organo & paraquat poisoning
TRANSCRIPT
-
7/24/2019 Organo & Paraquat Poisoning
1/54
Case presentation
(Paraquat poisoning)
Ngu Ing Soon
-
7/24/2019 Organo & Paraquat Poisoning
2/54
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*
-
7/24/2019 Organo & Paraquat Poisoning
3/54
Chief Complaint
+ Allerged drinking paraquat at 7pm on4!"#$
-
7/24/2019 Organo & Paraquat Poisoning
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$
-
7/24/2019 Organo & Paraquat Poisoning
5/54
%istor& of Presenting Illness
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$
-
7/24/2019 Organo & Paraquat Poisoning
6/54
%istor& of Presenting Illness
+ :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
-
7/24/2019 Organo & Paraquat Poisoning
7/54
%istor& of Presenting Illness
+ 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$No more sui/idal thought$
-
7/24/2019 Organo & Paraquat Poisoning
8/54
Famil& %istor&
+ No famil& histor& of mental illness orsui/idal attempt
-
7/24/2019 Organo & Paraquat Poisoning
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$
-
7/24/2019 Organo & Paraquat Poisoning
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
-
7/24/2019 Organo & Paraquat Poisoning
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
-
7/24/2019 Organo & Paraquat Poisoning
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
-
7/24/2019 Organo & Paraquat Poisoning
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&
-
7/24/2019 Organo & Paraquat Poisoning
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
-
7/24/2019 Organo & Paraquat Poisoning
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> $!)
-
7/24/2019 Organo & Paraquat Poisoning
16/54
Serial I3 Charting
4/9/13 5/9/13 6/9/13 7/9/13 8/9/13 9/9/13
F-C 1*./1.8/192
Creat 6* 98 219 **
-0 11/.1/
1/8
1*9/*.3/
93/6.*
1**/*.7/
83/16.*
1**/*./
89/2.6
1*2/2.9/
88/29.8
1*6/*./
92/*1.9AST/ALT 172/16* 92/139 21/193
C4/5O 2.19/1.33 1.97/1.7
CorrC4 2.7 1.93
Urineparaquat
+ve -ve -ve -ve
#n%$t 4500 4700 4650 5050 4500
0rineo$t%$t
2050 2550 2850 2300 3200
-
7/24/2019 Organo & Paraquat Poisoning
17/54
Serial I3 Charting
4"#7# 4"4# 4"4#4 4"4H4
+
"
"+
+
#
#+
4
Creatinine
AS=
Column"
-
7/24/2019 Organo & Paraquat Poisoning
18/54
Ngu Ing Soon
-
7/24/2019 Organo & Paraquat Poisoning
19/54
6rganophosphate
-
7/24/2019 Organo & Paraquat Poisoning
20/54
0e/ts of 6P
-
7/24/2019 Organo & Paraquat Poisoning
21/54
0e/ts of 6P
-
7/24/2019 Organo & Paraquat Poisoning
22/54
0e/ts of 6P
-
7/24/2019 Organo & Paraquat Poisoning
23/54
-
7/24/2019 Organo & Paraquat Poisoning
24/54
Paral&sis in 6P Poisoning
=&pe " =&pe =&pe #
-
7/24/2019 Organo & Paraquat Poisoning
25/54
Paral&sis in 6P Poisoning
=&pe " =&pe =&pe #
A/ute paral&sis se/ondar& to
/ontinued depolariation at theneuromus/ular Gun/tion$
-
7/24/2019 Organo & Paraquat Poisoning
26/54
Paral&sis in 6P Poisoning
=&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
-
7/24/2019 Organo & Paraquat Poisoning
27/54
Paral&sis in 6P Poisoning
=&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
-
7/24/2019 Organo & Paraquat Poisoning
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
-
7/24/2019 Organo & Paraquat Poisoning
29/54
-
7/24/2019 Organo & Paraquat Poisoning
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
-
7/24/2019 Organo & Paraquat Poisoning
31/54
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 '+
-
7/24/2019 Organo & Paraquat Poisoning
32/54
-
7/24/2019 Organo & Paraquat Poisoning
33/54
Danagement
-
7/24/2019 Organo & Paraquat Poisoning
34/54
Adequate Atropinisation
+ 'r&ing of tra/heo-ron/hial se/retion(most important)
+ 'r& mouth
+ Flushing
+ %eart rate M"
+'ilated pupils
-
7/24/2019 Organo & Paraquat Poisoning
35/54
-
7/24/2019 Organo & Paraquat Poisoning
36/54
Paraquat
-
7/24/2019 Organo & Paraquat Poisoning
37/54
Paraquat
-
7/24/2019 Organo & Paraquat Poisoning
38/54
3tent of Poisoning
+ Amount
+ @oute
+'uration of e3posure+ Persons health /ondition at the timeof the e3posure$
-
7/24/2019 Organo & Paraquat Poisoning
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$)
+ 24-!2 ours, %epato/ellular inGur&
, A/ute tu-ular ne/rosis
+ !2-96 ours, Pulmonar& -rosis (dt sele/ti.e a//umulation in lung
tissues)
-
7/24/2019 Organo & Paraquat Poisoning
40/54
Paraquat 0e/ts
+ Dulti*organ failure in fulminant poisoning (IFmore than +*" g of paraquat is ingested)
, A/ute renal failure, %epati/ ne/rosis
, D&o/ardial ne/rosis
, A/ute pneumonia
, Internal hemorrhages, Pulmonar& -rosis
, 'eath
-
7/24/2019 Organo & Paraquat Poisoning
41/54
-
7/24/2019 Organo & Paraquat Poisoning
42/54
-
7/24/2019 Organo & Paraquat Poisoning
43/54
-
7/24/2019 Organo & Paraquat Poisoning
44/54
'eterminants of se.erit&
+ 6esophageal and gastri/ erosions
+ @enal failure
+ Ingestion of more than one mouthfulof /on/entrate
+ 'e.elopment of pulmonar& opa/itieson /hest L*ra&
+ 'e/reasing lung .olumes onspirometr&
+ Paraquat /on/entration M #*+ mg8
Compli/ations
-
7/24/2019 Organo & Paraquat Poisoning
45/54
I3
+ astri/ la.ageaspirate5 urine 9 -lood forto3i/olog& s/reening
+ astri/ la.ageaspirate 9 urine for
paraquat+ Erine for paraquat dail& 3 #7
+ Erinar& sodium dithionite test
+ BES dail&+ FBC5 8F=5 Creat 9 CL@ e.er& # da&s
+ AB
-
7/24/2019 Organo & Paraquat Poisoning
46/54
Prognosti/ fa/tors
+ s*/reatinine
+ s*protein
+ s*potassium5 -i/ar-onate
+ plasma Paraquat /on/entration
+ SIPP [time to treatment sinceingestion of paraquat x serum
paraquat at admission (g/ml)]
-
7/24/2019 Organo & Paraquat Poisoning
47/54
SIPP
SIPP -& Sa,ada et al. (Appli/a-le up to %)
S"PP s#ores Pre$i#tion
" Sur.i.al
"*+ 'eath from lung i-rosis
M+ 'eath from /ir/ulator&
failure
-
7/24/2019 Organo & Paraquat Poisoning
48/54
-
7/24/2019 Organo & Paraquat Poisoning
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$+ Dg sulphate (Dist al-a) ! ml e'er& 4 %r
until diarrhoea 9 passage of Fullers earth
-
7/24/2019 Organo & Paraquat Poisoning
50/54
%emodial&sisChar/oal%emoperfusion
+ Eseful if started ,ithin +*7 hrs ofingestion (-efore distri-ution ofparaquat into tissues espe/iall& the
lungs)$+ =he greatest paraquat /on/$ Is found
in the lungs 9 the /on/entration
peaks in +*7 hrs post*ingestion$+ @epeated %P is not helpful$
-
7/24/2019 Organo & Paraquat Poisoning
51/54
-
7/24/2019 Organo & Paraquat Poisoning
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
-
7/24/2019 Organo & Paraquat Poisoning
53/54
@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="
-
7/24/2019 Organo & Paraquat Poisoning
54/54
%an& 'ou