☠️ AGRICULTURAL POISONING – INDIA

COMPREHENSIVE DUAL-LEVEL CARE PROTOCOL

PRIMARY CARE → SECONDARY CARE

📋 For Doctors Only | Not for Public Use

Covers: Organophosphate (OP) | Carbamate | Aluminum Phosphide (Celphos) | Paraquat | Pyrethroid

🏥 LEVEL OF CARE OVERVIEW

Procedure/Action	Primary Care	Secondary/Tertiary Care
Recognition of toxidrome	✅	✅
Decontamination	✅	✅
Airway protection	✅	✅
IV access & fluids	✅	✅
Atropine therapy (OP/Carbamate)	✅	✅
Pralidoxime (2-PAM)	⚠️ (if available)	✅
Gastric lavage	⚠️ (with caution)	✅
Mechanical ventilation	❌	✅
Hemodialysis	❌	✅
ICU-level monitoring	❌	✅

⏱️ CRITICAL TIME TARGETS

Milestone	Target Time
Remove contaminated clothing	Immediate
Decontamination (skin/eye wash)	Immediate
Secure airway if compromised	Immediate
IV access	≤ 5 min
Start Atropine (OP/Carbamate)	≤ 10 min
Start Pralidoxime (OP)	≤ 6 hours (ideally ≤ 4 hours)
Transfer to higher centre	ASAP after stabilization

⚠️ In Aluminum Phosphide poisoning: NO specific antidote exists – early aggressive supportive care is critical

📖 OVERVIEW OF COMMON AGRICULTURAL POISONS IN INDIA

Quick Comparison Table

Poison	Mechanism	Onset	Antidote	Mortality
Organophosphate (OP)	Irreversible AChE inhibition	30 min - 12 hrs	Atropine + Pralidoxime	10-40%
Carbamate	Reversible AChE inhibition	15 min - 2 hrs	Atropine only	5-10%
Aluminum Phosphide (Celphos)	Phosphine gas → mitochondrial toxicity	30 min - 6 hrs	⛔ NONE	40-90%
Paraquat	Oxidative stress → pulmonary fibrosis	Hours to days	⛔ NONE	50-90%
Pyrethroid	Sodium channel modulation	30 min - 2 hrs	Supportive	< 5%

Common Products in India

Category	Common Products / Trade Names
Organophosphates	Monocrotophos, Phorate, Methyl Parathion, Chlorpyrifos, Malathion, Dimethoate, Quinalphos
Carbamates	Carbofuran (Furadan), Carbaryl (Sevin), Propoxur (Baygon), Aldicarb
Aluminum Phosphide	Celphos, Quickphos, Alphos, Phosphume, Rice tablets
Paraquat	Gramoxone, Parazone
Pyrethroids	Cypermethrin, Deltamethrin, Permethrin, Allethrin

🟢 PART 1 — PRIMARY CARE

Goal: Recognise → Decontaminate → Stabilise → Antidote (if applicable) → TRANSFER

1️⃣ INITIAL ASSESSMENT & SAFETY

Healthcare Worker Safety (CRITICAL)

⚠️ Risk	Precaution
Skin contamination	Wear gloves (double-gloving preferred), gown, apron
Inhalation (especially AlP)	Well-ventilated area; face mask; avoid enclosed spaces
Eye splash	Eye protection / goggles
Secondary contamination	Remove patient's clothing before entering ED
Vomitus	Highly toxic – handle with care, dispose safely

📌 In Aluminum Phosphide poisoning: Phosphine gas released from vomitus/gastric contents can poison healthcare workers. Ensure good ventilation.

History Taking (If Patient/Family Can Provide)

Question	Why Important
What substance was taken?	Bring container/label if available
How much was taken?	Dose estimation
When was it taken?	Time to intervention
Route of exposure?	Ingestion, inhalation, dermal
Intentional or accidental?	Psychiatric assessment needed
Any vomiting?	May have expelled some poison
Any treatment given before arrival?	Home remedies, other facilities
Past medical history?	Comorbidities affecting management

2️⃣ TOXIDROME RECOGNITION

Cholinergic Toxidrome (Organophosphate / Carbamate)

SLUDGE + BBB Mnemonic (Muscarinic Effects)

Letter	Sign
S	Salivation
L	Lacrimation
U	Urination
D	Defecation / Diarrhea
G	GI cramps
E	Emesis
---	---
B	Bronchorrhea
B	Bronchospasm
B	Bradycardia

Alternative Mnemonic: DUMBELS

Letter	Sign
D	Diarrhea
U	Urination
M	Miosis (pinpoint pupils)
B	Bronchorrhea / Bronchospasm / Bradycardia
E	Emesis
L	Lacrimation
S	Salivation

Nicotinic Effects (Also Present in OP/Carbamate)

Effect	Signs
Muscle	Fasciculations, weakness, paralysis
Cardiovascular	Tachycardia, hypertension (may override muscarinic bradycardia)
CNS	Anxiety, restlessness, seizures, coma

CNS Effects

Effect
Anxiety, agitation
Confusion
Seizures
Coma
Respiratory depression

Aluminum Phosphide Toxidrome

System	Signs & Symptoms
GI	Severe burning epigastric pain, nausea, vomiting (garlic/fish odor)
Cardiovascular	Profound hypotension, shock (most common cause of death)
	Arrhythmias (VT, VF, heart block)
	Myocarditis
Respiratory	Dyspnea, pulmonary edema, ARDS
CNS	Agitation, dizziness, headache, seizures, coma
Metabolic	Severe metabolic acidosis
Renal	Acute kidney injury
Hepatic	Hepatic injury

📌 Characteristic: Garlic/fish odor of breath and vomitus

Paraquat Toxidrome

Phase	Timing	Features
Phase 1	0-24 hrs	GI corrosive injury: oral/esophageal burns, vomiting, diarrhea
Phase 2	24-72 hrs	Multi-organ damage: hepatic, renal, cardiac injury
Phase 3	Days to weeks	Pulmonary fibrosis (progressive, irreversible)

Key Feature
Oral mucosal ulceration ("Paraquat tongue") – burns in mouth/throat
Delayed respiratory failure (days to weeks)
High FiO₂ worsens lung injury (avoid excess O₂)

Pyrethroid Toxidrome

Type	Symptoms
Type I (without cyano group)	Tremors, hyperexcitability, ataxia
Type II (with cyano group – e.g., Cypermethrin)	Choreoathetosis, salivation, seizures
Allergic	Dermatitis, rhinitis, bronchospasm
Severity	Usually mild; rarely life-threatening

3️⃣ DIFFERENTIATING OP vs CARBAMATE vs AlP

Feature	Organophosphate	Carbamate	Aluminum Phosphide
AChE inhibition	Irreversible	Reversible	No AChE effect
Cholinergic toxidrome	✅ Prominent	✅ Prominent	❌ Absent
Miosis	✅ Yes	✅ Yes	❌ No (or late dilated pupils)
Garlic/fish odor	❌ No	❌ No	✅ Yes
Shock	Late	Late	✅ Early, profound
Metabolic acidosis	Mild-moderate	Mild	✅ Severe
Pralidoxime useful?	✅ Yes	❌ No	❌ No
Atropine useful?	✅ Yes	✅ Yes	❌ No

4️⃣ IMMEDIATE MANAGEMENT – ALL AGRICULTURAL POISONS

Step 1: Ensure Your Safety & Decontamination

Action	Details
Don PPE	Gloves, gown, mask, eye protection
Well-ventilated area	Critical for AlP (phosphine gas)
Remove all clothing	Place in plastic bag; dispose safely
Skin decontamination	Wash entire body with soap and water
Hair washing	Shampoo thoroughly
Eye decontamination	Irrigate with NS or water for 15-20 min (if eye exposure)
Avoid contaminating yourself	Handle patient carefully

Step 2: Airway, Breathing, Circulation

Action	Details
Airway	Suction secretions (copious in OP); position patient
Oxygen	If SpO₂ < 94% (but use cautiously in Paraquat – avoid high FiO₂)
IV Access	2 large-bore cannulas
Fluids	NS bolus if hypotensive (especially AlP)
Monitor	BP, HR, SpO₂, GCS, pupils
Intubation	If GCS < 8, severe respiratory secretions, impending failure

Step 3: Gastric Decontamination

Should You Do Gastric Lavage?

Poison	Gastric Lavage Indicated?	Notes
Organophosphate	⚠️ May consider within 1-2 hrs	Only if airway protected; controversy exists
Carbamate	⚠️ May consider within 1 hr	Less benefit than OP
Aluminum Phosphide	⚠️ May consider ONLY with KMnO₄ or NaHCO₃	Controversial; risk of aspiration; may increase phosphine release
Paraquat	✅ Yes – within 1-2 hrs	Fuller's earth or Activated charcoal
Pyrethroid	⚠️ Rarely needed	Usually mild

Gastric Lavage – General Precautions

Contraindication
Altered consciousness without airway protection
Corrosive ingestion (acid/alkali)
> 2 hours since ingestion (limited benefit)
Convulsions (uncontrolled)

Activated Charcoal

Poison	Activated Charcoal Useful?	Dose
Organophosphate	⚠️ Limited evidence	1 g/kg (max 50 g)
Carbamate	⚠️ Limited evidence	1 g/kg (max 50 g)
Aluminum Phosphide	❌ NOT effective	—
Paraquat	⚠️ May help if early (< 1-2 hrs)	1-2 g/kg
Pyrethroid	⚠️ May help	1 g/kg

📌 Activated charcoal is NOT a priority over antidote administration in OP poisoning

5️⃣ ORGANOPHOSPHATE POISONING – PRIMARY CARE MANAGEMENT

Atropine – The Lifesaving Antidote

Indication

All patients with cholinergic toxidrome (SLUDGE + BBB)
Especially bronchorrhea / bronchospasm

Atropine Protocol

Step	Action
1	Test dose: 1-2 mg IV bolus (adults); 0.02 mg/kg (children)
2	Observe for 3-5 minutes
3	If no atropinization: Double the dose (2-4 mg → 4-8 mg → 8-16 mg...)
4	Repeat every 3-5 min until ATROPINIZATION achieved
5	Once atropinized: Start infusion (10-20% of total loading dose per hour)

Atropinization End-Points (Target These)

Chest clear (no wheeze/crackles)	✅ Most important
Dry axillae	✅
Heart rate > 80 bpm	✅
Systolic BP > 80 mmHg	✅
Pupils dilated	Not a target – occurs late

📌 The goal is DRYING SECRETIONS (especially pulmonary), not pupil dilation

Atropine Dose Escalation

Dose	If No Response
1-2 mg	Give 2-4 mg
2-4 mg	Give 4-8 mg
4-8 mg	Give 8-16 mg
8-16 mg	Give 16-32 mg
Continue doubling...	May need 100+ mg in severe cases

⚠️ Do NOT be afraid to give large doses of Atropine – there is no maximum dose in OP poisoning

Atropine Infusion (After Loading)

Calculation	Example
Infusion rate = 10-20% of total loading dose per hour	If 30 mg needed to atropinize → Infuse 3-6 mg/hr
Preparation	Add Atropine to NS in syringe pump
Titrate	Increase/decrease to maintain atropinization
Duration	May need 24-48 hrs or more

Signs of Over-Atropinization (Toxicity)

Sign	Action
Hyperthermia	Reduce dose; cooling
Agitation, delirium	Reduce dose; may need sedation
Urinary retention	Catheterize
Ileus	Reduce dose
Tachycardia > 120 (with above signs)	Reduce dose

📌 Tachycardia alone is NOT a contraindication to Atropine – continue if secretions persist

Pralidoxime (2-PAM) – The Oxime

Mechanism

Reactivates acetylcholinesterase by removing OP from enzyme
Must be given before "aging" occurs (irreversible binding)
Effective mainly against nicotinic effects (muscle weakness)

When to Give

Indication	Give Pralidoxime?
Organophosphate poisoning	✅ Yes
Carbamate poisoning	❌ No (reversible inhibition; may worsen)
Aluminum phosphide	❌ No
Unknown – but cholinergic toxidrome	✅ Yes (assume OP)

Timing

Timing	Effectiveness
< 6 hours	✅ Most effective
6-24 hours	⚠️ May still be beneficial
> 24-48 hours	❌ Limited benefit (aging has occurred)

Pralidoxime Dosing

Population	Loading Dose	Maintenance
Adult	1-2 g IV over 15-30 min	500 mg/hr infusion OR 1-2 g every 4-6 hrs
Child	25-50 mg/kg IV over 15-30 min	10-20 mg/kg/hr infusion

Pralidoxime Preparation

Preparation	Details
Available as	500 mg or 1 g vials (powder for reconstitution)
Reconstitute	With 20 mL sterile water
Dilute	In 100 mL NS for infusion
Rate	Over 15-30 min (rapid bolus can cause hypertension, muscle rigidity)

📌 Give Pralidoxime WITH Atropine – they work synergistically

If Pralidoxime Not Available at Primary Care

Action
Start Atropine (it alone can be life-saving)
Pralidoxime can be given at secondary care
Transfer urgently
Do not delay transfer waiting for Pralidoxime

Seizure Management

Drug	Dose	Route
Diazepam	5-10 mg	IV slow
	0.2-0.3 mg/kg (child)	IV/PR
Midazolam	2.5-5 mg	IV/IM
Lorazepam	2-4 mg	IV

⛔ Avoid Phenytoin in OP poisoning – may worsen outcomes

Primary Care Summary for OP Poisoning

Step	Action
1	PPE + Decontamination
2	Airway + Suction (copious secretions)
3	IV access
4	Atropine 1-2 mg IV; double every 3-5 min until dry
5	Pralidoxime 1-2 g IV over 30 min (if available)
6	Diazepam for seizures
7	TRANSFER to higher centre

6️⃣ CARBAMATE POISONING – PRIMARY CARE MANAGEMENT

Key Differences from OP

Feature	Organophosphate	Carbamate
AChE inhibition	Irreversible	Reversible
Duration of toxicity	Prolonged (days)	Shorter (hours)
Pralidoxime	✅ Yes	⛔ No (may worsen)
Atropine	✅ Yes	✅ Yes
Recovery	Slower	Faster

Management

Step	Action
1	Decontamination
2	Airway + Suction
3	Atropine (same protocol as OP)
4	⛔ Do NOT give Pralidoxime
5	Supportive care
6	Transfer if severe

📌 Carbamates are generally less severe and recover faster than OP

7️⃣ ALUMINUM PHOSPHIDE (CELPHOS) POISONING – PRIMARY CARE MANAGEMENT

⚠️ EXTREMELY HIGH MORTALITY (40-90%) – No Antidote Exists

Key Points

Point	Details
Mechanism	Phosphine gas (PH₃) → mitochondrial toxicity → cellular hypoxia
Lethal dose	150-500 mg (1 tablet can kill)
Antidote	⛔ NONE
Cause of death	Cardiogenic shock, arrhythmias, refractory hypotension
Odor	Garlic/fish smell of breath/vomitus

Immediate Actions at Primary Care

Step	Action
1	Ensure ventilation (open windows, fans) – phosphine gas danger
2	Remove clothing (dispose in open area)
3	Do NOT induce vomiting at primary level
4	IV access × 2
5	IV fluids: NS bolus if hypotensive
6	Oxygen if SpO₂ < 94%
7	TRANSFER IMMEDIATELY – this is highest priority

Gastric Lavage in AlP (Controversial)

Consideration	Details
If performed	Use Potassium permanganate (KMnO₄) 1:10,000 OR Sodium bicarbonate 2%
Rationale	KMnO₄ oxidizes phosphine; NaHCO₃ reduces absorption
Risk	Gastric lavage may increase phosphine release; aspiration risk
Current consensus	Controversial; many centres avoid gastric lavage
At primary care	Do NOT perform unless trained; prioritize transfer

If Gastric Lavage Done (At Secondary Care)

Solution	Preparation
KMnO₄ 1:10,000	100 mg in 1 L water (light pink color)
NaHCO₃ 2%	20 g in 1 L water
Coconut oil	100 mL via NG tube (to reduce phosphine release) – limited evidence

What NOT to Do in AlP Poisoning

⛔ Do NOT
Induce vomiting (aspiration risk, more phosphine release)
Perform CPR in enclosed space without ventilation
Delay transfer for any procedure
Give any "antidote" (none exists)
Allow patient to lie in enclosed room (phosphine accumulates)

Primary Care Summary for AlP Poisoning

Step	Action
1	Ventilation / Open space
2	Remove clothing
3	IV access, IV NS bolus
4	Oxygen
5	TRANSFER IMMEDIATELY
6	Pre-alert receiving hospital

8️⃣ PARAQUAT POISONING – PRIMARY CARE MANAGEMENT

Key Points

Point	Details
Mechanism	Generates free radicals → oxidative stress → pulmonary fibrosis
Lethal dose	20-40 mg/kg (~10-20 mL of 20% solution)
Antidote	⛔ NONE
Cause of death	Pulmonary fibrosis → respiratory failure (days to weeks)
Paradox	⚠️ High-dose oxygen WORSENS lung injury

Clinical Features

Phase	Timing	Features
Immediate	0-24 hrs	Oropharyngeal/esophageal burns, vomiting, diarrhea, abdominal pain
Intermediate	24-72 hrs	Hepatic, renal, cardiac injury
Late	Days-weeks	Progressive pulmonary fibrosis → respiratory failure

Oral Examination

Finding	Significance
Oral mucosal ulceration	"Paraquat tongue" – suggestive of paraquat
Tongue edema, erosions	Corrosive injury
Pharyngeal burns	Indicates significant ingestion

Immediate Actions at Primary Care

Step	Action
1	Decontamination (skin, remove clothing)
2	IV access
3	Gastric decontamination (if < 1-2 hrs)
4	Fuller's Earth 15% (100-150 g in 1 L water) via NG tube OR
5	Activated charcoal (1-2 g/kg) if Fuller's Earth unavailable
6	⚠️ Avoid high FiO₂ (keep SpO₂ 88-92% if possible)
7	TRANSFER IMMEDIATELY

Oxygen Therapy in Paraquat

SpO₂	Action
> 92%	No supplemental oxygen
88-92%	Tolerate lower SpO₂ (to minimize O₂ toxicity)
< 88% with distress	Low-flow O₂ to maintain SpO₂ 88-92%

📌 Oxygen is toxic in paraquat poisoning – it accelerates lung injury. Use minimum FiO₂ necessary.

What NOT to Do in Paraquat

⛔ Do NOT
Give high-flow oxygen (worsens pulmonary fibrosis)
Delay gastric decontamination
Give emetics (risk of re-exposure to esophagus)

9️⃣ PYRETHROID POISONING – PRIMARY CARE MANAGEMENT

Key Points

Point	Details
Mechanism	Sodium channel modulators → neuronal hyperexcitability
Toxicity	Usually mild (low mammalian toxicity)
Route	Dermal, inhalation, ingestion
Antidote	⛔ None (supportive care)
Mortality	Very low (< 5%)

Clinical Features

Type	Compounds	Features
Type I (non-cyano)	Permethrin, Allethrin, Tetramethrin	Tremor, hyperexcitability, paresthesias
Type II (cyano)	Cypermethrin, Deltamethrin, Fenvalerate	Choreoathetosis, salivation, seizures ("CS syndrome")
Allergic	Any	Dermatitis, rhinitis, bronchospasm, anaphylaxis (rare)

Management

Step	Action
1	Decontamination (remove clothing, wash skin with soap and water)
2	Symptomatic treatment
3	Diazepam for seizures/tremor
4	Bronchodilators for bronchospasm
5	Antihistamines for allergic reactions
6	Usually does NOT require transfer unless severe

Skin Paresthesias (Common)

Treatment
Wash area with soap and water
Apply Vitamin E oil or cream (may reduce paresthesia)
Usually resolves in 24-48 hours

🔟 TRANSFER PROTOCOL

Transfer Urgency

Poison	Transfer Urgency
Organophosphate (moderate-severe)	✅ URGENT
Carbamate (severe)	✅ URGENT
Aluminum Phosphide (any)	✅ IMMEDIATE (highest mortality)
Paraquat (any)	✅ URGENT
Pyrethroid (mild)	⚠️ May observe; transfer if severe

Pre-Transfer Checklist

Item	Done?
Decontamination completed	☐
Airway secure / Secretions suctioned	☐
IV access established	☐
Atropine started (OP/Carbamate)	☐
Pralidoxime given (OP) – if available	☐
Poison/container brought with patient	☐
Time of ingestion documented	☐
Estimated amount ingested documented	☐
All treatment given documented with times	☐
Receiving hospital pre-alerted	☐

What to Communicate to Receiving Hospital

Information
Type of poison (bring container if available)
Time of ingestion
Estimated amount
Route (ingestion, dermal, inhalation)
Symptoms on presentation
Treatment given (especially Atropine dose)
Current vitals and GCS
Response to treatment

🔵 PART 2 — SECONDARY/TERTIARY CARE

1️⃣1️⃣ EMERGENCY DEPARTMENT PROTOCOL

Immediate Assessment

Action	Target Time
Confirm poison type	Immediate
Assess airway, breathing, circulation	Immediate
Check GCS, pupils	Immediate
Continue/escalate Atropine (OP/Carbamate)	Ongoing
IV access (if not done)	Immediate
Draw blood samples	≤ 15 min
ECG	≤ 15 min
ABG	≤ 30 min

Investigations

Investigation	Purpose
Serum Cholinesterase (Pseudocholinesterase)	Confirms OP/Carbamate; monitor recovery
RBC Cholinesterase	More specific for OP (if available)
ABG	Acidosis, oxygenation
Electrolytes (Na, K, Mg)	Correct abnormalities (especially in AlP)
Renal function (Cr, BUN)	AKI monitoring
LFT	Hepatotoxicity
Blood glucose	Hypo/hyperglycemia
ECG	Arrhythmias (especially AlP)
Chest X-ray	Pulmonary edema, aspiration
Serum Lactate	Tissue hypoxia (AlP)
Cardiac enzymes (Troponin)	Myocarditis (AlP)
Echocardiography	LV function (AlP)

Serum Cholinesterase Interpretation

Level	Interpretation
Normal	Unlikely OP/Carbamate poisoning (or very early)
50-75% of normal	Mild poisoning
25-50% of normal	Moderate poisoning
< 25% of normal	Severe poisoning
< 10% of normal	Very severe poisoning

📌 Serum cholinesterase is NOT required to start treatment – treat based on clinical toxidrome

1️⃣2️⃣ ORGANOPHOSPHATE – SECONDARY CARE MANAGEMENT

Continued Atropine Therapy

Phase	Management
Loading	Continue doubling dose every 3-5 min until atropinized
Maintenance	Infusion at 10-20% of loading dose per hour
Titration	Increase if secretions recur; decrease if toxicity signs
Duration	May need 24-72+ hours
Weaning	Gradually reduce as patient improves

Atropine Infusion Preparation

Preparation	Example
Add 50-100 mg Atropine to 500 mL NS	0.1-0.2 mg/mL
Titrate infusion rate	To maintain atropinization

Pralidoxime Continuation

Regimen	Details
Loading (if not given)	1-2 g IV over 30 min
Maintenance	500 mg/hr continuous infusion OR 1-2 g every 4-6 hrs
Duration	Continue until clinical improvement and atropine weaning
WHO recommendation	May continue for 7+ days in severe cases

Airway Management

Indication	Action
GCS < 8	Intubate
Copious secretions despite atropine	Intubate
Respiratory failure	Intubate + Ventilate
Anticipate prolonged course	Early intubation

Ventilator Management

Parameter	Target
Mode	Volume control or Pressure control
Avoid	Succinylcholine (prolonged paralysis due to ↓ cholinesterase)
Use	Non-depolarizing NMBAs (if needed)
Expect	Prolonged ventilation (days to weeks)

Intermediate Syndrome

Feature	Details
Timing	24-96 hours after acute cholinergic crisis has resolved
Cause	Persistent neuromuscular junction dysfunction
Features	Proximal muscle weakness, neck flexor weakness, respiratory failure, cranial nerve palsies
Mortality	High if not recognized (respiratory failure)
Management	Supportive; continued ventilation; atropine not helpful
Recovery	Days to weeks

Organophosphate-Induced Delayed Neuropathy (OPIDN)

Feature	Details
Timing	2-4 weeks after exposure
Cause	Axonal degeneration of long nerves
Features	Distal motor weakness (legs > arms), sensory loss, "dying-back" neuropathy
Compounds	Certain OPs (triorthocresyl phosphate, chlorpyrifos)
Management	Supportive; physiotherapy; may have persistent deficits

Complications and Management

Complication	Management
Aspiration pneumonia	Antibiotics, ventilatory support
Seizures	Diazepam; avoid phenytoin
Arrhythmias	Treat per ACLS; correct electrolytes
Pulmonary edema	PEEP, diuretics if cardiogenic
Rhabdomyolysis	IV fluids, monitor CK, prevent AKI

1️⃣3️⃣ ALUMINUM PHOSPHIDE – SECONDARY CARE MANAGEMENT

⚠️ No antidote. Management is entirely supportive. Mortality remains high despite best care.

Principles of Management

Principle	Details
Aggressive fluid resuscitation	Treat profound hypovolemia
Vasopressors	Often required (refractory shock)
Correct metabolic acidosis	NaHCO₃ for severe acidosis
Correct electrolytes	Especially Mg²⁺ (hypomagnesemia common)
Cardiac support	Inotropes, treat arrhythmias
Multi-organ support	Ventilation, dialysis as needed

Fluid Resuscitation

Action	Details
Initial bolus	NS or RL 20-30 mL/kg
Reassess	If still hypotensive → continue boluses
Target	MAP ≥ 65 mmHg, UOP > 0.5 mL/kg/hr
Caution	May develop pulmonary edema – monitor closely

Vasopressor/Inotrope Therapy

Drug	Dose	Notes
Norepinephrine	0.1-1+ μg/kg/min	First-line vasopressor
Dopamine	5-20 μg/kg/min	Alternative
Dobutamine	5-20 μg/kg/min	If low cardiac output
Vasopressin	0.03-0.04 U/min	Add if refractory

Magnesium Sulfate

Rationale	Details
Hypomagnesemia common	Phosphine depletes Mg²⁺
Cardioprotective	Anti-arrhythmic
Vasodilatory	May improve perfusion
Dose	1-2 g IV bolus → 1-2 g/hr infusion
Target	Serum Mg 3-4 mg/dL

Sodium Bicarbonate

Indication	Dose
Severe metabolic acidosis (pH < 7.1)	50-100 mEq IV bolus
Target	pH > 7.2
Caution	May cause hypokalemia, volume overload

N-Acetylcysteine (NAC)

Rationale	Details
Antioxidant	May counteract oxidative stress
Evidence	Limited; some case reports suggest benefit
Dose	150 mg/kg IV over 1 hr → 50 mg/kg over 4 hrs → 100 mg/kg over 16 hrs
Recommendation	May be tried; not standard of care

Cardiac Monitoring & Management

Arrhythmia	Management
VT/VF	Defibrillation, Amiodarone 150-300 mg IV
Bradycardia	Atropine 0.5-1 mg IV; Pacing if refractory
Torsades de Pointes	IV Magnesium 2 g; Correct K⁺

Experimental/Adjunct Therapies (Limited Evidence)

Therapy	Rationale	Evidence Level
Magnesium sulfate	Cardioprotective	Moderate
N-Acetylcysteine	Antioxidant	Low
Coconut oil (NG)	Reduce phosphine release	Very low
Intra-aortic balloon pump (IABP)	Refractory cardiogenic shock	Case reports
ECMO	Refractory shock	Case reports
Triiodothyronine (T3)	May improve cardiac function	Very low

Prognostic Factors in AlP Poisoning

Good Prognosis	Poor Prognosis
Fresh tablet (exposed to air = less phosphine)	Unexposed / new tablet
Vomiting occurred early	No vomiting
Small amount ingested	Large amount (> 1 tablet)
Arrived early (< 2 hrs)	Delayed presentation
No shock on arrival	Shock at presentation
Mild metabolic acidosis	Severe acidosis (pH < 7.1)
Preserved consciousness	Coma

What NOT to Do in AlP (Secondary Care)

⛔ Do NOT
Give any specific "antidote" (none exists)
Delay aggressive fluid resuscitation
Forget magnesium supplementation
Give up early – survival is possible with aggressive support

1️⃣4️⃣ PARAQUAT – SECONDARY CARE MANAGEMENT

⚠️ No antidote. Avoid oxygen if possible. Supportive care is the mainstay.

Key Principles

Principle	Details
Limit oxygen exposure	O₂ accelerates pulmonary fibrosis
Early GI decontamination	Fuller's earth / Activated charcoal
Hemodialysis/Hemoperfusion	May help if early (< 4 hrs)
Immunosuppression	Controversial; may reduce fibrosis
Supportive care	Fluid, nutrition, treat complications

Gastric Decontamination

Agent	Dose	Notes
Fuller's Earth 15%	100-150 g in 1 L water via NG	Adsorbs paraquat; give ASAP
Activated Charcoal	1-2 g/kg	If Fuller's Earth unavailable
Repeat doses	Every 2-4 hrs × 3-4 doses	Continue adsorption
Cathartic	Magnesium sulfate 250 mg/kg or Mannitol 20%	Promote GI elimination

Oxygen Management

SpO₂	Management
> 92%	No supplemental O₂
88-92%	Tolerate – avoid O₂ if possible
< 88% with distress	Low-flow O₂ (1-2 L/min) to maintain SpO₂ 88-92%
Severe hypoxia	Use minimum FiO₂ necessary; avoid > 21% if possible

📌 High FiO₂ is contraindicated in paraquat poisoning – oxygen is toxic to paraquat-damaged lungs

Enhanced Elimination

Method	Effectiveness	When to Consider
Hemodialysis	⚠️ Limited	If < 4 hrs post-ingestion; renal failure
Hemoperfusion (Charcoal)	⚠️ May help early	If < 4 hrs post-ingestion
Continuous RRT	⚠️ Limited	For renal failure support

📌 Paraquat rapidly distributes to tissues – dialysis helps only if done very early

Immunosuppressive Therapy (Controversial)

Protocol	Details
Cyclophosphamide + Methylprednisolone	"Pulse therapy" regimen
Cyclophosphamide	15 mg/kg/day IV × 2 days
Methylprednisolone	1 g IV daily × 3 days → taper
Evidence	Mixed; some studies show reduced mortality if given early
Recommendation	Consider in moderate-severe cases; discuss with toxicologist

Monitoring

Parameter	Frequency
SpO₂	Continuous
RFT	Daily
LFT	Daily
Chest X-ray	Daily initially
ABG	As needed (avoid routine if stable)

Prognosis Estimation (SIPP – Severity Index of Paraquat Poisoning)

SIPP = Plasma paraquat concentration (mg/L) × Time since ingestion (hours)

SIPP Value	Prognosis
< 10	Likely to survive
10-50	Guarded
> 50	High mortality

Clinical Predictors of Mortality

Large ingestion (> 40 mL of 20% solution)	Very high mortality
Oral mucosal ulceration severe	Significant absorption
Early respiratory failure	Poor
Renal failure	Poor
Delayed presentation	Poor

1️⃣5️⃣ SUPPORTIVE CARE (ALL POISONS)

ICU Monitoring

Parameter	Frequency
Vitals (HR, BP, RR, SpO₂)	Continuous
GCS	Hourly
Urine output	Hourly
Blood glucose	4-6 hourly
Electrolytes	6-12 hourly
ABG	As indicated
Serum Cholinesterase (OP)	Daily until improving
Lactate (AlP)	4-6 hourly

Nutritional Support

Aspect	Recommendation
Route	Enteral preferred (unless contraindicated)
Timing	Within 24-48 hrs if stable
Caution in Paraquat	Oral/esophageal burns may limit enteral route

Psychosocial Care

Aspect	Action
Psychiatric assessment	All intentional self-harm cases
1:1 supervision	Suicide precautions
Family counseling	Support and education
Social work referral	Address underlying stressors
Safe discharge planning	Remove access to poisons at home

1️⃣6️⃣ DISCHARGE PLANNING

Discharge Criteria

Criterion	Met?
Hemodynamically stable	☐
Off vasopressors	☐
Respiratory stable (no supplemental O₂ or minimal)	☐
Eating and drinking	☐
No ongoing atropine requirement	☐
Cholinesterase recovering (OP)	☐
Psychiatric clearance (if intentional)	☐
Follow-up arranged	☐

Follow-up

Appointment	Timing
General physician	1-2 weeks
Pulmonologist (Paraquat survivors)	2-4 weeks and ongoing
Neurologist (if OPIDN suspected)	2-4 weeks
Psychiatrist (if intentional)	Within 1 week

Patient/Family Education

Topic	Details
Safe storage of pesticides	Locked, labeled, away from living areas
Avoid decanting into food/drink containers	Common cause of accidental ingestion
Protective equipment	Use when handling pesticides
Seek help for mental distress	Helpline numbers
Warning signs to return	Weakness, breathing difficulty, confusion

📌 QUICK REFERENCE CARDS

🔴 PRIMARY CARE – AGRICULTURAL POISONING CARD

text

╔══════════════════════════════════════════════════════════════════════╗

║ AGRICULTURAL POISONING – PRIMARY CARE ║

╠══════════════════════════════════════════════════════════════════════╣

║ ║

║ STEP 1: PROTECT YOURSELF (PPE, ventilation) ║

║ STEP 2: DECONTAMINATE PATIENT (remove clothing, wash skin) ║

║ STEP 3: AIRWAY + IV ACCESS ║

║ ║

║ ┌─────────────────────────────────────────────────────────────────┐ ║

║ │ CHOLINERGIC TOXIDROME (OP / Carbamate)? │ ║

║ │ SLUDGE: Salivation, Lacrimation, Urination, Diarrhea, GI cramps,│ ║

║ │ Emesis + Bronchorrhea, Bronchospasm, Bradycardia │ ║

║ │ → ATROPINE 1-2 mg IV; DOUBLE every 3-5 min until DRY │ ║

║ │ → PRALIDOXIME 1-2 g IV over 30 min (OP only) │ ║

║ └─────────────────────────────────────────────────────────────────┘ ║

║ ║

║ ┌─────────────────────────────────────────────────────────────────┐ ║

║ │ GARLIC/FISH ODOR + SHOCK → ALUMINUM PHOSPHIDE (Celphos) │ ║

║ │ → NO ANTIDOTE │ ║

║ │ → IV fluids aggressively │ ║

║ │ → TRANSFER IMMEDIATELY │ ║

║ └─────────────────────────────────────────────────────────────────┘ ║

║ ║

║ ┌─────────────────────────────────────────────────────────────────┐ ║

║ │ ORAL BURNS + CORROSIVE INJURY → PARAQUAT │ ║

║ │ → NO ANTIDOTE │ ║

║ │ → Fuller's Earth / Activated Charcoal early │ ║

║ │ → AVOID HIGH-DOSE OXYGEN (worsens lung injury) │ ║

║ │ → TRANSFER │ ║

║ └─────────────────────────────────────────────────────────────────┘ ║

║ ║

║ 🚑 TRANSFER ALL MODERATE-SEVERE CASES ║

║ ║

╚═══════════════════════════════════════════════════════════════════════╝

🔵 ATROPINE PROTOCOL QUICK REFERENCE

Step	Action
1	Test dose: 1-2 mg IV
2	Wait 3-5 min
3	If not atropinized: DOUBLE the dose
4	Repeat every 3-5 min
5	Target: Clear chest, dry axillae, HR > 80, SBP > 80
6	Maintenance: 10-20% of loading dose per hour

Atropinization Targets
✅ Chest clear (most important)
✅ Dry axillae
✅ HR > 80 bpm
✅ SBP > 80 mmHg
❌ Pupil dilation (NOT a target)

💊 PRALIDOXIME QUICK REFERENCE

Population	Loading Dose	Maintenance
Adult	1-2 g IV over 30 min	500 mg/hr infusion
Child	25-50 mg/kg IV over 30 min	10-20 mg/kg/hr

Key Points
✅ Give within 6 hrs of exposure (best < 4 hrs)
✅ Give WITH Atropine (synergistic)
⛔ Do NOT give in Carbamate poisoning
⛔ Slow infusion (rapid can cause hypertension, rigidity)

☠️ ALUMINUM PHOSPHIDE QUICK REFERENCE

Key Point	Action
Antidote	⛔ NONE
Fluids	Aggressive IV NS boluses
Vasopressors	Norepinephrine early if shock
Magnesium	1-2 g IV bolus → infusion
Bicarbonate	If pH < 7.1
Mortality	40-90%

🌿 PARAQUAT QUICK REFERENCE

Key Point	Action
Antidote	⛔ NONE
GI decontamination	Fuller's Earth / Activated Charcoal early
Oxygen	⚠️ AVOID – worsens lung injury
Target SpO₂	88-92% (tolerate lower)
Death	Pulmonary fibrosis (days-weeks)

⚠️ CRITICAL WARNINGS

⛔ NEVER	✅ ALWAYS
Touch patient without PPE	Decontaminate patient first
Fear large Atropine doses (OP)	Give until secretions dry
Give Pralidoxime in Carbamate	Give Pralidoxime in OP
Give high O₂ in Paraquat	Keep SpO₂ 88-92% in Paraquat
Expect antidote for AlP	Give aggressive supportive care
Perform CPR in closed room (AlP)	Ensure ventilation (phosphine gas)
Delay transfer for procedures	Transfer early in severe cases
Discharge without psychiatric assessment (intentional)	Assess and refer all intentional cases

🆚 QUICK DIFFERENTIATION

Feature	OP	Carbamate	AlP	Paraquat
Cholinergic toxidrome	✅	✅	❌	❌
Garlic odor	❌	❌	✅	❌
Oral burns	❌	❌	❌	✅
Atropine helpful	✅	✅	❌	❌
Pralidoxime helpful	✅	❌	❌	❌
Avoid O₂	❌	❌	❌	✅

📚 ABBREVIATIONS

Abbreviation	Full Form
OP	Organophosphate
AChE	Acetylcholinesterase
2-PAM	Pralidoxime (Pyridine-2-aldoxime methiodide)
AlP	Aluminum Phosphide
SLUDGE	Salivation, Lacrimation, Urination, Defecation, GI cramps, Emesis
DUMBELS	Diarrhea, Urination, Miosis, Bronchorrhea/Bradycardia, Emesis, Lacrimation, Salivation
PPE	Personal Protective Equipment
IMS	Intermediate Syndrome
OPIDN	Organophosphate-Induced Delayed Neuropathy
GCS	Glasgow Coma Scale
ABG	Arterial Blood Gas
NS	Normal Saline
RL	Ringer's Lactate
NG	Nasogastric
KMnO₄	Potassium Permanganate
NaHCO₃	Sodium Bicarbonate
MgSO₄	Magnesium Sulfate
NAC	N-Acetylcysteine
IABP	Intra-Aortic Balloon Pump
ECMO	Extracorporeal Membrane Oxygenation
RRT	Renal Replacement Therapy
SIPP	Severity Index of Paraquat Poisoning
MAP	Mean Arterial Pressure
UOP	Urine Output
CK	Creatine Kinase
AKI	Acute Kidney Injury
ARDS	Acute Respiratory Distress Syndrome
VT/VF	Ventricular Tachycardia/Ventricular Fibrillation

📖 REFERENCES

Guideline/Source	Year
WHO Guidelines on Prevention and Management of Pesticide Poisoning	2020
Eddleston M, et al. Management of Acute Organophosphorus Pesticide Poisoning. Lancet	2008
NPIC (National Poison Information Centre, AIIMS) Guidelines	Current
API Textbook of Medicine	Latest
Toxicology Handbook (Australia)	2021
Nelson's Textbook of Toxicology	Latest
Journal of Association of Physicians of India (JAPI) – Celphos Poisoning Reviews	Various
Indian Journal of Critical Care Medicine – Pesticide Poisoning	Various

Document Version: 1.0

India-Specific Notes:

Agricultural poisoning is a leading cause of suicide in rural India
Aluminum Phosphide (Celphos) is banned for sale in many states but still widely available
Organophosphate poisoning remains very common despite restrictions
Mental health support and pesticide access restriction are key prevention strategies
Paraquat is restricted but still encountered

Disclaimer: This protocol provides general guidance. Clinical judgment must be exercised. Local protocols may vary. Psychiatric assessment is mandatory for all intentional poisoning cases.

Toxicology

Emergency Protocols

Agricultural Poisoning – India