Adequate external decontamination is important to prevent continued exposure. All clothing and jewelry should be removed and placed in sealed plastic bags. Contaminated skin should be irrigated with copious amounts of water, or gently washed with soap and water. Vigorous scrubbing should be avoided since it might actually increase systemic uptake.
To prevent secondary contamination, all members of the medical team who are directly treating or decontaminating the patient should wear adequate protective gear. Simple surgical masks and gowns do not provide sufficient protection. Butyl rubber gloves and aprons are more effective. If the patient is vomiting, gastric contents may contain the organophosphate agent and be a source of secondary contamination.
Neither gastric lavage nor activated charcoal has any demonstrated benefit in the setting of organophosphate ingestion. Either intervention would be expected to increase the risk of pulmonary aspiration.
As for any seriously ill patient the primary goal is support of airway, breathing, and circulation. This is accomplished by routine interventions and by the timely administration of sufficient antidote.
The goal is to treat respiratory insufficiency, which is the primary threat. The antidote is atropine sulfate, which reverses the muscarinic bronchospasm and bronchorrhea. The initial dose is 0.02 mg/kg intravenously. In severe cases, this dose should be doubled every 5 minutes until pulmonary secretions dry up, bronchospasm resolves, and the child can be oxygenated and ventilated.7 Tachycardia is not a contraindication to the administration of atropine. There is no maximum dose of atropine. Frequently, surprisingly large amounts are required.
Pralidoxime chloride should be given to treat moderate-to-severe cholinergic toxicity from organophosphates or an unknown agent. The dose is 25–50 mg/kg IV over 30 minutes. Pralidoxime regenerates acetylcholinesterase by removing organophosphate from the enzyme's active site. The dose can be repeated at 6 hours intervals, or a continuous infusion of 10 mg/kg/h can be started after the initial load. Pralidoxime is not indicated in confirmed carbamate exposure because the bond between carbamate and acetylcholinesterase is weak and spontaneously reverses. However, it should be administered in cases of significant cholinergic toxicity where the specific insecticide is not known.
Diazepam is the treatment of choice for seizures. Studies indicate that it may also be beneficial in any patient with evidence of severe central cholinergic toxicity, such as those who are comatose or minimally responsive. If a patient needs to be paralyzed to facilitate endotracheal intubation, succinylcholine should not be used because it is metabolized by plasma cholinesterase. Since this enzyme is inactivated by organophosphates, administration of succinylcholine may result in markedly prolonged paralysis.8,9
Arrangements should be made for admission to a critical care unit.