Intended for healthcare professionals

Clinical Review

Management of acute organophosphorus pesticide poisoning

BMJ 2007; 334 doi: (Published 22 March 2007) Cite this as: BMJ 2007;334:629
  1. Darren M Roberts, clinical researcher1,
  2. Cynthia K Aaron, fellowship director2
  1. 1South Asian Clinical Toxicology Research Collaboration, Australian National University
  2. 2Regional Poison Center, Children's Hospital of Michigan, Detroit, MI 48201, USA
  1. Correspondence to: C K Aaron caaron{at}

    Organophosphorus pesticides are used widely for agriculture, vector control, and domestic purposes. Despite the apparent benefits of these uses acute organophosphorus pesticide poisoning is an increasing worldwide problem, particularly in rural areas. Organophosphorus pesticides are the most important cause of severe toxicity and death from acute poisoning worldwide, with more than 200 000 deaths each year in developing countries.1 Although the incidence of severe acute organophosphorus pesticide poisoning is much less in developed countries, many patients with acute low dose unintentional or occupational exposures present to health facilities.2 3 We provide an evidence based review of the management of acute organophosphorus pesticide poisoning. Risk assessment in patients with acute unintentional poisoning is discussed, in addition to special considerations for severe poisoning.


    • Acute organophosphorus poisoning may induce multisystem toxicity leading to severe toxicity and death

    • Poisoning is diagnosed on the basis of history and clinical examination; biochemical investigations can have a role for confirming the diagnosis

    • Management consists of prompt resuscitation, antidotes as required (particularly atropine, oximes, benzodiazepines), and selective decontamination

    • Ongoing monitoring and high quality supportive care are essential

    • Healthcare staff treating exposed patients should exercise standard precautions

    Sources and selection criteria

    We searched several resources to identify relevant information on the diagnosis and management of acute organophosphorus poisoning: Medline, Embase, the Cochrane Library, and the Chemical Safety Information for Intergovernmental Organizations database (; websites for registration of clinical trials, including the Current Controlled trials website ( using the mRCT search feature; personal archives; and attendance at, and review of abstracts from, workshops and conferences on pesticide poisoning.

    Levels of evidence in the review

    The evidence supporting specific therapeutic approaches to patients with acute organophosphorus poisoning is listed after each management recommendation. We have adopted the classification used in the BMJ publication Clinical Evidence4:

    • Beneficial (B)

    • Likely to be beneficial (LB)

    • Trade-off between benefits and harms …

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