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tox.organophosphate-poisoning.core.v1

Organophosphate and carbamate poisoning

toxicologyacuteadultpediatricacuteinpatient
Start encounter →Print handoutPRODUCTION

Manifest pointer is a PLACEHOLDER (reuses tox.co-poisoning.core.v1.ts scaffold) — a dedicated tox.organophosphate-poisoning manifest is not yet authored; see brief Open gaps. workup.organophosphate is referenced as the primary INITIAL_WORKUP adapter but is not yet a registered clinical-tools-registry entry — the audit will surface it as an unresolved registry id until the adapter ships (expected for a new tox engine; mirrors the CO scaffold pattern). No RxCUIs anywhere — atropine, pralidoxime, diazepam, glycopyrronium, magnesium are clinical staples but RxNav validation is deferred (no fabrication per spec). Decontamination, intubation/ventilation, non-depolarizing NMB substitute and crystalloid flagged non_pharm. Diagnosis is CLINICAL — RBC AChE is more specific than plasma/pseudocholinesterase but confirmatory only; never delay atropine/oxime for assays. Core teaching encoded: muscarinic killers (bronchorrhea + bronchospasm + bradycardia), atropine titrated to DRYING (not pupils/HR) via escalating-doubling then infusion, early pralidoxime before aging (WHO bolus + infusion), benzodiazepines for CNS, succinylcholine contraindicated, intermediate syndrome (24–96 h) + OPIDN, carbamate = spontaneously reversible (oximes usually deferred). PRODUCTION blockers: dedicated manifest + atoms, workup.organophosphate registry adapter, RxNav-validated regimen, terminology code reconciliation, engine-specific tests.

Entry points (4)

  • symptom
    Cholinergic toxidrome — diaphoresis, miosis, salivation, bronchorrhea, vomiting, diarrhea, fasciculations (WHO/IPCS; Eddleston Lancet 2008)
    cholinergic_toxidrome
  • history
    Known or suspected organophosphate/carbamate pesticide ingestion, dermal exposure, or nerve-agent attack (WHO/IPCS)
    pesticide_nerve_agent_exposure
  • symptom
    Unexplained copious secretions + bronchospasm + bradycardia + pinpoint pupils + AMS cluster (Eddleston Lancet 2008)
    unexplained_bronchorrhea_bradycardia_miosis
  • symptom
    Coma / seizure with hypersecretion and respiratory distress of unknown cause (critical-care tox review)
    depressed_consciousness_with_secretions

Required inputs (12)

  • agerequired
    demographic • used at CONTEXT
    Pediatric atropine/pralidoxime dosing is weight-based; children present atypically (more CNS, less classic muscarinic) (WHO/IPCS)
  • weightrequired
    demographic • used at CONTEXT
    All antidote dosing (atropine titration ceiling, pralidoxime WHO bolus/infusion) and ventilator settings are weight-based (WHO/IPCS)
  • agent_identity_and_routerequired
    history • used at CONTEXT
    OP vs carbamate (oximes usually deferred in carbamate — spontaneous reversal) and ingestion vs dermal vs inhalational drives decontamination + oxime decision (Eddleston Lancet 2008)
  • time_since_exposurerequired
    history • used at CONTEXT
    Oxime efficacy falls after enzyme "aging" — give pralidoxime EARLY; informs intermediate-syndrome surveillance window (24–96 h) (WHO/IPCS)
  • secretion_burdenrequired
    symptom • used at RED_FLAGS
    Bronchorrhea/salivation/sweat are the atropine titration endpoint (titrate to DRYING, NOT to pupils or HR) (Eddleston Lancet 2008)
  • spo2required
    vital • used at RED_FLAGS
    Hypoxemia from bronchorrhea + bronchospasm + respiratory-muscle weakness is the leading cause of death (WHO/IPCS)
  • hrrequired
    vital • used at RED_FLAGS
    Muscarinic bradycardia (a killer) vs nicotinic tachycardia; do NOT titrate atropine to HR alone (Eddleston Lancet 2008)
  • rrrequired
    vital • used at RED_FLAGS
    Respiratory failure / hypoventilation from nicotinic paralysis + intermediate syndrome drives intubation decision (WHO/IPCS)
  • pupil_size
    symptom • used at CONTEXT
    Miosis supports cholinergic dx and is the OPPOSITE of anticholinergic mydriasis — but is NOT the atropine endpoint (Eddleston Lancet 2008)
  • neuromuscular_status
    symptom • used at BRANCHING_WORKUP
    Fasciculations → flaccid weakness/paralysis (nicotinic) and delayed proximal/respiratory weakness (intermediate syndrome 24–96 h) (critical-care tox review)
  • seizure_or_coma
    symptom • used at RED_FLAGS
    CNS toxicity (seizures, coma) — atropine does NOT treat CNS; needs benzodiazepines (WHO/IPCS)
  • rbc_acetylcholinesterase
    lab • used at INITIAL_WORKUP
    RBC AChE is more specific than plasma/pseudocholinesterase for severity/recovery — but is CONFIRMATORY ONLY; never delay treatment for it (Eddleston Lancet 2008)

12-phase flow (12)

  1. 1FRAME
    Recognize anticholinesterase poisoning from the cholinergic toxidrome in a plausible exposure context; identify the killers early (bronchorrhea + bronchospasm + bradycardia, respiratory-muscle failure) (WHO/IPCS; Eddleston Lancet 2008)
    inputs: agent_identity_and_route, time_since_exposure
    advance: Cholinergic poisoning suspected and exposure context framed
  2. 2ENTRY
    Trigger on cholinergic toxidrome (DUMBELS/SLUDGE + bronchorrhea), known pesticide/nerve-agent exposure, or unexplained secretions + miosis + bradycardia (Eddleston Lancet 2008)
    inputs: age, weight
    advance: Trigger present + demographics (age/weight for dosing) captured
  3. 3CONTEXT
    Classify agent (OP vs carbamate — carbamate spontaneously reversible, oximes usually unnecessary/deferred), route (ingestion/dermal/inhalational), time since exposure (oxime "aging" window), co-ingestants, pregnancy (WHO/IPCS)
    inputs: agent_identity_and_route, time_since_exposure, pupil_size
    advance: Agent class + route + time + decontamination need classified
  4. 4RED_FLAGS
    Screen the killers: bronchorrhea/bronchospasm causing hypoxemia, bradycardia, respiratory-muscle weakness/paralysis, seizures, coma; staff/RPE secondary-contamination risk (Eddleston Lancet 2008; critical-care tox review)
    inputs: secretion_burden, spo2, hr, rr, seizure_or_coma
    actions: workup.airway_distress
    advance: Life-threats screened; resuscitation + decontamination + antidotes initiated in parallel
  5. 5INITIAL_WORKUP
    Diagnosis is CLINICAL — do NOT delay atropine/oxime for assays. Send RBC AChE (more specific) + plasma/pseudocholinesterase for severity/trend; ABG, electrolytes, glucose, ECG (QTc), troponin if cardiac, CBC; cholinesterase is confirmatory only (Eddleston Lancet 2008)
    inputs: rbc_acetylcholinesterase, spo2
    actions: workup.organophosphate, panel.abg, panel.metabolic, panel.tox_screen, cascade.acid_base
    advance: Empiric treatment started; confirmatory labs sent without delaying antidotes
  6. 6BRANCHING_WORKUP
    By finding: persistent/recurrent muscarinic features → escalate atropine + restart oxime infusion; new proximal/respiratory/cranial weakness at 24–96 h → intermediate syndrome → pre-emptive ventilatory support; delayed (1–3 wk) distal sensorimotor neuropathy → OPIDN (Eddleston Lancet 2008; critical-care tox review)
    inputs: neuromuscular_status, secretion_burden
    actions: workup.acute_weakness, workup.bradycardia
    advance: Intermediate-syndrome surveillance active; antidote response branch selected
  7. 7DIFFERENTIAL
    Rule in cholinergic toxidrome; exclude/contrast anticholinergic toxidrome (DRY skin, mydriasis, tachycardia — the OPPOSITE), sympathomimetic, opioid, sedative-hypnotic, CNS infection/sepsis, hypoglycemia, status epilepticus, GBS/botulism (descending weakness) (WHO/IPCS)
    inputs: pupil_size, secretion_burden
    actions: workup.delirium, workup.first_seizure
    advance: Cholinergic anticholinesterase poisoning confirmed as principal diagnosis
  8. 8RISK_STRATIFICATION
    Stratify by airway/respiratory compromise, atropine requirement (escalating-doubling dose to atropinization), GCS, hemodynamics, intermediate-syndrome risk; NEWS2/qSOFA flag deterioration and ICU need (critical-care tox review)
    inputs: spo2, rr, hr
    actions: calc.news2, calc.qsofa
    advance: Severity classified and ICU disposition decided (most symptomatic patients → ICU)
  9. 9TREATMENT
    Decontamination + PPE → ATROPINE titrated to drying of secretions / clear chest / adequate oxygenation (escalating-doubling dose then infusion) → PRALIDOXIME early before aging (WHO bolus then infusion) → BENZODIAZEPINE for seizures (atropine does NOT treat CNS) → airway/ventilation (AVOID succinylcholine — prolonged paralysis); manage intermediate syndrome with ventilatory support (Eddleston Lancet 2008; WHO/IPCS)
    inputs: secretion_burden, spo2, seizure_or_coma, weight
    advance: Atropinized (dry chest, SpO2 adequate, HR/SBP adequate) + oxime running + seizures controlled + airway secured if needed
  10. 10DISPOSITION
    ICU for any significant cholinergic features, atropine infusion, oxime infusion, intubation, or intermediate-syndrome risk; observation only for trivial carbamate exposure that is asymptomatic after an adequate watch (WHO/IPCS)
    advance: Disposition assigned (ICU for almost all symptomatic OP; carbamate may de-escalate sooner)
  11. 11MONITORING
    Continuous secretions/chest/SpO2/HR/BP, atropine-infusion titration, oxime infusion, serial RBC/plasma cholinesterase trend, daily neuromuscular exam for intermediate syndrome (24–96 h), telemetry/QTc, recurrent toxicity from lipophilic agents redistributing (Eddleston Lancet 2008)
    inputs: secretion_burden, spo2, neuromuscular_status
    actions: panel.abg, panel.cardiac, panel.metabolic
    advance: Secretions controlled, off/declining atropine infusion, no new weakness, cholinesterase recovering
  12. 12FOLLOWUP
    Watch for OPIDN delayed neuropathy (1–3 wk) and chronic neuropsychiatric sequelae; psychiatry referral if intentional self-poisoning; occupational/agricultural exposure source remediation + PPE education; outpatient neuro follow-up (WHO/IPCS; critical-care tox review)
    advance: Discharge plan + OPIDN counseling + psych (if intentional) + source remediation arranged