SUPERVASMOL POISONING

Super-vasmol poisoning is emerging as a major cause of suicidal poisoning in India…as it is a cheap ,freely available hair dye

It contains potential toxins like PPD which can result in multiorgan dysfunction

The main important constituent is

PPD(paraphenylene diamine)- <4%

Other constituents are Propylene glycol Resorcinol EDTA Sodium Ceto stearyl alcohol Sodium lauryl sulphate Liquid paraffin Preservatives and water

COMPONENTS OF HAIR DYE

PPD(paraphenylene diamine):it is the major toxin among all constituents

PPD metabolised by CYP450 to form BRANDOWASKI’S BASE

It is an anaphylactic,highly toxic and strongly mutagenicThe lethal dose is 7 to 10 gms..But 3gms is sufficient to cause systemic

complications

It produces both local and systemic effects.Systemic effects occurs in two phases:

Phase 1 Acute presentation (4-6hrs):cervicofacial

edema,airway obstruction,gastritis and severe vomiting.

Phase 2 Subacute presentation withARF,rhabdomyolysis

and hemolysis. Hepatitis. Hyperkelemia,hypocalcemia,hyperphosphatemia. Severe metabolic acidosis

Even 5 to 10 ml super vasmol can cause laryngeal edema due to direct toxic effect of PPD on membranes..

No specific antidote available for PPD,hence management is only symptomatic & supportive .

Development of pneumothorax is reported following laryngeal edema

Intense inspiratory effort secondary to laryngeal edema leading to overdistension of alveoli.

Local effects of PPD:

• Skin iritation• Contact dermatitis• Chemosis,lacrimation and exopthalmous• Permanent blindness

Chronic hair dye use is associated with non-Hodgkin’s lymphoma,multiple myeloma,acute leukemia,and bladder cancer

Resorcinol- it causes methemoglobinemia and

renal toxicity

EDTA sodium-

it causes hypocalcemia

Propylene glycol-

it is ass. with hyperosmolarity, CNS depression, arrythmias

it is nephotoxic and results in high anion gap metabolic acidosis and acute renal failure.

In addition to these a few hair dyes also contain Lead acetate and Bismuth sulphate which causes CKD and Acute interstitial nephritis respectively..

1.Angioedema or Cervicofacial edema:

Early manifestation (within 4-6 hours) include respiratory distress due to swelling of upper airway and angioedema

Angioedema is immunologically mediated,anatomically limited,nonpitting edema.

It is an abrupt swelling of the dermis and subcutis

CLINICAL FEATURES

STAGING OF ANGIOEDEMA:

This is to predict airway risk at presentation.

Stage 1 - Facial and lip edemaStage 2 - soft palate edemaStage 3 - Lingual edemaStage 4 - Laryngeal edema

2.RHABDOMYOLYSIS:

Symptoms are back pain,limb pain,generalised myalgias

Acute muscle necrosis is the cause for tenderness and local edema of muscles

The initial sign of rhabdomyolysis is the appearance of cola-colored urine

There is dissolution of striated muscle fibres, with leakage of muscle Enzymes,myoglobin, potassium,calcium and other intracellular constituents.

CK levels are the most sensitive indicators of myocyte injury.

3.RENAL FAILURE: It testifies to the severity of intoxication.

The causes are Toxic injury Myoglobinuria Hemoglobinuria Hypovolemia Propylene glycol is also a nephrotoxic

4.MYOCARDITIS: It is due to rhabdomyolysis of myocardium

It is reported in 15% of cases with mortality rate of 29%.

Ventricular arrythmias,sudden cardiac death

5.Neurological:convulsions

Cause of death: Respiratory obstuction

Renal failure

Arrythmias

ARDS

Treatment is aimed at rapid identification of potentially life-threatening complications and prevention of renal failure

GASTRIC LAVAGE: is useful if the patient presents within 1 hour of ingestion but contraindicated if airway protective reflex is lost.

Airway protection is the most important consideration with laryngeaal edema…it should be ensured with timely endotracheal intubation or tracheostomy.

MANAGEMENT

Steroids – hydrocortisone 200mg stat f/b 100mg every 6th hourly.

If not responded to hydrocortisone , methyl prednisolone 125mg iv infusion given 6th hourly

In the event of life threatening reaction involving urticaria with angioedema or laryngeal edema Epinephrine may be neded to stabilise the patient

Aggressive fluid resuscitation

with isotonic fluids to restore the renal perfusion and increase renal flow is necessary to prevent AKI

Dialysis support may be life saving when oliguria develops.

Myocarditis requires continous cardiac monitoring in order to timely intervene life-threatening arrythmias and sudden cardiac death.

Alkaline diuresis- using isotonic saline,sodium bicarbonate and diuretics

Sodabicarb 20meq 8th hourly

In conclusion,hair dye poisoning is a life-threatening emergency which requires emergency resuscitation and aggressive management of anaphylaxis

Preventing renal failure is a very important goal,since its occurrence is associated with high mortality and increase in ICU stay

The time of development of renal failure is uncertain and hence all patients should be monitored in hospital for renal failure complications…

THANK YOU