Post on 29-Dec-2015
Pattern and outcome of poisoning at DHQ Hospital Rawalpindi Dr.Touseef Mehmood PGR Medicine
Case 1
A 30 years old male a brick Kiln workerPresented in DHQ ER with suicidal ingestion of one packet(30 grams)of Kala Pathar 6 hours ago.
Presenting complaints
Swollen neck and face Dyspnea Altered level of consciousness Passage of dark coloured urine Generalized body pains
…
Patient was in obvious distress with swollen neck and face;
Examination also revealed cyanosis both peripheral and central.
Vitals at the time of presentation
Pulse 110 bpm regular Bp 90/60 mmHg Temp 98.6Resp Rate 30 /min
Systemic examination
Altered mental status with GCS of 10/15
(confused speech and drowsiness)
On Auscultation of chest bilateral crepitations were audible
Abdominal examination tender epigastrium
Management The patient was immediately resuscitated
Airway and breathing maintained with intubation and oxygen inhalation
IV fluids and antibiotics given
Gastric lavage carried out with normal saline and charcoal
Patient’s haemodynamic status continued to deteriorate!
…Patient shifted to intensive care unit
Inotropic support started alongwith CVP guided fluids
Other supportive measures included steroids,soda bicarbonate and calcium gluconate.
Methylene blue and exchange transfusions
Investigations
Blood complete picture showed neutrophilic leucocytosis
ECG showed sinus tachycardia
Urinalysis showed brown coloured urine with WBC casts and albuminuria(+)
pH 7.32 7.35-7.45
pO2 116 83-108
pCO2 29.5 35-45
HCO3 14.9 21-28
ABGs
Test Result Unit Normal Range
ALT 270 U/L 43
Urea 25 mg/dl 12-45
Na 137 mmol/l 135-145
K 4 mmol/l 3.5-5
Cl 100 mmol/l 98-108
Chemistry
Test Result Unit Normal
ALT 547 U/L 43
Alkaline Phosphatse
312 U/L 65-360
Urea 16 mg/dl 12-45
Creatinine 1.2 mg/dl Upto 1.2
Uric Acid 5.4 mg/dl 2-7
Na 140 mmol/l 135-145
K 5.9 mmol/l 3.5-5
Cl 107 mmol/l 98-108
Chemistry
Despite all our utmost efforts;
unfortunate patient died after 6
hours stay at hospital.
Case 2
A 26 yrs old male working in a textile industry brought to ER with suicidal intake of ½ cup of solution which is used to remove tags of clothes(benzole solution).
.
Complaining of palpitations,apprehension,epigastric discomfort and repeated episodes of vomiting,shortness of breath
..
A toxic looking patient highly irritable,apprehensive and in respiratory distress
..Vitals
Pulse 110 bpm
B.P 100/60 mmHg
Temp. 98.6
Respiratory rate 36/min
Systemic examination was unremarkable other than bilateral ronchi in chest on auscultation and epigastric tenderness
Management
Patient resucitated with oxygen,back to back nebulization and IV fluids.
Gastric lavage carried out with normal saline and charcoal.
…
Patient shifted to intensive care unit for further investigations and management
…
Supportive care with
steroids,antibiotics,fluids,soda bicarb
and proton pump inhibitors continued.
Methylene blue was given at this stage.
Exchange transfusion carried out according to haematologist advice.
Progress
Dark coloured urine (day1)
Cyanosis (day2)
Ventilatory support (day2)
Central line (day2)
Day1 Day2 Day3 Day4
Blood Pressure
125/80 130/90 155/90 70 systolic
SaO2 87% 77% 68% 65%
GCS 15/15 8/15 5/15 3/15
Out Put 700ml
Investigations
Blood complete picture
RBS 136 mg /dl
ECG sinus tachycardia
Parameter
ResultDay1
ResultDay2
Result Day4
Unit Reference Range
WBCs 15.1 18.3 27.2 109 per liter
4-11x109 per liter
Neutrophils
82% 88% 93% 54-62
Hb 13.6 11.6 10.2 g/dl 13.5-17.5 g/dl
Plt 215 188 129 109 per liter
150-450 x 109 per liter
Urinalysis showed brown coloured urine
Colour Brown
Turbidity +ve
pH 6.5
Sediment +ve
Sp gravity 1.025
Urobilinogen Normal
Pus cells 4-5
RBCs 1-2
Crystals 0-1
Casts WBC
Albumin +ve
Glucose Nil
Day1 Day4
pH 7.36 7.3 7.35-7.45
pCO2 36.5 32.5 35-45
pO2 80 78 83-108
HCO3 23.5 18.5 21-28
ABGs
Test ResultDay1
Result Day2
Result Day3
Result Day4
Unit Normal
ALT 45 75 105 123 U/L 43
Alkaline Phosphatse
312 346 378 U/L 65-360
Urea 43 86 106 116 mg/dl 12-45
Creatinine
1.8 2.1 2.3 mg/dl Upto 1.2
Uric Acid 6.8 6.9 7.1 mg/dl 2-7
Na 137 140 142 140 mmol/l 135-145
K 4 4.3 4 4.5 mmol/l 3.5-5
Cl 100 103 107 105 mmol/l 98-108
Chemistry
Patient developing multiorgan failure…
..
But patient failed to maintain vitals and ultimately went into cardiorespiratory arrest and could not be revived..
He died after 4 days stay at hospital
Case 3
A 26 years old presented in ER with suicidal ingestion of 2 tablets of wheatpill(aluminium phosphide)1 and a half hour ago.
..
Complaining of multiple episodes of vomiting..
..
A young anxious looking female with vitals of
Bp 110/70
Pulse 86/bpm
T 98.6 F
R/R 18/min
Systemic examination was unremarkable..
Investigations
Blood complete picture
RBS 128 mg /dl
ECG
Parameter Result Unit Reference Range
WBCs 11.6 109 per liter 4-11x109 per liter
Neutrophils 79.8% 54-62
Hb 12.7 g/dl 13.5-17.5 g/dl
Plt 179 109 per liter 150-450 x 109 per liter
pH 7.34 7.35-7.45
pCO2 29.5 35-45
pO2 116 83-108
HCO3 17.9 21-28
ABGs
Colour Yellow
Turbidity +ve
pH 6.2
Sediment +ve
Sp gravity 1.025
Urobilinogen Normal
Pus cells 6-7
RBCs 1-2
Crystals 0-1
Casts Nil
Albumin -ve
Glucose Nil
Urine analysis
Test Result Unit Normal
ALT 42 U/L 43
Alkaline Phosphatse
326 U/L 65-360
Urea 35 mg/dl 12-45
Creatinine 1.1 mg/dl Upto 1.2
CKMB 25 IU/L Upto 25
Na 140 mmol/l 135-145
K 4.1 mmol/l 3.5-5
Cl 107 mmol/l 98-108
Chemistry
.. Gastric lavage carried out with 1lit of edible
oil and charcoal.
Supportive management done with iv fluids,magnesium sulphate,calcium gluconate
steroids,antibiotics and PPIs.
Continuous cardiac monitoring done. ECG&ABGs 12 hourly Amiodarone Strict vitals monitoring and input output
charting done.
..
Standard protocol treatment continued for 4 days during hospital stay.
Stay remained uneventful and patient discharged in a healthy state and
referred to psychiatry department.
Case 4
A 22 years old female presented with suicidal ingestion of 2 teaspoonfull of rat killing granules;2 hours before presentation to Emergency department.
..
Presented with complains of
frothing,
shivering,
urinary and fecal incontinence,
multiple episodes of vomiting and
abdominal cramps.
..
Vitals showed bradycardia
Bp 100/70
Pulse 58/min
T 98.6F
r/r 22/min
..Systemic examination revealed
Bilateral crepitations in chest on auscultation
GCS 9/15 and pinpoint pupils
Hyperactive Bowel sounds
Rest of the examination was unremarkable
Management
Airway maintained and oxygen administered
Deep throat suctioning carried out.Fluids given.Gastrointestinal decontamination
done with normal saline and charcoal.
…
Specific antidotes pralidoxime and atropine given per protocol.
Investigations
Blood complete picture
RBS 119 mg /dl
ECG
Parameter Result Unit Reference Range
WBCs 12.1 109 per liter 4-11x109 per liter
Neutrophils 82.8% 54-62
Hb 13.1 g/dl 13.5-17.5 g/dl
Plt 198 109 per liter 150-450 x 109 per liter
pH 7.42 7.35-7.45
pCO2 33.7 35-45
pO2 82 83-108
HCO3 23.6 21-28
ABGs
Colour Yellow
Turbidity -ve
pH 6.9
Sediment -ve
Sp gravity 1.025
Urobilinogen Normal
Pus cells 4-5
RBCs 3-4
Crystals 0-1
Casts Nil
Albumin -ve
Glucose Nil
Urine analysis
Test Result Unit Normal Range
ALT 41 U/L 43
Urea 39 mg/dl 12-45
Na 139 mmol/l 135-145
K 3.95 mmol/l 3.5-5
Cl 103.5 mmol/l 98-108
Chemistry
Test Result Unit Normal
ALT 42 U/L 43
Alkaline Phosphatse
278 U/L 65-360
Urea 35 mg/dl 12-45
Creatinine 1.0 mg/dl Upto 1.2
Na 140 mmol/l 135-145
K 4.1 mmol/l 3.5-5
Cl 107 mmol/l 98-108
PT 15 sec 13
aPTT 28 sec 27
Chemistry
…
Standard therapy continued for 3 days.
Patient improved and recovery was uneventful.
Dischrged after 3 days stay in a stable state and referred for psychiatric
evaluation.
Cases of poisoning received by DHQ
Rawalpindi in 3 months from JAN
till march 2015
Cases of Poisoning seen at ER in 3 Months
Acid/corrosive 31
Wheat pill 35
Organophosphate/Rat pill 104
Opioid 3
Benzodi-azepine 25
Mixed 11Kalapathar 1
Kerosine oil 1
Paracetamol 6
NSAIDs 7
Unknown 25
Poisoning 239
Cases of Poisoning seen at ER in 3 Months
12%14%
42%
1%
10%4%
0.4%
0.4%2%
3%
10%Total Cases 239
Acid/corrosive 31Wheat pill 35Organophosphate/Rat pill 104Opioid 3Benzodiazepine 25Mixed 11Kalapathar 1Kerosine oil 1Paracetamol 6NSAIDs 7Unknown 25
Cases of Poisoning seen at ER in 3 Months
Acid/corrosive 3113%
Wheat pill 3514%
Organophosphate/Rat pill 10442%
Opioid 31%
Benzodi-azepine 25
10%
Mixed 115%
Kalapathar 10.4%
Kerosine oil 10.4%
Paracetamol 6
2%NSAIDs 7
3%
Unknown 2510%
Total Cases 239
Mortality of Poisoning patients in 3 months
Wheat pill 6
Organophosphate2
Unknown 3
Opioid 1
Kalapathar 1
Others 1Deaths due to poisoning 14
Mortalty of Poisoning patients in 3 months
Total Cases239
Deaths 146%
Deaths due to poisoning
Mortalty of Poisoning patients in 3 months
Total Cases104
Deaths 22%
Mortality of organophosphate poisoning
Mortalty of Poisoning patients in 3 months
Total Case
s35
Deaths 617%
Mortality wheat pill poisoning
Mortalty of Poisoning patients in 3 months
Total Cases 25
Deaths 312%
Mortality unknown poisoning
Mortalty of Poisoning patients in 3 months
Total Cases
3
Deaths 133%
Mortality opioid poisoning