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201103 hydrogen sulfide poisoning

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201103 hydrogen sulfide poisoning

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201103 hydrogen sulfide poisoning

  1. 1. ACUTE RENAL FAILURE, LACTIC ACIDOSIS, AND SUDDEN COLLAPSE FOLLOWING HYDROGEN SULFIDE SEWER GAS POISONING 潘恆之, 林杰樑, 顏宗海 硫化氫沼氣中毒導致急性腎衰竭, 乳酸中毒及突發性心肺停止 林口長庚紀念醫院 腎臟系 臨床毒物科
  2. 2. Patient's Profiles Case 1 Age: 28 Gender: male Ethnic: Filipino Marital status: married Occupation: worker Case 2 Age: 34 Gender: male Ethnic: Filipino Marital status: married Occupation: worker
  3. 3. Present Illness  Two otherwise healthy, Filipino workers from a poultry meat-processing factory suffered sudden loss of consciousness while cleaning pig slotted floors.
  4. 4. 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 1V 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
  5. 5. 血液 WBC 8700 1/µL Hemoglobin 13.4 g/dL MCV 91.6 fL Platelets 289K 1/µL Segment 70 % Lymphocyte 22 % Eosinophil 4 % PT (INR) 1.0 APTT 23.8 sec 生化 Fasting sugar 133 mg/dL ALT 96 U/L BUN 22.1 mg/dL Creatinine 1.50 mg/dL eGFR 53 mL/min/1.73㎡ Na 149 mEq/L K 6.4 mEq/L Cl 103 mEq/L Ca 8.1 mg/dL P 2.4 mg/dL Mg 1.7 mEq/L CK-MB 3.9 ng/mL Troponin-I 0.01 ng/mL Lactate 24.2 mg/dL Free-T4 1.38 ng/dL TSH 0.77 µIU/mL Cortisol 22.3 µg/dL O2HB 63.6 % COHB 1.2 % METHB 0.3 % O2CT 64.9 % 動脈血 PH 6.799 PCO2 90.0 mmHg PO2 69.3 mmHg HCO3 13.7 mm/L SBE - 20.9 mm/L Sa% 60.5 % Lab data (28 y/o male)
  6. 6. 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
  7. 7.  Vital signs: T: 33.0 ℃ P: 131 bpm R: 6 cpm BP: 77/51 mmHg  GENERAL APPEARANCE: acute-ill looking, foul odor  CONSCIOUSNESS: E 2V 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
  8. 8. 血液 WBC 9500 1/µL Hemoglobin 14.4 g/dL MCV 83.8 fL Platelets 162K 1/µL Segment 57.9 % Lymphocyte 37.6 % Eosinophil 1.8 % PT (INR) 1.0 APTT 23.8 sec 生化 Fasting sugar 119 mg/dL ALT 41 U/L BUN 18.1 mg/dL Creatinine 1.54 mg/dL eGFR 52 mL/min/1.73㎡ Na 138 mEq/L K 3.1 mEq/L Cl 101 mEq/L Ca 8.7 mg/dL P 3.1 mg/dL Mg 1.7 mEq/L CK-MB 5.1 ng/mL Troponin-I 0.017 ng/mL Lactate 23.8 mg/dL Free-T4 1.36 ng/dL TSH 0.69 µIU/mL Cortisol 50.3 µg/dL O2 HB % 70.3 % CO HB % 0.9 % MET HB % 7.2 % O2 CT 78.3 % 動脈血 PH 6.979 PCO2 84.1 mmHg PO2 51.9 mmHg HCO3 19.3 mm/L SBE -12.3 mm/L Sa% 73.8 % Lab data (34 y/o male)
  9. 9. CXR (34 y/o male) EKG (34 y/o male)
  10. 10. 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 G a
  11. 11. 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
  12. 12. Introduction  Hydrogen sulfide (H2S) is a colorless toxic gas that has strong odor of “rotten eggs”  H2S poisoning usually occurs by inhalation Discussion ~WoodallGM et al, InhalToxicol. 2005;17:593-639
  13. 13. 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 ofToxicology. 2010, 29:569-581
  14. 14. Knock down !! Apnea !! ~ Doujaiji B et al, Ann Saudi Med. 2010;30:76-80
  15. 15. 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 ofToxicology. 2010, 29:569-581
  16. 16. 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, AmericanJournal of Industrial Medicine. 1999, 35:192-195
  17. 17. Treatment ~ Gregorakos L et al, Angiology. 1995, 46:1123-1131
  18. 18. 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 Met-Hb Sulfa-MetHb Oxy-Hb + SO2 ~ Smith RP et al, Ann RevToxicol. 1976, 16:189 Mitochondria Blood
  19. 19. Nitrite Kit Amyl 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 andToxicology. 2010, 5:28
  20. 20. 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
  21. 21. THANKS FOR YOUR LISTENING!!

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