arsenic poisoning
Post on 19-Nov-2014
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A patient was bought to the Emergency ward with history of rashes and blebs all over his skin mainly on his arms and feet. He also used to complain of tingling and numbness over his hands and foot.
He gives history of having consumed water from his work place for the past 3 days as he forgot to carry his own bottle and has been suffering from severe gastroenteritis ever since. Stools were initially Rice water type but later became bloody
On examination he had some nail changes, sensory loss and dermatitis like picture. His blood picture and abdomen radiography were as in the images. Patient went into shock and finally was admitted in the ICU
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Arsenic Poisoning
A presentation by Telugu Doctor
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History Of Arsenic
• its very name has become synonymous with poison.
• the Italian family of Borgias used arsenic as their favorite poison for political assassinations.
• It is believed that Napoleon was poisoned by arsenic-tainted wine served to him while in exile.
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Arsenic in the World
• Arsenic is ubiquitous in the environment. • It ranks 20th in abundance in the earth's crust, 14th
in seawater, and 12th in the human body.
20th 14th12th
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Possible Arsenic poisoning
• Today, arsenic poisoning occurs through industrial exposure, from contaminated wine or moonshine, or because of malicious intent.
• The possibility of heavy metal contamination of herbal preparations and so-called nutritional supplements must also be considered.
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Arsenic – Medicinal Value?
• There has been a resurgence of interest in arsenic as a medicinal agent for treatment of 1. Acute promyelocytic leukemias2. Multiple myeloma3. Myelodysplastic syndromes and 4. Assorted resistant solid tumors
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Protection from Arsenic ?
• An inverse correlation was found between consumption of vitamins A, C, and E, riboflavin and folic acid, and the existence of dermatological manifestations or chronic arsenic exposure.
• The population was recently surveyed and those individuals who had diets deficient in certain B vitamins and antioxidants appeared to have greater risk of arsenic dermatoses.
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Poisonous Compounds of Arsenic
Arsenic oxide or Arsenic Trioxide
• It is the most common form of arsenic used.• It is also known as White Arsenic.• No taste or smell and is sparingly soluble in water.• It is heavier than water by three and half times but
freely floats on water.Telugu Doctors.co.in
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Uses Of Arsenic
Fruit sprays Sheep-dips
Weed-killers
Rat poisons
Fly papers
Calico printing
TaxidermyPreserving timber and skin against white ants
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Mode Of Action
• Arsenic interferes with cellular respiration by combining with the sulphydryl groups of mitochondrial enzymes.
• It particularly targets vascular endothelium leading to increased permeability, tissue edema and hemorrhage, especially in the intestinal canal.
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Mode Of Action
Locally it causes irritation of the mucous membranes and remotely depression of the nervous system.
Arsenic also interferes with glycolysis.
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Circumstances Of Poisoning
• It is cheap• Easily obtained• Colourless• No smell• No taste• Small quantity is required to cause death.• Can be easily administered with food or drink.• Onset of symptoms is gradual• Symptoms simulate those of Cholera.
Arsenic is the most popular Homicidal poison
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Circumstances Of Poisoning
Disadvantages Of Arsenic:
• It delays putrefaction• Can be detected in completely decomposed bodies.• Can be found in bones, hairs and nails for several
years.• Can be detected in charred bones or ashes.
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Signs And Symptoms
1. The Fulminant type2. The Gastroenteric Type
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The Fulminant type
• Massive doses of arsenic when rapidly absorbed cause death in one to three hours from shock and peripheral vascular failure.
• All the capillaries are markedly dilated, especially in the splanchnic area with a marked fall of blood pressure.
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The Gastroenteric Type
• This is the common form of acute poisoning and resembles bacterial food poisoning.
• Symptoms usually appear half to one hour after ingestion, but may be delayed many hours especially when arsenic is taken with food.
• Burning and colicky pain in the esophagus, stomach and bowel occur.
• Intense thirst and severe vomiting which may be projectile are the common symptoms.
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Signs And Symptoms
Acute severe arsenic poisoning Vital signs - Tachycardia and hypotension, even shock CNS - Altered mental status, delirium, coma, and seizures
(acute encephalopathy)
Frequently, patients exposed to arsenic have a garlic smell to their breath and tissue fluids.
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Signs And Symptoms
• Arsine gas exposure manifests with an acute hemolytic anemia and striking chills.
• Hemoglobinuria causes the urine to appear black, and the patient becomes rapidly obtunded and shocky.
• Shaking chills are often described in these patients.
Frequently, patients exposed to arsenic have a garlic smell to their breath and tissue fluids.
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Signs And Symptoms
• Acute exposures generally manifest with the cholera-like gastrointestinal symptoms of
• vomiting (often times bloody) and • severe diarrhea (which may be rice-watery in
character and often bloody); • these patients will experience acute distress,
dehydration (often), and hypovolemic shock.Telugu Doctors.co.in
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Chronic toxicity is more insidious and may manifest as a classical dermatitis (hyperkeratosis with a classical "dew drops on a dusty road" appearance)
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whitish lines (Mees lines) that look much like traumatic injuries are found on the fingernails.
Contact dermatitis may also be induced in occupational arsenic poisoning. Arsenic dust coming into contact with the skin produces four main types of reactions: 1. Toxic2. Eczematous3. Combined toxic and
eczematous and 4. Reactions characterized by
follicular lesions.
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Laboratory Studies
Complete Blood Count
Microcytic Hypochromic Anemia
• Obtain a CBC with indices and a reticulocyte.
• Acute hemolytic anemia is the rule with arsine exposure.
• Type and screen or crossmatch blood for the transfusion in patients exposed to arsine gas.
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Laboratory Studies
1. Serum Magnesium2. Serum Potassium3. Serum Sodium4. Serum Calcium5. Serum Chloride
Serum Electrolytes
Do Serum electrolytes in patients with Diarrhea and Vomiting
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Laboratory Studies
• Blood arsenic concentrations should not exceed 50 mcg/L.
• The reported half-life of arsenic in blood immediately following ingestion is in hours, while whole-body clearance may be in days or months and is apparently dose-related.
Serum Electrolytes
Plasma Arsenic Analyser
Serum Arsenic Analysis Telugu Doctors.co.in
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Laboratory Studies
• Urine spot test for arsenic• 24-hour urine collection for
total arsenic excretion• Methylarsonic acid (MMA)
and dimethylarsenic acid (DMA) – metabolites of arsenic in the body
Urine analysis
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Laboratory Studies
Reports of prolongation of the QT and ventricular fibrillation after acute arsenic intoxication make careful attention to cardiac status imperative.
ECG Changes
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Laboratory Studies
• Nerve conduction studies may confirm Peripheral neuropathy
• An abdominal radiograph may reveal the presence of radio-opaque densities
Other Tests
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Treatment and management
AirwayBreathingCirculation
Pre-Hospital care
Emergency Department
• Hemodynamic stabilization – to counteract GI loses• Orogastric lavage – for acute arsenic poisoning• Whole bowel irrigation with polyethylene glycol may be
effective to prevent GI tract absorption of arsenic.Telugu Doctors.co.in
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Treatment and management
• Dimercaprol (BAL in Oil): First-line agent for treating arsenic poisoning. May be administered to patients with renal failure.
• Succimer (DSMA): used only in childhood lead poisoning.
• Dimerval (DMPS): accepted DOC for treating most heavy metal poisonings.
Chelation Agents
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Treatment and management
• Hemodialysis is especially useful in a patient with arsenic poisoning with renal failure or with impending renal failure.
Hemodialysis
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Image Quiz
This was the blood picture of a patient who was admitted to the hospital with complaints of severe abdominal pain and afebrile seizures. What do you suspect ?
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Image Quiz
This Car driver had slept in his car with the engine on waiting for his customers to return from a late night party. He was found dead when the passengers gave a visit to the car next day morning. What is the cause of death in this case ?
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Image Quiz
This snake is said to be one of the poisonous land snakes. Its bite usually results in less to no local effects, but severe neurological effects. This snake easily enters human dwellings compared to other species. Which snake is it ?
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Image Quiz
This photograph was taken when a child was bought to the emergency department. The kids have been playing in the fields for some time after which the child started feeling very weak and couldn’t walk on her own. She couldn’t support her neck and opening her eyes seemed difficult for her. What is your provisional Diagnosis ?
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Image Quiz
Marilyn Monroe was found dead in the bedroom of her Brentwood home by her psychoanalyst on August 5, 1962. She was 36 years old at the time of her death. Her death was listed as "probable suicide“. The death of Monroe has since become one of the most debated conspiracy theories of all time. Do you know the possible cause of her Death ?
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Image Quiz
Mr. Ram had a fight at home after which he consumed a poisonous substance. He was bought to ED by his friends who weren’t aware of the poison. On examination Patient had the findings of the images on the left. What is your Diagnosis ?
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Image Quiz
These are a specific type of chambers used as a part of treatment for a certain poisoning. What are these chambers and to treat which poisoning are they used?
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Image Quiz
A 17 yr old boy got stung by a scorpion and was bought to the ED. His father was of the opinion that the boy will live through as he was stung by a bigger scorpion when he was a kid and nothing happened to him. But within hrs, the boy developed breathlessness with frothing and was admitted to the Intensive care unit. Was the fathers assumption right ?
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