What is the acute treatment for paraquat poisoning?

Acute Treatment of Paraquat Poisoning

Immediately remove all contaminated clothing, thoroughly wash exposed skin with soap and water, contact poison control, and administer multiple-dose activated charcoal (15-20g every 6 hours) after securing the airway—but critically, restrict supplemental oxygen to only when SpO2 falls below 85% and target oxygen saturation of 85-88%, as higher oxygen levels dramatically worsen paraquat-induced lung injury. 1, 2, 3

Immediate Decontamination (First Priority)

• Remove all contaminated clothing and jewelry immediately to prevent continued dermal absorption 2, 3
• Thoroughly wash all exposed skin areas with soap and water using warmed water at lower pressure in pediatric patients to prevent hypothermia 1, 2
• Healthcare workers must wear protective gloves and clothing when handling the patient or contaminated materials to prevent secondary exposure 2, 3

Gastrointestinal Decontamination

• Administer multiple-dose activated charcoal (15-20g every 6 hours) only after airway protection and hemodynamic stabilization 1, 2
• Do NOT perform routine gastric lavage—activated charcoal or Fuller's earth are preferred decontamination agents as they work through adsorption rather than mechanical removal 1
• Never attempt decontamination without first securing the airway due to significant aspiration risk 1

Critical Oxygen Management (Unique to Paraquat)

This is the most critical pitfall to avoid in paraquat poisoning:

• Avoid supplemental oxygen unless SpO2 falls below 85% 1, 2, 3
• Target oxygen saturation of 85-88%—significantly lower than typical critical care targets 2, 3
• Reduce or stop oxygen therapy if saturation rises above 88% 1, 2, 3
• Rationale: Oxygen accelerates paraquat-induced lung injury through increased free radical production, dramatically worsening toxicity 1, 2

Supportive Care

• Contact poison control centers immediately for expert guidance and maintain continuous contact for evolving recommendations 1, 2, 3
• Provide standard airway management if respiratory distress develops 3
• Treat hypotension and dysrhythmias according to standard protocols 3
• Administer benzodiazepines for seizures or severe agitation if they occur 3
• Correct metabolic derangements including acidosis 2

Extracorporeal Treatment Considerations

• Consider early hemodialysis in cases of massive ingestion to enhance elimination, particularly when combined with antioxidant therapy 4
• Research suggests early hemodialysis combined with antioxidant therapy (deferoxamine 100 mg/kg/24h and continuous acetylcysteine 300 mg/kg/day) may improve outcomes in severe poisoning 4

Prognostic Factors

Poor prognostic indicators include: 5

• Older age
• Oral ingestion (versus percutaneous/inhalational exposure)
• Large volume ingested (>40-50 mL of concentrate)
• Leukocytosis on admission
• Metabolic acidosis
• Renal, hepatic, or pancreatic failure on admission
• Multiple organ failure

Common Pitfalls to Avoid

• Do NOT provide liberal supplemental oxygen—this is uniquely harmful in paraquat toxicity and represents the most dangerous error in management 1, 2, 3
• Do NOT delay airway protection to perform gastrointestinal decontamination 1
• Do NOT use gastric lavage routinely when activated charcoal is the evidence-based alternative 1
• Do NOT forget to protect healthcare workers from secondary exposure through contaminated clothing or body fluids 2, 3

Pediatric Modifications

• Use warmed shower water at lower pressure to prevent hypothermia and additional skin damage 1
• Use heat lamps and blankets to prevent hypothermia during decontamination 1
• Ensure thorough washing of all exposed skin areas to prevent secondary exposure 1