Organophosphate Pesticide Poisoning — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Cholinergic crisis?
   Cholinergic crisis (muscarinic + nicotinic + central)? (Organophosphates (pesticides) inhibit cholinesterase. Muscarinic (DUMBELS: diarrhea, urinary incontinence, miosis, bradycardia/bronchorrhea and bronchospasm, emesis, lacrimation, salivation — airway secretions/bronchospasm are the main cause of death) + nicotinic (fasciculations, weakness, paralysis) + central (seizures, coma).)
   • Cholinergic crisis / clear exposure → Cholinergic crisis → atropine + pralidoxime
   • Exposure only, asymptomatic → Exposure, asymptomatic
2. [End] Exposure, asymptomatic
   Clear exposure but asymptomatic: remove contaminated clothing, wash with soap and water (staff use PPE), observe and monitor cholinesterase and symptoms; treat as a crisis the moment muscarinic/nicotinic symptoms appear.
3. [End] Cholinergic crisis → atropine + pralidoxime
   1) Decontaminate and protect: remove clothing, wash skin, staff wear gloves/PPE. 2) Atropine (antimuscarinic, protects the airway): start 1–3 mg IV, double every 3–5 min until 'atropinized' — airway secretions dry up, lung crackles clear, good oxygenation (the endpoint is dry secretions, not pupils/heart rate), then a maintenance infusion. 3) Pralidoxime (an oxime, reactivates cholinesterase, targets nicotinic weakness, give early before aging): pralidoxime chloride ~30 mg/kg IV loading then a maintenance infusion. 4) Benzodiazepines for seizures/agitation. 5) Airway/ventilatory support, ICU; watch for the intermediate syndrome and delayed peripheral neuropathy.

Source guidelines & references

• Management of organophosphate poisoning (WHO; acute poisoning diagnosis and treatment)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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