What are the steps-wise management of Organophosphate poisoning?

protect airway

gastric lavage within time interval

atropinise the patient

give an antidote pralidoxime

control convulsion with Benzodizepine

ventilatory support if needed( do not use suxa)

1. Ensure adequate airways protection –If the patient has respiratory distress intubate early (avoid succinylcholine!) 2. Ensure adequate oxygenation – give high flow oxygen via a face mask. 3. Ensure adequate circulation – insert cannula and give ivi fluids 4. Give atropine until patient is fully atropinised. Start with 0.05mg/Kg of atropine ivi (2-4mg depending on patient weight). Repeat every 15 mins until full atropinisation. Aim for pulse rate >80 beats per minute and systolic blood pressure >80mm/Hg. Increase atropine bolus dose until response occurs. 5. Start atropine infusion when atropinisation achieved – 0.05mg/kg/hour. E.g. for a 70kg patient give 3.5 mg of atropine per hour as an infusion. Put 10mg of atropine in 200mLs of fluid run at 40 – 80mLs per hour (2-4mg/hr) depending on response. 6. Monitor patient ever 15 minutes. If the dose of atropine is too low cholinergic features will re occur. If the dose of atropine is too high agitation, pyrexia, reduced bowel sounds and urinary retention will occur – then reduce atropine infusion. 7. If patient presents within 24 hours of exposure and has signs of moderate to severe organophosphate poisoning give obidoxime 250mg ivi – repeat after 2 hours. Note give obidoxime after initial atropine bolus. Obidoxime is contraindicated in carbamate poisoning. 8. Perform a 12 lead ECG – treat arrhythmias as necessary, intravenous magnesium maybe helpful. 9. Monitor patient for secretions, pulse rate (use cardiac monitor), pupil size, blood pressure, oxygen saturation and pulse. Ideally serial vital capacity should be measured along with plasma cholinesterase levels. The aim of treatment is to excessive oral and respiratory secretions and prevent respiratory failure. Adequate atropinisation is indicated by reduction of secretions. 10. Control fits with boluses of diazepam – give 10mg ivi. Diazepam is also useful for delirium and agitation in these patients. If patient continues to fit consider midazolam infusion but patient must be intubated. Note agitation may be due to excess atropine. 11. There is no evidence to support the use of activated charcoal or gastric lavage. 12. Remove contaminated clothing (wear gloves) and dispose of as hazardous material. Wash the patient thoroughly with soap and water. 13. As soon as patient is stable start to reduce atropine infusion slowly over 24 hours. Infusion may need to be increased if symptoms and signs recur. 14. Patients with minor exposure to organophosphates can be discharged if asymptomatic after 12 hours of observation.