Toxicology Case Review 2010/12/01~2010/12/31 Date: 2011/01/13 Presentation:R2劉雨欣 Supervisor:游俊豪醫師 Moderator: 林志泉主任

全部中毒諮詢患者: 36位 可查詢中毒諮詢者: 18位 Toxidrome: 3 位: 皆為Cholinergic toxidrome (Organophosphate intoxication)

中毒個案男女分布 男 女 個數/比例 20 (56 %) 16 (44%)

中毒類別分類 濫用 醫療 職業 意外 自殺 其他 個數 2 3 1 5 24 比例(%) 6 8 14 66

中毒類別男女分類 濫用 醫療 職業 意外 自殺 其他 男 2 3 1 10 女 14

中毒個案年齡分布 濫用 醫療 職業 意外 自殺 其他 總計 <30 y/o 30-50 y/o 50-80 y/o 2 1 3 7 13 30-50 y/o 9 12 50-80 y/o 6 8 >80 y/o

處置上有建議:Theophylline Theophylline overdose 應在24小時後再追 蹤Theophelline level Theophylline overdose induced Af RVR  不一定成正相關

處置上有建議:Acetaminophen 病歷未記載外院是否洗胃與給charcoal

處置上有建議: r/o drug related bradycardia Pt's medication: indapin, dypiridamion (persantin), losartan, none of one induced bradycardia may check Ca, Mg, Thryoid function, Cortisol Treat bradycardia as ACLS guideline

Case review-1

General Data Vital sign : BT :36.8 ℃ HR: 100/min RR: 18/min Admission date: 2010/12/30 17:35 Chart No: 3937674 25 y/o Male Triage: 病患來診為肢體無力及 手腳麻，症狀發作時間 長達一個月 Vital sign : BT :36.8 ℃ HR: 100/min RR: 18/min BP: 152/96 mmHg GCS: E4V5M6

Chief Complaint 4 limbs numbness for more than one month

Present Illness Limbs weakness also but improved currently No problem in stool passage and urination Ever use N2O in night club days before the symptoms Head trauma:nil Fever:nil PH: no DM or HTN Allergy: NKA

PE and Lab PE: MP: 4 at all limbs, Parethesia at bil hands, trunk and lower limbs Lab: CXR:normal Brain CT: negative finding Cr:0.72 Na: 140 K: 4.0 CRP:3.95 Ca:9.6 Mg:2.1 Myoglobin:50.7 CPK:460 Hb: 15.5 mg/uL MCV: 92.3 fl PLT: 341000 /uL WBC: 14300 /uL

Deposition 入觀診斷:polyneuropathy Admission to Neuro’s ward During waiting for bed, p’t discharge

Discussion-Nitrous oxide

笑氣(N2O, Nitrous oxide) 一氧化二氮，無色有甜味氣體，又稱笑 氣，是一種氧化劑，化學式N2O，在一 定條件下能支持燃燒，但在室溫下穩定 ，有輕微麻醉作用，並能致人發笑。 一種強大的溫室氣體，效果是二氧化碳 的296倍。 臨床上，當作吸入麻醉時的輔助性氣體 麻醉劑，尤其是牙科手術的麻醉。 有些被拿來當作汽車直線加速的助燃氣 使用 近年來，常被年輕人拿來濫用…

Pathophysiology highly lipid soluble rapidly absorbed  pulmonary bed  bloodstream  distributed the body particularly susceptible to the solvent properties of these compounds: Neurons CNS depressants by alteration of glutamate or GABA receptors function

Once: effect typically lasts 15 to 45 mins Initial euphoria  lethargy. Judgment and coordination are impaired Repeated use: Intoxication

Intoxication Neurologic effects —polyneuropathy, ataxia, and psychosis. Neurotoxicity is potentially reversible with B12 supplementation and abstinence from N2O. Vitamin B12 :coenzyme of methionine synthase. Nitrous oxide vitamin B12 from the active form to the inactive form irreversible inhibition of methionine synthase Inhibitor of generation of synthesis of DNA, RNA, and myelin. The clinical effects are similar to the subacute combined degeneration syndrome associated with pernicious anemia. Nitrous oxide is known to precipitate vitamin B12 deficiency when used on a chronic basis or acutely in patients with marginal stores of vitamin B12 such as the elderly or malnourished

Vitamin B12 synthesis of DNA, RNA, and myelin

Hematologic effects —megaloblastic anemia due to interaction with B12. Reproductive effects —Animal studies have demonstrated fetotoxicity with prolonged exposure to N2O Pulmonary effects — Pneumothorax may occur if gas is inhaled directly from a pressurized tank

Diagnosis : primarily based on history or circumstance No specific lab for N2O

Management of acute intoxication: supportive care Maintenance of cardiorespiratory function and removal the source of the toxin May give B12 supplement No antidote Long-term management: referral for addiction treatment

Question A:Supportive care and consider B12 Q1:如何治療濫用笑氣而產生Neuropathy的病 人？ A:Supportive care and consider B12 Q2:什麼時候病人需要住院? A:Central nervous system findings (eg, neuropathy, coma, seizures)hospital admission asymptomatic or mild symptoms (eg, lethargy)  may be discharged home

Case review-2

General Data Vital sign : BT :35.6 ℃ HR: 101/min RR: 18/min Admission date: 2010/12/30 23:37 Chart No: 8742287 56 y/o Female Triage: 病患來診為物質誤用/中 毒.高危險物質/不明物 質.服用可滅鼠30分鐘 Vital sign : BT :35.6 ℃ HR: 101/min RR: 18/min BP: 219/125 mmHg GCS: E4V5M6

Chief Complaint Took 可滅鼠 30 minutes ago

Present Illness 家屬十一點發現病人打開可滅鼠包裝 藥物灑在地上 病人堅決否認有吃下去 Alcohol use:+ Denied any drug use PH: no DM or HTN Allergy: NKA

PE and Lab PE: Conscious:clear HEENT:no gingiva bleeding, Chest:clear Ext: no echymosis Lab: Cr:1.0 ALT:24 CO2:22.7 Alcohol:95.7 Hb: 13 mg/uL MCV: 88 fl PLT: 231000 /uL WBC: 6700 /uL PT/INR:10.3/1.0 Aptt:24.3

ER management Charcoal +Magnesium sulfate Consult PSY Arrange admission to Nephro’s ward Check PT at 12/31 12:00, then qd x 3 days Amission on 12/31 Refuse further treatment and AAD on 1/1 12/31 0000 12/31 1200 1/1 0730 1/4 1100 PT 10.3 10.7 10.8 Normal plasma mean INR 1.0

Discussion-RODENTICIDES

可滅鼠(Brodifacoum) 可滅鼠的成分為 Brodifacoum Brodifacoum 是一高度致死抗凝劑毒物 近年來，成為世界用途最廣泛的殺蟲劑 大部分是拿來製作為殺鼠劑 但少數也使用在 其他哺乳的動物上

RODENTICIDES Brodifacoum Noncoagulant coagulant Superwarfarin: High toxicity: Arsenic-no longer use Barium Phosphorous PNU Sodium monofluoroacetate Strychnine Thallium Zinc phosphide Moderate toxicity: a-Naphthylthiourea Cholecalciferol Low toxicity: Bromethalin Norbormide Red Squill Warfarin type Superwarfarin: 4-hydroxy-coumarins brodifacoum diphenacoum coumafuryl bromadiolone Brodifacoum

Non-coagulant-High Toxicity s/s Tx: Others Barium NM blockade and paralysis respiratory failure BLS+ ACLS+ Gastric larvage magnesium sulfate convert carbonate to less toxic sulfate Phosphorous toxic  myocardium, kidney, and peripheral vessels cardiovascular collapse BLS + ACLS GL+C nil Strychnine CNS stimulation  Medullary paralysis Thallium GI hemorrhage Respiratory failure and dysrhythmias Multiple doses of activated charcoal or Prussian blue Zinc phosphide Myocardial toxicity, shock, and noncardiogenic pulmonary edema, agitation, coma, and seizures intragastric alkalinization with sodium bicarbonate

Anticoagulant-Warfarin One-time warfarin ingestions : not cause any bleeding problem Toxicity: large amounts in a single exposure or a repetitive exposure over several days> 5 to 20 mg per d for more than 5 days. Onset of effect : 12 to 48 h after ingestion. Warfarin‘ half-life is approximately 42 h. Therapy is not necessary for ingestion of a single mouthful of warfarin. Tx: activated charcoal, INR determinationrepeated 12 to 24 h. Vitamin K1  INR >2X and bleeding risk

Superwarfarins more potent, more prolonged anticoagulant activity. Half-life : 120 days Single ingestion  anticoagulation effects for weeks to months. Clinical findings : ecchymoses, hematuria, uterine or GI bleeding, gingival hemorrhage and epistaxis, hematomas, and hemoptysis. Large doses also cause prolongation of the aPTT. brodifacoum

Superwarfarins Tx: BLS +ACLS, Gastic larvage, Activated charcoal Vitamin K1 : if INR elevated +Bleeding risk FFP : if bleeding is severe or unresponsive to vitamin K1 therapy Desposition: ingested a highly toxic rodenticide & symptomatic admission

Question Q1:長效型抗凝劑中毒PT要多久測一次? A:無症狀:qd x 3 daysqw, q2w, per month, until total 3 months 有症狀:Vit K1 +/-FFP, q4h check PT Q2: 病人原先已有使用抗凝血藥物的處置? A2:keep PT INR:1.5~3.0, 若有需使用Vit-K ，必要時可考慮使用heparin來維持抗凝血作 用

Thanks for your attention!