A 60-year-old man was found unconscious in the fields with profuse frothing at the mouth. He was well the previous night and had his usual dose of alcohol with his meal. He had incurred heavy debts after marrying off his daughter and had appeared depressed of late. How would you assess, investigate, diagnose and treat him based on evidence in literature?

Immediate resuscitation comes before diagnosis. Airway, Breathing, Circulation, Disability, Exposure. Position laterally, suction copious secretions repeatedly, give high-flow oxygen, and secure the airway by early intubation if there is a reduced conscious level, inability to protect the airway, uncontrolled bronchorrhoea or respiratory muscle weakness. Establish two wide-bore IV lines, attach a monitor, and check a capillary blood glucose immediately. Wear gloves and an apron and decontaminate the patient — remove all clothing and wash the skin and hair with soap and water — to protect both the patient and the staff from continuing dermal absorption.

Recognise the toxidrome. Anticholinesterase poisoning produces a cholinergic crisis. Muscarinic (DUMBBELS) — Diarrhoea, Urination, Miosis, Bronchorrhoea, Bradycardia, Emesis, Lacrimation, Salivation; bronchorrhoea and bronchospasm are what kill. Nicotinic — fasciculations, muscle weakness, cramps, respiratory muscle paralysis, tachycardia, hypertension, mydriasis. Central — anxiety, confusion, seizures, coma and central respiratory depression. A garlic-like odour on the breath or clothes supports the diagnosis.

History and examination. Obtain a history from family, neighbours and the people who found him; ask for the container, label or a sample of the substance, the time of exposure and the approximate amount, and the route. Document the psychiatric history — depression, previous attempts, alcohol use, the debt and the recent marriage of his daughter. Examine for pupil size, secretions, chest crackles and wheeze, fasciculations, muscle power, reflexes, conscious level (GCS), temperature, and evidence of head injury, snake bite, or aspiration. Grade severity using the Peradeniya Organophosphorus Poisoning (POP) scale.

Investigations. Confirmatory — plasma (pseudo)cholinesterase and red cell acetylcholinesterase; RBC AChE correlates best with severity and with recovery, and a persistently low level is a useful diagnostic marker. Baseline and monitoring — CBC, sodium and potassium (mEq/L), calcium and magnesium (mg/dL), random blood sugar (mg/dL), renal and liver function, serum amylase and lipase (pancreatitis is common), arterial blood gas, ECG (look for QTc prolongation, bradyarrhythmia and torsades), chest X-ray (aspiration, pulmonary oedema), and troponin where indicated. Add a toxicology screen and blood alcohol, and CT head if the conscious level does not improve as expected.

Atropine — the life-saving antidote, given by rapid dose escalation. Optimise oxygenation before giving atropine to minimise the risk of dysrhythmia. Give an initial IV bolus and then double the dose every 5 minutes (for example 2 → 4 → 8 → 16 mg) until atropinisation is achieved. Far larger doses are needed than for any other indication — commonly tens of milligrams in the first day. Endpoints of atropinisation: clear chest on auscultation, dry axillae, heart rate above 80/min, systolic BP above 80 mmHg, and pupils no longer pinpoint. Clearing of secretions, not pupil size alone, is the target. Then maintain with an infusion titrated to these endpoints, and watch for atropine toxicity — hyperthermia, delirium, ileus, urinary retention and tachyarrhythmia.

Oximes and benzodiazepines. Pralidoxime reactivates acetylcholinesterase before "ageing" of the enzyme occurs, and is therefore most useful early; it acts mainly on the nicotinic features — fasciculations, weakness and respiratory muscle paralysis. Give as a loading dose followed by a continuous infusion. Its clinical benefit is genuinely controversial — Indian and international randomised trials have shown no appreciable benefit of adding pralidoxime to atropine on mortality, ventilation requirement or length of stay, and high-dose regimens have been associated with more respiratory complications; nonetheless it remains standard therapy in most Indian protocols. Benzodiazepines (diazepam or midazolam) are indicated for seizures, agitation and fasciculations, and are neuroprotective.

Decontamination and supportive care. Gastric lavage only if the patient presents within about one hour, with a protected airway, and it is never to be performed in an unprotected unconscious patient; a single dose of activated charcoal may be considered early. Otherwise meticulous supportive care determines the outcome — mechanical ventilation, repeated suction, fluid and electrolyte correction (especially hypokalaemia and hypomagnesaemia), glycaemic control, nutrition, DVT and stress-ulcer prophylaxis, pressure-area care, and prevention and treatment of aspiration pneumonia — the commonest cause of late death.

Anticipate the three phases and their complications. (i) Acute cholinergic crisis — minutes to hours. (ii) Intermediate syndrome — 24–96 hours after apparent recovery, with proximal limb, neck flexor, cranial nerve and respiratory muscle weakness, requiring ventilation; anticipate it by serial neck-flexion and single-breath-count testing, and do not extubate prematurely. (iii) Organophosphate-induced delayed polyneuropathy (OPIDN) — 2–3 weeks later, a distal sensorimotor axonopathy. Also watch for arrhythmia and torsades, pancreatitis, hyperglycaemia and neuropsychiatric sequelae — depression, cognitive deficits and recurrent seizures are documented in survivors.

Manage the alcohol dimension. He drinks regularly, so anticipate alcohol withdrawal from 6–72 hours after admission, which may be misread as atropine toxicity or as the intermediate syndrome. Give parenteral thiamine before any glucose-containing fluid to prevent Wernicke's encephalopathy, monitor with CIWA-Ar where the patient is conscious, use short-acting benzodiazepines, and correct magnesium, potassium and phosphate. Screen formally with CAGE or SMAST-G once he is awake, and treat the alcohol use disorder as part of the discharge plan.

The psychiatric and medico-legal management — where most marks are lost. Once medically stable, arrange a formal psychiatric assessment before discharge for every patient after deliberate self-poisoning. Diagnose and treat the depressive illness — the strongest risk factor for suicide — with an SSRI plus psychotherapy; problem-solving therapy is particularly appropriate given a debt-related, problem-focused crisis. Conduct a structured suicide risk assessment — intent, planning, ongoing wish to die, hopelessness, previous attempts — remembering that an older person's attempt carries far higher lethality and a much lower attempt-to-completion ratio. Arrange means restriction and family supervision, a written safety plan, social work referral for the debt, and structured follow-up contact after discharge. Medico-legally, Section 115 of the Mental Healthcare Act 2017 presumes severe stress and protects him from prosecution, and imposes a duty on the state to provide care and rehabilitation; document injuries carefully, preserve samples, and inform the police as required for a medico-legal case while maintaining a non-judgemental therapeutic stance. Signpost Tele-MANAS 14416 and, given his age, Elder Line 14567.

2023 American Heart Association guidelines for the management of patients with cardiac arrest or life-threatening toxicity due to poisoning. These recommend immediate atropine for bronchospasm, bronchorrhoea, seizures or significant bradycardia in severe organophosphate poisoning, with rapid dose-doubling escalation to achieve atropinisation, and note that early oximes may be considered — particularly where there are fasciculations, weakness or paralysis — but "are not universally effective." Recent reviews (2024–2025) additionally evaluate magnesium sulphate, sodium bicarbonate, fresh frozen plasma and haemoperfusion as adjuncts, all of which remain investigational and are not standard of care.

Means restriction as the highest-yield preventive intervention. India's National Suicide Prevention Strategy 2022 — the country's first, targeting a 10% reduction in suicide mortality by 2030 — places restricting access to highly hazardous pesticides as its leading pillar, alongside gatekeeper training, responsible media reporting and improved surveillance; India has progressively banned or restricted several highly hazardous pesticide formulations, and WHO's LIVE LIFE framework cites national pesticide bans as the single most cost-effective population-level suicide-prevention measure. NCRB data show suicides in those aged 60 and above rose about 40% between 2019 and 2022, with illness the leading recorded cause — making systematic psychiatric follow-up of survivors such as this patient a national priority. MANAGEMENT ALGORITHM — SUSPECTED ORGANOPHOSPHATE POISONING Unconscious + frothing + agricultural setting | A-B-C-D-E | staff PPE | REMOVE CLOTHES, WASH SKIN & HAIR | suction | O2 | Check glucose -> intubate if GCS low / bronchorrhoea uncontrolled / muscle weakness | ATROPINE bolus, DOUBLE every 5 min (2->4->8->16 mg) until ATROPINISED: clear chest . dry axillae . HR >80 . SBP >80 . pupils not pinpoint | Maintain atropine INFUSION titrated to these endpoints (watch for atropine toxicity) | PRALIDOXIME loading dose + infusion (early; benefit debated) DIAZEPAM / MIDAZOLAM for seizures, agitation, fasciculations | Send plasma cholinesterase + RBC AChE | ABG | ECG (QTc) | amylase | CXR | electrolytes | ICU: ventilate, suction, correct K+/Mg2+, nutrition, prophylaxis, treat aspiration | WATCH: 24-96 h INTERMEDIATE SYNDROME (neck flexion, single-breath count) 2-3 wk OPIDN | 6-72 h ALCOHOL WITHDRAWAL (thiamine BEFORE glucose) | BEFORE DISCHARGE: psychiatric assessment . treat depression . suicide risk assessment means restriction . social work for debt . safety plan . structured follow-up MHCA 2017 Sec 115 - no prosecution . Tele-MANAS 14416 . Elder Line 14567 Section C — Anxiety and Related Disorders The anxiety spectrum, from the general essay through GAD, phobias, OCD and the somatoform disorders.