Organo & Paraquat Poisoning

7/24/2019 Organo & Paraquat Poisoning

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Case presentation

(Paraquat poisoning)

Ngu Ing Soon


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Patients Biodata

Name : Christinia

Date of birth : 1/1/1987 (26 YO)

Gender : Femae

!a"e : #ndonesian

O""$%ation : &/'

arita stat$s : arried

Date of admission : /9/1*


3/54

Chief Complaint

+ Allerged drinking paraquat at 7pm on4!"#$


4/54

%istor& of Presenting Illness

+ 'rank " mouthful of paraquat (" *"+ml) afterquarreling ,ith her hus-and$ (paraquat ,asreadil& a.aila-le at her hs)

+ %us-and suspe/ted her of ha.ing a0air ,ith otherman (%us-and ,as under al/ohol in1uen/e)

+ She -e/ame impulsi.e and drank paraquat

+ %er mind ,as full of anger at that time

+She did not ha.e pre*planned sui/idalplanideation

+ 'enied taking other drugs at the same time$


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Post-paraquat ingestion

+ 2omited 34 after ingestion of paraquat, reenish .omitus5 not -lood*stained

+No a-d paindiarrhoea+ No S6B/hest paindiiness

+ No sore throat5 oral ul/ers

+ No 86C

+ No d&suria+ Prior to that5 no depressi.e 9 ps&/hoti/

s&mptoms$


6/54


+ :ent to ;; Selangau at < =ime, Patient ,as alert

, CS> "+"+

, 2S> BP ? "#! P@ * 4

Sp6 ? !! *" under room air

, 8ungs ,ere /lear

, C2S> '@ND, A-d> soft5 non*tender


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+ Danaged ,ith+ astri/ la.age

+ I2' one pint NS

+ CB' insertion+ A/ti.ated /har/oal +g stat

+ @emo.e and /hange /lothes

+ Epon admission to the ,ard5 she/laimed she regretted for her a/tion$No more sui/idal thought$


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Famil& %istor&

+ No famil& histor& of mental illness orsui/idal attempt


9/54

So/ial %istor&

+ She ,as married for 7 &ears

+ No maGor relationship /risis -ut /laimedha.ing frequent quarrel ,ith her hus-and

o.er tri.ial matters5 esp$ suspe/ting her ofha.ing a0air for mths$

+ Completed primar& H edu/ation

+ :orked as a salesgirl for # &rs5 thenstopped after married$

+ Currentl& sta&ing ,ith hus-and 9 #/hildren$


10/54

In A9

+ p%> 7$#H

+ P6> ""$4

+ PC6> #4$H+ B> *#$!

+ %C6#> "$

(Deta-oli/ a/idosis)+ astri/ la.age 9 urine> positi.e for

paraquat


11/54

Ph&si/al 3amination

+ Alert5 pink

+ CS> "+"+ (orientated to =PP)

+ P2 ? good5 regular

+ 2omitus noted -ro,nish in /olour

+ Erine ,as /lear

+ C2S> '@ND

+ A-d ? soft5 non*tender+ 8ungs ? /lear5 A equal

+ No pedal oedema


12/54

D3 in the :ard

+ Cont /har/oal + g 4 hourl&

+ I2' # 8da&5 all NS

+ Fuller # m8 stat5 then m8 hourl& until

diarrhoea+ I2 pantopraole 4 mg 6'

+ I2 lasi3 mg stat then tds

+ 4*hrl& 2S J Sp6 monitoring

+ ;eep NP6+ %= tds

+ Stri/t I6 /harting


13/54

Progress in :ard

+ 5/9/13 (D1), 2omiting 35 -la/kish ,ater& stool 3#

(total B6 3H)5 sore throat

, No a-d pain5 oral ul/er5 S6B5 d&suria

, Start on I2 meth&lprednisolone infusion("gda&) o.er " hour 3 #7

, I2I /&/lophosphamide +mg 6' in "pint NS o.er 4 % 3 7

, Allo, orall&


14/54

Progress in :ard

+ 6/9/13 (D2), No a/ti.e /omplaint

, No a-d pain5 oral ul/ers5 sore throat

, 6>+ 8ungs ? /lear

+ A-d ? soft5 non*tender

+ No oral ul/ers5 throat N

,D3>+ 60 N5 /har/oal5 fullers earth

+ Allo, soft diet

+ Cont meth&lprednisolone 9 /&/lophosphamide


15/54

Progress in :ard

+ 8/9/13 (D4), Patient ,as as&mptomati/

, 2S sta-le

, Afe-rile, 2B> impro.ing %C6# (from "$ to $7)

, D3>+ =$ 'e3amethasone mg tds (after /ompleted

meth&prednisolone)+ =$ /al/ium /ar-onate + mg B'

+ Add $+ g ;C8 in ea/h pint of NS (;K> $!)


16/54

Serial I3 Charting

4/9/13 5/9/13 6/9/13 7/9/13 8/9/13 9/9/13

F-C 1*./1.8/192

Creat 6* 98 219 **

-0 11/.1/

1/8

1*9/*.3/

93/6.*

1**/*.7/

83/16.*

1**/*./

89/2.6

1*2/2.9/

88/29.8

1*6/*./

92/*1.9AST/ALT 172/16* 92/139 21/193

C4/5O 2.19/1.33 1.97/1.7

CorrC4 2.7 1.93

Urineparaquat

+ve -ve -ve -ve

#n%$t 4500 4700 4650 5050 4500

0rineo$t%$t

2050 2550 2850 2300 3200


17/54

Serial I3 Charting

4"#7# 4"4# 4"4#4 4"4H4

+

"

"+

+

#

#+

4

Creatinine

AS=

Column"


18/54

Ngu Ing Soon


19/54

6rganophosphate


20/54

0e/ts of 6P


21/54

0e/ts of 6P


22/54

0e/ts of 6P


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24/54

Paral&sis in 6P Poisoning

=&pe " =&pe =&pe #


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=&pe " =&pe =&pe #

A/ute paral&sis se/ondar& to

/ontinued depolariation at theneuromus/ular Gun/tion$


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=&pe " =&pe =&pe #

Intermediate s&ndrome

+ 'e.elop 4*!H hours afterresolution of a/uteorganophosphate poisonings&mptoms

+ S&ndrome in.ol.es ,eakness ofpro3imal mus/le groups5 ne/k5 andtrunk5 ,ith relati.e sparing of distalmus/le groups$

+S&ndrome persists for 4*" da&s


27/54


=&pe " =&pe =&pe #

6rganophosphate*indu/ed dela&ed

pol&neuropath& (6PI'P)+6//urs *# ,eeks after e3posure tolarge doses+ 'istal mus/le ,eakness ,ith

relati.e sparing of the ne/k mus/les5/ranial ner.es5 and pro3imal mus/legroups+@e/o.er& /an take up to " months


28/54

6rganophosphate Poisoning radingCriteria (Bardin et al., 1994)

Poisoning Signs/Symptoms

Dild Normal le.el of/ons/iousness

Dild se/retionsFe, fas/i/ulations

Se.ere Altered le.el of/ons/iousness

Copious se/retionseneralied fas/i/ulations

8ife threatening Sui/ide attemptStupor


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30/54

I3

+ Cholinesterase a/ti.it& in plasma 9in red -lood /ells ? redu/ed ('o not,ait for /holinesterase results -efore

initiating @3)+ Erine to3i/olog& s/reen

+ FBC5 BES5 /reat5 -lood glu/ose

+ CL@5 C

+ AB


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Danagement

+ @emo.e /ontaminated /lothing5 ,ashskin 9 mu/ous mem-rane ,ith /opiousamount of ,ater

+ astri/ la.age (if presentation is ,ithin" hr) follo,ed -& a/ti.ated /har/oal, Cont la.age until returning 1uid ? free

from odour of poison+ Adequate o3&genation

+ Normal saline or '+


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33/54

Danagement


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Adequate Atropinisation

+ 'r&ing of tra/heo-ron/hial se/retion(most important)

+ 'r& mouth

+ Flushing

+ %eart rate M"

+'ilated pupils


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Paraquat


37/54

Paraquat


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3tent of Poisoning

+ Amount

+ @oute

+'uration of e3posure+ Persons health /ondition at the timeof the e3posure$


39/54

Paraquat 0e/ts

+ First 24 ours, astrointestinal e0e/ts$

+ 8eading to oesophageal 9 gastri/ erosions as ,ell as -urns inthe mouth and throat$ (/orrosi.e e0e/ts * similar to thato-ser.ed ,ith alkali ingestion$)

+ 24-!2 ours, %epato/ellular inGur&

, A/ute tu-ular ne/rosis

+ !2-96 ours, Pulmonar& -rosis (dt sele/ti.e a//umulation in lung

tissues)


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Paraquat 0e/ts

+ Dulti*organ failure in fulminant poisoning (IFmore than +*" g of paraquat is ingested)

, A/ute renal failure, %epati/ ne/rosis

, D&o/ardial ne/rosis

, A/ute pneumonia

, Internal hemorrhages, Pulmonar& -rosis

, 'eath


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'eterminants of se.erit&

+ 6esophageal and gastri/ erosions

+ @enal failure

+ Ingestion of more than one mouthfulof /on/entrate

+ 'e.elopment of pulmonar& opa/itieson /hest L*ra&

+ 'e/reasing lung .olumes onspirometr&

+ Paraquat /on/entration M #*+ mg8

Compli/ations


45/54

I3

+ astri/ la.ageaspirate5 urine 9 -lood forto3i/olog& s/reening

+ astri/ la.ageaspirate 9 urine for

paraquat+ Erine for paraquat dail& 3 #7

+ Erinar& sodium dithionite test

+ BES dail&+ FBC5 8F=5 Creat 9 CL@ e.er& # da&s

+ AB


46/54

Prognosti/ fa/tors

+ s*/reatinine

+ s*protein

+ s*potassium5 -i/ar-onate

+ plasma Paraquat /on/entration

+ SIPP [time to treatment sinceingestion of paraquat x serum

paraquat at admission (g/ml)]


47/54

SIPP

SIPP -& Sa,ada et al. (Appli/a-le up to %)

S"PP s#ores Pre$i#tion

" Sur.i.al

"*+ 'eath from lung i-rosis

M+ 'eath from /ir/ulator&

failure


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49/54

I 'e/ontamination

+ !! ml of Fullers earth ("+ suspension).ia N tu-e as soon as possi-le5

+ =hen "! ml of Fullers earth e.er& hour

until diarrhoea 9 P@ Fullers earth6r

+ A/ti.ated /har/oal #! g stat $ "# g 4 %rl&

for se.eral da&s$+ Dg sulphate (Dist al-a) ! ml e'er& 4 %r

until diarrhoea 9 passage of Fullers earth


50/54

%emodial&sisChar/oal%emoperfusion

+ Eseful if started ,ithin +*7 hrs ofingestion (-efore distri-ution ofparaquat into tissues espe/iall& the

lungs)$+ =he greatest paraquat /on/$ Is found

in the lungs 9 the /on/entration

peaks in +*7 hrs post*ingestion$+ @epeated %P is not helpful$


51/54


52/54

6ther D3

+ I2 1uid 4*+ 8da& (NS and '+) 3 "st4 hr5 then #8da& orall& or I2 for

se.eral da&s

+ ;Ksupplement (depending on BES)

+ Frusemide 4 mg -d I2 or oral

+ 6 * a.oided unless Pa6falls to H

mm%g


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@eferen/es

+ Sara,ak %and-ook of Dedi/al mergen/ies (#rddition)

+ emergen/&$/d/$go.agentparaquat-asi/sfa/ts$asp

+ http>,,,$slideshare$netkiriekoanega,aorganophospha

te*poisoning*!447+#,,,$slideshare$netfo,realorganophosphate*

poisoning*and*management/e&/ollph&si/ians$orgimages//pparaquat

pre$pdf

+ http>emedi/ine$meds/ape$/om

+ http>,,,$n/-i$nlm$nih$go.pm/arti/lesPDCH+!Hta-l

e="


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Organo & Paraquat Poisoning