General Measures in the Management of Acute Pesticide Poisoning

I. Emergency stabilization

B. Provide adequate oxygenation/ventilation
Inadequate oxygen delivery to the lungs may be due to ventilatory failure, hypoxia or bronchospasm. In all cases, arterial blood gas determination (ABG) should be done to accurately assess ventilation. If the patient manifests clinical signs of poor oxygenation, or pO₂ is less than 80 mmHg, oxygenation must be initiated. Oxygen may be given via nasal cannula, face mask, or with a mechanical ventilator, depending on the availability of equipment and the FiO₂ level required by the patient. If the patient manifests with bronchospasm, evaluate the need for bronchodilators.

IMPORTANT: Oxygen may be contraindicated in the initial management of zinc phosphide and paraquat poisoning. Zinc phosphide is a flammable substance. The presence of oxygen increases the risk of pulmonary fibrosis in paraquat poisoning.	Modes of Oxygen Delivery with Equivalent FiO2 Nasal cannula 44% Plastic Mask 60% Rebreathing mask 60-80% Ventilator 100%
C. Maintain adequate circulation
Secure venous access and initiate intravenous infusion of the appropriate fluids. In case of hypotension (SBP < 80 mmHg in patients under 40 years of age, or SBP < 90 mmHg in patients over 40 years), elevate the legs by about 15 cm from the horizontal plane to increase venous return to the heart. Fluid challenge should then be done using 200 mL normal saline solution for adults and, for children, 10 mL/kg D5 0.3NaCl. At times, hypotension is resolved when ventilation problems are corrected.
In severe poisoning cases, maintenance drips and fluid challenge may be ineffective. For severe hypotension, a central venous line should be inserted, hydration status monitored, and plasma expanders infused to augment intravascular volume. If still unsuccessful, Dopamine at 1.0-2.5 mcg/kg/min may be started to increase renal blood flow. With adequate urine output, higher doses of Dopamine can then be given to maintain blood pressure.	Recommended IV Fluids Hypotensive Patients: NSS Crystalloid solution Adult Maintenance: NSS D5AR Pediatric Maintenance: D5 0.3 NaCl