潘恆之 , 林杰樑 , 顏宗海
DESCRIPTION
硫化氫沼氣中毒導致急性腎衰竭 , 乳酸中毒及 突發性心肺停止. 潘恆之 , 林杰樑 , 顏宗海. Acute Renal Failure, Lactic acidosis, and Sudden Collapse following Hydrogen Sulfide Sewer Gas Poisoning. 林口長庚紀念醫院 腎臟系 臨床毒物科. Patient's Profiles. Case 2 Age : 34 Gender: male Ethnic: Filipino Marital status : married - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: 潘恆之 , 林杰樑 , 顏宗海](https://reader033.vdocuments.net/reader033/viewer/2022061506/56816728550346895ddbc614/html5/thumbnails/1.jpg)
ACUTE RENAL FAILURE, LACTIC ACIDOSIS, AND SUDDEN COLLAPSE
FOLLOWINGHYDROGEN SULFIDE SEWER GAS
POISONING潘恆之 , 林杰樑 , 顏宗海
硫化氫沼氣中毒導致急性腎衰竭 , 乳酸中毒及突發性心肺停止
林口長庚紀念醫院 腎臟系 臨床毒物科
![Page 2: 潘恆之 , 林杰樑 , 顏宗海](https://reader033.vdocuments.net/reader033/viewer/2022061506/56816728550346895ddbc614/html5/thumbnails/2.jpg)
Patient's ProfilesCase 1Age: 28Gender: maleEthnic: Filipino Marital status: marriedOccupation: worker
Case 2Age: 34Gender: maleEthnic: Filipino Marital status: marriedOccupation: worker
![Page 3: 潘恆之 , 林杰樑 , 顏宗海](https://reader033.vdocuments.net/reader033/viewer/2022061506/56816728550346895ddbc614/html5/thumbnails/3.jpg)
Present Illness Two otherwise healthy, Filipino
workers from a poultry meat-processing factory suffered sudden loss of consciousness while cleaning pig slotted floors.
![Page 4: 潘恆之 , 林杰樑 , 顏宗海](https://reader033.vdocuments.net/reader033/viewer/2022061506/56816728550346895ddbc614/html5/thumbnails/4.jpg)
Case 1 (28 y/o male) -- Physical examination Vital signs: T: 35.8 ℃ P: 0 bpm R: 0 cpm
BP: 0/0 mmHg GENERAL APPEARANCE: pale and cyanotic,
foul odor CONSCIOUSNESS: E 1 V 1 M 1 HEENT: sclera: anicteric, conjunctiva: not pale pupil size L/R: 6/6 (mm), cyanotic lips NECK: supple, no jugular vein engorgement CHEST: no breathing sounds HEART: no heart sounds ABDOMEN: soft and flat, hypoactive bowel
sounds EXTREMITIES: freely movable, no pitting
edema
![Page 5: 潘恆之 , 林杰樑 , 顏宗海](https://reader033.vdocuments.net/reader033/viewer/2022061506/56816728550346895ddbc614/html5/thumbnails/5.jpg)
血液WBC 8700 1/µLHemoglobin 13.4 g/dL
MCV 91.6 fLPlatelets 289K 1/µLSegment 70 %Lymphocyte 22 %
Eosinophil 4 %
PT (INR) 1.0APTT 23.8 sec
生化 Fasting sugar 133 mg/dL
ALT 96 U/LBUN 22.1 mg/dLCreatinine 1.50 mg/dLeGFR 53 mL/min/1.73㎡Na 149 mEq/LK 6.4 mEq/LCl 103 mEq/LCa 8.1 mg/dLP 2.4 mg/dLMg 1.7 mEq/LCK-MB 3.9 ng/mLTroponin-I 0.01 ng/mLLactate 24.2 mg/dLFree-T4 1.38 ng/dLTSH 0.77 µIU/mLCortisol 22.3 µg/dLO2HB 63.6 %COHB 1.2 %METHB 0.3 %O2CT 64.9 %
動脈血PH 6.799PCO2 90.0 mmHgPO2 69.3 mmHgHCO3 13.7 mm/LSBE - 20.9 mm/LSa% 60.5 %
Lab data (28 y/o male)
![Page 6: 潘恆之 , 林杰樑 , 顏宗海](https://reader033.vdocuments.net/reader033/viewer/2022061506/56816728550346895ddbc614/html5/thumbnails/6.jpg)
Course (28 y/o male)
An out-of-hospital cardiac arrest victim Blood tests revealed hypoxemia,
hypercapnia, acute renal failure, lactate acidosis and hyperkalemia
Electrocardiogram showed asystole CPCR failure
![Page 7: 潘恆之 , 林杰樑 , 顏宗海](https://reader033.vdocuments.net/reader033/viewer/2022061506/56816728550346895ddbc614/html5/thumbnails/7.jpg)
Vital signs: T: 33.0 ℃ P: 131 bpm R: 6 cpm BP: 77/51 mmHg
GENERAL APPEARANCE: acute-ill looking, foul odor
CONSCIOUSNESS: E 2 V 1 M 4 HEENT: sclera: anicteric, conjunctiva: not pale pupil size L/R: 3/3 (mm), throat: not injected NECK: supple, no jugular vein engorgement CHEST: respiratory pattern: slow and shallow breathing sound: clear HEART: rapid heart beat without murmurs ABDOMEN: Soft and flat, normoactive bowel
sounds, no local tenderness, no rebounding pain EXTREMITIES: freely movable, symmetric
peripheral pulse
Case 2 (34 y/o male) -- Physical examination
![Page 8: 潘恆之 , 林杰樑 , 顏宗海](https://reader033.vdocuments.net/reader033/viewer/2022061506/56816728550346895ddbc614/html5/thumbnails/8.jpg)
血液WBC 9500 1/µLHemoglobin 14.4 g/dL
MCV 83.8 fLPlatelets 162K 1/µLSegment 57.9 %Lymphocyte 37.6 %
Eosinophil 1.8 %
PT (INR) 1.0APTT 23.8 sec
生化 Fasting sugar 119 mg/dL
ALT 41 U/LBUN 18.1 mg/dLCreatinine 1.54 mg/dLeGFR 52 mL/min/
1.73㎡Na 138 mEq/LK 3.1 mEq/LCl 101 mEq/LCa 8.7 mg/dLP 3.1 mg/dLMg 1.7 mEq/LCK-MB 5.1 ng/mLTroponin-I 0.017 ng/mLLactate 23.8 mg/dLFree-T4 1.36 ng/dLTSH 0.69 µIU/mLCortisol 50.3 µg/dLO2 HB % 70.3 %CO HB % 0.9 %MET HB % 7.2 %O2 CT 78.3 %
動脈血PH 6.979PCO2 84.1 mmHgPO2 51.9 mmHgHCO3 19.3 mm/LSBE -12.3 mm/LSa% 73.8 %
Lab data (34 y/o male)
![Page 9: 潘恆之 , 林杰樑 , 顏宗海](https://reader033.vdocuments.net/reader033/viewer/2022061506/56816728550346895ddbc614/html5/thumbnails/9.jpg)
CXR (34 y/o male) EKG (34 y/o male)
![Page 10: 潘恆之 , 林杰樑 , 顏宗海](https://reader033.vdocuments.net/reader033/viewer/2022061506/56816728550346895ddbc614/html5/thumbnails/10.jpg)
Course (34 y/o male)
Day 1, at ER
Day 1, in ICU
Intubation with mechanical ventilator support
N/S challenge, Norepinephrine run 30 µg/min
Give amyl nitrite 1pc inhalation and 3% sodium nitrite 10ml iv drip for 20 mins
Brain CT: no evidence of ICH or structural lesions
Day 2, in ICU Consciousness: confused and
disoriented
Ga
![Page 11: 潘恆之 , 林杰樑 , 顏宗海](https://reader033.vdocuments.net/reader033/viewer/2022061506/56816728550346895ddbc614/html5/thumbnails/11.jpg)
Course (34 y/o male)
Day 4, in ICU
Day 5, at ordinary ward Aspiration pneumonia => give empiric antibiotics: Ceftazidime 2g q8h
Day 16, at ordinary ward Consciousness clear Discharge
Extubation EEG: diffuse cortical dysfunction
![Page 12: 潘恆之 , 林杰樑 , 顏宗海](https://reader033.vdocuments.net/reader033/viewer/2022061506/56816728550346895ddbc614/html5/thumbnails/12.jpg)
Introduction Hydrogen sulfide (H2S) is a colorless
toxic gas that has strong odor of “rotten eggs”
H2S poisoning usually occurs by inhalation
Discussion
~ Woodall GM et al, Inhal Toxicol. 2005;17:593-639
![Page 13: 潘恆之 , 林杰樑 , 顏宗海](https://reader033.vdocuments.net/reader033/viewer/2022061506/56816728550346895ddbc614/html5/thumbnails/13.jpg)
Source Organic 1. Incomplete oxidation of sulfur compounds 2. Bacterial degradation of sulfur compounds Inorganic, mainly industrial 1. Petroleum industry -- contamination or by-product 2. Chemical industry -- reactant for production of chemicals 3. Production of heavy water 4. Metal refining
~ Tee L. Guidotti , International Journal of Toxicology. 2010, 29:569-581
![Page 14: 潘恆之 , 林杰樑 , 顏宗海](https://reader033.vdocuments.net/reader033/viewer/2022061506/56816728550346895ddbc614/html5/thumbnails/14.jpg)
Knock down !!
Apnea !!
~ Doujaiji B et al, Ann Saudi Med. 2010;30:76-80
![Page 15: 潘恆之 , 林杰樑 , 顏宗海](https://reader033.vdocuments.net/reader033/viewer/2022061506/56816728550346895ddbc614/html5/thumbnails/15.jpg)
Symptoms 0.05 ppm
(airbone concentration)
Pungent smell mimicking “rotten egg”
0.1 ppm Anosmia50-150
ppmParalysis, conjunctivitis
250 ppm Photophobia, pulmonary edema250-500
ppmHeadache, nausea, vomiting, confusion, tachycardia, hypotension
500-750 ppm
Respiratory arrest
750-1000 ppm
Knocked down (central neurotoxicity)
> 1000 ppm
Dying immediately within a breath
~ Tee L. Guidotti , International Journal of Toxicology. 2010, 29:569-581
![Page 16: 潘恆之 , 林杰樑 , 顏宗海](https://reader033.vdocuments.net/reader033/viewer/2022061506/56816728550346895ddbc614/html5/thumbnails/16.jpg)
Diagnosis Measurement of blood sulfide in acute emergencies is of little clinical value. History of hydrogen sulfide exposure Odor of hydrogen sulfide Serum BUN, Cr, electrolyte, glucose,
CPK, blood gas & serum lactate ECG & Chest X-ray CT scan
~ Milby HT et al, American Journal of Industrial Medicine. 1999, 35:192-195
![Page 17: 潘恆之 , 林杰樑 , 顏宗海](https://reader033.vdocuments.net/reader033/viewer/2022061506/56816728550346895ddbc614/html5/thumbnails/17.jpg)
Treatment
~ Gregorakos L et al, Angiology. 1995, 46:1123-1131
![Page 18: 潘恆之 , 林杰樑 , 顏宗海](https://reader033.vdocuments.net/reader033/viewer/2022061506/56816728550346895ddbc614/html5/thumbnails/18.jpg)
Antidote – Nitrite Salt Nitrite salt oxidizes
the Fe2+ of hemoglobin to Fe3+, deriving Met-Hb
Met-Hb competes with the Fe3+ of cytochrome oxidase and protects it from oxidization by H2S
Keep the Met-Hb level < 25% with a concern of hypoxemia from methemoglobinemia
Oxy-Hb
Met-Hb
Sulfa-MetHb
Oxy-Hb + SO2
H2S
Amyl nitrite, Sodium nitrite
cyt c2+cyt c3+
cyt a2+cyt a3+
cyt a32+cyt a3
3+
H2O2+ 2H+ 2H2O
~ Smith RP et al, Ann Rev Toxicol. 1976, 16:189Mitochondria
Blood
![Page 19: 潘恆之 , 林杰樑 , 顏宗海](https://reader033.vdocuments.net/reader033/viewer/2022061506/56816728550346895ddbc614/html5/thumbnails/19.jpg)
Nitrite KitAmyl nitrite
• If spontaneous breathing remains,
give amyl nitrite inhalation every 3 min until sodium nitrite is ready
Sodium nitrite
• Dissolve 0.6g sodium nitrite to 20 ml of water ( 3% solution)
• IV 10ml of the 3% sodium nitrite solution > 20 mins
~ Morii et al, Journal of Occupational Medicine and Toxicology. 2010, 5:28
![Page 20: 潘恆之 , 林杰樑 , 顏宗海](https://reader033.vdocuments.net/reader033/viewer/2022061506/56816728550346895ddbc614/html5/thumbnails/20.jpg)
![Page 21: 潘恆之 , 林杰樑 , 顏宗海](https://reader033.vdocuments.net/reader033/viewer/2022061506/56816728550346895ddbc614/html5/thumbnails/21.jpg)
Highlights Hydrogen sulfide poisoning is a
relatively uncommon and frequently lethal hazard
Toxidrome : 1. odor perception followed by olfactory paralysis 2. burning eyes 3. pulmonary edema 4. knock down Foul odor Keep Airway, breath, circulation,
O2 100% Antidote : Amyl nitrite 、 Sodium
nitrite
![Page 22: 潘恆之 , 林杰樑 , 顏宗海](https://reader033.vdocuments.net/reader033/viewer/2022061506/56816728550346895ddbc614/html5/thumbnails/22.jpg)
THANKS FOR YOUR LISTENING!!