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小儿毒物学
给我Evidence其余免谈!!
实证医学文献回顾
Shin Kong Memorial Hospital
Department of Emergency Medicine
Dr. Dorji Harnod哈多吉
Toxicologic Emergency Goldfrank
Review in Toxicology P. Bryson
Pediatric Emergency G. Fleisher
小儿毒物学
给我Evidence其余免谈!!
实证医学文献回顾
实证医学文献回顾之后仅发现一篇
於中毒之昏迷病患使用Flumazenil之安全
性研究. Hojer BMJ. 1991.
105 昏迷病人.
排除怀孕癫痫及已知药物中毒者
IV flumazenil 10ml v.s 安慰剂
减少插管比 : 25%-55%.减少洗胃
比 : 21%-51%,减少导 管比 :
21%-51%,
9 并发症.
结 :安全 TCA
小儿中毒真的常 吗
台 荣总毒物科谘询中心资 统计自1985 to 1993.
C.C. Yang (杨振昌) / J.F. Deng (邓昭芳)
J. of Clinical Toxicology 1996
台湾常 十大毒物
Paraquat巴 刈, organophosphate有机磷,
amphetamine安非他命, Hydrocarbon轻油, CO
一氧化碳, BZD安眠药, aspirin阿斯匹 , CV
drugs心脏用药, theophylline气喘用药,
Mercury水银, toluene, herb……
US v.s Taiwan (This is PCC data!!)
美国毒药物控制中心:
儿童中毒占60%,其中54%为 岁以下from
home
荣总毒药物控制中心:
儿童中毒占24.8%,其中69%为 岁以下
from H!!
主要中毒物质: 浴室厨房用品及药物
实证医学1-
from AACT / Shannon NEJM 2000 / Liebelt JAMA 1999
吐根 浆Ipecac Syrup
无 床报告显示有效
可能 低活性碳之 床效果.
仅可用於中毒 十分钟内之清醒病患
廿分钟内发生效果持续吐三小时
可用於意 昏迷的病患, 腐蚀剂中毒病
患,轻油中毒病患
台湾尚无此药
实证医学1-
洗胃Gastric Lavage
无 床报告显示有效
仅可用於中毒 十分钟内之清醒病患(30%)
可用於意 昏迷的病患, 腐蚀剂中毒病患,
轻油中毒病患
并发症可能为吸入性肺炎,肠穿孔喉头痉挛,
电解质 平衡, 混 病患无法使用…
必须头低左侧躺, 36 Fr!!
10-15 ml/kg for kids.
2
实证医学1-
单次使用活性碳:Single-dose AC
无 床报告显示有效
仅可用於中毒 十分钟内之清醒病患. (75%)
酒精Alcohol, 氰Cyanide, 电解质Electro,铁剂
Iron, 溶剂solvent等无效
剂 : >1y/o=>1g/kg, 1-12 y/o=> 25-50gm
adolescent and adult=>25-100gm
并发症最怕吸入性肺炎而造成脓胸.
以麦当 的巧克 杯加入活性碳骗小孩喝!!
活性碳:中毒药物= 10:1
实证医学1-
泻药:Cathartics
无 床报告显示有效!!
无必要使用,除非使用於「重复使用活
性碳」的情况Mg Citrate 4ml/kg.
最近曾发生腹部外伤或手术时, 腐蚀剂中
毒, 休克,电解质 平衡, 毒症病患
可使用.
.
并发症为电解质 平衡及休克.
实证医学1-
灌肠: Whole Bowel Irrigation
无 床报告显示有效!!
使用时机: 长效剂型药物/ 肠溶碇药物
铁剂中毒/ 锂盐中毒( 上有效.)
禁用时机:肠阻 ,休克,内出血,
没有保护呼吸道
并发症: 肠胃 适,吸入性肺炎
Polyethylene Glycol 500ml/hr v.s 2L/hr in adult.
大 透-1!
12 岁 童於和母亲口角之后喝 一口除
草剂,之后吐 二次.
第二天送达急诊, ( 色液体农药)
脸颊红肿,合并口内溃疡.
"我 想死!"
你的诊断为何
巴 刈
Paraquat Intoxication: diagnosis
*第一天造成口内溃疡
*第一周内肝肾受损
*第一周后,肺部纤维化
人在意 清醒下喘到死亡
巴 刈
Paraquat Intoxication
巴 刈是最简单处 的农药中毒. :必死!
Case NumberMortality Num Mortality arate
CH Christian H295 220 74.6%
CG Memorial H165 108 72.0%
MC Memorial H39 27 71.4%
Total 499 355 71.1%
3
巴 刈
Paraquat Intoxication: 中毒机转
氧气哪 多就哪 死!所以忌用氧气
巴 刈
Paraquat : 治 -通通无效
Positive study:(Addo & Poon-King 1986)
Dramatic fall of mortality(68% 41/61 v.s 28%20/72)
after treat with dexamethasone/ cyclophosphamide
But not all cases were confirmed by serum levels!!
Negative study:(Perriens, 1992)
Prospective non-randomized study showed of no use!
Vit.Eis not useful in animal study
Radiotherapy:(Franzen 1991 Jaeger 1995)
lack of evidence of efficacy
Lung transplantation:(Toronto lung transplantation
group): no survival
Hemoperfusion : no clinical evidence(Hampson 1990)
Little evidence 2-Study from Taiwan!!
Paraquat Intoxication: treatment
A prospective trial of pulse therapy with Glucocorticoid
and Cyclophosphamide in moderate-severe patients.
Ja-Liang Lin 1999 Am J Respiratory Crit Care Med.
1992-1997, 142 cases, test by sodium dithionite.
50 cases mod- severe included.
8 hr H/P, then Dexamethason 10mg q8h 14days.
15g/kg CP, 1gm MP iv 2h/day for 3 days.
No significant difference except serum Cr p=0.004
Need randomized study.
大 透!!
八岁男童误食药物之后,产生毒性症 ………
Diarrhea腹泻
Urination 多
Miosis缩瞳
Bradycardia心跳慢, bronchorrhea痰多,
bronchospasm支气管收缩
Emesis呕吐
Lacrimation
Salivation 口水
你的诊断为何 中邪吗
有机磷中毒
Organophosphate : 治
Cholinergic Syndrome!!胆碱症候群
The Pharmacokinetics of Continuous Infusion Pralidoxime
in Children with Organophosphate poisoning.
Stephen S. (11cases)J. Clinical Toxicology,1998
Traditional dosage: 1gm stat & q8h in adult
(5-10mg/kg)25-50mg/kg stat & q8h in child
25-50 mg/kgloading then 10-20mg/kg/hr.
50 mg/kg stat for severe intoxication
**点滴静注PAM!!
**Atropine 阿托平0.01mg/kg in children.
有机磷:小儿中毒之 同症
Organophosphate / Carbamate
Poisoning in
MatitiahuPediatric Emergency Care 1999.
Symptoms in 36 carbamate poisoning on admission
Stupor/Coma昏迷36(100)
Hypotonia四肢无 36(100)
Diarrhea 12(33)
Miosis 20(55)
Bradycardia 6 (16)
Seizure 3 (8)
Respiratory failure 3 (8)
Fasciculation 2 (5.5)
4
有机磷:小儿中毒之 同症
Organophosphate / Carbamate
Poisoning in
Symptoms in 16 OPP poisoning on admission
Stupor/Coma 16(100)
Hypotonia 16(100)
Diarrhea 5 (30)
Miosis 9 (56)
Bradycardia 4 (25)
Salivation 6 (37)
Lung Edema 6 (37)
CNS depression>>Cholinergic syndrome!!
$$$$ What is the component of必安住 蟑螂特效药
大 透!!
岁男童误食哥哥" 床的药"之后被送 急诊
Hypoactive bowel sound.肠蠕动音减低
Distended urinary bladder.膀胱胀大
Mydriasis.瞳孔放大
Tachycardia.心跳加快
Dry skin.皮肤乾燥
Shock.休克
Delirium…..意 迷
你的诊断为何 中邪吗
三环抗忧郁药物
Tricyclic Antidepressants: 诊断
Anticholinergic Syndrome!!抗胆碱症候群
QRS versus serum level in predicting seizure and VT after
TCA overdose. Boehnert. NEJM 1985
QRS 100msec 1/3 got seizure
QRS > 160msec got ventricular arrhythmia
EKG criteria for TCA Niemann, Am J. Cardio 1986
12 cases : QRS prolong, QT prolong, sinus tachycardia,
and QRS complex terminal 40 msec R axis deviation .
PPV: 66% NPV: 100% EKG efficiency: 97%
三环抗忧郁药物
Tricyclic Antidepressants: 诊断
Terminal 40ms R axis deviation. 小儿科 准!!
Berkovitch CA. sensitivity 35%, specificity 74%.
三环抗忧郁药物
Tricyclic Antidepressants: 治
1.Children are more sensitive to TCAs …....Fleisher/Goldfrank
2.TCA bind to (picroToxin)binding site on GABA receptor
then cause seizure.
Valium镇定剂治 抽筋, Dilantin癫能停无法治 此抽筋
且动物实验中会增加心脏毒性. (钠 子通道阻断剂)
3.Physostigmine for delirium will cause asystole!!
Delay and repeat charcol use( Cholinergic block )
4.静脉输液以及正肾上腺素治 休克( Alpha block ).
5.NaHCO3.1-2mEq/kg if QRS>100ms.(Sodium channel block)
If cannot, use hyperventilation and hypertonic saline!!
TCA block reuptake!!
1.block reuptake.
initial BP increase.
2.then NE decrease.
so shock!!
3.give NE is better
then Dopamine!!
5
Drinking will make trouble!!大 透!!
1. 5岁男童喝酒之后意 昏迷送入急诊.
麼是 即有答案的检查
2. 14 岁少 喝酒之后气喘
气喘却无面色发紫, 上腹痛, 呕吐 次.
你的诊断为何 酒醉吗
Toxic Alcohol: Methanol甲醇
源: 抗冻剂, 雨刷清洁剂, 假酒
高挥发性, 低燃点.
中毒症 :
a. 第一天左右:
可能有中毒症 , 合并酒精中毒
b.一小时之后,通常在一天左右:
High anion gap metabolic acidosis代谢性酸中毒.
Visual change (snow field ) or blindness 视 改变之后甚
至会瞎眼
Methanol FormaldehydeFormic AcidCO2+H2O
ADH ALDH folate
Toxic Alcohol:Ethylene Glycol
源: 抗冻剂, 雨刷清洁剂.
高挥发性, 低燃点.
中毒症 :
a. 第一天左右:
可能有中毒症 , 合并酒精中毒
b.一小时之后,通常在4-6小时以后:
High anion gap metabolic acidosis代谢性酸中毒.
Oxaluria hypocalcemia and renal toxicity. 草酸
钙於 中生成之后造成肾脏毒性
Toxic Alcohol:Ethylene Glycol
Crystal of Calcium Oxalate
6
Toxic Alcohol: Evaluation
Toxic level: 25mg/dl of both is toxic!
If serum level is not available:
Osmo gap= measured osm-calculated osm.
2Na + BUN/2.8 + Sugar/18 + Alcohol/N
N=MW/10, alcohol=4.6, methanol=3.2, ethylene glycol=6.2
Normal Osm gap is -2+/-6, -14~10.
Can not rule out toxicity with normal Osm gap!!
If a patient gap is 5 but his base line is -5, the change 10 =
methanol level of 32mg/dl / or ethylene glycol 64 mg/dl.
The patient's base line Osm gap is unknown!!
High gap will lead to toxic alcohol but uremia, sepsis,
mannitol, hyperlipidemia and hyperpreoteinemia also!!
Toxic Alcohol: Evaluation
ABG: High anion gap metabolic acidosis:
C: CO, CN
A: aspirin, alcohol
T: toluene, theophylline
M: methanol, metformin
D: DKA, AKA, SKA.
U: uremic toxin
P: paraldehyde, phenformin
I : Iron, INH
L: lactic acidosis
E: ethylene glycol.
Toxic Alcohol: Evaluation
Bed side pearls:
1.Methanol:
Fundus exam have hyperemia and pallor disc.
Subjective "snow vision".
(Methanol metabolized to formic acid, that will
inhibit the cytochrome oxidase chain and injure
the cell.)
2.Ethylene Glycol:
hypocalcemia, calcium oxalate in urine, urine
fluorescence and " how it taste "
Toxic Alcohol: Treatment
ABC's, GI decontamination only Antizole(New)
More effective with a more safety profile.(FDA)
Ethylene Glycol/Ethanol 15 ml can kill a child.
FDA only proved for EG intoxication for child.
But now they use for both!!
Expensive,($1000) but decrease the complication of
ethanol therapy and long term ICU cost.
7
Little evidence 5-
New Antidote : Fomepizole (Antizole)
Mechanism: competitive inhibitor of ADH
4-methylpyrazole, 8000x stronger than ethanol
Indication: Ethylene glycol / ethanol
Contraindication: hypersensitivity to pyrazoles
Dosage: 15mg/kg loading, then10mg/kg q12h x 4
then 15mg/kg q12h till level mixed => acidosis
S: sugar level change
P: pyrexia, uncouples oxidative phosphorylation.
I : intestinal irritation.
R: renal failure in chronic user.
I : increase bleeding tendency.
N: neurologic s/s.
PD is useless and when to use HD
End organ damage, renal failure or 100mg/dl in acute
60mg/dl in chronic
大 透!
十岁 生洗澡之后昏迷送入急诊.
Anion gap metabolic acidosis. 代谢性酸血症
EKG : sinus tachycardia. 心搏过速
CXR : pulmonary edema. 肺水肿
Rhabdomyolysis may cause ARF. 急性肾衰竭
Bullae noted on skin.
你的诊断为何
CO intoxication一氧化碳中毒
一氧化碳中毒及高压氧治
CO intoxication and HBO
正常大气压下半生期4小时, 100%浓 氧
气之下90分钟, 高压氧治 之下30分钟
多 医学中心治 之标准= 成人25, 小孩
15.
无明显医学证据可证明高压氧治 之 效, 但
如果病人coma昏迷/ end organ damage器官受伤
/ neurologic deficit开始时有神经学失常.
100 - 7 test!!
大 透!!
10 岁男童吃"心脏药".
Clear, HR:40-50, BP: 100/60.
12岁男童吃"心脏药".
Relative clear, HR: 40, BP: 70/40 sugar higher.
11岁男童吃"心脏药".
Confusion, HR: 40, BP: 70/40 sugar lower.
你的诊断为何
Digoxin: 毛地黄中毒机转
2.Increase vagal tonesinus brady/AV blockbradyca.
3.Any dysrhythmia except supraventricular tachycardia.
9
Digoxin毛地黄中毒机转
高钾血症为急性毛地黄中毒之表徵: J Toxicol 1973
K < 5.0 mEq/dl all survive.
5.0 < K 5.5 mEq all died.
甲 子浓 大於5为急性中毒之表徵.
可以使用DigiBind.
Retrospective study showed internal pacing will increase
mortality. 心脏电击器 可使用於此 病患
Taboulet J Toxicol 1993
Digoxin : 治
活性碳是最有效的, 但鼻胃管插入会造成心跳
变慢.
以阿扥平Atropine治 心跳变慢bradycardia.
Lidocaine / Dilantin for Ventri. Arrhythmia.
Cardioversion电击要从25焦尔开始.
Acute : 10 vials Chronic: 2 vials in kids.
Replace K, Mg if low..
If K is high in acute cases, not to use Ca!!!!
Beta blocker / CCBBB and CCB
Gastric emptying / WBI
Atropine may not have effect. Pacing/ IABP!!
CaCl2 1amp 10% 3-5 min for both in adults.
In kids: CaGluconate 10-20mg/kg (CaCl2sclerosis)
Glucagon via G3 protein 50-150mcg/kg then
50mcg/kg/hr up to adult dose.
Catecholamine, no good evidence which is better.
Insulin/sugar: 10u RI/25gm dextrose 0.1-1.0u/kg/hr.
Experimental evidence!!
大 透!!
14 岁 生吃药自 送入急诊.
Nausea恶心/ vomiting呕吐/ pallor苍白(第一天).
肝功能 常(第二天).
肝肾功能 常(第三天).
第4-14天.将会死亡或是完全恢
你的诊断为何
Acetaminophen 普拿疼没有毒, 但NAPQI 有!
10
Normogram for Acetaminophen overdose
FDA asked for 25% safety margin!! 150mg/kg!
Canada and Europe use 200mg/kg line!!
Acetaminophen overdose
Based on UK study, 1/500 suicide pt will get toxic
level so check ACT level in all suicide pt.
Gastric lavage is not as good as AC.
10 volunteers, randomized but not double blind
Robert G. Ca Annals of Emerg. Med. 2000
When using NAC within 8 hours, it will be the
same efficacious!!Smilkstein NEJM. 1988
When given late, NAC still have some benefit.
NAC starting after 10-36 hrs reduced fulminant
hepatic failure Harrison Lacet 1990
Acetaminophen: treatment protocol
Oral dosing: USA
Loading dose: 140mg/kg.
Maintenance : 70mg/kg q4h for 17 doses.
total 1330mg/kg in 72 hours
**Oral is safer but bad taste, usually cause vomiting.
Need Primperan up to 1-2 mg/kg / cover cup!!
Iv dosing : in Canada / Europe.
The same dosing as oral ones.
**Watch out for anaphylactoid Rx ( related to rate)!!
The regimen is not pyogen free!! Harrisson use IV.
Street drugs
14 Y/O girl come in coma Date rape
Vital signs stable with
1.No airway reflex.
2.OK airway reflex.
What kind of date rape drug you should know
Date rape drugs
1.Benzodiazepam.
2.GHB r-Hydroxy-butyrate/ GBL r-Butyro-Lactone.
3.Ketamine.
Others club drug you need to know!!
1.Amphetamine.
2.Meth-Amphetamine.
3.MDMA: methylene-dioxy-meth-amphetamine
Hyponatremia, dehydration, serotonin syndrome.
大 透!!
1 y/o boy come in after
drinking oil.
Vomiting once.
Acidosis, cyanosis
intubation.
Blood from ETT/NG.
Die in ICU hours later.
你的诊断为何
11
Hydrocarbon
No lavage nor AC need.
Protect airway.
GI disturbance.
If acidosis, NG/ETT ob,
initial cyanosis, coma
Poor outcome!!
Surfactant for treatment
Without any evidence!!
Toxidrome is important!!
1.Hypoglycemia / hyperglycemia.
2.Hypothermia / hyperthermia.
3.H ypotension / hypertension.
4.Hyperventilation / hypoventilation.
5.Bradycardia / tachycardia.
6.Big pupil / small pupil.
7.Anion gap metabolic acidosis.
8.Vomiting
9.Seizure
Hypoglycemia
A: Alcohol, Acetaminophen.
E: Ethanol.
I : Insulin.
O: OHA.
U: Uremia.
P: Propranolol.
S: Salicylate.
Hyperglycemia
A: Aminophylline.
B: Beta agonist.
C: Calcium channel blocker.
D: Dextrose.
E: Epinephrine/catacholamine/
sympathomimetics
Hypothermia
A: Alpha agonist (clonidine).
B: Barbiturate.
C: CO.
O: Opiate.
O: OHA.
L: Liqual.
S: Sedatives.
Hyperthermia.
M: Malignant neuroleptics, MAOI.
A: Anticholinergic, Antihistamine.
Li: Lithium
S: Salicylate, Serotonin syndrome.
A: Amphetamine.
Wi: Withdrawal from alcohol, BZD.
12
Hypotension
A: Antihypertension.
B: Beta blocker.
C: CCB, Cyclic antidepressant.
D: Diuretics.
E: Ethanol.
I : Iron.
O: Opiate.
T : Theophylline.
Hypertension and tachycardia.
C: Caffeine.
T: Theophylline.
S: Sympathomimetics.
C: Cocaine.
A: Anticholinergics.
N: Nicotine.
Wi: Withdrawal.
Bradycardia
P: Propranolol.
A: Anticholinergic.
C: CCB.
E: Ethanol.
D: Digoxin.
O: Opiate.
C: Cholinergic
Li: Lithium
Hypoventilation
Hy: Hypnotics.
P: organoPhosphate.
O: Opiate.
V: Venom from snake.
E: Ethanol.
N: N-M junction blocker.
T: TCA
Ni: Nicotine.
Vomiting
C: Colchicin.
A: Aminophylline.
N: Nicotine.
M: Methanol.
I : INH. Iron.
S: Salicylate.
S: Solvent.
Li: Lithium
Seizure
O: OHA.
T: Theophylline.
I : INH.
S: Sympathomimetics.
C: Cholinergic.
A: Anticholinergic.
M: Methanol.
P : Phenytoin.
B: Boric acid.
E: Ethanol withdrawal.
L: Lithium/ Lead…
13
1 or 2 pills game!!
A: anticholinergic / anticoagulant.
B: beta blocker / benzodiazepam.
C: Ca channel blocker / clonidine.
D: digoxin / Diaquat.
T: theophylline / toxic alcohol.
I : INH / Iron.
S: sympathomimetics / SSRI
Prevention is "more" important!
Don't feed me poison again!!
Question Command
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小儿毒物学
给我Evidence其余免谈!!
实证医学文献回顾
Shin Kong Memorial Hospital
Department of Emergency Medicine
Dr. Dorji Harnod哈多吉
Toxicologic Emergency Goldfrank
Review in Toxicology P. Bryson
Pediatric Emergency G. Fleisher
小儿毒物学
给我Evidence其余免谈!!
实证医学文献回顾
实证医学文献回顾之后仅发现一篇
於中毒之昏迷病患使用Flumazenil之安全
性研究. Hojer BMJ. 1991.
105 昏迷病人.
排除怀孕癫痫及已知药物中毒者
IV flumazenil 10ml v.s 安慰剂
减少插管比 : 25%-55%.减少洗胃
比 : 21%-51%,减少导 管比 :
21%-51%,
9 并发症.
结 :安全 TCA
小儿中毒真的常 吗
台 荣总毒物科谘询中心资 统计自1985 to 1993.
C.C. Yang (杨振昌) / J.F. Deng (邓昭芳)
J. of Clinical Toxicology 1996
台湾常 十大毒物
Paraquat巴 刈, organophosphate有机磷,
amphetamine安非他命, Hydrocarbon轻油, CO
一氧化碳, BZD安眠药, aspirin阿斯匹 , CV
drugs心脏用药, theophylline气喘用药,
Mercury水银, toluene, herb……
US v.s Taiwan (This is PCC data!!)
美国毒药物控制中心:
儿童中毒占60%,其中54%为 岁以下from
home
荣总毒药物控制中心:
儿童中毒占24.8%,其中69%为 岁以下
from H!!
主要中毒物质: 浴室厨房用品及药物
实证医学1-
from AACT / Shannon NEJM 2000 / Liebelt JAMA 1999
吐根 浆Ipecac Syrup
无 床报告显示有效
可能 低活性碳之 床效果.
仅可用於中毒 十分钟内之清醒病患
廿分钟内发生效果持续吐三小时
可用於意 昏迷的病患, 腐蚀剂中毒病
患,轻油中毒病患
台湾尚无此药
实证医学1-
洗胃Gastric Lavage
无 床报告显示有效
仅可用於中毒 十分钟内之清醒病患(30%)
可用於意 昏迷的病患, 腐蚀剂中毒病患,
轻油中毒病患
并发症可能为吸入性肺炎,肠穿孔喉头痉挛,
电解质 平衡, 混 病患无法使用…
必须头低左侧躺, 36 Fr!!
10-15 ml/kg for kids.
2
实证医学1-
单次使用活性碳:Single-dose AC
无 床报告显示有效
仅可用於中毒 十分钟内之清醒病患. (75%)
酒精Alcohol, 氰Cyanide, 电解质Electro,铁剂
Iron, 溶剂solvent等无效
剂 : >1y/o=>1g/kg, 1-12 y/o=> 25-50gm
adolescent and adult=>25-100gm
并发症最怕吸入性肺炎而造成脓胸.
以麦当 的巧克 杯加入活性碳骗小孩喝!!
活性碳:中毒药物= 10:1
实证医学1-
泻药:Cathartics
无 床报告显示有效!!
无必要使用,除非使用於「重复使用活
性碳」的情况Mg Citrate 4ml/kg.
最近曾发生腹部外伤或手术时, 腐蚀剂中
毒, 休克,电解质 平衡, 毒症病患
可使用.
.
并发症为电解质 平衡及休克.
实证医学1-
灌肠: Whole Bowel Irrigation
无 床报告显示有效!!
使用时机: 长效剂型药物/ 肠溶碇药物
铁剂中毒/ 锂盐中毒( 上有效.)
禁用时机:肠阻 ,休克,内出血,
没有保护呼吸道
并发症: 肠胃 适,吸入性肺炎
Polyethylene Glycol 500ml/hr v.s 2L/hr in adult.
大 透-1!
12 岁 童於和母亲口角之后喝 一口除
草剂,之后吐 二次.
第二天送达急诊, ( 色液体农药)
脸颊红肿,合并口内溃疡.
"我 想死!"
你的诊断为何
巴 刈
Paraquat Intoxication: diagnosis
*第一天造成口内溃疡
*第一周内肝肾受损
*第一周后,肺部纤维化
人在意 清醒下喘到死亡
巴 刈
Paraquat Intoxication
巴 刈是最简单处 的农药中毒. :必死!
Case NumberMortality Num Mortality arate
CH Christian H295 220 74.6%
CG Memorial H165 108 72.0%
MC Memorial H39 27 71.4%
Total 499 355 71.1%
3
巴 刈
Paraquat Intoxication: 中毒机转
氧气哪 多就哪 死!所以忌用氧气
巴 刈
Paraquat : 治 -通通无效
Positive study:(Addo & Poon-King 1986)
Dramatic fall of mortality(68% 41/61 v.s 28%20/72)
after treat with dexamethasone/ cyclophosphamide
But not all cases were confirmed by serum levels!!
Negative study:(Perriens, 1992)
Prospective non-randomized study showed of no use!
Vit.Eis not useful in animal study
Radiotherapy:(Franzen 1991 Jaeger 1995)
lack of evidence of efficacy
Lung transplantation:(Toronto lung transplantation
group): no survival
Hemoperfusion : no clinical evidence(Hampson 1990)
Little evidence 2-Study from Taiwan!!
Paraquat Intoxication: treatment
A prospective trial of pulse therapy with Glucocorticoid
and Cyclophosphamide in moderate-severe patients.
Ja-Liang Lin 1999 Am J Respiratory Crit Care Med.
1992-1997, 142 cases, test by sodium dithionite.
50 cases mod- severe included.
8 hr H/P, then Dexamethason 10mg q8h 14days.
15g/kg CP, 1gm MP iv 2h/day for 3 days.
No significant difference except serum Cr p=0.004
Need randomized study.
大 透!!
八岁男童误食药物之后,产生毒性症 ………
Diarrhea腹泻
Urination 多
Miosis缩瞳
Bradycardia心跳慢, bronchorrhea痰多,
bronchospasm支气管收缩
Emesis呕吐
Lacrimation
Salivation 口水
你的诊断为何 中邪吗
有机磷中毒
Organophosphate : 治
Cholinergic Syndrome!!胆碱症候群
The Pharmacokinetics of Continuous Infusion Pralidoxime
in Children with Organophosphate poisoning.
Stephen S. (11cases)J. Clinical Toxicology,1998
Traditional dosage: 1gm stat & q8h in adult
(5-10mg/kg)25-50mg/kg stat & q8h in child
25-50 mg/kgloading then 10-20mg/kg/hr.
50 mg/kg stat for severe intoxication
**点滴静注PAM!!
**Atropine 阿托平0.01mg/kg in children.
有机磷:小儿中毒之 同症
Organophosphate / Carbamate
Poisoning in
MatitiahuPediatric Emergency Care 1999.
Symptoms in 36 carbamate poisoning on admission
Stupor/Coma昏迷36(100)
Hypotonia四肢无 36(100)
Diarrhea 12(33)
Miosis 20(55)
Bradycardia 6 (16)
Seizure 3 (8)
Respiratory failure 3 (8)
Fasciculation 2 (5.5)
4
有机磷:小儿中毒之 同症
Organophosphate / Carbamate
Poisoning in
Symptoms in 16 OPP poisoning on admission
Stupor/Coma 16(100)
Hypotonia 16(100)
Diarrhea 5 (30)
Miosis 9 (56)
Bradycardia 4 (25)
Salivation 6 (37)
Lung Edema 6 (37)
CNS depression>>Cholinergic syndrome!!
$$$$ What is the component of必安住 蟑螂特效药
大 透!!
岁男童误食哥哥" 床的药"之后被送 急诊
Hypoactive bowel sound.肠蠕动音减低
Distended urinary bladder.膀胱胀大
Mydriasis.瞳孔放大
Tachycardia.心跳加快
Dry skin.皮肤乾燥
Shock.休克
Delirium…..意 迷
你的诊断为何 中邪吗
三环抗忧郁药物
Tricyclic Antidepressants: 诊断
Anticholinergic Syndrome!!抗胆碱症候群
QRS versus serum level in predicting seizure and VT after
TCA overdose. Boehnert. NEJM 1985
QRS 100msec 1/3 got seizure
QRS > 160msec got ventricular arrhythmia
EKG criteria for TCA Niemann, Am J. Cardio 1986
12 cases : QRS prolong, QT prolong, sinus tachycardia,
and QRS complex terminal 40 msec R axis deviation .
PPV: 66% NPV: 100% EKG efficiency: 97%
三环抗忧郁药物
Tricyclic Antidepressants: 诊断
Terminal 40ms R axis deviation. 小儿科 准!!
Berkovitch CA. sensitivity 35%, specificity 74%.
三环抗忧郁药物
Tricyclic Antidepressants: 治
1.Children are more sensitive to TCAs …....Fleisher/Goldfrank
2.TCA bind to (picroToxin)binding site on GABA receptor
then cause seizure.
Valium镇定剂治 抽筋, Dilantin癫能停无法治 此抽筋
且动物实验中会增加心脏毒性. (钠 子通道阻断剂)
3.Physostigmine for delirium will cause asystole!!
Delay and repeat charcol use( Cholinergic block )
4.静脉输液以及正肾上腺素治 休克( Alpha block ).
5.NaHCO3.1-2mEq/kg if QRS>100ms.(Sodium channel block)
If cannot, use hyperventilation and hypertonic saline!!
TCA block reuptake!!
1.block reuptake.
initial BP increase.
2.then NE decrease.
so shock!!
3.give NE is better
then Dopamine!!
5
Drinking will make trouble!!大 透!!
1. 5岁男童喝酒之后意 昏迷送入急诊.
麼是 即有答案的检查
2. 14 岁少 喝酒之后气喘
气喘却无面色发紫, 上腹痛, 呕吐 次.
你的诊断为何 酒醉吗
Toxic Alcohol: Methanol甲醇
源: 抗冻剂, 雨刷清洁剂, 假酒
高挥发性, 低燃点.
中毒症 :
a. 第一天左右:
可能有中毒症 , 合并酒精中毒
b.一小时之后,通常在一天左右:
High anion gap metabolic acidosis代谢性酸中毒.
Visual change (snow field ) or blindness 视 改变之后甚
至会瞎眼
Methanol FormaldehydeFormic AcidCO2+H2O
ADH ALDH folate
Toxic Alcohol:Ethylene Glycol
源: 抗冻剂, 雨刷清洁剂.
高挥发性, 低燃点.
中毒症 :
a. 第一天左右:
可能有中毒症 , 合并酒精中毒
b.一小时之后,通常在4-6小时以后:
High anion gap metabolic acidosis代谢性酸中毒.
Oxaluria hypocalcemia and renal toxicity. 草酸
钙於 中生成之后造成肾脏毒性
Toxic Alcohol:Ethylene Glycol
Crystal of Calcium Oxalate
6
Toxic Alcohol: Evaluation
Toxic level: 25mg/dl of both is toxic!
If serum level is not available:
Osmo gap= measured osm-calculated osm.
2Na + BUN/2.8 + Sugar/18 + Alcohol/N
N=MW/10, alcohol=4.6, methanol=3.2, ethylene glycol=6.2
Normal Osm gap is -2+/-6, -14~10.
Can not rule out toxicity with normal Osm gap!!
If a patient gap is 5 but his base line is -5, the change 10 =
methanol level of 32mg/dl / or ethylene glycol 64 mg/dl.
The patient's base line Osm gap is unknown!!
High gap will lead to toxic alcohol but uremia, sepsis,
mannitol, hyperlipidemia and hyperpreoteinemia also!!
Toxic Alcohol: Evaluation
ABG: High anion gap metabolic acidosis:
C: CO, CN
A: aspirin, alcohol
T: toluene, theophylline
M: methanol, metformin
D: DKA, AKA, SKA.
U: uremic toxin
P: paraldehyde, phenformin
I : Iron, INH
L: lactic acidosis
E: ethylene glycol.
Toxic Alcohol: Evaluation
Bed side pearls:
1.Methanol:
Fundus exam have hyperemia and pallor disc.
Subjective "snow vision".
(Methanol metabolized to formic acid, that will
inhibit the cytochrome oxidase chain and injure
the cell.)
2.Ethylene Glycol:
hypocalcemia, calcium oxalate in urine, urine
fluorescence and " how it taste "
Toxic Alcohol: Treatment
ABC's, GI decontamination only Antizole(New)
More effective with a more safety profile.(FDA)
Ethylene Glycol/Ethanol 15 ml can kill a child.
FDA only proved for EG intoxication for child.
But now they use for both!!
Expensive,($1000) but decrease the complication of
ethanol therapy and long term ICU cost.
7
Little evidence 5-
New Antidote : Fomepizole (Antizole)
Mechanism: competitive inhibitor of ADH
4-methylpyrazole, 8000x stronger than ethanol
Indication: Ethylene glycol / ethanol
Contraindication: hypersensitivity to pyrazoles
Dosage: 15mg/kg loading, then10mg/kg q12h x 4
then 15mg/kg q12h till level mixed => acidosis
S: sugar level change
P: pyrexia, uncouples oxidative phosphorylation.
I : intestinal irritation.
R: renal failure in chronic user.
I : increase bleeding tendency.
N: neurologic s/s.
PD is useless and when to use HD
End organ damage, renal failure or 100mg/dl in acute
60mg/dl in chronic
大 透!
十岁 生洗澡之后昏迷送入急诊.
Anion gap metabolic acidosis. 代谢性酸血症
EKG : sinus tachycardia. 心搏过速
CXR : pulmonary edema. 肺水肿
Rhabdomyolysis may cause ARF. 急性肾衰竭
Bullae noted on skin.
你的诊断为何
CO intoxication一氧化碳中毒
一氧化碳中毒及高压氧治
CO intoxication and HBO
正常大气压下半生期4小时, 100%浓 氧
气之下90分钟, 高压氧治 之下30分钟
多 医学中心治 之标准= 成人25, 小孩
15.
无明显医学证据可证明高压氧治 之 效, 但
如果病人coma昏迷/ end organ damage器官受伤
/ neurologic deficit开始时有神经学失常.
100 - 7 test!!
大 透!!
10 岁男童吃"心脏药".
Clear, HR:40-50, BP: 100/60.
12岁男童吃"心脏药".
Relative clear, HR: 40, BP: 70/40 sugar higher.
11岁男童吃"心脏药".
Confusion, HR: 40, BP: 70/40 sugar lower.
你的诊断为何
Digoxin: 毛地黄中毒机转
2.Increase vagal tonesinus brady/AV blockbradyca.
3.Any dysrhythmia except supraventricular tachycardia.
9
Digoxin毛地黄中毒机转
高钾血症为急性毛地黄中毒之表徵: J Toxicol 1973
K < 5.0 mEq/dl all survive.
5.0 < K 5.5 mEq all died.
甲 子浓 大於5为急性中毒之表徵.
可以使用DigiBind.
Retrospective study showed internal pacing will increase
mortality. 心脏电击器 可使用於此 病患
Taboulet J Toxicol 1993
Digoxin : 治
活性碳是最有效的, 但鼻胃管插入会造成心跳
变慢.
以阿扥平Atropine治 心跳变慢bradycardia.
Lidocaine / Dilantin for Ventri. Arrhythmia.
Cardioversion电击要从25焦尔开始.
Acute : 10 vials Chronic: 2 vials in kids.
Replace K, Mg if low..
If K is high in acute cases, not to use Ca!!!!
Beta blocker / CCBBB and CCB
Gastric emptying / WBI
Atropine may not have effect. Pacing/ IABP!!
CaCl2 1amp 10% 3-5 min for both in adults.
In kids: CaGluconate 10-20mg/kg (CaCl2sclerosis)
Glucagon via G3 protein 50-150mcg/kg then
50mcg/kg/hr up to adult dose.
Catecholamine, no good evidence which is better.
Insulin/sugar: 10u RI/25gm dextrose 0.1-1.0u/kg/hr.
Experimental evidence!!
大 透!!
14 岁 生吃药自 送入急诊.
Nausea恶心/ vomiting呕吐/ pallor苍白(第一天).
肝功能 常(第二天).
肝肾功能 常(第三天).
第4-14天.将会死亡或是完全恢
你的诊断为何
Acetaminophen 普拿疼没有毒, 但NAPQI 有!
10
Normogram for Acetaminophen overdose
FDA asked for 25% safety margin!! 150mg/kg!
Canada and Europe use 200mg/kg line!!
Acetaminophen overdose
Based on UK study, 1/500 suicide pt will get toxic
level so check ACT level in all suicide pt.
Gastric lavage is not as good as AC.
10 volunteers, randomized but not double blind
Robert G. Ca Annals of Emerg. Med. 2000
When using NAC within 8 hours, it will be the
same efficacious!!Smilkstein NEJM. 1988
When given late, NAC still have some benefit.
NAC starting after 10-36 hrs reduced fulminant
hepatic failure Harrison Lacet 1990
Acetaminophen: treatment protocol
Oral dosing: USA
Loading dose: 140mg/kg.
Maintenance : 70mg/kg q4h for 17 doses.
total 1330mg/kg in 72 hours
**Oral is safer but bad taste, usually cause vomiting.
Need Primperan up to 1-2 mg/kg / cover cup!!
Iv dosing : in Canada / Europe.
The same dosing as oral ones.
**Watch out for anaphylactoid Rx ( related to rate)!!
The regimen is not pyogen free!! Harrisson use IV.
Street drugs
14 Y/O girl come in coma Date rape
Vital signs stable with
1.No airway reflex.
2.OK airway reflex.
What kind of date rape drug you should know
Date rape drugs
1.Benzodiazepam.
2.GHB r-Hydroxy-butyrate/ GBL r-Butyro-Lactone.
3.Ketamine.
Others club drug you need to know!!
1.Amphetamine.
2.Meth-Amphetamine.
3.MDMA: methylene-dioxy-meth-amphetamine
Hyponatremia, dehydration, serotonin syndrome.
大 透!!
1 y/o boy come in after
drinking oil.
Vomiting once.
Acidosis, cyanosis
intubation.
Blood from ETT/NG.
Die in ICU hours later.
你的诊断为何
11
Hydrocarbon
No lavage nor AC need.
Protect airway.
GI disturbance.
If acidosis, NG/ETT ob,
initial cyanosis, coma
Poor outcome!!
Surfactant for treatment
Without any evidence!!
Toxidrome is important!!
1.Hypoglycemia / hyperglycemia.
2.Hypothermia / hyperthermia.
3.H ypotension / hypertension.
4.Hyperventilation / hypoventilation.
5.Bradycardia / tachycardia.
6.Big pupil / small pupil.
7.Anion gap metabolic acidosis.
8.Vomiting
9.Seizure
Hypoglycemia
A: Alcohol, Acetaminophen.
E: Ethanol.
I : Insulin.
O: OHA.
U: Uremia.
P: Propranolol.
S: Salicylate.
Hyperglycemia
A: Aminophylline.
B: Beta agonist.
C: Calcium channel blocker.
D: Dextrose.
E: Epinephrine/catacholamine/
sympathomimetics
Hypothermia
A: Alpha agonist (clonidine).
B: Barbiturate.
C: CO.
O: Opiate.
O: OHA.
L: Liqual.
S: Sedatives.
Hyperthermia.
M: Malignant neuroleptics, MAOI.
A: Anticholinergic, Antihistamine.
Li: Lithium
S: Salicylate, Serotonin syndrome.
A: Amphetamine.
Wi: Withdrawal from alcohol, BZD.
12
Hypotension
A: Antihypertension.
B: Beta blocker.
C: CCB, Cyclic antidepressant.
D: Diuretics.
E: Ethanol.
I : Iron.
O: Opiate.
T : Theophylline.
Hypertension and tachycardia.
C: Caffeine.
T: Theophylline.
S: Sympathomimetics.
C: Cocaine.
A: Anticholinergics.
N: Nicotine.
Wi: Withdrawal.
Bradycardia
P: Propranolol.
A: Anticholinergic.
C: CCB.
E: Ethanol.
D: Digoxin.
O: Opiate.
C: Cholinergic
Li: Lithium
Hypoventilation
Hy: Hypnotics.
P: organoPhosphate.
O: Opiate.
V: Venom from snake.
E: Ethanol.
N: N-M junction blocker.
T: TCA
Ni: Nicotine.
Vomiting
C: Colchicin.
A: Aminophylline.
N: Nicotine.
M: Methanol.
I : INH. Iron.
S: Salicylate.
S: Solvent.
Li: Lithium
Seizure
O: OHA.
T: Theophylline.
I : INH.
S: Sympathomimetics.
C: Cholinergic.
A: Anticholinergic.
M: Methanol.
P : Phenytoin.
B: Boric acid.
E: Ethanol withdrawal.
L: Lithium/ Lead…
13
1 or 2 pills game!!
A: anticholinergic / anticoagulant.
B: beta blocker / benzodiazepam.
C: Ca channel blocker / clonidine.
D: digoxin / Diaquat.
T: theophylline / toxic alcohol.
I : INH / Iron.
S: sympathomimetics / SSRI
Prevention is "more" important!
Don't feed me poison again!!
Question Command
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