ED/ICU Mortality & Morbidity Conference Date: 2011/09/29 主講 R 江秉晏 講評 MA 鄒先令 Moderator MA 邱德發

場景 Time: 2011/08/13 W6 19:58 ~ Location : 林口急診一區 A2 Event: 10 分鐘內進三床

A: 28 y/o male, 疑沼氣吸入, OHCA (BT 35 A: 28 y/o male, 疑沼氣吸入, OHCA (BT 35.8) B: 34 y/o male, 疑沼氣吸入, (BT 33, PR 72, RR 6, BP 77/51, GCS: E1V1M4)

病患A EMT 接獲病死豬處理場人員報案, 6mins抵達現場, 發現病患A俯趴在槽底, 無生命跡象 CPCR: 21mins Initial AED: 不建議電擊 LMA use 現場停留時間: 28 mins 現場到醫院時間: 19 mins

病患A PI&PE Initial Order OHCA 身上有屍臭味 pupil 6-/6- HEENT: not pale Neck: no jugular vein engorge Chest: no spont. breathing Heart : no spont. HB Abdomen: soft and flat Extremities: flaccid CPCR since arrival On monitor: asystole On endo with MV Bosmine q3m iv CBC/DC, PT/aPTT Cr/Na/K/Cl CKMB/Trop-I IV N/S full run ABG CO oximeter panel

病患B (19:58, 0 min) PI Physical Exam BT 33, PR 72, RR 6, BP 77/51 與病患A同時被EMT送醫 身上有屍臭味 NKA GCS E2V1M4, pupil 2-/2- HEENT not pale, not icteric Neck no jugular vein engorge Chest: BS clear Heart : RHB , no murmur Abdomen soft and flat no tenderness Extremities: freely movable

Question As an emergency physician, do you need more information for this situation ? What’s your tentative diagnosis What’s your next step for this patient ? 找R2以上問

關於病史 詳細事情發生經過? 發生地點? 接觸氣體及液體? 身上特殊氣味? 意外或蓄意? 附近是否有遺書或藥品空罐? 精神病史? 藥物史? 外傷? 骨折? 瘀青? 內出血的可能性？

About PE Toxidrome Mental status: clear, drowsy, coma Pupil size: miosis or mydriasis; light reflex Heart rate: tachy or brady Bowel sound: hyper or hypo Muscle power: normal, rigidity, or flaccid Skin and mucosa: wet or dry

雇主表示: 兩名工人為外籍人士(之前身體檢查正常), 負責處理病死豬處理槽,病患B因為塑膠袋掉入槽裡(槽約1 雇主表示: 兩名工人為外籍人士(之前身體檢查正常), 負責處理病死豬處理槽,病患B因為塑膠袋掉入槽裡(槽約1.5~2m深)因此入槽撿出,下去沒幾分鐘就被發現仰躺在裡面, 呼叫無反應,病患A因病患B久未出來也入槽, 進入約幾分鐘後也被發現俯臥在槽底… 找人回答

Impression Intoxication sudden onset, knocked-down, enclosed space => asphyxiating gas (CO, cyanide, H2S) Trauma, less likely 3 種如何分別要講

Goldfrank's, 9th

病患B 20:03 (5 mins) On endo with MV , On monitor IV with N/S challenge 500ml F/S stat_308 CBC/DC , PT/aPTT Cr, Na / K/Cl, AST CK-MB/Trop-I, EKG ABG/CO-oximeter panel CXR(B) 字體要28以上

Question Do you think these all enough for this patient?

請標記你有疑問或此病患沒有的 可向淑婷要電子檔

病患B 20:03 (5 mins) ON Endo with MV , ON Monitor IV WITH N/S 1000ML FULL RUN F/S stat_308 CBC/DC , PT/aPTT Cr, NA / K/Cl, AST CK-MB/Trop-I, EKG ABG/CO-OXIMETER PANEL CXR(B) On critical Hypothermia: warm saline, lamp use Decontamination? how? 字體要28以上

Question ? What kind of intoxication should be considered in this patient ? Is there any antidote ?

沼氣成分

Decontamination Inhalation: move to fresh air and administer 100% oxygen. Prevent self-exposure and possible death by wearing a self-contained breathing apparatus to rescue the victim. (Poisindex) GI: Hydrogen sulfide is a gas at room temperature, making ingestion unlikely (Poisindex) Skin: remove clothing and wash exposed area thoroughly (Poisindex) 有必要skin or GI DECONTAMINATION ?

Antidote 20:15(17 mins) Cyanide antidote package Amyl nitrite inhalation 1 pc Sodium nitrite injection slowly push > 10 mins

Question Are you familiar with the usage of cyanide antidote package? What’s the indication to use antidote?

Indication Patients with suspected hydrogen sulfide poisoning who have altered mental status, coma, hypotension, or dysrhythmia should receive sodium nitrite.(Goldfrank's)

Cyanide Antidote Package Amyl nitrite 0.3 ml/Amp. (*12) Sodium nitrite 300 mg/10 ml/ Amp. (*2) Sodium thiosulfate 12.5 g/50 ml/Amp (*2)

Pathophysiology 氰化物及硫化物都因對三價鐵有高度輕和力, 容易和粒線體裡細胞色素氧化脢的三價鐵結合,而阻斷電子傳遞鏈,降低ATP的產生而造成毒性

Mechanism Nitrites: Amyl nitrate or sodium nitrate 遇到血紅素後,形成變性血紅素, 變性血紅素競爭帶走影響粒線體的硫, 而形成硫化變性血紅素,而硫化變性血紅素可經人體慢慢排除

Amyl Nitrite Amyl nitrite (0.3 ml/Amp)-> inhalation before iv sodium nitrite used Amyl nitrite are included in the kit of prehospital use(Goldfrank's) 打開1安瓿的Amyl nitrite，用手帕包住且握住放在病人嘴巴前吸入15秒，再停止15秒 一瓶約可用3分鐘

Sodium Nitrite Sodium nitrite (300 mg/10 ml/ Amp): iv > 5 mins If signs of poisoning reappear, injection of Sodium Nitrite should be repeated, but in one-half of the original dose. prophylactic purposes 2 hours after the first injections

Warning Hypotension: fluid and intropics Excessive methemoglobinemia Inhalation of the amyl nitrite ampule generates approximately 5% methemoglobin while sodium nitrite given IV generates approximately 8% to 20% (Tintinalli's ) The amounts found in a single Cyanide Antidote Package are not excessive for an adult. (仿單) Children ?

Avoid overdose in children-> adjust by Hb

OHCA 的A男 ABG => Jusomin 4PC stat => Amyl nitrite 1pc inh. inhalation

A男需要antidote? As long as the heart is still beating, the chances of recovery by utilizing this method are very good.(仿單)

病患B的ABG 20:03(5mins)

EKG

CO Oximeter Panel 20:28(30mins) Normal circumstances, < 1% to 2% of Hb exists as methemoglobin

LAB 20:46 (48 mins)

北榮毒物諮詢 諮詢前已使用Cyanide antidote package 屠宰場因為屍體腐敗, 通風不良, 的確可以懷疑硫化氫中毒

21:12 ( 1hr, 17min) Convulsion or seizure-like movement noted Vitals: PR 110, RR 21, BP 160/90 SpO2: 93% Arrange Brain CT

CXR Infiltration in bil perihilar area and RLL Normal heart size Endotracheal tube in place EKG leads in place

Brain CT

Brain CT No evidence of ICH. The hyperacute to acute infarcts can't be totally excluded base on this image study, suggest clinical correlation.

22:07 (2hrs 9mins) BT:37.8’C HR:131/min RESP:25/min BP:128/73mmHg Admission to MICU 2

Time line Endo+Order Cyanide kit Brain CT MICU2 21:12 1hr14min 20:03 5 min 20:15 17 min

Hospital course Hypothermia therapy: 08/14 13:39 ~( about 20 hours ) 8/16 EEG: abnormal mild, intermittent diffuse, slow waves over bilateral hemisphere 8/17 extubation: GCS E 4 V 3 M 6 8/18 transfer to Nephro ward 8/29 MBD and OPD f/u: E4V4M6

H2S Concentration Symptoms 0.13-30PPM 味道明顯且令人不快 50PPM下 鼻子和咽喉乾噪刺激 嚴重刺激及頭痛、惡心、嘔吐和頭昏眼花等症狀，暴露4至8小時可能致死 300-500PPM 症狀同，暴露1至4小時可能致死 500PPM以上 快速失去意識及死亡，未導致死亡之嚴重暴露可能引起記憶喪失、臉部肌肉麻庳、神經組織受損。 經患者公司主管表示, 隔天地檢署人員有去測濃度: 告知約250ppm

Cyanide Antidote Kit配置 林口急診藥師 李庭芳組長: 一組是毒物中心提供的藥品(材料編號P3A087P),使用後需24小時通報回中心,並且填寫使用說明書,與病歷影本 二組是中油煉油廠提供(材料編號PAA022P),但是內容物少了Amyl Nitrite(inh)...(因為中油把這個藥放在廠區,有狀況時先吸再後送至醫院),使用中油提供的藥品,優點是不需填寫任何表單,耗用後中油還是會免費提供給我們

Take Home Message Keep in mind about asphyxiating gas intoxication: H2S, Cyanide => why? because we have antidote!!! As an emergency doctor, you should Be familiar with how to use Cyanide kit

Thanks for your attention ~

同場加映_開箱文

Cyanide Antidote Kit

Amyl Nitrite

Amyl Nitrite

Sodium Nitrite

Sodium Thiosulfate

Hypothermia therapy in MICU2

Changes in body temperature

Course of induced hypothermia Adverse events Coffee-ground NG discharge Junctional rhythm GTC seizure after return to 37ºC No hypotension, hyper-K+ or hypoglycemia Reactive hyperthermia

Post-TH course Appeared confused the next day, E4M4VE Brain CT: no ICH, indistinct gray-white junction Two days later, began to smile and move about. Successfully extubated Still 2 days later, could answer his name and hometown, and claimed himself as 7-year-old