common poisoning in medical practice poisoning in medical... · common poisoning in medical...
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Common Poisoning
in Medical Practiceวินัย วนานุกูล
ศูนยพิษวิทยา
ภาควิชาอายุรศาสตร
คณะแพทยศาสตร โรงพยาบาลรามาธิบดี
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Common poison exposureRamathibodi Poison Center: 2001-2005
กลุมสาร จํานวน %
สารปองกันกําจัดศัตรูพืช (pesticides) 9,327 39.9
สารใชในบาน (household products) 4,421 18.9
ยา (pharmaceutical products) 4,397 18.8
สารใชในงานอุตสาหกรรม (occupational products) 2,537 10.9
พืชพิษ (plant toxins/poisonous plants) 977 4.2
สัตวพิษ (poisonous animals) 621 2.7
รวม 23,368
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Outline
Pesticides
– Organophosphorus & Carbamate
Household products
– Caustic ingestion
Pharmaceutical products
– Paracetamol
– Psychotropic drugs
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Common pesticide exposure and their death rateRamathibodi Poison Center: 2001-2005
สารปองกันกาํจัดศัตรูพืช จํานวนผูปวย (%) จํานวนผูเสียชีวิต อัตราการตาย
สารปองกันกาํจัดแมลง (insecticide) 4,832 50.0 470 9.7
สารปองกันกาํจัดวัชพืช (herbicide) 2,426 25.1 295 12.2
สารปองกันกาํจัดหนู (rodenticide) 1,301 13.5 27 2.1
สารปองกันกาํจัดหอย (mollusicide) 428 4.4 5 1.2
สารปองกันกาํจัดปลวก (miticide) 147 1.5 34 23.1
อื่นๆ 527 5.5 11 2.1
รวม 9,661 842 8.7
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ชาย 20 ป
มีผูพบผูปวยนอนหมดสติอยูในสวน มีน้ําลายฟูมปาก พบขวดสารฆาแมลงตกอยูขางตัว
ตรวจรางกาย ที่ ER
BP 160/80 mmHg, HR 180/min., RR 20/min. shallow respiration
T 36.5 C
Unconscious, not response to pain stimuli, pupils 2 mm.
Hypersecretion with bilateral wheezes
Increased bowel sounds
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ชาย 20 ป
การวินิจฉัย: ผูปวยมีภาวะเปนพิษจากสารชนิดใด?
ก. Abamectin
ข. Carbamate
ค. Organophosphate
ง. Organochlorine
จ. Pyrethroid
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ACh synthesis, stroage and release
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ACh- AhE Reaction
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What is the mechanism of OP &CB poisoning?
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Acetylcholine (Ach)
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ToxidromesToxidrome Cholinergic Muscarinic Cholinergic Nicotinic
Vital signs ↓HR, ↓BP ↑HR, ↑BP
Mental Stutus Lethargy-coma
Symptoms Diarrhea, vomitting,
blurred vision
Motor weakness
Signs Salivation, diaphoresis, miosis
Fassiculation
Paralysis
Substances Pilocarpine
Mushroom
Organophosphates
Carbamates
Tobacco
Organophosphates
Carbamates
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ชาย 20 ป
มีผูพบผูปวยนอนหมดสติอยูในสวน มีน้ําลายฟูมปาก พบขวดสารฆาแมลงตกอยูขางตัว
ตรวจรางกาย ที่ ER
BP 160/80 mmHg, HR 180/min., RR 20/min. shallow respiration
T 36.5 C
Unconscious, not response to pain stimuli, pupils 2 mm.
Hypersecretion with bilateral wheezes
Increased bowel sounds
CNSNicotinic
Muscarinic
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ชาย 20 ป
Diagnosis:
Organophosphorus or Carbamate poisoning
Differential Diagnosis of “Unconsciousness with hypersecretion and small pupils”
– Abamectin insecticide poisoning
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Abamectin
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ชาย 20 ป
Diagnosis:
Organophosphorus or Carbamate poisoning
Differential Diagnosis of “Unconsciousness with
hypersecretion and small pupils”
– Abamectin insecticide poisoning
– Pyrethroid insecticide poisoning
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lambda-cyhalothrin 2.5% W/V
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ชาย 20 ป
Diagnosis:
Organophosphate or Carbamate poisoning
Differential Diagnosis of “Unconsciousness with hypersecretion and
small pupils”
– Abamectin insecticide poisoning
– Pyrethroid insecticide poisoning
– Chlorophenoxy herbicide poisonings
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Chlorophenoxy herbicides (2,4-D)
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ชาย 20 ป
Diagnosis:
Organophosphate or Carbamate poisoning
Differential Diagnosis of “Unconsciousness with hypersecretion and small pupils”
– Abamectin insecticide poisoning
– Pyrethroid insecticide poisoning
– Chlorophenoxy herbicide poisonings
– Mushroom poisoning (Amanita pantherina, เห็ดเกลด็ดาว)
– Cholinergic drugs poisoning
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Classification of Insecticide Exposure(Ramathibodi Poison Center: 2001-2006)
6,740 Cases
Organophosphorus
21%
Pyrethroid
25%
Abamectin
3%
Others
5%
Combined
12%
Unknown
5%Organochlorine
4%
Carbamate
25%
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Anticholinesterase-AChE Reactions
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Organophosphorus VS. Carbamate Poisoning
Reversible vs. Irreversible Inhibition
– Reversible vs. Irreversible clinical poisoning
– Time to recover (duration of clinical course)
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Management of
Organophosphate & Carbamate Poisoning
General Management
Specific Treatment
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Management of OP & CB Poisoning
Supportive Care
– Vital signs
– Respiration: • secretion block and airway obstruction
• respiratory motor weakness
– Seizure
Specific Treatment
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Airway
Skin
Parenteral
GI.
Tissues &Organs
MDAC.
Decontamination Increase Elimination
Antidotes
Hemodialysis, Hemoperfusion
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Specific Treatment
Decontamination:
– NG tube irrigation
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Head DownLeft Lateral
Decubitus In Awake Patient
Limit! 1 hours after ingestion only
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Specific Treatment
Decontamination:
– NG tube irrigation
– Activated Charcoal 1 g/kg orally or per gastric tube
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Antidotes
Antimuscarinic effects
“ Atropine”
Antinicotinic effects
“ 2 PAM ”
CNS (seizure)
“Diazepam”
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Muscarinic Effects
SecretionHeart RatePupil size
Atropine
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Atropine
Clinical Parameters for titration
– Secretion
– Heart rate
– Pupil diameters
Choices for administration
– intermittent iv. bolus
– continuous iv. infusion
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Atropine
Endpoints:
– Minimal secretion AND/OR
– Heart rate > 60/min., or stable hemodynamics
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ESTERATICSITE
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Nicotinic EffectsMuscarinic Effects
(Muscle Weakness)
2-PAM
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หญิงอายุ 20 ป
PI 6 ชั่วโมงกอน กินน้ํายาลางหองน้ํา “เปดโปร” ประมาณ 50 ml.
หลังกินมีอาการแสบคอมาก และปวดทองโดยเฉพาะบริเวณลิ้นป
PE P 110/min, BP 90/60, RR 24/min, T 37.8 ๐C
Erythema or soft palate and posterior pharynx, no stridor
Lung : clear
Abdomen : tender at epigastrium,
no guarding or rigidity, normal bowel sound
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Hydrochloric acid 8.5%
Sodium hypochlorite 2.7%
Hydrochloric acid 15%
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Caustic Agents
Irritant Corrosive (caustic) agent
SoapNonionic detergentAnionic detergent
AcidAlkali
Cathionic detergentHypochlorite
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Head DownLeft Lateral
Decubitus In Awake Patient
Limit! 1 hours after ingestion only
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Contraindication for Gastric Lavage
Corrosive Agents
Drugs caused rapid deterioration of consciousness
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Ineffectiveness of Activated Charcoal
Strong Acid & Alkali
Alcohol
Cyanide
Elemental Metal
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Management of Caustic ingestion
Mild gastroesophageal injury– Supportive treament only
Moderate to Severe (significant) gastroesophageal injury– Supportive treatment
– Endosccopy for evaluation the injury
– Parenteral nutrion (TPN, PPN)
– + steroid
– Observe for its complication• GI Bleeding
• GI perferation
• Infection
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ชาย 22 ป
มีญาตพิบหมดสตใินหองนอนกอนมา รพ. ครึ่งชั่วโมง
PE BP 80/50 mmHg, HR 110/min, RR 8/min, T 36 C
Unconscious, not response to pain
Pupil 1 mm. in diameter, not react to light
No localizing sign
Lung: fine crepitation bilateral
Otherwise: normal
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Therapeutic Diagnosis for Unconscious Patients
50% Dextrose in Water 50 ml.
Naloxone 2-10 mg iv
Thiamine 50 -100 mg iv.
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Psychotropic Agents
Sedative Hypnotics
Benzodiazepines
Antidepressants
– Tricyclic antidepressants
– Selective serotonin reuptake inhibitors
Antipsychotics
Opiates
Barbiturates
Stimulant Hallucinogens
Amphetamine & derivatives
Cocaine
Caffeine
Marihuana
LSD
Ketamine
Volatile substance
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Autonomic (ANS.) Signs
Pulse
Blood Pressure
Respiration
Temperature
Skin
Secretion
Bowel sound & Bowel
movement
Urinary Bladder
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Pupils
Differentiate between Structural vs. Metabolic
– Equal in Size?
– React to light?
Differentiate Among the Causative Agents
– Nonspecific
– Interpretation with Precaution
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ชาย 22 ป
มีญาตพิบหมดสตใินหองนอนกอนมา รพ. ครึ่งชั่วโมง
PE BP 80/50 mmHg, HR 110/min, RR 8/min, T 36 C
Unconscious, not response to pain
Pupil 1 mm. in diameter, not react to light
No localizing sign
Lung: fine crepitation bilateral
Otherwise: normal
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Suspected CNS Suppression Intoxication
Anticholinergic Signs
Respiratory Suppression
Constricted Pupils
Opiates
Yes
Yes
No
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Opiod Overdose
Diagnostic Tools
– Therapeutic Diagnostic: Naloxone
– Urine opiod
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Suspected CNS Suppression Intoxication
Anticholinergic Signs
Respiratory Suppression
Constricted Pupils
Opiates
Barbiturate
Yes
Yes
No
No
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Barbiturate Overdose
Diagnostic Tools
– Can mimic brain death
– Skin Blisters (6%)
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Barbiturate Overdose
Diagnostic Tools
– Can mimic brain death
– Skin Blisters (6%)
– Blood & urine barbiturate
– Therapeutic diagnostic: None,
– But need to R/O opiate toxicity
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Drugs Eliminated by
Multiple Doses of Activated Charcoal
Phenobarbital
Phenytoin
Theophylline
Salicylates
Carbamazepine
Dapsone
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Choice of Hemodialysis & Hemoperfusion
Hemodialysis
Lithium
Bromide
Ethanol
Methanol
Ethylene Glycol
Salicylates
Hemoperfusion
Barbiturate
Theophylline
Disopyramide
Meprobamate
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Suspected CNS Suppression Intoxication
Anticholinergic Signs
Respiratory Suppression
Constricted Pupils
Benzodiazepine
Opiates
Barbiturate
Yes
Yes
No
No
No
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Benzodiazepine Overdose
Diagnostic Tools
– Blood & Urine Benzodiazepine
– Therapeutic Diagnostic: ?? Flumazenil
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Suspected CNS Suppression Intoxication
Anticholinergic Signs
Respiratory Suppression
Constricted Pupils
Dilated PupilsTCA
Benzodiazepine
Opiates
Barbiturate
YesYes
Yes
Yes
No
No
No
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Tricyclic Antidepressants (TCA) Overdose
Diagnostic Tools
– Blood & Urine TCAs
– EKG: Widening of QRS complexes
R in aVR
– Therapeutic Diagnostic: None
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QRS Complexes As a Predictor for TCAs Toxicity
QRS Duration Risk
> 0.10 sec Seizure
>0.16 sec Ventricular Arrhythmias
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Suspected CNS Suppression Intoxication
Anticholinergic Signs
Respiratory Suppression
Constricted Pupils
Dilated PupilsTCA
Phenothiazine
Benzodiazepine
Opiates
Barbiturate
YesYes
Yes
Yes
NoNo
No
No
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หญงิ 20 ป นักศึกษา
6 ชั่วโมงกอน รับประทานยาพาราเซทตามอล 60 เม็ด
2 ชั่วโมงกอน มีอาการคลื่นไสอาเจยีนหลายครั้ง ญาตจิึง
นําสง รพ.
ตรวจรางกายไมพบความผิดปกตใิดๆ
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OH
NHCOCH3
Glucoronide
NHCOCH3
Sulfate
NHCOCH3
O
NHCOCH3
OH
NHCOCH3
OH
NHCOCH3
X
Glutathione
GSH
+
Cell Death
KIDNEYS
NAPQI
PARACETAMOL
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Clinical Stages of Paracetamol Poisoning
Stage 1 (12 - 24 hours post-ingestion):
nausea, vomiting, anorexia, diaphoresis
Stage 2 ( 24 - 48 hours):
Clinically improved,
↑Transaminase enzymes, ↑ Bilirubin, ↑ Prothrombin Time
Stage 3 (72 - 96 hours):
Peak hepatotoxicity
Stage 4 (7 - 8 days):
Recovery
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What should predict the risk to develop paracetamol
induced hepatic injury in the early phase?
The blood paracetamol level
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4 248 12 16 20 Hours after ingestion
200150
90% of cases will have enzyme > 1,000 if no Treatment
60% of cases will have enzyme > 1,000 if no Treatment
300
Recommending of Treatment
From Rumack BH, et al. Arch Intren Med 1981;141:380-5.
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OH
NHCOCH3
Glucoronide
NHCOCH3
Sulfate
NHCOCH3
O
NHCOCH3
OH
NHCOCH3
OH
NHCOCH3
X
Glutathione
GSH
+
Cell Death
KIDNEYS
NAPQI
N-Acetylcysteine
PARACETAMOL
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N-acetylcysteine regimens
Oral Regimen
– LD 140 mg/kg
– MD 70 mg/kg every 4 hours 17 doses
IV. Regimen
– LD 150 mg/kg iv drip in 15 -30 min.
– MD 50 mg/kg iv. drip in 4 hours followed by
100 mg/kg iv. drip in 16 hours
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Hepatic injury and Dead in patients treated with NAC(Line 200)
Treatment group N % of liver
injury
% Dead from
liver failure
Supportive treatment only 57 58.0 5.3
Time of delayed NAC treatment
< 10 hrs 527 6.1 0.0
10 -24 hrs 953 26.4 1.1
< 24 hrs 1,462 19.1 0.7
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