What is the management approach for a 20-year-old male with no reported medical history who ingested approximately 200ml of Glyphosate (herbicide) 2 hours prior to presentation?

Management of Acute Glyphosate Herbicide Poisoning

For this 20-year-old male who ingested 200ml of glyphosate herbicide 2 hours ago, immediately contact Poison Control (1-800-222-1222), initiate aggressive supportive care with close monitoring for respiratory distress and hemodynamic instability, and do NOT induce vomiting or administer activated charcoal at this time point. 1, 2

Immediate Actions (First 30 Minutes)

Contact and Protection

• Call Poison Control Center immediately (1-800-222-1222) while initiating treatment to obtain expert guidance on specific management 1, 3
• Healthcare workers must wear appropriate personal protective equipment (gloves, protective clothing) when handling the patient or contaminated materials to prevent secondary exposure 1

Decontamination Considerations

• Do NOT induce vomiting with syrup of ipecac - this is contraindicated and may worsen the condition 1
• Do NOT administer activated charcoal at 2 hours post-ingestion unless specifically directed by Poison Control, as the patient is beyond the 1-hour window where it provides benefit and may cause aspiration 3
• Remove all contaminated clothing immediately if any external exposure occurred 1

Risk Stratification for This Patient

This patient is at HIGH RISK for serious complications based on the following factors:

• Volume ingested (200ml) exceeds the 100ml threshold associated with significant toxicity and need for intensive care 2, 4
• Ingestion of >85ml of concentrated formulation is likely to cause significant systemic toxicity 2
• The 2-hour timeframe means complications may develop imminently, as most severe manifestations occur within 24 hours 4

Monitor for Poor Prognostic Indicators

• Age >50 years (not applicable here, but important to note) 4
• Chest X-ray abnormalities 4
• Elevated ALT >40 U/L 4
• Elevated amylase 4

Supportive Care Algorithm

Airway and Breathing Management

• Prepare for early endotracheal intubation if any signs of respiratory distress, impaired consciousness, or hemodynamic instability develop 1
• Respiratory distress and pulmonary edema are common severe complications that can develop rapidly 2, 5
• Monitor oxygen saturation continuously 5

Cardiovascular Support

• Establish large-bore IV access immediately and begin aggressive fluid resuscitation 5, 6
• Monitor for hypotension requiring vasopressor support (noradrenaline and vasopressin may be needed) 6
• Continuous cardiac monitoring for bradycardia and ventricular arrhythmias, which are often pre-terminal signs 2
• Treat dysrhythmias according to standard ACLS protocols 1

Seizure Management

• Administer benzodiazepines (diazepam first-line or midazolam) for seizures or severe agitation 1

Laboratory Monitoring

Initial Laboratory Assessment (Obtain Immediately)

• Complete metabolic panel including electrolytes, renal function (BUN, creatinine) 2, 4
• Liver function tests (ALT, AST) - ALT >40 U/L predicts complications 4
• Amylase and lipase - elevated amylase predicts complications 4
• Arterial blood gas - monitor for metabolic acidosis (most common complication) 2, 4
• Serum potassium - monitor for hyperkalemia 2
• Lactate level - severe lactic acidosis can develop 5

Serial Monitoring

• Repeat metabolic panel every 4-6 hours for first 24 hours 2
• Monitor for acute kidney injury requiring hemodialysis 2, 6

Imaging

• Obtain chest X-ray immediately - abnormalities are an independent predictor of complications and need for ICU admission 4
• Monitor for pulmonary edema and infiltration 2

Expected Clinical Course and Complications

Gastrointestinal Effects (Most Common)

• Mouth, throat, and epigastric pain with dysphagia are common early manifestations 2
• Nausea and vomiting 5, 7
• Delayed gastric ulceration and pyloric obstruction can occur weeks to months later - consider long-term acid suppression and mucosal protection therapy 7

Severe Systemic Complications (Within 24 Hours)

• Metabolic acidosis (most common serious complication) 4
• Respiratory distress and ARDS 5
• Hypotension and shock 2
• Acute kidney injury 2
• Hyperkalemia 2
• Renal and hepatic impairment reflecting reduced organ perfusion 2

Life-Threatening Complications

• Severe lactic acidosis 5
• Aspiration pneumonia 5
• Cardiovascular collapse 2
• Bradycardia and ventricular arrhythmias (pre-terminal) 2

Advanced Therapies to Consider

Renal Replacement Therapy

• Continuous veno-venous hemodiafiltration (CVVHD) may be required for severe metabolic acidosis, hyperkalemia, or acute kidney injury 6

Experimental Therapy

• IV lipid emulsion (20% intralipid 100ml) has been reported in successful case management, though evidence is limited to case reports 6

Disposition

This patient requires ICU admission based on:

• Volume ingested (200ml) exceeding high-risk threshold 2, 4
• High likelihood of developing serious complications within 24 hours 4
• Need for continuous cardiorespiratory monitoring 2

Critical Pitfalls to Avoid

• Do not delay supportive care while waiting for laboratory confirmation or specific herbicide identification - treatment is based on clinical presentation 1
• Do not use gastric lavage or attempt neutralization with acid-base reactions - this may worsen gastric mucosal injury 7
• Do not underestimate the severity based on initial presentation - serious complications can develop rapidly even if patient appears stable initially 2, 5
• Do not forget healthcare worker protection during any decontamination procedures 1
• Do not discharge early - complications can develop up to 24 hours post-ingestion, and delayed gastric complications can occur weeks later 7, 4

Mechanism of Toxicity

The toxicity results from both glyphosate itself and the surfactant polyoxyethylene amine (POEA), which causes uncoupling of oxidative phosphorylation and direct cardiotoxicity 5. The surfactant POEA may contribute more to acute toxicity than glyphosate alone 2.

Prognosis

There is no specific antidote for glyphosate poisoning - aggressive supportive therapy is the sole treatment approach 6. With the volume ingested (200ml), this patient has multiple poor prognostic factors, but timely aggressive supportive management can result in successful recovery even in critically ill patients 5, 6.