A young woman presented to the emergency department with a history of pesticide intake. She has massive frothing from the mouth and nose.

Initial Assessment and Stabilization

The first priority is to assess the patient’s vital signs – airway, breathing, and circulation (ABC). Simultaneous assessment of neurological status (Glasgow Coma Scale) is also crucial. The patient is likely experiencing respiratory distress due to frothing and potential bronchospasm. Immediate interventions include:

• Airway Management: Suctioning of the oropharynx to remove froth and secretions is paramount. Consider intubation and mechanical ventilation if the patient is unable to maintain a patent airway or exhibits signs of respiratory failure (hypoxia, hypercapnia).
• Breathing: Administer high-flow oxygen via a non-rebreather mask. Monitor oxygen saturation continuously.
• Circulation: Establish intravenous access with two large-bore catheters. Monitor blood pressure and heart rate.

Decontamination

Decontamination aims to remove the pesticide from the patient’s skin and gastrointestinal tract. This is crucial to prevent further absorption.

• Skin Decontamination: Remove contaminated clothing and thoroughly wash the skin with soap and water.
• Gastrointestinal Decontamination:
  • Activated Charcoal: Administer activated charcoal if the patient is alert and able to protect their airway. It is most effective if given within one hour of ingestion. However, its use is controversial in certain pesticide poisonings (e.g., corrosive substances).
  • Gastric Lavage: Generally not recommended unless a life-threatening amount of pesticide was ingested within the past hour. It carries risks of aspiration.
  • Whole Bowel Irrigation: May be considered for slow-release formulations or when activated charcoal is contraindicated.

Identifying the Pesticide

Determining the specific pesticide involved is critical for targeted treatment. Information can be obtained from:

• Patient/Family: Inquire about the pesticide used, its formulation, and the amount ingested.
• Container: If available, bring the pesticide container to the hospital for identification.
• Poison Control Center: Contact the local poison control center for assistance with identification and treatment recommendations.

Specific Treatment – Organophosphates/Carbamates (Most Likely Scenario)

Given the frothing, organophosphate or carbamate poisoning is highly suspected. These pesticides inhibit acetylcholinesterase, leading to cholinergic crisis.

• Atropine: Administer atropine intravenously. The dose is titrated to effect – continue until secretions are dried and heart rate improves. Atropine reverses the muscarinic effects of the poisoning.
• Pralidoxime (2-PAM): Administer pralidoxime intravenously. Pralidoxime reactivates acetylcholinesterase, but its effectiveness decreases with time. It is most effective if given within 24 hours of exposure.
• Benzodiazepines: Administer benzodiazepines to control seizures, which are a common complication of organophosphate poisoning.

Supportive Care and Monitoring

Supportive care is essential throughout the management process.

• Continuous Monitoring: Monitor vital signs, oxygen saturation, ECG, and neurological status continuously.
• Fluid Management: Maintain adequate hydration with intravenous fluids.
• Electrolyte Correction: Correct any electrolyte imbalances.
• Respiratory Support: Continue mechanical ventilation as needed.

Other Pesticide Classes

While organophosphates/carbamates are most likely, other pesticide classes require different management strategies. For example, pyrethroid poisoning typically presents with neurological symptoms (tremors, seizures) and requires supportive care and benzodiazepines. Glyphosate poisoning can cause metabolic acidosis and renal failure, requiring aggressive fluid resuscitation and electrolyte management.