1.2, 2.4)
Others 66 (15.5) 359 (84.5) 0.8 (0.6, 1.1)
Age (years)
≤18 62 (9.4) 600 (90.6) 1.0
19-29 316 (17.0) 1,538 (93.0) 1.4 (0.9, 2.0)
30-39 255 (13.5) 1,632 (86.5) 1.4 (1.0, 2.0)
40-49 198 (14.8) 1,142 (85.2) 2.0 (1.4, 2.9)
50-59 221 (18.8) 955 (81.2) 2.9 (2.0, 4.2)
60-69 221 (22.4) 765 (77.6) 4.7 (3.2, 6.9)
≥70 245 (27.4) 648 (72.6) 6.7 (4.6, 9.8)
Unknown 34 (25.8) 98 (74.2) 3.8 (2.1, 7.0)
Route of exposure
Oral only 1,546 (17.7) 7,215 (82.4) 1.0
Oral and other route(s) 6 (3.6) 163 (96.5) 0.3 (0.1, 0.7)
表十二、非口服暴露中毒死亡與非死亡組間 ， 基本資料之差異及相對之 O
No. of fatal cases No. of non-fatal cases Adjusted OR*
(n= 23) (%) (n= 2,085) (%) (95%CI)
Substances
Paraquat 3 (2.6) 112 (97.4) 4.2 (0.4, 46.2)
Glyphosates 1 (0.9) 110 (99.1) 1.0 (0.1, 21.5)
Other herbicides 3 (3.0) 96 (97.0) 5.0 (0.5, 54.1)
Organophosphates 7 (1.2) 562 (98.8) 1.5 (0.2, 13.4)
Carbamates 0 (0.0) 307 (100.0) N/A
Pyrethrin & 1 (0.7) 134 (99.3) 1.0
pyrethroids
Mixed insecticides 0 (0.0) 21 (100.0) N/A
Other insecticides 0 (0.0) 88 (100.0) N/A
Fungicides 3 (1.5) 203 (98.5) 2.7 (0.2, 30.0)
Others 5 (1.1) 452 (98.9) 1.9 (0.2, 18.3)
Calendar year
1985-1988 6 (1.9) 306 (98.1) 1.0
1989-1991 4 (1.3) 304 (98.7) 1.4 (0.3, 6.0)
1992-1994 1 (0.3) 379 (99.7) 0.2 (0.0, 1.6)
1995-1997 7 (1.3) 547 (98.7) 1.0 (0.3, 3.9)
1998-2001 5 (0.9) 549 (99.1) 0.6 (0.1, 2.5)
表十二、非口服暴露中毒死亡與非死亡組間 ， 基本資料之差異及相對之 O
No. of fatal cases No. of non-fatal cases Adjusted OR*
(n= 23) (%) (n= 2,085) (%) (95%CI)
Intent of exposure
Accidental 6 (0.9) 649 (99.1) 1.0
Occupational 11 (0.8) 1,382 (99.2) 0.6 (0.2, 1.6)
Suicide 4 (8.2) 45 (91.8) 10.4 (2.4, 45.7)
Unknown 2 (8.7) 9 (81.8) 18.6 (2.6, 135.1)
Other toxins
No 14 (0.9) 1,508 (99.1) 1.0
Pesticides 7 (1.2) 563 (98.8) 2.2 (0.8, 6.0)
Others 2 (12.5) 14 (87.5) 27.7 (3.6, 211.9)
Age (years)
≤18 0 (0.0) 101 (100.0) N/A
19-29 1 (0.7) 154 (99.4) 0.7 (0.1, 6.4)
30-39 1 (0.4) 260 (99.6) 0.4 (0.0, 4.2)
40-49 4 (1.3) 316 (98.8) 1.0 (0.2, 4.6)
50-59 4 (0.8) 513 (99.2) 1.0
60-69 5 (1.0) 500 (99.0) 1.4 (0.3, 5.4)
≥70 7 (3.6) 190 (96.5) 5.2 (1.4, 19.2)
Unknown 1 (1.9) 51 (98.1) 3.4 (0.4, 33.2)
農藥中毒之流行病學：
其他地區
 農藥中毒之流行病學
• 每年約 300 萬嚴重的急性農藥中毒個案，其中
約 22 萬人死亡 (WHO 1990)
• 中毒個案 95% 發生在開發中國家，並導致約
2500 萬農夫之中毒個案
• 在已開發國家，農藥中毒不是大問題，但中毒
而住院者，死亡率並不低。以英格蘭及威爾斯
為例，中毒住院者之死亡率約 12% (Vale JA
1987) ，蘇格蘭則約 19% (Proudfoot AT 1988)
 農藥中毒之流行病學
• 美國 (1985-1990)
• 25,418 人住院，其中 78% 為意外中毒
• 341 人因農藥中毒死亡，其中 64% 為自殺
• 中毒住院及死亡者，皆以男性居多
• 同時期報告至毒物中心之農藥中毒個案共 338,170
人，其中嚴重中毒者 782 人，死亡 97 人
• 除草劑佔中毒者之 8% ，但佔死亡者之 25%

Ann Emerg Med 1997;29;232-8

 農藥中毒之流行病學
• 美國 (2002)
• 2,380,028 名通報個案，其中 1,153 人死亡 ( 死
亡率約為 0.04%)
• 96,112 人為農藥中毒 (4.0%) ，多數無或僅有
輕微症狀，其中僅 18 人死亡
• 農藥中毒以殺蟲劑 ( 以氨基甲酸鹽為首 ) 及殺
鼠劑居多
• 中毒原因以意外佔絕大部份

Am Emerg Med 2003;21;353-421

 Table 1. Deaths frompesticide poisoninginEngland

andWales 1945-1989
Pesticide Number (%of all
pesticide deaths)
Herbicides 787(77.7% )
Paraquat 570(56.3)
Sodiumchlorate 113(11.2)
Phenoxyacetate 50(4.9)
Other/ Unknown 54(5.3)
Insecticides 110(10.9)
Organophosphorus 68(6.7)
Organochlorine 8(0.8)
Other/ Unknown 34(3.4)
Rodenticides 69(6.8)
W oodPreservatives 30(3.0)
Molluscicides 7(0.7)
Fungicides 6(0.6)
Miscellaneous 3(0.3)
Total 1012(100)
* 同時期共有 87,385 名中毒死亡個案，農藥中毒者以男性及自殺居多
** Hum Exp Toxicol 1994;13:95-101
Table 3. Pesticide groups identified by toxicological analysis
among 1,138 fatal cases in Northern Greece
Ye a r O r g a n o p h so p h a te s C a r b a m a te s M isc e lla n e o u s
N o. % N o. % N o. %
1990 15 6 5 .2 5 2 1 .7 3 1 3 .0
1991 11 5 5 .0 6 3 0 .0 3 1 5 .0
1992 4 5 0 .0 2 2 5 .0 2 2 5 .0
1993 9 5 6 .2 5 3 1 .2 2 1 2 .5
1994 3 3 0 .0 5 5 0 .0 2 2 0 .0
1995 7 8 7 .5 1 1 2 .5 -- --
* 45% of fatal poisoning cases were attributed to pesticides
** Vet Hum Toxicol 1996;38:366-367
 農藥中毒之流行病學
• 德國的 Bonn 毒物中心 (1974-1993)
• 共 111,313 名資料完整之通報中毒個案
• 56% 為兒童， 13.4% 有產生毒性，藥物中
毒居多 (37.1%) ，其次為家庭用品 (31.2%)
及植物 (9.7%)
• 農藥中毒在成人僅佔 7.6%
• 中毒物質之個別比重，在研究期間並無明顯
之改變

* Vet Hum Toxciol 1995;37:367-8

 農藥中毒之流行病學
• 日本的 Hidaka 毒物中心 (1982-1995)
• 共 1,000 名住院中毒個案，其中 89.5% 為自殺個案
• 中毒死亡率為 27% ( 意外者為 1% ，自殺者為 30%)
• 農藥中毒佔 518 名，死亡率為 51%
• 農藥中毒者以巴拉刈居多 (291 名個案， 76% 之死亡
率 ) ，其次為有機磷及氨基甲酸鹽殺蟲劑 (155 名個案
， 24% 之死亡率 )

* Vet Hum Toxciol 1996;38:34-5

 農藥中毒之流行病學
• 伊朗德黑蘭的 Loghman-Hakim 醫院 (1994)
• 7,000 名中毒個案
• 中毒個案 65% 為成人、女性居多、 89.8% 服食一
種毒性物質、自殺佔 87.5% 、口服暴露為主
(78%) 、藥物為主 (60.2%)
• 農藥中毒僅佔 4.9% ，中毒物質以
organophosphates(57%) 、 aluminum phosphide 及
zinc phosphide 為主
• 死亡率以農藥中毒者居首

*J Toxicol-Clin Toxciol 1997;35:387-93

 農藥中毒之流行病學
• (1) 土耳其 Izmir 市 (1996-2000 年 )
• 4,251 名解剖個案，其中 331 名為中毒死亡
• 男性居多、 43% 為殺蟲劑中毒、自殺及口服暴露為主
• 殺蟲劑中以有機磷為主 (78%)
• (2)1993-2001 年 25,572 名中毒個案中， 8.8% 為農藥中毒，其
中 80.3% 為殺蟲劑中毒， 19.7% 為殺鼠劑；中毒者以 0-6 歲
及 19-29 歲為主；中毒死亡率僅 0.4%

* Vet Hum Toxciol 2003;45:106-8

Table 2. Hospital admissions and deaths from poisoning in
Sri Lanka, 1998
Tox ic agen t To tal h o spita l H osp ital d ea th s
ad m ission s
O rg an op h osp h ate an d carb am ates 1 4,973 1 ,4 40
O th er p esticides 6,45 6 81 0
M ed icin al ag en ts 1 0,813 19 1
S n ak e b ites 3 3,607 16 9
O th er p oison in g an d toxic effects 1 4,205 42 4
Total 8 0,054 3 ,0 34
* Poisoning is the third leading cause of death in Sri Lanka
** 4,070 reports to the PCC between 1988-1997; 48.8% were suicidal;
34% were due to pesticide exposure (10% mortality rate among hospitalized
patients) * J Toxicol-Clin Toxicol 2002;40:551-5
Table 3. The distribution of acute poisonings vs type of
toxic agent in the years 1989-1991 in Poland
Toxic agent 1989 (%) 1990 (%) 1991 (%)
Drugs 4728 (56.0) 4121 (53.3) 3879 (52.4)
Alcohols 1697 (20.1) 1608 (20.8) 1841 (24.9)
Gases 868 (10.3) 868 (11.2) 714 (9.7)
Pesticides 285 (3.4) 210 (2.7) 252 (3.3)
OPs 109 (1.3) 85 (1.1) 102 (1.4)
Carbamate 12 (0.1) 17 (0.2) 24 (0.3)
Dipyridyl 12 (0.1) 6 (0.1) 6 (0.1)
Coumarin 4 (0.05) 7 (0.1) 5 (0.1)
Others 148 (1.8) 95 (1.2) 115 (1.6)
Mushrooms 256 (3.0) 380 (4.9) 204 (2.8)
Remaining 587 (7.0) 519 (6.7) 444 (6.0)
Unknown 22 (0.3) 33 (0.4) 65 (0.9)
Total 8447 7737 7399
* Vet Hum Toxciol 1994;36:228-233
 臺灣地區常見之農藥中毒
• 殺蟲劑 (Insecticides)
有機磷殺蟲劑 (Organophosphates)
氨基甲酸鹽殺蟲劑 (Carbamates)
除蟲菊殺蟲劑 (Pyrethrin and pyrethroids)
• 除草劑 (Herbicides)
巴拉刈 (Paraquat)
嘉磷塞異丙胺鹽除草劑 (Glyphosate-surfactant
herbicide)
•有機磷農藥 : 美文松 (Mevinphos)
殺狗蚤之有機磷製劑
低毒性之有機磷製劑 : 陶斯松
 有機磷殺蟲劑中毒
Stage of clinical presentations
• Acute cholinergic syndrome (crisis):
muscarinic effect, nicotinic effect, CNS
effect
• Intermediate syndrome: proximal muscle
involvement
• Delayed polyneuropathy: distal muscle
weakness, motor nerve predominant
 有機磷殺蟲劑中毒
Clinical manifestations
• Symptoms are usually rapid onset and patients may die
within 30 minutes due to respiratory failure
• Muscarinic effects ： Salivation, Lacrimation,
Urinary incontinence, Diarrhea, Gastrointestinal cramp,
sweating, bronchorrhea, Emesis, bradycardia,
hypotension, miosis
• Nicotinic effects ： muscle paralysis, weakness,
fasciculation, hypertension, tachycardia
• Central nervous system effects ： dizziness, lethargy,
headache, delirium, seizures, coma
• Miscellaneous ： Garlic-like odor, whitish vomitus ,
hyperamylasemia, pancreatitis
嚴重度 初始症 狀及 徵候
無 無;RBCcholinesterase>50%ofnormal

輕度 病患可以行走但抱怨倦怠感 ,頭痛 ,頭暈 ,四

肢麻木 ,嘔吐 ,流汗稍 增,流涎,胸悶 ,氣管 分泌
物略增,腹絞痛 或腹瀉 ;RBCcholinesterase
20-50%ofnormal
中度 病患須臥 床且合併 有縮瞳 ,全身明顯無力 ,
肌肉束抽動 (fasciculation), 及上述 之症狀變
嚴重 ,但尚未 導致立即的生 命危險 ;RBC
cholinesterase10-20%ofnormal
重度 昏迷 ,明顯縮瞳且 無光反射 ,四肢癱瘓 ,口鼻
及氣管 分泌物大量增加 ,肺部囉音 ,呼吸困
難或衰竭 ,發紺,低血壓 ,休克或明 顯之心搏
過緩 ;RBCcholinesterase<10%of
normal
表二 .有機磷殺蟲劑中毒 嚴重度 之分類 標準
左肺塌
陷
左肺塌陷
( 恢復正
 左肺塌陷 (I)
(one lung intubation)
左肺塌陷 (II)
( 進步中 )
急性肺水腫
(I)
急性肺水腫
(II)
急性肺水腫
 有機磷殺蟲劑中毒
Treatment of poisoning
• Keep airway patent (intubation as needed)
• Decontamination (gastric lavage, skin and hair
decontamination) & activated charcoal
• IV fluid and dopamine for hypotension
• Benzodiazepine, phenobarbital & dilantin for seizures
• Charcoal hemoperfusion maybe useful in severely
poisoned patients who were not responded to above
treatment ： usually not recommended!
• More aggressive treatment required for patients with
moderate to severe poisoning
• Antidotes ： atropine & pralidoxime
 Atropine
• Indication ： patients with muscarinic symptoms/signs
• Dosage ： 2-4mg (pediatric dose 0.05 mg/kg), repeat
every 10-15 minutes until atropinization; OR 0.004-
0.016mg/kg/min, adjust the dosage by the amount of
bronchial secretion (not by heart rate or pupil size!)
• Course of therapy depends on the clinical severity
Should be used with caution in patients with BPH,
glaucoma, high fever, hypertension, hypothyroidism
• Adverse effects ： anticholinergic manifestations, e.g.
dry mouth, decreased intestinal motility, mydriasis, urine
retention, tachycardia, fever, psychosis, hallucination,
seizures, coma, ventricular dysrrhythmias
 Atropine
Continuous infusion
Advantages
less dosage required
less incidents of overdose
less complications
less nursing care

Disadvantages
infusion pump is needed
 有機磷殺蟲劑使用 atropine 之方式

輕度或無中毒 中度中毒 重度中毒

輕微分泌物增加 ( 針瞳 ,fasciculation, ( 呼吸衰竭 , 昏迷 ,
頭暈 , 腹痛等症狀 分泌物明顯增加等症狀 休克 , 抽搐等症狀
HEase 20%-50% N)* CHEase 10-20% N)* CHEase < 10% N)*

無症狀則不用給 Atropine 5-10mg in Atropine 10-20mg in

ropine, 否則 atropine IV bottle 500ml (= IV bottle 500ml (=
5mg in IV bottle 0.01 or 0.02mg/ml) 0.02 or 0.04mg/ml)
0ml (=0.006 or 0.01 Start with 0.004 Start with 0.008mg
g/ml), Start with 0.002 mg/kg/hr ( 在 50Kg 的患 /kg/hr ( 在 50Kg 的
g/kg/hr ( 在 50Kg 的患者 者約 20 or 10ml/hr) 者約 20 or 10ml/hr)
17 or 10ml/hr)

根據患者的呼吸狀況 ( 有無 rales, 痰量多寡 ,chest X-ray 是否有肺葉塌陷 ) 以調整藥

量 . 原則上勿以瞳孔及心跳快慢作為調藥之依據 , 但應注意避免因使用 atropine 後
可能引起的心跳過速 (>=140/min)
*cholinesterase 佔標準值之比率
圖二 . Atropine continuous infusion 之使用方式
 Atropine
• In tachycardia ： first correct the possible causes of
tachycardia, such as dehydration, fever, hypoxemia,
hypotension
• In tachycardia ： If tachycardia persists or worsens
after atropine usage and other possible factors have
been corrected, decreased dose of atropine or change
parenteral atropine to inhalation atropine should be
warranted
• In fever ： differential diagnosis between atropine
overdose and infection (especially aspiration
pneumonia) is indicated
 Pralidoxime (2-PAM)
• Indication ： reactivates acetylcholinesterase and
antagonizes nicotinic effects of OPS poisoning
• Dosage: 1-2gm (pediatric dose 25-50 mg/kg) over 30
minutes, repeat the dose every 6-12 hours; OR 500mg/hr
(maximum dose 12gm/day)
• Usual treatment ： 3 days; longer therapy maybe
needed on few occasions
• Rapid infusion (> 500mg/min) or large dose ：
dizziness, headache, nausea, neuromuscular blockade,
inhibition of cholinesterase, weakness, blurred vision,
diplopia, tachycardia, CPK & ALT
• Obidoxime or HI-6 maybe more potent than 2-PAM
 氨基甲酸鹽殺蟲劑中毒
• Natural carbamate: physostigmine (calabar
bean)
• Synthesized since 1940s
Carbamate insecticides
Carbamate herbicides
Carbamte fungicides
• Toxicities of carbamate insecticides are
entirely different from carbamate herbicides
and carbamate fungicides
 氨基甲酸鹽殺蟲劑中毒
英文名 中文名 白鼠或 小白 鼠之 LD50
(mg/kg)
Aldicarb 得滅克 (地蜜) 0.3-0.8
BPMC 丁基滅 必蝨 340-410
Carbaryl 加保 利 850
Carbofuran 加保 扶(好年 冬) 2-5
Carbosulfan 丁基加保 扶(新好年 64-218
丹)
Hokbal 雙滅必蝨 340-470
Methomyl 納乃得 (萬靈) 10-14.7
(lannate)
MIPC 滅必蝨 150
Propoxur 安丹 23.5-41
表一 .臺灣地區 市面上 可見之部 份氨基甲酸鹽殺蟲劑
最常見導致中毒之 carbamate: 納乃得
 氨基甲酸鹽殺蟲劑中毒
• Reason of exposure ： suicide, food residues...
• Route of exposure ： GI tract, airway, & skin
• Interact with acetylcholinesterase (carbamylation
of esteratic site) inhibition of hydrolysis of
acetylcholine acetylcholine excess cholinergic
symptoms or signs
• Clinical manifestations are not easily
distinguishable from organophosphate insecticide
poisonings except
Rapid reactivation of acetylcholinesterase
No garlic-like odor
 氨基甲酸鹽殺蟲劑中毒
• Muscarinic effect ： miosis, salivation,
lacrimation, urinary incontinence, diarrhea,
gastrointestinal cramping, emesis, bronchorrhea,
bronchospasm, hypotension, bradycardia, pulmonary
edema (“SLUDGE” or “DUMBELS” syndrome)
• Nicotinic effect ： hypertension, tachycardia,
dystonia, muscle paralysis, fasciculation
• CNS effect ： anxiety, headache, dizziness,
confusion, coma, seizure, respiratory depression
• Children are more likely to have CNS effects (e.g.
seizure) instead of muscarinic effects
 氨基甲酸鹽殺蟲劑中毒
• Other manifestations ： extrapyramidal signs,
aspiration, hyperamylasemia, pancreatitis, DIC,
metabolic acidosis,…
• Mortality rate ~ 5.8% and cause of death mainly
due to respiratory failure (airway obstruction, muscle
paralysis, or respiratory depression)
• To date, intermediate syndrome hasn’t been
reported in patients with carbamate poisoning
• Delayed neuropathy (?) ： possible since there
were 2 case reports (carbaryl & m-tolyl methyl
carbamate)
 氨基甲酸鹽殺蟲劑中毒
• Diagnosis ： history and clinical manifestations;
response to low-dose atropine, RBC & plasma
cholinesterase (should be measured earlier after
poisoning)
• Treatment ： decontamination, maintain
respiratory and cardiovascular function, IV fluid,
diazepam, atropine, pralidoxime,...
• Laboratory workup ： CXR, arterial blood gases,
CBC, biochemistry, ECG, and abdominal
ultrasonograph (if needed)
 Atropine
• Indication ： patients with muscarinic symptoms/signs
• Dosage: 2-4mg (pediatric dose 0.05 mg/kg), repeat
every 10-15 minutes until atropinization; OR 0.004-
0.016mg/kg/min, adjust the dosage by the amount of
bronchial secretion (not by heart rate or pupil size!)
• Course of therapy depends on the clinical severity
• Should be used with caution in patients with BPH,
glaucoma, high fever, hypertension, hypothyroidism
• Adverse effects ： anticholinergic manifestations, e.g.
dry mouth, decreased intestinal motility, mydriasis, urine
retention, tachycardia, fever, psychosis, hallucination,
seizures, coma, ventricular dysrrhythmias
 Pralidoxime (2-PAM)
• The use of PAM in patients with carbamate
insecticide poisonings remains controversial
Reasons proposed against the use of PAM
(1). Rapid hydrolysis of carbamylated
acetylcholinesterase
(2). PAM, in high concentration, can react with
anionic site of acetylcholinesterase and then inhibit
enzymatic hydrolysis of acetylcholine
(3). In anecdotal reports, PAM has been reported to
potentiate the toxic effects of carbaryl
(4). Possible toxicities of PAM
 Pralidoxime (2-PAM)
• Indication ： concomitant organophosphate
insecticide poisoning, severe toxic manifestations,
requiring large dose of atropine, or insecticide poisoning
with uncertain cause
• Dosage ： 1-2gm (pediatric dose 25-40 mg/kg with
total dose < 1gm), repeat the dose every 6-12 hours; OR
500mg/hr with maximum dose no more than 12gm/day
• Rapid infusion (> 500mg/min) or large dose may lead
to neuromuscular blockade, inhibition of cholinesterase,
weakness, blurred vision, diplopia, dizziness, headache,
nausea, tachycardia, CPK & ALT
 除蟲菊精殺蟲劑中毒
• 天然除蟲菊 (pyrethrum) 及人工除蟲菊酯
(pyrethroids)
• 天然除蟲菊來自菊科植物 Chrysanthemum
flower ，包括 pyrethrin I 、 II 、 cinerin
II 、 jasmolin I 、 II 等成份
• 除蟲菊酯 (pyrethroid) 為人工合成的產品，如
permethrin 、 cymethrin 、 allethrin 、 fenothrin
、 fenfluvalerate
 除蟲菊精殺蟲劑中毒
• Type I syndrome (T syndrome) ： restlessness, incoordination,
palpitation, paralysis, aggressive sparring, elevated startle response,
tremor, hyperexcitation
Example: pyrethrin I, allerthrin, tetramethrin, kadethrin, resmethrin,
phenothrin, permethrin
• Type II syndrome (CS syndrome) ： hyperactivity, convulsions,
ataxia, choreoathetosis, dermal tingling, coarse tremor, paresthesia,
profuse salivation
Examples:cypermethrin, cyhalothrin, deltamethrin, fenvalerate,
fluvalinate, decamethrin, cyfluthrin, flucythrinate, cyphenothrin
除蟲菊精殺蟲劑 (I)
除蟲菊精殺蟲劑 (II)
除蟲菊精殺蟲劑 (III)
除蟲菊精殺蟲劑 (IV): 噴香及拜貢
除蟲菊精殺蟲劑 (V): Type II 製劑的賽滅寧
 除蟲菊精殺蟲劑中毒
• 對於昆蟲及害蟲有極佳之效果
• 對於人體一般毒性很低，因此常作為家庭及
住家附近環境之殺蟲劑
• 半致死劑量一般在數百至數千 mg/kg
• 支氣管痙攣及過敏性肺炎為較主要的毒性症
狀
• 市面產品中常添加高比率之溶劑，但其成份
多半不明
 除蟲菊精殺蟲劑中毒
• 毒性症狀：
• facial dysthesia 、
、 corneal
damage 、 rhinitis 、 sore throat 、 asthma 、
respiratory paralysis 、 pulmonary
edema 、 nausea 、 vomiting 、 paresthesia
、 contact dermatitis
• 嚴重病患： convulsion 、 coma
• 天然除蟲菊精較易導致過敏症狀
 除蟲菊精殺蟲劑中毒
• 治療原則：
洗胃
活性碳 (?)
如有呼吸困難時，則使用氧氣，必要時
給予氣管擴張劑，甚至於氣管插管
有抽搐時以藥物控制抽搐
其他支持性療法
巴拉刈 (paraquat) 除草劑 (I)
巴拉刈 (paraquat) 除草劑 (II)
巴拉刈除草劑致口腔潰瘍 (I)
巴拉刈除草劑致口腔潰瘍 (II)
Paraquat 致急性肺泡炎 (I)
Paraquat 致急性肺泡炎 (II)
Paraquat 致肺纖維化 (I)
Paraquat 致肺纖維化 (II)
Paraquat 致肺纖維化 (III)
Paraquat 致肺纖維化 (IV)
巴拉刈除草劑與檢驗試劑 sodium dithionite 反應 (I)
巴拉刈除草劑與檢驗試劑 sodium dithionite 反應 (II)
巴拉刈除草劑與檢驗試劑 sodium dithionite 反應 (III)
 巴拉刈除草劑中毒
Treatment
• Inducing emesis is not recommended (additive
PP796, a phosphodiesterase inhibitor is emetic)
• If no contraindication (e.g. seizure, CNS depression
with unprotected airway, GI tract not intact): early
gastric lavage until return fluid is clear &
administration of activated charcoal
• The effect of sodium polystyrene sulfonate
(Kayexalate) remains inconclusive: survival in 6 of
22 patients (Yamashita 1987)
• Whole bowel irrigation has not been shown to be of
any benefit
 巴拉刈除草劑中毒
Treatment
• Do not administer supplemental oxygen unless the
patient presents with marked hypoxic symptoms/signs
• Forced diuresis has not been shown to modify the
outcome; possible aggravation of pulmonary edema
• Hemoperfusion maybe useful if it can be
commenced within 2 hours of ingestion
Longer duration of hemoperfusion ?
Possible complications of hemoperfusion:
thrombocytopenia, hypocalcemia, hypotension,
hypoglycemia, hypothermia
 巴拉刈除草劑中毒
Treatment
• N-acetylcysteine may be effective (limited evidence)
• Cyclophosphomide + corticosteroid:
(1). 68% (41/61) mortality rate in untreated group vs.
28% (20/72) in treatment group (Addo & Poon-King
1986); but not all cases were confirmed by serum
paraquat levels.
(2). Survival in 18/22 patients (treated) vs. 12/28
patients (untreated) with moderate poisoning (Lin
1999); the data lost statistical significance when
reanalyzed on an intention to treat basis (Buckley 2001)
 巴拉刈除草劑中毒
Treatment
(3). No difference in survival between groups (Perriens
1992)
Possible complications of therapy: septicemia, alopecia,
acne, infertility in female patients
• Vitamin C, vitamin E, sodium thiosulfate, colchicine,
superoxide dismutase, radiotherapy...: lack of
supporting clinical evidence
• NO inhalation maybe helpful (Koppel 1994)
• Hemodialysis if acute renal failure develops
• Lung transplantation ： occasional survival
 嘉磷塞異丙胺鹽除草劑中毒
• 主成份： isopropylamine salted glyphosate
(41%), polyoxyethyleneamine (a non-ionic
surfactant, 15%)
俗稱 : 年年春 , 好你春 , 好伯春 , 日日好 ,
紅星…
• Color ： brown yellow, pH 4.8
• LD50 of glyphosate ： 5,200 mg/kg
• Toxic mechanism ： remains unclear but
probably related to the surfactant
polyoxyethyleneamine (GI tract irritation or
ulcer, hypotension, diarrhea…)
 嘉磷塞異丙胺鹽除草劑中毒
• Initial symptoms/signs ： nausea, vomiting, sore
throat, salivation, oral and GI tract ulcer (no severe
injury)
• Later stage (6-8 hours) ： diarrhea and abdominal
pain (uncommon and maybe due to the frequent use
of cathartics in treatment of poisoning)
• Other manifestations ： conjunctivitis following
splash contact, hypothermia, nystagmus, periorbital
edema/burn, tachycardia, palpitation, erythema,
contact dermatitis, hyperamylasemia, elevated liver
enzymes, leukocytosis
 嘉磷塞異丙胺鹽除草劑中毒
• Severe toxicity ： metabolic acidosis, fever,
hypotension, hypovolemia,acute renal failure, GI
hemorrhage, ileus, hypoxia, bronchospasm,
pulmonary edema, ARDS, seizure, hyperkalemia,
cardiac arrhythmia, shock, coma
• Airway injury due to aspiration is likely to be the
major cause of death ： injury of the
artenoepiglottic fold may indicate airway injury
(Chang 1995)
• Mortality rate: 3%-11.3%
• Predictors of mortality ： hyperkalemia,
pulmonary edema, and metabolic acidosis (Lee
 嘉磷塞異丙胺鹽除草劑中毒
• Diagnosis ： history and clinical manifestations;
differential diagnosis between various herbicides
• Treatment ： decontamination (use of activated
charcoal ?), fluid and electrolyte replacement, airway
protection and aggressive treatment of aspiration
pneumonia
• Hemodialysis if acute renal failure develops
Never use atropine or pralidoxime
• Laboratory workup ： CXR, arterial blood gases,
CBC, biochemistry, ECG
 嘉磷塞異丙胺鹽除草劑中毒之建議處理
方式
血壓下降或休克 腹痛或食道 少量服食
疼痛 , 潰瘍

高度懷疑 疑吸入性肺炎 , 先禁食並觀察 依吸入性

低血壓 肺炎
吸入性肺炎 或併服其他毒藥物
補充水份及電解 必要時安排上 之治療原
CXR, 動脈血液 質 , 監測血壓及心 則處
氣體分析 , 抗生 電圖 , 腎功能 消化道內視鏡 理 ; 如有
素 ; 監測血壓 , 心 吸入性肺炎或 其他症
跳及呼吸 , 必要時 低血壓產生時 , 檢查及給予必 狀 , 則症
給予氣管插管 依其治療方式 必要時給予升壓劑
狀治療 ( 如 dopamine
處理 ; 其他藥物 要之藥物治療 腎功能不佳則
norepinephrine);
之檢驗 , 並作必 安排 hemodialysis
要之處理

圖一 . 嘉磷塞異丙胺鹽除草劑中毒之建議治療流程