What are the admitting orders for a patient with intentional cypermethrin (pyrethroid insecticide) ingestion?

Admitting Orders for Intentional Cypermethrin Ingestion

Admit all patients with intentional cypermethrin ingestion to a monitored setting with immediate psychiatric consultation, as intentional poisoning carries extreme risk of repeated suicide attempts and premature death from completed suicide. 1

Immediate Management and Monitoring

Airway and Respiratory Support

• Establish airway patency and provide mechanical ventilation support if needed, as cypermethrin can cause severe respiratory depression and coma mimicking organophosphate poisoning 2
• Monitor respiratory rate and oxygen saturation continuously 2
• Prepare for endotracheal intubation in symptomatic patients with altered mental status 3

Dermal Decontamination

• Perform thorough skin decontamination with soap and water immediately, as this is an essential component of treatment even with oral ingestion 2
• Remove all contaminated clothing outside the treatment area to prevent secondary exposure 3

Cardiovascular Monitoring

• Continuous cardiac monitoring for arrhythmias, as pyrethroid poisoning can present with cardiovascular instability 2, 4
• Monitor blood pressure for hypotension or shock 4
• Establish IV access and administer crystalloid fluids as needed for hemodynamic support 3

Pharmacologic Management

Atropine Administration

• Use LOW-DOSE atropine only if muscarinic symptoms are present (bronchorrhea, bronchospasm, bradycardia) 2
• Start with 0.5-1.0 mg IV every 3-5 minutes, titrating to reversal of bronchorrhea and bronchospasm 3
• Avoid high-dose atropine protocols used for organophosphate poisoning, as cypermethrin does not cause cholinesterase inhibition and excessive atropine can cause complications 2

Seizure Management

• Benzodiazepines are first-line for seizure control if they occur 3, 5
• Do NOT administer flumazenil, as it has no role in pyrethroid poisoning and is contraindicated 3, 5

Laboratory and Diagnostic Studies

Initial Laboratory Panel

• Complete blood count with differential to identify leukocytosis (occurs in 33% of cases) and rule out infection 1, 4
• Complete metabolic panel including electrolytes (sodium, potassium, magnesium, phosphorus, calcium) to detect imbalances causing neurological deterioration 1
• Renal function tests (BUN, creatinine) with monitoring for first 72 hours 1
• Hepatic panel (AST, ALT, bilirubin, alkaline phosphatase) as mild hepatic dysfunction occurs in 6% of cases 1, 4
• Serum glucose monitoring every 4-6 hours for first 72 hours 1

Imaging Studies

• Chest X-ray to evaluate for aspiration pneumonitis (occurs in 17% of cases) or pulmonary edema 4
• Brain MRI with T2-FLAIR and diffusion sequences if patient develops insidious mental deterioration, akinetic mutism, diffuse rigidity, or motor changes between 72 hours and 40 days post-ingestion 1

Clinical Monitoring Parameters

Neurological Assessment

• Serial neurological examinations for confusion (13% of cases), coma (21%), or seizures (8%) 4
• Monitor for central nervous system depression, which is the most clinically significant complication 4
• Evaluate immediately for any reduced level of consciousness or new confusion 1

Gastrointestinal Monitoring

• Monitor for sore throat, mouth ulcerations, dysphagia, epigastric pain, and vomiting (occurs in 73% of cases) 4
• These symptoms are primarily from the xylene and surfactant components in formulations 4

Pulmonary Monitoring

• Watch for aspiration pneumonitis development, which is the most common cause of mortality 4
• Monitor for pulmonary edema (occurs in 4% of cases) 4

Mandatory Psychiatric Evaluation

• Psychiatric consultation is mandatory and non-negotiable for all intentional ingestions 1
• Inform family members of the extreme risk of repeated suicide attempts and recruit them to ensure compliance with psychiatric follow-up 1
• Do not discharge until psychiatric clearance is obtained 1

Follow-Up Care

• Schedule clinical follow-up 1-2 months after discharge with a family member present to provide observations 1
• Continue monitoring renal and hepatic function if abnormalities were present during admission 1

Common Pitfalls to Avoid

• Do not treat as organophosphate poisoning with high-dose atropine, despite similar presentation—this can cause atropine toxicity 2
• Do not delay psychiatric evaluation—these patients have underlying psychiatric illness requiring immediate intervention 1
• Do not miss aspiration pneumonitis, which is the primary cause of mortality in these cases 4
• Do not discharge asymptomatic patients early—symptoms can develop up to 6 hours post-ingestion and neurological complications can occur weeks later 1, 5