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tox.organophosphate-poisoning.core.v1PRODUCTION
tox.organophosphate-poisoning.core.v1

Organophosphate and carbamate poisoning

toxicologyacuteadultpediatric
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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)

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Cholinergic poisoning suspected and exposure context framed

Patient inputs (12)

Pediatric atropine/pralidoxime dosing is weight-based; children present atypically (more CNS, less classic muscarinic) (WHO/IPCS)

All antidote dosing (atropine titration ceiling, pralidoxime WHO bolus/infusion) and ventilator settings are weight-based (WHO/IPCS)

OP vs carbamate (oximes usually deferred in carbamate — spontaneous reversal) and ingestion vs dermal vs inhalational drives decontamination + oxime decision (Eddleston Lancet 2008)

Oxime efficacy falls after enzyme "aging" — give pralidoxime EARLY; informs intermediate-syndrome surveillance window (24–96 h) (WHO/IPCS)

Bronchorrhea/salivation/sweat are the atropine titration endpoint (titrate to DRYING, NOT to pupils or HR) (Eddleston Lancet 2008)

Hypoxemia from bronchorrhea + bronchospasm + respiratory-muscle weakness is the leading cause of death (WHO/IPCS)

Muscarinic bradycardia (a killer) vs nicotinic tachycardia; do NOT titrate atropine to HR alone (Eddleston Lancet 2008)

Respiratory failure / hypoventilation from nicotinic paralysis + intermediate syndrome drives intubation decision (WHO/IPCS)

Fasciculations → flaccid weakness/paralysis (nicotinic) and delayed proximal/respiratory weakness (intermediate syndrome 24–96 h) (critical-care tox review)

Miosis supports cholinergic dx and is the OPPOSITE of anticholinergic mydriasis — but is NOT the atropine endpoint (Eddleston Lancet 2008)

RBC AChE is more specific than plasma/pseudocholinesterase for severity/recovery — but is CONFIRMATORY ONLY; never delay treatment for it (Eddleston Lancet 2008)

CNS toxicity (seizures, coma) — atropine does NOT treat CNS; needs benzodiazepines (WHO/IPCS)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningbronchorrhea_respiratory_failure
    Bronchorrhea + bronchospasm with hypoxemia / impending respiratory failure (the primary muscarinic killer) (Eddleston Lancet 2008)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcholinergic_seizure_or_coma
    Seizure or coma from CNS cholinergic toxicity (Eddleston Lancet 2008)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningintermediate_syndrome_weakness
    New proximal limb / neck-flexor / respiratory / cranial-nerve weakness 24–96 h after exposure (intermediate syndrome) (critical-care tox review)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererefractory_bradycardia_hypotension
    Muscarinic bradycardia / AV block with hypotension refractory to volume (Eddleston Lancet 2008)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereinadequate_atropinization
    Persistent secretions / wet chest / hypoxemia despite initial atropine (under-atropinized) (Eddleston Lancet 2008)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverestaff_secondary_contamination_risk
    Dermal/clothing contamination with a lipophilic agent — risk to rescuers/ED staff (Eddleston Lancet 2008)
    Trigger could not be auto-evaluated — needs clinician judgement.

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RISK_STRATIFICATIONrequiredDrives severity classification
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Recommended regimen

Cholinergic crisis — decontaminate → atropinize → oxime → control seizures → airway/ventilate (incl. intermediate syndrome)
axis: organophosphate_cholinergic_crisis_bundlestep 1 - Step 1 — Decontamination + staff PPE (secondary-contamination control)
Selected step "Step 1 — Decontamination + staff PPE (secondary-contamination control)" — Any dermal/clothing contamination or significant ingestion; BEFORE or in parallel with antidotes
  • skin and clothing decontamination + RPE/PPE
    first line
    decontamination
    Remove ALL clothing (double-bag), copious soap-and-water / water irrigation of skin, eye irrigation if ocular; staff in chemical-resistant gloves/gown + respiratory protection • topical/physical • once, repeat irrigation until decontaminated
    triggers: dermal_or_clothing_contamination, lipophilic_agent, nerve_agent_attack
    Secondary contamination of rescuers/ED staff is a real hazard — lipophilic OPs penetrate skin and off-gas; decontaminate at the door, never in a closed treatment bay (WHO/IPCS; Eddleston Lancet 2008)

ed playbook — drug actions (4)

  1. 1. skin/clothing decontamination + staff PPE
    Remove all clothing, copious water/soap irrigation; staff chemical-resistant gloves/gown + respiratory protection • physical • at the door, in parallel with resuscitation
    trigger: Any dermal/clothing contamination (decontaminate before closed-bay care) (Eddleston Lancet 2008)
    Prevents secondary contamination of ED staff (WHO/IPCS)
  2. 2. atropine (escalating-doubling)
    1–3 mg IV (peds 0.02 mg/kg), DOUBLE q~5 min until atropinized, then infusion ~10–20% of loading dose/h • IV • q5min doubling then infusion
    trigger: Any muscarinic feature (do not wait for labs) (Eddleston Lancet 2008)
    Endpoint = dry chest + adequate oxygenation, NOT pupils/HR (WHO/IPCS)
  3. 3. pralidoxime
    WHO: ≥30 mg/kg IV load over 20–30 min then ≥8 mg/kg/h infusion • IV • load then continuous infusion
    trigger: OP confirmed/suspected — give EARLY before aging (defer for pure carbamate) (Eddleston Lancet 2008)
    Reactivates AChE; targets nicotinic features atropine does not treat (WHO/IPCS)
  4. 4. diazepam/lorazepam
    Diazepam 5–10 mg IV (peds 0.1–0.3 mg/kg) PRN • IV • PRN seizures
    trigger: Seizure or severe agitation (atropine does not treat CNS) (WHO/IPCS)
    First-line anticonvulsant + neuroprotective in OP (critical-care tox review)

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Cholinergic toxidrome — diaphoresis, miosis, salivation, bronchorrhea, vomiting, diarrhea, fasciculations (WHO/IPCS; Eddleston Lancet 2008); Known or suspected organophosphate/carbamate pesticide ingestion, dermal exposure, or nerve-agent attack (WHO/IPCS); Unexplained copious secretions + bronchospasm + bradycardia + pinpoint pupils + AMS cluster (Eddleston Lancet 2008).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Organophosphate and carbamate poisoning** (tox.organophosphate-poisoning.core.v1).
Phenotype framing: 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)
Scope: 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)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Cholinergic crisis — decontaminate → atropinize → oxime → control seizures → airway/ventilate (incl. intermediate syndrome)** — step "Step 1 — Decontamination + staff PPE (secondary-contamination control)".
1. skin and clothing decontamination + RPE/PPE Remove ALL clothing (double-bag), copious soap-and-water / water irrigation of skin, eye irrigation if ocular; staff in chemical-resistant gloves/gown + respiratory protection topical/physical once, repeat irrigation until decontaminated (decontamination, first line) — Secondary contamination of rescuers/ED staff is a real hazard — lipophilic OPs penetrate skin and off-gas; decontaminate at the door, never in a closed treatment bay (WHO/IPCS; Eddleston Lancet 2008)

Setting playbook (ed) — Decontaminate safely (protect staff), recognize cholinergic crisis clinically, atropinize to dry chest, start pralidoxime early, control seizures, secure airway WITHOUT succinylcholine, triage to ICU (WHO/IPCS; Eddleston Lancet 2008)
2. skin/clothing decontamination + staff PPE Remove all clothing, copious water/soap irrigation; staff chemical-resistant gloves/gown + respiratory protection physical at the door, in parallel with resuscitation — Any dermal/clothing contamination (decontaminate before closed-bay care) (Eddleston Lancet 2008) (Prevents secondary contamination of ED staff (WHO/IPCS))
3. atropine (escalating-doubling) 1–3 mg IV (peds 0.02 mg/kg), DOUBLE q~5 min until atropinized, then infusion ~10–20% of loading dose/h IV q5min doubling then infusion — Any muscarinic feature (do not wait for labs) (Eddleston Lancet 2008) (Endpoint = dry chest + adequate oxygenation, NOT pupils/HR (WHO/IPCS))
4. pralidoxime WHO: ≥30 mg/kg IV load over 20–30 min then ≥8 mg/kg/h infusion IV load then continuous infusion — OP confirmed/suspected — give EARLY before aging (defer for pure carbamate) (Eddleston Lancet 2008) (Reactivates AChE; targets nicotinic features atropine does not treat (WHO/IPCS))
5. diazepam/lorazepam Diazepam 5–10 mg IV (peds 0.1–0.3 mg/kg) PRN IV PRN seizures — Seizure or severe agitation (atropine does not treat CNS) (WHO/IPCS) (First-line anticonvulsant + neuroprotective in OP (critical-care tox review))

Non-pharmacologic actions:
- High-flow O2 + aggressive airway suctioning for bronchorrhea (WHO/IPCS)
- Intubate for hypoxemia/secretion burden/paralysis/coma — AVOID succinylcholine; use higher-dose non-depolarizing NMB if paralytic needed (Eddleston Lancet 2008)
- Continuous cardiac monitoring + QTc (WHO/IPCS)
- IV crystalloid for GI-loss volume depletion / hypotension (critical-care tox review)
- Poison-centre / medical-toxicology consult; psychiatry flag if intentional (WHO/IPCS)

AVOID / contraindication checks:
- AVOID succinylcholine — pseudocholinesterase inhibition causes grossly prolonged paralysis; use non depolarizing NMB at higher dose (Eddleston Lancet 2008)
- AVOID morphine/opioids — respiratory depression compounds cholinergic respiratory failure (WHO/IPCS)
- AVOID aminophylline/theophylline — lowers seizure threshold and worsens dysrhythmia in cholinergic crisis (WHO/IPCS)
- AVOID phenothiazines and other anticholinergic/CNS depressant antiemetics/sedatives — confound the toxidrome and lower seizure threshold (critical care tox review)
- Do NOT titrate atropine to pupils or to heart rate — endpoint is drying of secretions + clear chest + adequate oxygenation (Eddleston Lancet 2008)
- Do NOT delay atropine/pralidoxime to await cholinesterase assays — diagnosis is clinical (Eddleston Lancet 2008)
- Oximes usually unnecessary / often deferred in pure carbamate poisoning (spontaneously reversible) (WHO/IPCS)

Monitoring

Regimen monitoring:
- continuous secretion burden + chest auscultation + SpO2 (atropine titration endpoint) (Eddleston Lancet 2008)
- continuous HR/BP + telemetry + QTc (WHO/IPCS)
- atropine total dose log + maintenance infusion titration (Eddleston Lancet 2008)
- pralidoxime infusion continuity until clinically improved (WHO/IPCS)
- serial RBC acetylcholinesterase + plasma/pseudocholinesterase trend (confirmatory only) (Eddleston Lancet 2008)
- daily neuromuscular exam for intermediate syndrome 24–96 h (critical-care tox review)
- watch for recrudescent toxicity from lipophilic-agent redistribution + need to re-escalate atropine (Eddleston Lancet 2008)

Setting (ed) monitoring:
- Secretions + chest + SpO2 continuously (atropine endpoint) (Eddleston Lancet 2008)
- HR/BP/telemetry/QTc continuous (WHO/IPCS)
- Atropine cumulative dose + response q5–15 min (Eddleston Lancet 2008)
- Neuromuscular strength baseline (intermediate-syndrome reference) (critical-care tox review)

Follow-up plan: 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)
- Close-out criterion: Discharge plan + OPIDN counseling + psych (if intentional) + source remediation arranged

Monitoring phase: 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)

Disposition

Current setting: ed — Decontaminate safely (protect staff), recognize cholinergic crisis clinically, atropinize to dry chest, start pralidoxime early, control seizures, secure airway WITHOUT succinylcholine, triage to ICU (WHO/IPCS; Eddleston Lancet 2008)

Disposition criteria:
- ICU: any significant cholinergic features, atropine/oxime infusion, intubation, or intermediate-syndrome risk (almost all symptomatic OP) (WHO/IPCS)
- Observation/ward: trivial carbamate exposure, asymptomatic after an adequate monitored watch with normal exam (WHO/IPCS)
- Psychiatry hold + medical clearance pathway if intentional self-poisoning (critical-care tox review)

Escalation triggers (move to higher acuity):
- Bronchorrhea/bronchospasm with hypoxemia → aggressive atropine + intubation + ICU (Eddleston Lancet 2008)
- Seizure / coma → benzodiazepine + airway + ICU (WHO/IPCS)
- Nicotinic weakness/paralysis or rising oxime/atropine need → ICU (critical-care tox review)
- Refractory bradycardia/hypotension → escalate atropine, ICU (Eddleston Lancet 2008)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Bronchorrhea + bronchospasm with hypoxemia / impending respiratory failure (the primary muscarinic killer) (Eddleston Lancet 2008)
- [LIFE_THREATENING] Seizure or coma from CNS cholinergic toxicity (Eddleston Lancet 2008)
- [LIFE_THREATENING] New proximal limb / neck-flexor / respiratory / cranial-nerve weakness 24–96 h after exposure (intermediate syndrome) (critical-care tox review)

Citations

- WHO/IPCS organophosphate management; 2024-2025 critical-care tox reviews; Eddleston Lancet OP poisoning [PMID:18242601](https://pubmed.ncbi.nlm.nih.gov/18242601/)
- Cited evidence (PMID 17961051) [PMID:17961051](https://pubmed.ncbi.nlm.nih.gov/17961051/)
- Cited evidence (PMID 15555635) [PMID:15555635](https://pubmed.ncbi.nlm.nih.gov/15555635/)
- Cited evidence (PMID 16039337) [PMID:16039337](https://pubmed.ncbi.nlm.nih.gov/16039337/)
- Cited evidence (PMID 24050627) [PMID:24050627](https://pubmed.ncbi.nlm.nih.gov/24050627/)

Last reconciled with current guidelines: 2026-05-16.
References