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How to handle Gramoxone poisoning in a limited resource setting

M3 India Newsdesk Oct 31, 2018

Government medical college doctors from a small town in Kolhapur regularly see a high load of patients admitted for poisoning, chief among them being gramoxone, a weedicide that is the most potent of all poisons. Here is the protocol they follow to manage poisioning cases at the hospital.


The government medical colleges which are hardly a few in number have been serving rural India for quite some time, mostly because they are the only hospitals in the vicinity that are cost-effective. Likewise, each state has exhibited particular pathology more often than others; viz., Leptospirosis in Maharashtra, Leishmaniasis in Bihar, and so on and so forth.

Here we bring to you a list of typical presentations from the medical college of a small town in Kolhapur, Maharashtra. Over a period of many years, the Kolhapur Government Medical College (KGMC) has witnessed several cases of poisoning. The casualty is the emergency spot for such timed cases, and the list of poisons, which the sufferer consumes has undergone an innovative revolution leaving the doctors harried.

A concise list (in descending order of severity) would be:

  • Gramoxone
  • Organophosphate
  • Phenyl cleaner
  • Drugs- Antibiotics, paracetamol, benzodiazepine

Standard emergency protocol followed for poisoning cases

Gramoxone stands out as the most severe of all poisons with almost a 90% chance of death. But, the most commonly used from the above-mentioned list are organophosphates which account for more than 2 lakh deaths a year.

Treatment modality of all poisoning cases follows the standard protocol which includes (strictly adhering to government hospital protocols):

  • Remove and wash the clothes and skin to stop topical absorption of poison
  • Secure an IV access
  • Catheterise the bladder
  • Inject Atropine bolus followed by an Atropine infusion
  • Intubate and ventilate if there is respiratory compromise
  • Restrain agitated patient and provide adequate sedation

Gramoxone Poisoning

The more severe patients who come in with Gramoxone poisoning are immediately monitored. This poison has made its way to the top of the deadliest toxins out there, which is available commercially.

It is a weedicide used to protect the main produce and hence almost always present in every Indian farmer’s home. The outcome of taking this compound is dire as it affects multiple organs at the same time and leads to a painful death.

Mechanism of action of gramoxone

Gramoxone-induced toxicity is a manifestation of its ability to undergo redox potential and catalyse the formation of highly reactive oxygen and nitrite species. This results in toxicity in most organs, but the toxicity is particularly severe in the lungs as it is taken up against a concentration gradient into the lungs.

Medical management of Gramoxone poisoning (as followed by Kolhapur Government Medical College)

  1. Usually, the ingestion of such a poison is clean and hardly ever contaminates clothes or the skin of the patient. So, if any external exposure is noticed, the body must be thoroughly cleansed, and garments must be removed.
  2. An IV line must immediately be secured with a wide-bore needle usually of 22- and 20-sized gauge (blue and pink respectively).
  3. A ‘Ryle’s tube’ should be inserted for easy parenteral access specifically for washing and lavage (in this scenario).
  4. Next, a solution containing Fullers Earth (Multani Mithi) mixed with plain water/normal saline should be prepared. The only indication for this modality is whether the poison was consumed within 2-4 hours of bringing the patient to the emergency department. Fullers Earth is a common household powder used massively by Indian women for cosmetic purposes. It is the use of such unconventional methods and a narrow time frame which make such cases worth discussing and exploring. Very little has been studied about Fullers Earth being utilised for medical emergencies and thus, the mechanism of action by which it wins life over is still unclear. The solution prepared in a tub should immediately be pushed via two maneuvers:
    1. Manually pushing repeated amounts of 50 ml of the mixture till 500-1000 ml in total is achieved.
    2. Mixing the compound in a 500 ml bottle of normal saline and directly giving a wash through the “Ryle’s tube” leads to quicker results. In this case, the patient might start vomiting because of certain uncalled reflexes but the wash must still go on until the desired amount of Fullers Earth and water is not achieved.
  5. After this tedious process, there should be a waiting period of around 15 minutes to allow the poison to get completely absorbed into the mixture.
  6. The process of gastric lavage must be initiated when any such external agent is used for a bowel wash, but as the mixture is coarse, using a suctioning machine is futile. Therefore, a 20- or 50-ml syringe is used, and the stomach content is pulled out via the “Ryle’s Tube”.
  7. The stomach contents should be collected and the suctioning should continue until a clear fluid is obtained in the container or the entire bowel is empty, whichever is achieved first. After the patient stabilises, he should be prepared for 'Haemodialysis' to prevent acute renal failure. 
  8. Throughout this process, a continuous access of IV normal saline infusion should be administered to maintain the volume loss and to compensate for the patient's inability to swallow.

Note: Various organ pathologies which are simultaneously going on have not been discussed as they are out of the context with this text.

Depending on the hospital one gets treated in, there are many interventional modalities for managing gramoxone poisoning all over the country, but the above-mentioned text proves to be the bare minimum followed by most hospitals in the interiors of the state.


Poisoning cases & scenario in India

Despite the fact that a doctor or intern dissipates a lot of his/her time in the emergency room for such patients, the consequences are often grave, even though the attempt is sincere. Most of the time, the patient dies of pulmonary or renal complications and this happens within just a week or so, and nothing can be done about it.

The credibility of the reasons for consuming poison has changed; from farmers facing injustice and getting suffocated under unceasing debt to those people who consume toxins just to get away with a tantrum. There have been tons of cases where the family comes in sobbing for their child who has had a fight with his/her mother and due to this has taken a gulp of anything which is nearby, simply to scare her and get his demands in check. This is a serious problem growing in the agrarian societies. If only, the juvenile understands the meaning of life and not play around with it; quite literally! Although sympathising with those who are being oppressed and choose to cease their life, there are always those who make physicians think otherwise.

Doctors thus end up wasting their valuable time behind such childish feuds and there is a sense of helplessness as these scenarios almost always make it to the top of the triage system.


The Maharashtra government's health sector has seen a declining age trend in patients who consume poison. A very common association with these cases is ‘Illiteracy’; as the urban population are socially and mentally a tad bit more evolved. This text not only points towards the prevalence of poisoning cases in a government health sector but also emphasises over the rightful approach towards mental health issues in every household.

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