What is the emergency management for a patient who has taken paraquat orally but has not yet swallowed it?

Emergency Management of Paraquat Oral Intake Without Swallowing

If paraquat is in the mouth but not yet swallowed, immediately have the patient spit out all contents and thoroughly rinse the mouth with water—do NOT induce swallowing, vomiting, or give anything by mouth. 1

Immediate Actions (First Minutes)

Prevent Further Absorption

• Have the patient expectorate (spit out) all oral contents immediately without swallowing 1
• Rinse the mouth thoroughly with water and spit repeatedly—do not allow the patient to swallow the rinse water 1
• Do NOT give water or milk to drink, as this provides no benefit and may cause the patient to swallow residual paraquat or induce vomiting 1
• Never induce vomiting or administer ipecac, as aspiration risk is significant and contraindicated 1

Decontamination of Exposed Areas

• Remove all contaminated clothing and jewelry immediately to prevent continued dermal absorption 2, 3
• Thoroughly wash all exposed skin (face, lips, hands) with soap and water to prevent secondary absorption 2
• Use warmed water at lower pressure if available to prevent hypothermia 2

Healthcare Worker Protection

• Wear gloves and full protective equipment when handling the patient or any contaminated materials, as paraquat can be absorbed through skin or respiratory tract 1

Critical Early Management Steps

Immediate Consultation

• Contact poison control center immediately for expert guidance and maintain continuous contact for evolving recommendations 2, 3
• Activate emergency response systems without delay for coordination of specialized care 3

Airway and Hemodynamic Stabilization

• Secure airway protection first before any decontamination attempts, as aspiration risk is significant 2
• Provide standard treatment for hypotension or dysrhythmias if they develop 3
• Administer benzodiazepines for seizures or severe agitation if they occur 3

Oxygen Management (Critical and Counterintuitive)

• Avoid supplemental oxygen unless SpO2 falls below 85%—this is uniquely important in paraquat toxicity 2, 3
• Target oxygen saturation of 85-88%, significantly lower than typical critical care targets 2, 3
• If oxygen saturation rises above 88%, reduce or stop oxygen therapy immediately 2, 3
• Rationale: Oxygen dramatically worsens paraquat toxicity through increased free radical production and accelerates lung injury 2

Gastrointestinal Decontamination (If Any Swallowing Occurred)

Activated Charcoal Administration

• If any paraquat was swallowed, consider multiple-dose activated charcoal (15-20g every 6 hours) only after securing the airway and achieving hemodynamic stability 2
• Activated charcoal or Fuller's earth are preferred decontamination agents over gastric lavage, as they work through adsorption 2
• Do not delay airway protection to perform gastrointestinal decontamination 2

Gastric Lavage (Generally Not Recommended)

• The American College of Medical Toxicology recommends against routine gastric lavage for paraquat poisoning 2
• Gastric lavage should only be considered in the earliest phases of certain poisonings but is not standard practice 2

Monitoring and Assessment

Prognostic Indicators

• The most important prognostic indicator is the quantity of paraquat absorbed, as shown by plasma paraquat concentration 4
• Obtain baseline laboratory investigations including complete blood count, liver and renal function, electrolytes, and urinalysis 5
• Send urine and plasma paraquat levels if available 5
• Monitor for development of acute kidney injury, which may develop 3-4 days after exposure 5

Psychiatric Evaluation

• All patients with intentional paraquat exposure should receive psychiatric evaluation before discharge 1

Common Pitfalls to Avoid

• Do NOT provide supplemental oxygen liberally—this is uniquely harmful in paraquat toxicity and accelerates lung injury 2, 3
• Do NOT give water or milk by mouth to dilute the poison, as this provides no proven benefit and may provoke emesis or cause swallowing of residual toxin 1
• Do NOT induce vomiting, as aspiration may occur 1
• Do NOT use gastric lavage routinely when activated charcoal is the evidence-based alternative 2
• Do NOT delay airway protection to perform decontamination procedures 2
• Do NOT handle patient or contaminated materials without appropriate personal protective equipment 1

Key Clinical Context

The scenario of paraquat in the mouth but not swallowed represents a critical window for prevention of systemic toxicity. Even small amounts of paraquat (20 mg/kg) can cause moderate to severe poisoning with pulmonary fibrosis and death 6. Ingestion of greater than 40 mg/kg causes acute fulminant poisoning with multiple organ failure and death within hours to days 6. The prognosis is determined primarily by the amount absorbed, making immediate oral decontamination without swallowing absolutely critical 4, 6.