Administering Atropine Through Autoinjectors Within Ambulance Services for Poisoning Patients in Sri Lanka's North Central Province

Feasibility of Using Ambulance Services to Administer Atropine Using Autoinjectors in Farming Communities in the North Central Province, Sri Lanka

Pesticide poisoning remains one of the most serious public health challenges in rural Sri Lanka, particularly in the North Central Province (NCP), where intensive farming and heavy pesticide use have led to high rates of accidental and intentional poisoning. Although the antidote, atropine, is routinely used in hospitals, delays in receiving treatment often occur because patients must travel long distances before reaching care. Early initiation of treatment is critical, and survival depends on the speed with which atropine is administered.

The government's free 1990 Suwa Seriya ambulance service, established in 2016, provides emergency transport across Sri Lanka but currently has limited capacity for administering time-sensitive antidotes. Community consultations conducted during an earlier study revealed that people preferred life-saving treatments such as atropine to be managed through the formal health system, rather than stored in villages. This led to the idea of exploring whether ambulance staff could safely use atropine autoinjectors; simple, pre-filled devices that deliver the drug quickly and can safely be used even by non-medical professionals.

The FAST-AID study aims to assess the feasibility of introducing atropine autoinjectors into Sri Lanka's emergency ambulance system for use in pesticide poisoning cases. The main question is:

How feasible is it to integrate atropine autoinjectors into the ambulance service to provide earlier treatment for pesticide poisoning patients? Secondary questions explore (1) how ambulance coverage and travel routes affect timely administration; (2) how ambulance and hospital staff experience the use of the devices; and (3) how patients perceive the care they received.

The study will be carried out in the Anuradhapura District of the NCP, in collaboration with the Suwa Seriya ambulance service and selected hospitals. Two geographical clusters, one densely populated and one more remote, have been chosen to compare different service conditions. Around 30 pesticide poisoning patients will receive atropine using autoinjectors during ambulance transport, under guidance from an on-call emergency physician.

Data will be collected through several complementary methods:

• Operational data from ambulance and hospital records (e.g., response times, use of autoinjectors, patient outcomes).
• Geographic mapping (GIS) of ambulance coverage to assess accessibility and response patterns.
• Focus group discussions with ambulance and hospital staff to explore training, practical challenges, and perceptions of the intervention.
• Semi-structured interviews with patients to understand their lived experience of emergency care.
• Participant observation in ambulances and hospitals to capture the everyday realities of emergency response.

Participants will be adults (aged 18 or above) who either work in the ambulance or hospital system or who have experienced pesticide poisoning and received atropine during the study period. All participants will provide written informed consent.

The research team will include Sri Lankan and UK collaborators from the University of Edinburgh and the South Asian Clinical Toxicology Research Collaboration (SACTRC).

By assessing the operational and social feasibility of using atropine autoinjectors in ambulances, this study aims to strengthen Sri Lanka's emergency response system and provide a foundation for a larger trial that could ultimately help save lives of those experiencing pesticide poisoning.

Inclusion Criteria:

• Participants over the age of 18 who are willing and able to provide written informed consent will be asked to participate in the study.
• Ambulance staff directly involved in the management and response to pesticide poisoning cases during the intervention period in the selected two geographical clusters.
• Doctors and nurses from selected hospitals in the two geographical clusters who managed pesticide poisoning patients that received atropine via autoinjectors administered by ambulance staff during the intervention period.
• Pesticide poisoning patients managed by Suwa Seriya ambulances in the selected two geographical clusters of the Anuradhapura district during the intervention period.

Exclusion Criteria:

• Participants who are unwilling or unable to provide written informed consent will not be included in the study.
• Participants who do not speak Sinhala.
• Participants under the age of 18 years.