Op poisoning and its management
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OP POISONING AND ITS MANAGEMENT
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CASE I
HISTORY- B Raju a 27 yr old unmarried gentleman, was brought
to CMC casualty at 3am on 22-04-11 with alleged history of consumption of Phorate (OP compound) mixed with water, at 5pm the previous evening.
He had 4 episodes of non-projectile, non-bilious vomiting. No h/o blood in vomitus.
No h/o of increased salivation, urination or defecation.
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In the casualty, gastric lavage was done and activated charcoal was given.
O/E-
drowsy, GCS 15/15
febrile
Pulse rate- 100/min
Blood presssure- 90/70mmHg
Respiratory rate- 28/min
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Neck muscle weakness Bilateral PINPOINT PUPILS, not reacting to light No focal neurological deficit Tone of upper limb muscles increased bilaterally, normal
tone in lower limb Power- grade 3 in all 4 limbs Reflexes- all deep tendon reflexes are preserved,
however plantar reflex was unresponsive bilaterally
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CVS- 1st and 2nd heart sounds heard, no added sounds RS- normal vesicular breathe sounds heard P/A- soft, non-tender, no organomegaly
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INVESTIGATIONS-
ABG-
Ph- 7.4
Pco2- 34
Po2- 118
ELECTROLYTES-
Na- 125
K- 6.9
Cl- 108
Ca- 4.35
HCO3-
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Hb- 16.3 Platelets- 136000 WBC Total- 7500 WBC Diff- N-83, E-6, B-1, L-10 LFT- Direct bilirubin- 0.2 Total bilirubin- 1.1 Total protein- 6.7 Albumin- 3.8 SGOT- 54 SGPT- 63 Alkaline phosphatase- 102
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Diagnosis???
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Organophosphorus poisoning…
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COMMON AMONG FARMERS-
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MECHANISM OF ACTION
Inactivates acetylcholinesterase by phosphorylation, followed by accumulation of Ach in the synapses.
Recovery Aging
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ORGANOPHOSPHORUS COMPOUNDS
Dichlorvos Fenthion malathion
Diazion Parathionchlor chlorpyrifos
DIMETHYL COMPOUNDS DIETHYL COMPOUNDS
NERVE AGENTS- G agents- Sarin, tabun, somanV agents- VX, VE
INSECTICIDES-
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CLINICAL FEATURES-Muscarinic Nicotinic Central receptors
Cardiovascular Bradycardia Hypotension
Respiratory Rhinorrhea Bronchorrhea/spasm Cough
Gastrointestinal Increased salivation Nausea/vomiting Abdominal pain Diarrhoea Fecal incontinence
Genitourinary Urinary incontinence
Ocular Blurred vision/miosis Increased lacrimation
Cardiovascular Tachycardia Hypertension
Musculoskeletal Weakness Fasciculations Cramps Paralysis
Anxiety Restlessness Ataxia Convulsions Insomnia Dysarthria Tremors Coma Absent reflexes CS respiration Resp. depression Circulatory collapse
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TRIPHASIC ILLNESS…
ACUTE CHOLINERGIC SYNDROME-
-Cholinergic symptoms within first 24 hours
Due to persistent depolarization of the neuromuscular junction due to blockade of AChE at all the receptors
Features include garlic like odour in the breath/vomit/clothes, bradycardia (80%), miosis, fasciculations, twitching, convulsions, flacid paralysis of limbs and extraocular muscles, central depression of respiratory system.
Some response to atropine claimed
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INTERMEDIATE SYNDROME 24-96 hours after poisoning after the cholinergic phase
settles Excess Ach an NMJ causes down regulation of nicotinic
receptors- muscles affected Characterized by proximal neck muscle leading to
respiratory distress and failure without muscarinic signs Without intervention, cyanosis, coma and death occurs
rapidly Incidence 8-49%, lasts for few days to about 3 weeks
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OP INDUCED DELAYED POLYNEUROPATHY
1-3 weeks after acute exposure Due to degeneration of long myelinated nerve fibres. Pure motor or sensor-motor Characterized by cramps in the legs, numbness and
paraesthesiae in the distal UL & LL, shuffling gait, foot and wrist drop.
Wasting, DTR reduced/absent, pyramidal tract signs Recovery is incomplete
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MANAGEMENT- Airway - ensure clear airway, clear secretions,
check for cough/gag
Breathing - check oxygenation, supplemental O2, breathing pattern & adequacy
Circulation - heart rate, rhythm, blood pressure
Decontamination – gut and skin
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ACUTE CHOLINERGIC SYNDROME-
Atropine-
- 1.8- 3mg bolus
- dose doubled every 5mins until atropinised
- then 20-30% dose needed for maintenance,
given as infusion/ hour Oximes-
- Pralidoxime chloride (1gm bolus in 30mins, then infusion 0.5g/hr) OR
- Obidoxime (0.25mg bolus, then infusion 0.75g/24hr)
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iv Diazepam Oxygen and ventilatory support
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INTERMEDIATE SYNDROME-
Ventilatory support while on sedation Parenteral nutrition
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OPIDN-
No specific treatment Exercise recommended
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HISTORY: 35 year old male following consumption of oduvanthalai
with alcohol, presented with breathlessness and palpitations Vomiting (3-4 episodes/day ) a/w abdominal pain Giddiness
CASE 2
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EXAMINATION:
Patient oriented, dyspnoeic, afebrile
Pulse rate:91/min
Blood pressure= 110/70 mm Hg
Respiratory rate:20/minute
Diffuse abdominal tenderness
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pH 7.33 (7.35- 7.45) pCO2 33 pO2 97
ELECTROLYTES Na 128 K 2.1 Cl 102 HCO3 (24-28) Ca 4.15 Lac 1.0 mmol/l
ABG
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Hb 12.2 Creatinine 1.6( 0.5-1.4) Urinary pH 7 (<6) LIVER FUNCTION TESTS Bilirubin(total) 0.7 Direct 0.2 Protein (total) 7.4 Albumin 3.9 SGOT 602 (8-40) SGPT 143 (5-35) ALP 336
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ODUVANTHALAI POISONING
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CLEISTANTHUS COLLINUS(ODUVANTHALAI)
•Commonly consumed as a leaf decoction.•Fatal dose: 10.5 g/kg body weight/ 200-400 leaves
•Fatal Period : 1-3 days
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• MECHANISM OF ACTION : Injury to the distal renal tubules, pulmonary epithelium and peripheral blood vessels due to glutathione depletion
• ACTIVE PRINCIPLE: aryl-naphthalene lignin lactones: Collinusin, the glycosides Cleistanthin A and B, and their genin Diphyllin
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hypokalemia due to kaliuresis cardiac arrythmias metabolic acidosis due to distal renal tubular acidosis hypoxia due to ARDS hypotension due to vasodilatation Rhabdomyolysis occurs which leads to myoglobinuria
and renal failure
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SYMPTOMS Vomiting Headache, giddiness Palpitations Dyspnoea Neuromuscular weakness
SIGNS Tachypnoea( >30/min) Hypotension
CLINICAL FEATURES
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CHEST X RAY: may show infiltrates ( non cardiogenic pulmonary oedema- acute respiratory distress syndrome)
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ST segment depression,Prolongation of QT interval, dysrrhythmias( due to hypokalemia)
ECG
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Metabolic acidosis Lowered HCO3 levels Increased anion gap Respiratory compensation
ARTERIAL BLOOD GAS
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Hypokalemia( blood) Hyperchloremia
Rise in serum creatinine Elevated liver enzymes
ELECTROLYTES
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Increased potassium excretion Increased urinary pH( distal renal tubular acidosis) Decreased urine output( renal failure)
URINALYSIS
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Renal failure Acute respiratory distress syndrome Shock Cardiac dysrrythmias
CAUSES OF DEATH
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Supportive measures: Oxygen supplementation and positive pressure ventilatory support
i.v sodium bicarbonate( to correct acidosis) Potassium citrate administered enterally by NG tube I.v KCl (to correct hypokalemia) N-acetyl cysteine 150mg/kg over 1 hour followed by
50mg/kg over 4 hours then 100mg/kg over 16 hours (for decontamination)
TREATMENT
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OLEANDER POISONING
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Yellow oleander seeds contain highly toxic cardiac glycosides including thevetins A and B and neriifolin.
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MECHANISM OF ACTION-
Cardiac glycosides bind to Na-K ATPase and reduce uptake of potassium into the cells which causes intracellular Na and Ca accumulation and also transient Ca release from SR.
A transient inward current is produced which increases the arrhythmogenecity of heart
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CLINICAL FEATURES-
Numbness and heat in the mouth Purging Burning pain in the throat Dryness Vomiting, diarrhoea Headache, giddiness, dilated pupils Loss of muscle power Weak, rapid, irregular pulse BP is low Heart block
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ECG
Prolonged PR interval
FIRST DEGREE HEART BLOCK
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MANAGEMENT AND INITIAL STABILISATION
Initial assessment ABC ECG (to detect heart block) Atropine (block the parasympathetic system)
Supportive care Fluid resuscitation Anti emetic
Arrhythmia management(bradyarrhythmias…atropine,
tachyarrhythmias…lidocaine) Hyperkalemia is due to extracellular shift of potassium rather
than an increase in total body potassium and is best treated with insulin-dextrose infusion.
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DAVIDSON A clinical study of renal tubular dysfunction in Cleistanthus Collinus
(Oduvanthalai) poisoning Nampoothiri et al Cleistanthus collinus poisoning- a case report -Benjamin et al Efficacy of L-cysteine in countering cleistanthus collinus poisoning: an
indigenous phytotoxin. Sarathchandra, G.; Murthy, P. B. K. Indian Veterinary Journal 2000 Vol. 77 No. 3 pp. 209-211 ISSN INDIAN JOURNAL OF PHARMACOLOGY Cleistanthus collinus induces
type I distal renal tubular acidosis and type II respiratory failure in rats- Maneksh et al.,
Myasthenic crisis-like syndrome due to Cleistanthus collinus poisoning( a case report)-Damodaram et al
Pathophysiology of organ dysfunction in oduvanthalai poisoning- keshavan et al
REFERENCES
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ACKNOWLEDGEMENT
Dr RAMYA
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Thank you…