-prezentare de caz-anamneza l.d.m., ♀, 2 luni, podu iloaiei m.i.: varsaturi, diaree, cianoza...
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Universitatea de Medicina si Farmacie ‘Gr.T.Popa’ Iasi
Clinica I Pediatrie
Intoxicatia cu nitriti -Prezentare de Caz-
Sef lucrari Dr. Alina Luca
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Anamneza
L.D.M., ♀, 2 luni, Podu Iloaiei
M.I.: varsaturi, diaree, cianoza periorbitara, agitatie psihomotorie
A.H.C.: Mama 23 ani- III G II P- aparent sanatoasa
Tatal- 28 ani- aparent sanatos
Sora- 5 ani- aparent sanatoasa
- neaga contactul TBC si alte boli infectocontagioase
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A.P.F.:
-prenatale: provine din a doua sarcina, evolutia sarcinii fiind favorabila
-intranatale: nascuta la 8 luni pe cale naturala, prezentatie craniana, Gn=2400 g, APGAR=9
-postnatale: vaccinata in maternitate, nu a prezentat icter la nastere, alimentata natural pana la varsta de o luna, apoi cu lapte praf si lapte de vaca, nu a inceput profilaxia rahitismului
Conditii de viata si munca: 5 persoane in 2 camere, la casa
Comportamente: mama fumatoare, tatal fumator
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Istoricul bolii
Sugar distrofic grad II, in varsta de 2 luni se
interneaza pentru varsaturi, cianoza periorbitara,
agitatie psihomotorie. Conform relatarilor mamei,
simptomatologia a debutat in dimineata zilei de
23.10.2010, in urma consumului de lapte praf
preparat cu apa din fantana.
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Examen clinic
Stare generala: alterata
Stare de constienta: pastrata
Stare de nutritie:G=3250g, I.P.= 0,72- MPC grad II
G=-2 DS; T=-1.88 DS; PC=-1.28 DS
Facies:simetric, incercanat
Tegumente: palid-teroase, cianoza periorbitara
Mucoase: palide
Fanere: normal colorate, normal implantate
Tesut conjunctivo-adipos: slab reprezentat; P.C.A.= 0,5 cm
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Sistem ganglionar: micropoliadenopatie fiziologica
Sistem muscular: normoton, hipotrof, normokinetic
Sistem osteo-articular: aparent integru, F.A.= 2/1 cm, articulatii mobile cu miscarile pasive si active
Aparat respirator: cai aeriene superioare libere, torace evazat la baza, excursii costale simetrice, murmur vezicular fiziologic, F.R.= 40/min
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Aparat cardiovascular: arie precordiala normal conformata, soc apexian spatiul IV i.c./l.m.c., zgomote cardiace ritmice, bine batute, fara sufluri supraadaugate, AV=140/min, artere periferice pulsatile
Aparat digestiv: cavitate bucala normal conformata, depozit albicios pe mucoasa linguala, abdomen destins, depresibil, nedureros, meteorism, tranzit intestinal accelerat
Ficat, cai biliare, splina: in limite normale
Aparat uro-genital: poli renali inferiori nepalpabili, mictiuni fiziologice, urini normocrome, organe genitale externe normal conformate
Sistem nervos, endocrin si organe de simt: fara semne de iritatie meningeana, ROT prezente simetric bilateral, reflexe arhaice prezente
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Diagnostic de etapa
Intoxicatie cu nitriti
Distrofie grad II
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Analize biologice
Hematologie
GA=10 570/mmc (VN=6 000 - 17 500/mmc)
GR=3 170 000/mmc (VN=5 000 000 - 6 000 000/mmc)
Hb=8.09 g/dl (VN=11 - 15g/dl)
Ht=24,41% (VN=35 - 45%)
Trombocite=447 000/mmc (150 000 - 400 000/mmc)
Biochimie
Uree=36.8mg/dl (VN=10 - 40 mg/dl)
Proteine totale=46.6 g/l (VN=46 - 68g/l)
TGP=12 U/l (VN=5 - 38 U/l)
Fe= 45 μg/dl (VN=60 - 130 μg/dl)
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Radiometrie 23.10 ora 08:48 PM
pH=7.441 (VN=7.35-7.45)
pCO2=30.1mmHg (VN=32-48 mmHg)
pO2=42.4mmHg (VN=83-108 mmHg)
Hb=7.7g/dl (VN=12-17.5 g/dl)
sO2=76.5% (VN=95-99%)
FO2Hb=63.7% (VN=94-99%)
FCOHb=1.8% (VN=0.2-0.8 %)
FMetHb=15% (VN=0.2-0.6%)
K= 4.9mmol/l (VN=3.4-4.5 mmol/l)
Na=131mmol/l (VN=136-146 mmol/l)
Ca=0.86mmol/l (VN=1.15-1.29 mmol/l)
Cl=134mmol/l (VN=98-106 mmol/l)
Glicemie=66mg/dl (VN=70-105 mg/dl)
Lactat=16mg/dl (VN=4-14 mg/dl)
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Radiometrie 23.10.2010 ora 09:55 PM
pH=7.436 (VN=7.35-7.45)
pCO2=29,4mmHg (VN=32-48 mmHg)
pO2=47.4mmHg (VN=83-108 mmHg)
Hb=7.7g/dl (VN=12-17.5 g/dl)
sO2=82.1% (VN=95-99%)
FO2Hb=79.5% (VN=94-99%)
FCOHb=1.6% (VN=0.2-0.8 %)
FMetHb=1.6% (VN=0.2-0.6%)
K=3.7mmol/l (VN=3.4-4.5 mmol/l)
Na=128mmol/l (VN=136-146 mmol/l)
Ca=1.05mmol/l (VN=1.15-1.29 mmol/l)
Cl=128mmol/l (VN=98-106 mmol/l)
Glicemie=252mg/dl (VN=70-105 mg/dl)
Lactat=14mg/dl (VN=4-14 mg/dl)
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EKG
Ritm sinusal
AV=160/min
ÂQRS:+75
PQ=0.10 sec
QT=0.26 sec
Morfologie normala
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Ecografie abdominala
Ficat cu echostructura omogena,
normoreflectogena
Colecist destins, CBIH nedilatate
Pancreas, splina echo normale
Rinichi normali
VU in semirepletie, cu continut lichidian omogen si
perete suplu
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Diagnostic
Intoxicatie acuta cu nitriti-forma usoara
Anemie nutritionala
Distrofie grad II
Intoleranta secundara la lactoza
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Tratament
UPU HHC 12.5mg i.v.
Albastru metilen 1 mg/kgc la 4 ore, i.v. (din dilutia 1 ml A.M. cu 1 ml glucoza 5%)
Glucoza 10% 35ml
SF 35ml
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Intraspitalicesc 7x90ml NAN delactozat in mucilagiu orez 5%
Smecta 1 plic/zi
Ca gluconic 10%, 10 ml
vitamina C 30 mg/kgc i.v.
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Intoxicatia cu methemoglobinizante
Methemoglobina este o hemoglobina oxidata ce se formeaza ca urmare a transformarii fierului bivalent in fier trivalent si crearea unei legaturi stabile cu molecula de apa care nu poate fi desfacuta prin cresterea presiunii partiale a oxigenului rezultand pierderea afinitatii hemoglobinei pentru oxigen. Se considera methemoglobinemie atunci cand in sange este prezenta o concentratie a methemoglobinei mai mare de 2% din intreaga hemoglobina.
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Aceasta stare poate fi intalnita in urmatoarele situatii:
-methemoglobinemii congenitale: prin deficit de methemoglobin-reductaza si in cadrul unor hemoglobinoze(hemoglobinoza M) in care substituirea unui aminoacid din molecula globinei va favoriza oxidarea fierului.
-methemoglobinemii castigate: prin substante oxidante ale hemoglobinei.
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Substantele methemoglobinizante care provoaca la copil intoxicatie acuta sunt:
-compusi organici: nitrati alifatici(nitroglicerina, ISDN), anilina, nitrobenzen, nitrotoluen si derivatii lor, sulfamide, fenacetina, chinina, hidrazina si fenilhidrazina
- compusi anorganici: nitriti de Na si K, nitrati de bismut si amoniu, gaz nitros, hidrogen arseniat, clorati-in special cloratul de potasiu folosit la ierbicid)
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Tablou clinic Semnul major al intoxicatiei este cianoza ce nu dispare
prin administrare de oxigen si care apare la concentratii ale methemoglobinei de 10-20% din hemoglobina totala, la o concentratie a methemoglobinei de 60% se instaleaza letargia, stuporul si coma, pentru ca la 75-80% sa survina decesul(coma, colaps, insuficienta cardiaca cu tulburari de ritm si insuficienta renala).
Concomitent cu methemoglobinemia in cazul unor toxice(anilina, fenacetina, nitrotoluen) se produce si hemoliza intravasculara cu icter hemolitic si hemoglobinurie si chiar exista riscul insuficientei renale acute prin precipitarea hemoglobinei in tubii renali.
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Tratamentul depinde de etiologia intoxicatiei si consta din:
scoaterea din mediu, indepartarea imbracamintei, decontaminarea cutanata si a parului cu apa si sapun in cazul contactului toxicului cu pielea si administrarea de oxigen in inhalarile de bioxid de azot, hidrogen arseniat
spalatura gastrica cu suspensie de carbune activat si purgativ salin in intoxicatia prin ingestia toxicului ulterior administrand oxigen izo- sau hiperbar.
administrarea de substante oxidoreducatoare: albastru de metilen 1% 1 ml/kgc administrat lent i.v. repetat la 3-4 ore, albastru de thionina(Heltion 2%) 0.1 mg/kgc administrat i.v. sau acid ascorbic(vitamina C) 30 mg/kgc i.v. singur sau concomitent cu albastru de metilen
in situatii grave exsanguinotransfuzie si chiar dializa peritoneala
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Va multumim!