1) Immediate stabilization (ABCDE)

1. Airway: suction secretions, consider early intubation if bronchorrhea, altered sensorium, or respiratory fatigue.
2. Breathing: oxygen, assisted ventilation as needed.
3. Circulation: IV access, fluids, monitor BP/HR/ECG.
4. Disability: assess GCS, seizures.
5. Exposure: remove contaminated clothes; wash skin/hair thoroughly.

2) Decontamination and staff safety

1. Protect healthcare workers with gloves, gown, mask/eye protection.
2. Dermal decontamination: soap and water irrigation.
3. Gastric decontamination (selected cases only):
   • If recent ingestion and airway protected, consider activated charcoal.
   • Gastric lavage only in severe/life-threatening ingestion and very early presentation with protected airway.

3) Recognize cholinergic syndrome

• Muscarinic: salivation, lacrimation, urination, diarrhea, vomiting, bronchorrhea, bronchospasm, bradycardia, miosis.
• Nicotinic: fasciculations, weakness, paralysis, tachycardia/hypertension sometimes.
• CNS: agitation, confusion, coma, seizures.

4) Specific antidotal therapy

A. Atropine (first-line, life-saving)

1. Start with 1–3 mg IV in adults (higher if severe).
2. Double dose every 3–5 min until atropinization endpoints:
   • drying of bronchial secretions,
   • improved oxygenation/air entry,
   • reduced wheeze/bronchorrhea,
   • adequate heart rate/BP.
3. Then start maintenance infusion (roughly 10–20% of total loading dose per hour), titrate to keep chest dry and oxygenation adequate.

B. Pralidoxime (2-PAM; oxime)

1. Give early (best before “aging” of enzyme complex).
2. Typical adult regimen:
   • 1–2 g IV over 20–30 min,
   • then repeat q6–12h or continuous infusion (commonly 500 mg/h) depending on severity/protocol.
3. Continue until clear clinical recovery (improved muscle strength, reduced ventilatory need).

C. Benzodiazepines

• For seizures, severe agitation, or marked CNS toxicity (e.g., diazepam/midazolam).

5) Supportive critical care

1. Frequent suctioning for secretions.
2. Mechanical ventilation if respiratory muscle weakness or persistent hypoxia.
3. Treat hypotension/arrhythmias per ICU protocol.
4. Correct fluids/electrolytes/acid-base issues.
5. Manage aspiration pneumonia if present.

6) Monitoring

• Continuous SpO2, ECG, BP, urine output.
• Serial neuro-respiratory exams.
• Cholinesterase levels (if available) help support diagnosis/trends but do not delay treatment.

7) Watch for complications

• Intermediate syndrome (24–96 h): proximal weakness, neck flexor/respiratory weakness.
• Delayed neuropathy (days to weeks).
• Aspiration, ARDS, prolonged ventilation complications.

8) Duration and de-escalation

• Continue atropine/oxime based on clinical signs, not fixed duration.
• Taper atropine infusion slowly once stable and chest remains dry.
• Observe for relapse after taper.

9) Disposition

• ICU for moderate/severe poisoning.
• Psychiatric assessment if intentional self-harm.
• Public health/occupational counseling for pesticide safety.

Quick bedside algorithm

1. PPE + decontaminate
2. Airway/oxygen/ventilate
3. Atropine rapidly and escalate
4. Add pralidoxime early
5. Control seizures with benzodiazepine
6. ICU monitoring and complication surveillance

• a weight-based pediatric protocol, or
• a one-page emergency dose chart for atropine and pralidoxime.