潘恆之 , 林杰樑 , 顏宗海

林口長庚紀念醫院 腎臟系 臨床毒物科

Patient's Profiles

Case 1Age: 28Gender: maleEthnic: Filipino Marital status: marriedOccupation: worker

Case 2Age: 34Gender: maleEthnic: Filipino Marital status: marriedOccupation: worker

Present Illness

Two otherwise healthy, Filipino workers from a poultry meat-processing factory suffered sudden loss of consciousness while cleaning pig slotted floors.

Case 1 (28 y/o male) -- Physical examination Vital signs: T: 35.8 ℃ P: 0 bpm R: 0 cpm BP: 0/0

mmHg GENERAL APPEARANCE: pale and cyanotic, foul odor CONSCIOUSNESS: E 1 V 1 M 1 HEENT: sclera: anicteric, conjunctiva: not pale

pupil size L/R: 6/6 (mm), cyanotic lips NECK: supple, no jugular vein engorgement CHEST: no breathing sounds HEART: no heart sounds ABDOMEN: soft and flat, hypoactive bowel sounds EXTREMITIES: freely movable, no pitting edema

血液WBC   8700 1/µLHemoglobin

13.4 g/dL

MCV 91.6 fLPlatelets

289K 1/µL

Segment

70 %

Lymphocyte

22 %

Eosinophil

4 %

PT (INR) 1.0APTT 23.8 sec

生化    Fasting sugar

133 mg/dL

ALT 96 U/LBUN 22.1 mg/dLCreatinine

1.50 mg/dL

eGFR 53 mL/min/1.73㎡

Na 149 mEq/LK 6.4 mEq/LCl 103 mEq/LCa 8.1 mg/dLP 2.4 mg/dLMg 1.7 mEq/LCK-MB 3.9 ng/mLTroponin-I

0.01 ng/mL

Lactate 24.2 mg/dLFree-T4 1.38 ng/dLTSH 0.77 µIU/mLCortisol 22.3 µg/dLO2HB 63.6 %COHB 1.2 %METHB 0.3 %O2CT 64.9 %

動脈血PH  6.799PCO2 90.0 mmHgPO2 69.3 mmHgHCO3 13.7 mm/LSBE - 20.9 mm/LSa% 60.5 %

Lab data (28 y/o male)

Course (28 y/o male)

An out-of-hospital cardiac arrest victim Blood tests revealed hypoxemia,

hypercapnia, acute renal failure, lactate acidosis and hyperkalemia

Electrocardiogram showed asystole CPCR failure

Vital signs: T: 33.0 ℃ P: 131 bpm R: 6 cpm BP: 77/51 mmHg

GENERAL APPEARANCE: acute-ill looking, foul odor CONSCIOUSNESS: E 2 V 1 M 4 HEENT: sclera: anicteric, conjunctiva: not pale

pupil size L/R: 3/3 (mm), throat: not injected NECK: supple, no jugular vein engorgement CHEST: respiratory pattern: slow and shallow

breathing sound: clear HEART: rapid heart beat without murmurs ABDOMEN: Soft and flat, normoactive bowel sounds,

no local tenderness, no rebounding pain EXTREMITIES: freely movable, symmetric peripheral pulse

Case 2 (34 y/o male) -- Physical examination

血液WBC   9500 1/µLHemoglobin

14.4 g/dL

MCV 83.8 fLPlatelets 162K 1/µLSegment 57.9 %Lymphocyte

37.6 %

Eosinophil

1.8 %

PT (INR) 1.0APTT 23.8 sec

生化    Fasting sugar

119 mg/dL

ALT 41 U/LBUN 18.1 mg/dLCreatinine

1.54 mg/dL

eGFR 52 mL/min/1.73 ㎡

Na 138 mEq/LK 3.1 mEq/LCl 101 mEq/LCa 8.7 mg/dLP 3.1 mg/dLMg 1.7 mEq/LCK-MB 5.1 ng/mLTroponin-I

0.017 ng/mL

Lactate 23.8 mg/dLFree-T4 1.36 ng/dLTSH 0.69 µIU/mLCortisol 50.3 µg/dLO2 HB % 70.3 %CO HB % 0.9 %MET HB %

7.2 %

O2 CT 78.3 %

動脈血PH  6.979PCO2 84.1 mmHgPO2 51.9 mmHgHCO3 19.3 mm/LSBE -12.3 mm/LSa% 73.8 %

Lab data (34 y/o male)

CXR (34 y/o male) EKG (34 y/o male)

Course (34 y/o male)

Day 1, at ER

Day 1, in ICU

Intubation with mechanical ventilator support N/S challenge, Norepinephrine run 30 µg/min Give amyl nitrite 1pc inhalation and 3% sodium nitrite 10ml iv drip for 20 mins

Brain CT: no evidence of ICH or structural lesions

Day 2, in ICU Consciousness: confused and

disoriented

Ga

Course (34 y/o male)

Day 4, in ICU

Day 5, at ordinary ward Aspiration pneumonia => give empiric antibiotics: Ceftazidime 2g q8h

Day 16, at ordinary ward Consciousness clear Discharge

Extubation EEG: diffuse cortical dysfunction

Introduction Hydrogen sulfide (H2S) is a colorless

toxic gas that has strong odor of “rotten eggs”

H2S poisoning usually occurs by inhalation

Discussion

~ Woodall GM et al, Inhal Toxicol. 2005;17:593-639

Source Organic 1. Incomplete oxidation of sulfur

compounds 2. Bacterial degradation of sulfur

compounds

Inorganic, mainly industrial 1. Petroleum industry -- contamination or by-product 2. Chemical industry -- reactant for production of

chemicals 3. Production of heavy water 4. Metal refining

~ Tee L. Guidotti , International Journal of Toxicology. 2010, 29:569-581

Knock down !!

Apnea !!

~ Doujaiji B et al, Ann Saudi Med. 2010;30:76-80

Symptoms

0.05 ppm(airbone

concentration)

Pungent smell mimicking “rotten egg”

0.1 ppm Anosmia

50-150 ppm

Paralysis, conjunctivitis

250 ppm Photophobia, pulmonary edema

250-500 ppm

Headache, nausea, vomiting, confusion, tachycardia, hypotension

500-750 ppm

Respiratory arrest

750-1000 ppm

Knocked down (central neurotoxicity)

> 1000 ppm

Dying immediately within a breath

~ Tee L. Guidotti , International Journal of Toxicology. 2010, 29:569-581

Diagnosis Measurement of blood sulfide in acute emergencies is of little clinical value. History of hydrogen sulfide exposure Odor of hydrogen sulfide Serum BUN, Cr, electrolyte, glucose,

CPK, blood gas & serum lactate ECG & Chest X-ray CT scan

~ Milby HT et al, American Journal of Industrial Medicine. 1999, 35:192-195

Treatment

~ Gregorakos L et al, Angiology. 1995, 46:1123-1131

Antidote – Nitrite Salt Nitrite salt oxidizes

the Fe2+ of hemoglobin to Fe3+, deriving Met-Hb

Met-Hb competes with the Fe3+ of cytochrome oxidase and protects it from oxidization by H2S

Keep the Met-Hb level < 25% with a concern of hypoxemia from methemoglobinemia

Oxy-Hb

Met-Hb

Sulfa-MetHb

Oxy-Hb + SO2

H2S

Amyl nitrite, Sodium nitrite

cyt c2+cyt c3+

cyt a2+cyt a3+

cyt a32+cyt a3

3+

H2O2+ 2H+ 2H2O

~ Smith RP et al, Ann Rev Toxicol. 1976, 16:189

Mitochondria

Blood

Nitrite KitAmyl nitrite

• If spontaneous breathing remains,

give amyl nitrite

inhalation every 3

min until sodium

nitrite is ready

Sodium nitrite

• Dissolve 0.6g sodium nitrite to 20 ml of water ( 3% solution)

• IV 10ml of the 3% sodium nitrite solution > 20 mins

~ Morii et al, Journal of Occupational Medicine and Toxicology. 2010, 5:28

Highlights Hydrogen sulfide poisoning is a relatively

uncommon and frequently lethal hazard Toxidrome ： 1. odor perception followed by olfactory paralysis

2. burning eyes 3. pulmonary edema 4. knock down Foul odor Keep Airway, breath, circulation, O2

100% Antidote ： Amyl nitrite 、 Sodium nitrite