Organophosphate poisoning at a peripheral health centre

The syndrome is cholinergic poisoning - sweating, salivation, pinpoint pupils, bradycardia, bronchial secretions and fasciculations - so death comes from a combination of hypoxia and bradycardia. Priorities follow that logic:

1. Airway and suction: he is drowsy and salivating heavily; secretions can obstruct him. Suction, position semi-prone or lateral, and keep suction ready. Do not leave him flat and unattended.
2. Oxygen and breathing: give high-flow oxygen by mask; watch respiratory rate, chest movement and crepitations. Bronchorrhoea and bronchospasm cause hypoxia, which is the commonest terminal event.
3. Atropine immediately: do not wait for a transfer or a laboratory result. Give atropine intravenously in repeated boluses.
4. Decontaminate: remove and bag all clothing and wash skin with soap and water, protecting yourself with gloves and an apron. He is still absorbing poison through skin and clothing, so this is treatment, not cleaning.
5. IV access and monitoring: secure the line, monitor pulse, blood pressure, oxygen saturation and pupils every few minutes.
6. Refer: arrange urgent transfer to the district hospital once he is stabilised enough to move, with a staff member accompanying him.

Family refusal is a separate emergency: explain that without atropine he will die, and document the conversation and the medical officer's involvement.

Dose and method: give an initial intravenous bolus of 2–4 mg (several 0.6 mg ampoules together), then repeat with doubling doses every 5–10 minutes until the end-points are reached. With ten 0.6 mg ampoules you have only 6 mg in total, so the first move must be to call for more atropine or arrange immediate transfer - atropine requirement in severe poisoning can be tens to hundreds of milligrams, and running out is the critical risk here.

End-points of adequate atropinisation:

• Chest clear - secretions and crepitations reduced, no bronchospasm.
• Heart rate above about 80/min.
• Skin dry or drying, not sweating.
• Pupils no longer pinpoint.
• No new fasciculations.

Avoid over-atropinisation: the aim is a dry chest and a normal pulse, not a dry mouth alone or dilated pupils with tachycardia. Signs of overdose are excessive tachycardia, urinary retention, hyperthermia, confusion and ileus; stop or slow if these appear.

Before transfer: leave with an atropine bolus on board and a note of the total dose given, the time of the last dose and the observed response, so the receiving team can continue titrating rather than restarting from zero. Keep the vial label and any pesticide container or name sent with him - identifying the compound guides further treatment.

• Staff protection: gloves, apron, mask and eye protection for everyone handling him; his clothing is contaminated and must be bagged, not handled bare-handed; wash hands afterwards. Contaminated clothing and wash water must not be left where children can touch them.
• Communication with the family: explain in simple language that the poison stops the nerves controlling breathing and that atropine is the antidote; the earlier it is given, the better. Say plainly that going home means he will probably die. Involving a senior family member and the medical officer reduces the chance of an Against Medical Advice departure.
• Referral: call the district hospital before transfer with his condition, the poison suspected, the atropine given and the estimated arrival time; send him in the ambulance with oxygen, suction, atropine and a trained escort, not merely 'sent by jeep'.
• Records: time of arrival, initial conscious level, pulse, blood pressure, respiratory rate, pupils and secretions; atropine doses with times; decontamination done; referral and the family's refusal being addressed; the name and phone number of the receiving facility. Note the pesticide container details if available.
• Reporting: poisoning of this kind is a preventable occupational injury - record it and inform the medical officer so that it can be counted and followed up, and so that field-level safety advice on pesticide handling reaches the farmer community.