herbicide ingestion - latest
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Herbicide Ingestion
By Mohd Feendi Bin Mohd Fauzi Yap
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Name : KS
43/I/male
RN: 774078
P/M : chronic alcoholic drinker >15years
chronic smoker
1st hospitalization
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P/W : alleged herbicide ingestion @11 amtoday.
Patient previously quarrelled with relative,ingested herbicide containing glyphosateisopropylamine and ammonium sulphate
Patient drank 100cc of herbicide and mixed it
with 1 bottle of beer
Vomited 2x, yellowish vomitus,
Feeling nausea
Central abdominal pain
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No SOB/ chest pain/ palpitation
No Diarrhea
No drop level of consciousness
No headache
No giddiness
No blurred vision
No other symptoms
Pt had intention to end his life, never had
suicidal attempt before
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Some questions to ponder:
What is our immediate management of thispatient if we are the one attending him?
How could we diagnose this patient from theinformation given.
What are the other signs and symptoms we
should look out for?
What are the other complications we shouldbe cautious of?
What are the investigations need to be done,articularl for monitorin ur ose?
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Physical Examinationalert, conscious, GCS full, hydration fairpink
not jaundicenot toxic looking
Mildly tachypneic
CRT < 2s
good pulse volume
Vital signs:- T 37.2BP 92/58
in ED PR 80RR 20
SpO294% NP O23L/MRepeated
BP : 88/61
PR: 90
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Throat: slightly injected
CVS S1S2 heard
no murmur
Lungs clear
Abdomen
central abdominal pain , mild epigastric
tenderness, no hepatosplenomegalyno pedal edema
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Investigation:
FBCBUSECREAT/LFTPT/APTTABGURINE PARAQUAT x 3 consecutive daysECGCHEST XRAY
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Treatment:For fluid resussitation IVD 4 pints NS/24HourIV Ranitidine 50 mg stat and TDSIV Maxalon 10mg stat and TDS
T. Activated charcoal 25mg QIDRT InsertionInsert CBDStrict I/O charting
Monitor BP and SpO2 hourlyTo inform if patient SOB/ Tachypneic/sudden drop of consciousness
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InvestigationIX 2/4 3/4 4/4
FBC
HB 14.6 14.0 13.2Leucocyte 9.1 8.6 8.8
Platelet 154 164 166
BUSE CREAT
Urea 4.8 5.6 7.4
Sodium 136 135 135
Potassium 3.7 4.0 4.1
Chloride 105 101 104
Creatinine 78 87 92
LFTTotal bilirubin 17.1 18.9 19.0
Total protein/ALP 77/66 77/66 74/58
Albumin/Globulin 38/39 38/39 36/35
ALT 61 62 58
Urine paraquat Day 1 (-) Day 2(-) Day 3 (-)
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ABG:
q ph 7.36
q CO2: 27
q O2: 90
q HCO3:18
ECG: SR, no acute ischemic changes
CXR : Clear lung field
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Herbicide poisoningDefinition
Herbicide poisoning is caused by inhaling,ingesting or otherwise absorbing substances thatare used for killing weeds and defoliating.Herbicides have been most often used foragricultural uses, in which poisoning can affectboth humans and animals.
(by Mosbys Medical Dictionary)
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What is Glyphosate?
GLYPHOSATE-broad spectrum,
-non-selective systemic herbicide.
-all grasses, sedges, broad- leaved weeds andwoody plants.
The chemical name of glyphosate is N-(phosphonomethyl) glycine.
While it can be described as an
organophosphorus compound glyphosate is
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CLINICAL EFFECTS
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Other effects
A variety of renal abnormalities occurincluding oliguria and occasional elevatedserum creatinine.
Cr in Our patient : 78 87 92
Liver enzymes may become abnormalalthough severe hepatitis is unusual.
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DETERMINATION OF SEVERITY
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Ingested dose
The ingestions of:
5-50 mL no symptoms or minor
gastrointestinal symptoms only.50-100 mL Moderate symptoms
100 mL or Severe symptoms
in our case patient drank 2 cups x 50mL ~100mL mixed with 1 bottle of beer
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Clinical grading of toxicity
From National Poison Center / Pusat Racun negara
(1-800-88-8099)
Mild-moderate toxicity :
mild throat pain, abdominal discomfort
Severe toxicity:
orogastro mucosal, ulceration,Hypotension,
Metabolic acidosis
source :
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source :http://curriculum.toxicology./Glyphosate)
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(source:http://www.prn.usm.my/mainsite/bulletin/toxicology/sun14.html)
Classification of toxicity:
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INVESTIGATIONS
Biochemistry
Patients should have serum electrolytes,creatinine, urea, liver function tests, glucoseand arterial blood gases.
ECG
Baseline then as indicated clinically.
Imaging
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TREATMENT
Treatment for minor exposures
In cases of dermal exposure remove allcontaminated clothing and flooding the skinsurface with water. Exposed skin is thenwashed with soap and water.
In eye exposures the exposed eyes shouldbe irrigated with copious amounts of water orsaline for at least 15 minutes
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Treatment for significant exposures
There is no available antidote for glyphosatepoisoning and treatment is largelysymptomatic.
In any significant ingestion exposure, theacute syndrome of glyphosate/ surfactant
toxicity may occur within the first 24 hours ofingestion and may progress rapidly.
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Prevention of absorption
Gastric lavage usually considered if nosignificant spontaneous vomiting has occurred.Gastric lavage may be very effective ifperformed within one to two hours post
ingestion.
Activated charcoal to absorb remaining
glyphosate.
Cathartics speed gastrointestinal transit time
and decrease the time that the drug orchemical is available for absor tion.
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Enhanced elimination
Glyphosate is excreted very well by thekidneys..Thus to increase the elimination ofthe glyphosate, adequate urine flow willensure the rapid elimination of the
glyphosate.
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Monitoring of the blood pressure
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Respiratory function
should be monitored closely
intubation with assisted ventilation may berequired
If pulmonary oedema occurs positive
respiratory pressure may be of value. Acidosis usually responds to bicarbonate
therapy but may on occasion be resistant.
GI Decontamination
Oral activated charcoal should only be given ifthe patient presents within 1 hour of
ingestion.
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,PROGNOSIS - FOLLOW
UPThere is the potential for long term lung injury if
significant ARDS occurs.
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~Thank You~