5 :2

Organophosphorus Poisoning:
Current management guidelines
ABSTRACT
Organophosphorus (OP) compounds which are in use since
1940s world wide as insecticides have been a source of poisoning
and continue to pose management problems. Resuscitation,
Decontamination, Specific antidote, and supportive measures
continue to be the main stay of therapy. Different authors have
prescribed different therapeutic regimens leading to controversies.
This paper aims at offering a comprehensive guideline on these
aspects of management. Decontamination of the body by washing
with soap and water is to be thorough and complete. A repeat
stomach wash in every case is recommended to remove residual
OP. Atropine is the only life saving antidote and is to be started
along with decontamination. Out of 38 protocols prescribed in
literature a protocol of starting with dose of 1-2 mg followed by
bolus doses, every 5 min, with double of previous dose, in case
of no response, to achieve the target end point is recommended.
Thereafter it is to be maintained through Atropine infusion (at
a rate of 10-20% of total atropine required to load the patient
per hour) for 24-48 hrs and gradually withdrawn over next 3-5
days. Clearance of chest of secretions and maintenance of BP has
been given more importance in the target point than size of pupil
and heart rate. Glycopyrrolate is recommended as an adjunct
to atropine to control secretions or when atropine toxicity is
confused with OP toxicity.The role of Oximes has been questioned
by different workers both from India and abroad. Though it has
been shown to reactivate RBC cholinesterase the causes of failure
to benefit have not been properly established. Because the idea
is sound it is appropriate to recommend Pralidoxime to start as
early as possible with a loading dose of 30 mg/kg IV to be given
over 30 minutes to be followed by a continuous infusion of 8-10
mg/kg/hr until clinical recovery or seven days whichever is later.
Ventilation is the most useful life saving advance in supportive care.
Criterias for ventilation have been defined. Use of tranquilizer
has been recommended to be liberal. Poisoning effect of solvent
in OP compounds contributing to chemical pneumonitis is to
be kept in mind. The need of close observation through OP obs
sheet has been stressed. Use of fluids, diuretics, antibiotics etc
has been discussed.
Introduction: - Organophosphorus (OP) compounds first
synthesized in early 1800s were developed as insecticides
in early 1900s and found world wide application by 1941. (I)

NK Sundaray, Ratheesh Kumar J, Trivandrum

Intoxication by these agents continues to be a therapeutic
problem. Possibility of exposure during war /terrorist activities
is increasing. Resuscitation, decontamination, early use of specific
antidote, close observation and good supportive care form the
basis of management. Despite large number of cases being
reported world wide, the current evidence base is small. (2)
Text books recommend varied therapeutic antidote regimens
leading to controversies and confusion. In this paper it is intended
to offer a comprehensive guideline so that junior physicians can
manage such acute poisoning cases efficiently. Before proceeding
to management guidelines it will be proper to review the
pharmacodyamics of the OP compounds, so that the rationale
behind the guidelines will be well appreciated.
Pharmacodynamics: - Orgnophosphates/carbamates inactivate
the enzyme Cholinesterase (ChE) by reacting at the esterase
site, which leads to an increase in Acetylcholine (ACh) at the
muscarinic receptors, nicotinic receptors and in CNS leading to
toxic effects. The phosphorylated/carbamated enzyme complex
subsequently undergoes hydrolysis spontaneously (carbamated
complexes within minutes to hours whereas phosphorylated
enzyme complexes take some 60 minutes to several weeks). The
reactivation time can be enhanced by oximes. Once OPenzyme
complex looses the alkyl group (Ageing) it can not be reactivated.
(3)
OP compounds can be absorbed through skin, conjunctiva, oral
mucosa, GI tract, respiratory tract, by direct contact, ingestion,
inhalation and injection. The hydrocarbon solvent also produces
its effects. Most patients become symptomatic rapidly, though
the onset and severity of symptoms depend on the nature of
the compound, amount, route of exposure and rate of metabolic
degradation. After absorption they are rapidly distributed in all
body tissues. Lipid solubility makes easy access to CNS and
fat stores. They are intermittently released from fat stores to
circulation/secreted to stomach and have been incrimininated for
the sudden deterioration in a stable patient. Metabolism occurs
principally by oxidation in the liver with conjugation and esterase
hydrolysis producing a half life of minutes to hours. Elimination
occurs via urine bile and faeces.Toxic effects of excreted products

Organophosphorus Poisoning: Current management guidelines

Fig. 1 : Showing pin point pupil in a case of OP poisoning

Table 1 : Grading Severity of Organophosphate
Poisoning

soap (OPs are hydrolyzed in an aqueous solution in high PH)

.Skin folds and underside of fingernails and long hairs require
particular attention. Ocular decontamination is to be carried
out by washing eyes with water/normal saline. Incontinent
patient requires repeat wash. Attention should not be diverted
from ABC of Cardiopulmonary resuscitation. Seizures are to be
controlled by appropriate measures.Two IV lines be secured and
blood samples for haematological and biochemical and ChE be
collected.ECG be recorded. Laboured breathing, sweating, pin
point pupil would suggest OP/carbamate poisoning. Fig-1 Antidote
inj atropine should be started immediately which should not be
withheld even if oxygen is not available.There is no good evidence
that giving atropine to a cyanosed patient would cause harm. (5)

Normal serum acetylcholinesterase / RBC Cholinesterase level is 8.0-20.0

u/l
MILD
Walks and talks
Headache, dizzy
Nausea,Vomiting
Abdominal pain
Sweating, salivation
Rhinorrhoea

MODERATE
Cannot walk
Soft voice
Muscle twitching
(fasciculations)
Anxiety, restlessness
Small pupils (miosis)

SEVERE
Unconscious, no
papillary reflex. Muscle
twitching, flaccid paralysis. Increased bronchial
secretions. Dyspnoea
crackles / wheeze. Possible convulsions
serum acetylcholinester- serum acetylcholinester- Respiratory failure
ase enzyme (AChE)
ase enzyme (AChE)
Results: 1.6-4.0 u/l
Results: 0.8-2.0 u/l
serum acetylcholinesterase enzyme (AChE)
Results: < 0.8 u/l

in stool locally in form of burns over gluteal region, natal cleft and
thighs have been noted.
Clinical features: - They are due to stimulation of muscarinic,
nicotinic and central receptors. Onset is usually within 30 min
to 03 hrs. This may be delayed depending on the type of OP,
route of exposure and amount of systemic poison.The severity of
poisoning has been graded as mild, moderate and severe. (Table1)(4) The end result may be a multi system event. Most fatality
occurs within 24 hrs.
Diagnosis: - History of exposure and clinical features suggest OP/
Carbamate poisoning. Measurement of ChE in serum and RBC
and detection of metabolic products in urine assist in diagnosis. .
Management: - OP poisoning is a medical emergency. They need to
be nursed in general ICU with adequate ventilation unless specific
complications need Specific ICU care. The health care workers
need protection through personnel protecting equipments.
Rubber Gloves and gowns are recommended as these compounds
are known to penetrate latex /vinyl gloves. Charcoal cartridge
masks are recommended for respiratory protection.The staff may
need to be rotated if they cant stand the noxious order.
Decontamination: - Besides, the decontamination at the site,
in the emergency department all clothing, hair accessories
are to be removed and placed in appropriate waste bags. The
person is to be washed with copious amount of water and

421

In case clinical presentation is not clear Inj. Atropine 0.6 mg to

1.0 mg may be given IV. Increase in heart rate by more than 20-25
beats/min and flushing would suggest that the patient does not have
significant cholinergic poisoning and further observation required.
While observing effects of atropine give 500- 1000 ml of Normal
saline (10-20 ml/kg) over 10-20 min to compensate fluid loss due
to sweating, diarrhoea and cholinergic hyper-secretion. There is
no evidence that it will harm the patient with bronchorrhoea as
long as atropine is being given. (5)History of alcohol ingestion
should be enquired as well as possibility of other poison being
consumed be ascertained.
Active cooling and sedation: - Cooling is indicated if the patient
is febrile and climate is hot & humid. Agitated patient need to be
sedated with Inj. Diazepam 10 mg IV slowly which can be repeated
up to 30-40 mg/24 hrs. Diazepam will help in allaying anxiety,
facilitate gastric lavage, reduce damage to CNS (6), diminish
central respiratory failure (7) and control seizure.
Gastric Decontamination: - Forced emesis and syrup Ipecac have
no role.(8)Gastric lavage is indicated once patient is stabilized,
calm enough to give consent and in unconscious intubated patient,
which is recommended to be repeated after 2-3 hrs (9).Though it
has been recommended only to be carried out within 1-2 hours
of ingestion of OP/carbamate elsewhere it has been started even
after 12 hrs of ingestion and repeated thrice at an interval of 4
hrs (10). Repeat stomach wash will remove the residual poison
if any/secreted to stomach subsequently from fat stores. After
aspirating the contents of stomach through stomach tube (if food
particles are present)/Ryles tube, water or normal saline in lots
of 300 ml be given and be aspirated. Continue it till the returning

Medicine Update 2010 Vol. 20

Table-2: OP / Carbamate Obs Sheet

Time

Heart rate

Clear lung

Pupil

Dry axilla

BP

Table 3 :Target end points for atropine therapy

Bowel
sounds

Mental state Fever >37.5c

SPO2

Remarks
Atropine
dose

the paucity of data to drive a guideline it is prudent to start the

loading bolus dose 1-2 mg depending on severity and then to
repeat same boluses every five minutes (in doubling doses in
case no improvement is seen) till atropinisation is achieved. An
atropine infusion titrated to achieve atropinisation is an alternate
protocol. Atropine administration by nebulisation also improves
respiratory distress and oxygenation (17). It can also be given
through endotracheal tube initially before securing a veinous
route.

Clear chest on auscultation with no wheeze

Heart rate> 80 beats/min
Pupil no longer pin point
Dry axilla
Systolic blood pressure > 80 mm of Hg

fluid is colourless and odourless. Ensure that no fluid is left inside

the stomach by measuring the fluid taken off.
Activated Charcoal: - Though there is no evidence that either
single dose or multiple dose regimens of active charcoal will
result in benefit yet a dose of charcoal (50 gm) can be left in the
stomach (11, 12).

Criteria of Atropinisation: - There are no comparative studies

of markers for adequate atropinisation. Since patients usually
die from respiratory or circulatory failure, air entry on chest
auscultation, heart rate and blood pressure were given more
importance than dilatation of pupil, rise in body temperature,
dryness of mouth/skin. The target end points for atropinisation
are given in Table- 3 (5).

Transfer to ICU: - Atropine and resuscitation measures are to be

continued and vitals recorded while transferring to ICU. Patients
with the following criteria may need ventilator support.(13)
History of intake of large dose

Atropine maintenance: - Target end point once achieved is to be

maintained by atropine infusion. Infusion of atropine reduces the
fluctuation in atropine concentration associated with repeated
bolus doses. The rate of infusion is set at 10 -20 % of the total
atropine required to load the patient every hour.

Copious secretions
Disturbed level of consciousness
Signs of hypoventilation or respiratory obstruction by secretions
Hence intubation and ventilation facilities should be ensured to
be available in ICU. Patient is to be placed on monitor. Parameters
including oxygen saturation are to be observed and recorded in
OP/Carbamate observation sheet. Table 2(5)
Antidote: - Anticholinergics are competitive antagonist to Ach
and reverse all muscarinic activities both in CNS and peripheral
nervous system. Inj.Atropine is the only life saving antidote. Full
and early atropinisation is an essential and simple part of early
management. Clinical toxicology text books describe varied
atropine regimens.The sum total of 38 regimes found in literature
is to start a Bolus loading dose followed by boluses after a fixed
time interval varying from 5-15-30 min till atropinisation or Bolus
loading dose followed by infusion (14).The latter regimen showed
improved outcome. (15) Although the benefit of infusion is not
yet proven this regime saves time, requires less observation,
produces less fluctuation in plasma atropine concentration and
makes weaning easier.(16) The dose of atropine recommended to
be low (1-2 mg) so as to cater for milder cases and then rapidly
escalated (doubled each time) to achieve atropinisation quite
fast. Alternatively it started with a bigger dose (5 mg) to ensure
rapid atropinisation. Because of danger of over atropinisation the
former practice offers more control by starting with low doses.
The peak effect of atropine is seen within three minutes of an IV
injection. Hence, one need not wait for more than five minutes
before giving another bolus. Though the authors acknowledged

422

Observation: - Observations made initially after each atropine

dose is entered in the observation sheet. Once atropinisation has
been attained, those five parameters are to be monitored every
15 minutes initially which can be gradually increased to 1-2-3
hours depending on the state of atropinisation. Close observation
and monitoring plays not only a vital role in the management but
also can contribute to the learning process by gathering new
symptoms and signs and can anticipate recurring cholinergic crisis
which may occur with little notice.
Atropine toxicity: - Confusion, agitation, hyperthermia, ileus,
tachycardia etc would suggest over atropinisation which would
necessitate discontinuation of the atropine infusion, followed by
frequent observation. When they settle down the infusion is to
be started at 70- 80 % of the previous rate. Hyperthermia is a
serious complication in hot wards which needs prevention. To
avoid preservative toxicity powder atropine be reconstituted in
normal saline and be used.
Duration of maintenance atropine therapy: - This depends on
the severity and response to therapy. Usually it is maintained for
24- 48 hrs or longer in severe cases, and gradually withdrawn
over 3-5 days. Frequent observation is required to detect early
signs of intermediate syndrome. Tidal volume and blood gases
are to be measured. Indications for ventilation have been spelt
out. Table-4 (3). .
Glycopyrolate: - Some studies have shown that glycopyrolate

Organophosphorus Poisoning: Current management guidelines

Table 4 : Guidelines for ventilator support

Table 5 : Equivalent dosing units of pralidoxine salts

Salt
Pralidoxine
Pralidoxine
Pralidoxine
Pralidoxine

I.

Respiratory Gas Tensions

i
Direct Indices

Arterial Oxygen Tension < 50 mm Hg on room air
Arterial Co2 Tension > 50 mm Hg in the absence of metabolic
alkalosis
ii
Derived Indices

P a o2/ Fio2 < 250 mm of Hg
PA-aOo2 ( Pulmonary arterial-alveolar O2 gradient) > 350 mm
of Hg
Vd/Vt> 0.6
II. Clinical - Respiratory Rate (RR)> 35 breaths/min
III. Mechanical Indices

Tidal Volume 5 ml/kg

Vital capacity < 15 ml/kg
Maximum inspiratory force <- 25 cm of H2O

chloride
mesilate
metilsulfate
iodide

Equivalent dose (g)

1.00
1.34
1.43
1.53

reactivation of red cell acetylcholinesterase in diethyl OP pesticide

poisoned patient (ageing in this compound AChE complex takes
much longer than Dimethyl OPs) the reason for their failure
to benefit was not apparent.(22) Further studies on different
regimens or different oximes have been recommended by these
workers while proposing type of OP and its coformulant, poison
load, time to start of therapy and the dose of oxime being the
limiting factors.(23)
Since the idea is sound and animal experiments suggest it is useful,
it is recommended preferably in moderate to severe cases. (9,
24)It is to be administered as early as possible post ingestion
to offer benefit. Delayed presentation is not a contraindication
(4). There are no definite dose recommendations. However, it
has been established that the therapeutically effective oxime
concentration in plasma is 4mg/litre though effect has been
demonstrated in lower concentration as well. Elsewhere it has
been used as 2gm loading followed by 1gm/h for 48h by infusion
(high dose) with benefit, concluding (25) that administration in
high dose and constant infusion is better than repeated bolus
administration. A low dose schedule (1gm bolus) has also shown
lower mortality suggesting that the bolus dose do achieve a
therapeutic concentration for a limited amount of time (26).

is equally effective with fewer central nervous system side

effects and better control of secretions. Since it does not enter
CNS initial muscarinic signs like coma or drowsiness will not
respond. Hence its use is recommended when there is copious
secretion as an adjunct to atropine or when features of atropine
toxicity like delirium etc are confused with CNS effects of
poison or when atropine is not available. Ampoules of 7.5 mg
of glycopyrolate in 200ml of saline is started as infusion and is
titrated to the desired effects of dry mucus membranes. (18)It
has also been given at a dose of 0.2mg IM stat and repeated 6hrly
if required. Diphenhydramine can be an alternate centrally acting
anticholinergic agent if atropine is not available (19).
Magnesium Therapy: - Magnesium therapy in addition to atropine
and oximes has been found to benefit.The mechanism appears to
be inhibition of AChE and OP antagonism. (20)

In view of above though guide lines are not definite, it is clear that
oximes are effective when given early and in high doses (dose to
be adjusted depending on the salt used) that too a bolus dose
offers benefit which is to be followed by infusion for a sufficient
duration (therapeutic window for Diethyl AChE complex is 133h)
Table-5 (27). Keeping these aspects in mind the guidelines followed
by Southern Hospitals Network appears most appropriate and
is recommended as Initial bolus dose of 2gm IV(30mg/kg) over
30 min(rapid administration leads to complications ) which is
to be followed by 1 gm IV every 8 hours in mild to moderate
poisoning and in severe poisoning cases 500 mg/hour(8-10mg/
kg/h)till clinical recovery(12-24h after atropine no longer required
or the patient is extubated) or 7 days which is later. Repeat bolus/
infusion is to be ceased based on clinical testing or plasma ChE
test.(4) Though oximes are not recommended for Carbamate
poisoning, their use should not be withheld in case of unknown
cholinergic poisoning as definite harm to human beings has not
been demonstrated. (5)

Cholinesterase Reactivators: - These agents known as oximes get

attached to the free anionic site of the enzyme ChE. The oxime
end then reacts with the phosphorus atom of OP attached at the
esteratic site of the enzyme. This oxime phosphate so formed
diffuses away leaving the enzyme intact (Reactivated ChE).In addition
to reactivation they also slow the ageing of the phosphoylated
enzyme complex and has a direct action in converting the OP to
a harmless compound (21). Reactivation of ChE is more marked
in the skeletal muscle than at autonomic site and not at all in CNS
(Do not enter CNS).Thus their use in OP poisoning is secondary
to that of atropine. Oximes (Pralidoxime, Obidoxime) are widely
used since 1955 in OP poisoning along with atropine within 24-48
hours post ingestion as pralidoxime chloride 1 gm every 3-4h for
1-3 days.WHO guidelines recommended giving a 30 mg/kg loading
dose of Pralidoxime over 10-20 min followed by a continuous
infusion of 8-10 mg/kg/hr until clinical recovery or seven days
have elapsed whichever is later. Where obidoxime is available a
loading dose of 250 mg is followed by an infusion of 750 mg every
24 hrs.Their efficacy however has been questioned over last two
decades by workers from Sri Lanka, South Africa,Taiwan, Iran and
India. All these studies have been criticized either on the basis
of non comparable groups of selected patients or inadequate
doses of PAM (9).Though these studies have demonstrated clear

Ventilation: - This is the most useful advance in the management of

Op poisoning and makes all the difference on outcome. Indications
for ventilation have already been tabled above. Regular and
close observation in initial course will guide when to ventilate.
Succinylcholine is to be avoided. Non-depolarising neuromuscular
blocking agents require higher doses to show effect.

423

Medicine Update 2010 Vol. 20

OP Patients
Vital data monitor
Physical exam
Glasgow Score

ABC resuscitation, Oxygen,

Fluid & Blood sample
Atropine 2 mg if needed

Prepare the monitor,

Gastric lavage

Aspired water without

smell and clean

Check the vital data,

respiratory exam, etc

Observation every 5
minutes

No improvement

Pralidoxime 30 mg/Kg
bolus in 30 minutes

8-10 mg/Kg. hr infusion

until clinical recovery

Improvement

Repeat with the

same dose

Double the dose

of Atropine

Atropinization

Atropine infusion
10%-20% of loading

Atropinization
cannot maintain

Maintain
Atropinisation

Atropine toxicity

Bolus + infusion

Keep on infusion

Stop until
toxicity resolved

Decrease until
stop atropine

Fig. 2 : Treatment Protocol for OP Poisoned Patient

Furosemide: - It is recommended if pulmonary oedema persists,
even after full atropinisation.
Hydrocarbon Aspiration: - In case of ingestion of liquid
concentrates of OP, hydrocarbon solvent aspiration causes
chemical pneumonitis. These cases are to be managed as a case
of Acute Respiratory Distress Syndrome.

Summary of treatment protocol is given in figure-2.(10)

Contraindications: - Drugs like morphine, succinylcholine,
theophylline, phenothiazine and reserpine are contraindicated.
Adrenergic amines should be given only if there is specific
indication, such as marked by hypotension.
Conclusion: - Medical management of Organophosphorus
pesticide poisoning demands close observation, timely institution
of antidote in adequate doses and duration and good supportive
care. Though available evidence is lacking in many aspects of
different controversies, attempt has been made to define them and
offer a pragmatic therapeutic protocol which will enable junior
physicians to manage these patients with confidence and success.

Antibiotics:- Broad spectrum antibiotics are to be instituted as

per antibiotics policy of the institution, considering the risk of
infection due to frequent and multiple interventions.
Agitation/Convulsion: - Causes of agitation unrelated to pesticide
toxicity like alcohol withdrawal/full bladder unless catheterized/
head injury etc are to be excluded. Role of Diazepam has already
been described and is preferred over haloperidol. Intraosseous
(Bone injection Gun, BIG) Midzolam demonstrated rapid peak
concentration in swine compared to IV or IM route, can be used
to control convulsion.(5)

References

Injected OP poisoning: - The effects OP poisoning are severe and

requires higher doses of antidotes. Local tissue necrosis may need
surgical intervention. All oily based OP need to be removed to
avoid systemic absorption (28).

424

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