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Common Toxicology sukit wipusattaya Emergency Medicine
Common poison exposure  Ramathibodi Poison Center: 2001-2005 Ramathibodi Poison Center: 2001-2005 กลุ่ม จํานวน % สารป้องกั...
Case <ul><li>PI : 6  ชั่วโมงก่อน กินน้ํายาล้างห้องน้ำ “เป็ดโปร” ประมาณ  50 ml.  หลังกินมีอาการแสบคอมาก และปวดท้องโดยเฉพาะบ...
Acid <ul><li>Sulfuric acid </li></ul><ul><li>Hydrochloric acid </li></ul><ul><li>Hydrofluoric acid </li></ul><ul><li>Formi...
Alkali <ul><li>Sodium hydroxide </li></ul><ul><li>Calcium hydroxide </li></ul><ul><li>Lithium hydroxide </li></ul><ul><li>...
determinants of damaging potential <ul><li>Volume  </li></ul><ul><li>Concentration </li></ul><ul><li>Physical state </li><...
Alkali burn <ul><li>Liquefaction necrosis </li></ul><ul><li>Protein dissolution, collagen destruction, fat saponification ...
Liquefaction necrosis
<ul><li>Coagulation necrosis   </li></ul><ul><li>protein precipitation and eschar formation </li></ul><ul><li>tend to be p...
Pathology <ul><li>Ingestion:  </li></ul><ul><ul><li>Squamous epithelium </li></ul></ul><ul><ul><li>Erythema, edema, erosio...
Clinical manifestations <ul><li>Drooling --> oropharyngeal injury  </li></ul><ul><li>Odynophagia ,dysphagia --> esophageal...
TREATMENT <ul><li>Initial Stabilization </li></ul><ul><li>Clinical Evaluation </li></ul><ul><li>Decontamination </li></ul>...
Initial stabilization <ul><li>Personal protective equipment </li></ul><ul><li>Airway: indications for  early intubation </...
Clinical Evaluation <ul><li>History  </li></ul><ul><ul><li>type and amount of caustic ingested </li></ul></ul><ul><ul><li>...
Decontamination <ul><li>contraindicated </li></ul><ul><li>No role of dilution or neutralization </li></ul>
Diagnostic test <ul><li>arterial blood gas </li></ul><ul><li>electrolyte </li></ul><ul><li>liver function </li></ul><ul><l...
Enhance elimination <ul><li>No role of enhance elimination </li></ul>
Antidote <ul><li>Some agents need specific antidote </li></ul><ul><ul><li>Hydrofluoric acid  </li></ul></ul><ul><ul><li>Ph...
Hydrofluoric acid
Hydrofluoric acid <ul><li>Apply 2.5% calcium gluconate gel  (10% calcium gluconate 10 ml in  KY gel 60 ml ) on skin until ...
Supportive care <ul><li>Endoscopy </li></ul><ul><li>Benefits: treatment plan, disposition and prognosis </li></ul><ul><li>...
<ul><li>Grade 0: Normal </li></ul><ul><li>Grade I: Mucosal edema or hyperemia </li></ul><ul><li>Grade II: Ulceration </li>...
Pathologic severity of injury
Management <ul><li>Mild gastroesophageal injury  </li></ul><ul><ul><ul><li>Supportivetreamentonly </li></ul></ul></ul><ul>...
Supportive care <ul><li>Corticosteroid </li></ul><ul><li>Aim: minimizing stricture in second degree (II, IIb) burns with p...
Disposition <ul><li>Grade 0 – I can be discharge if tolerate well to eating and drinking </li></ul><ul><li>Grade IIb-III n...
Question <ul><li>ผู้ป่วยชาย  30  ปี  chronic alcohol drinking  น้ำหนัก  50 kg  30  นาทีก่อนมาโรงพยาบาล กิน  paracetamol 10...
Acetaminophen
Paracetamol Sulfation Glucuronidation CYP2E1 Renal excretion NAPQI Reduced glutathione + CYP2E1 NAPQI
Clinical symptoms <ul><li>Stage I  : 0.5-24 hrs  </li></ul><ul><ul><ul><ul><li>nausea, vomiting </li></ul></ul></ul></ul><...
Diagnosis <ul><li>History of ingestion  > 150 mg/kg </li></ul><ul><ul><li>Exception   </li></ul></ul><ul><ul><ul><li>chron...
Overdose estimation: amount > 150 mg/kg
 
Treatment Paracetamal level N-acetylcysteine
NAC therapy : Routes of administration <ul><li>Oral  : 18 doses over ~70 hours </li></ul><ul><ul><li>140 mg/kg for loading...
Management of Anaphylactoid reactions from IV NAC <ul><li>Flushing: continue treatment </li></ul><ul><li>Urticaria:  </li>...
 
 
Disposition <ul><li>Follow up </li></ul><ul><li>LFT at 48 hrs , PT </li></ul><ul><li>BUN/Cr at day 7 </li></ul><ul><li>If ...
ผู้ป่วยรายใดที่กิน  paracent 10  เม็ดแล้วอาจไม่ต้องให้  acetylcysteine <ul><li>- chronic alcohol </li></ul><ul><li>- acute...
Case <ul><li>ผู้ป่วยชายอายุ  47  ปี มาด้วยอาการหมดสติ ไม่ค่อยรู้สึกตัว ตรวจร่างกายพบ  RR=8 , BP=80/50 , PR=60 T=36 O2sat =...
Suspected CNS Suppression Intoxication Anticholinergic sign Respiratory Suppress Constrict pupil dilate pupil Phenothizine...
Opioid
Opioid <ul><li>1.Natural derived from opium </li></ul><ul><ul><ul><li>Morphine, Codeine </li></ul></ul></ul><ul><li>2.Semi...
Opioid Toxidrome <ul><li>CNS depression </li></ul><ul><li>Miosis </li></ul><ul><li>Respiratory depression </li></ul>Miosis...
Treatment <ul><li>Initial Stabilization  </li></ul><ul><li>Clinical Evaluation  </li></ul><ul><li>Decontamination </li></u...
Initial stabilization <ul><li>Airway : oral airway , bag-mask valve , ETT  </li></ul><ul><li>Breathing : Improve oxygenati...
Decontamination <ul><li>No role of ipecac syrup  </li></ul><ul><li>NG lavage : not necessary  </li></ul><ul><li>Activated ...
Enhance elimination <ul><li>No role of cathartic alone  </li></ul><ul><li>Multiple dose activated charcoal may be useful i...
<ul><li>Naloxone   </li></ul><ul><li>Opioid antagonist : reverses almost all adverse effects mediated through opioid recep...
Naloxone  <ul><li>Repeat dose q 2-3 min until  </li></ul><ul><ul><ul><li>respiratory is reversed  </li></ul></ul></ul><ul>...
Case <ul><li>ผู้ป่วยชายอายุ  50  ปี มาด้วยอาการหมดสติ ไม่ค่อยรู้สึกตัว  </li></ul><ul><li>PE : RR=14 , BP=120/80 , PR=60 T...
Organophosphate/Carbamate <ul><li>Organophosphate : parathion, malathion </li></ul><ul><li>Carbamate : methamyl, methyl ca...
Inhibit acetylcholine esterase enzyme
 
 
Sign and Symptom Mnemonics DUMBELS D – Diarrhea U – Urination M – Miosis B  – bradycardia, bronchospasm, bronchorrhea   E ...
Treatment plasma cholinesterase level , gastric content atropine , 2-PAM <ul><li>Initial Stabilization  </li></ul><ul><li>...
Atropine <ul><li>Atropine 0.02 - 0.05 mg/kg (1-3 mg)  q 5 min until </li></ul><ul><ul><li>Control of mucous membrane hyper...
Pralidoxime (2-PAM) <ul><li>Pralidoxime 1-2 g bolus (20-50 mg/kg)   Then 500 mg/hr (10-25 mg/kg/hr) </li></ul><ul><li>Moni...
Paraquat Trade name: Gramoxone Herboxone Dextron Color: Blue - green
Toxicodynamic Mechanism PQ 2+ PQ + NADP + NADPH O 2 . PQ reductase Pentose phosphate pathway Cell death : (lung , liver , ...
Oropharyngeal ulceration and corrosion
Ocular injury
Clinical symptoms <ul><li>GI : like corrosive agent </li></ul><ul><li>Cardiovascular : Hypovolemia, shock, dysrhythmias </...
Paraquat Lung Day 1 Day 28
Treatment No oxygen  until PaO2<50 , resp distress lavage , fuller’s earth urine for paraquat hemoperfusion <ul><li>Initia...
Investigations <ul><li>Serum paraquat level </li></ul><ul><li>Urine paraquat level </li></ul><ul><li>Bedside : 1% Na-dithi...
alkaline sodium dithionate Paraquat
<ul><li>- antioxidant: Vit C, Vit E, NAC </li></ul><ul><li>- Immunosuppressive </li></ul><ul><li>Cyclophosphamide 5mg/kg/d...
Case <ul><li>เด็กผู้ชาย  5  ปี </li></ul><ul><li>CC.  กินแชมพู 30  นาทีก่อนมาโรงพยาบาล </li></ul><ul><li>PI. 30  นาที  ก่อ...
ผลิตภัณฑ์ทำความสะอาด  (cleaner) <ul><li>ทำความสะอาดร่างกาย </li></ul><ul><ul><li>สบู่อาบน้ํา  </li></ul></ul><ul><ul><li>แ...
Detergent Surfactant Builder
Surfactant <ul><li>Nonionic surfactant  </li></ul><ul><li>Anionic surfactant  </li></ul><ul><li>Cationic surfactant </li><...
Nonionic surfactant <ul><li>Condensation products of fatty alcohols + ethylene oxide  </li></ul><ul><ul><li>Alkyl phenol p...
Anionic surfactant <ul><li>Sodium, potassium, or ammonium salts of fatty acids </li></ul><ul><ul><li>Alkyl sulfonate </li>...
Cationic surfactant <ul><li>Pyridinium  compounds </li></ul><ul><ul><li>Cetalkonium chloride </li></ul></ul><ul><ul><li>Ce...
Example <ul><li>Sodium lauryl ether sulfate 14% w/w </li></ul><ul><li>Sodium lauryl sulfate 6%w/w </li></ul>
<ul><li>Sodiumdodecylbenzenesulphonate 6.7%w/w  </li></ul><ul><li>Nonyl phenol ethoxylated 9% w/w </li></ul><ul><li>Sodium...
<ul><li>Sodium lauryl ether sulfate 2.12% w/w </li></ul><ul><li>Sodium dodecyl benzene sulphonate 14.88% w/w </li></ul>Exa...
Example <ul><li>C12-C15 alcohol ethoxylated 1.2% w/w  </li></ul><ul><li>Sodium lauryl ether sulfate 3.92% w/w </li></ul>
Example <ul><li>Alkoxylated linear alcohol 8%w/w </li></ul>
<ul><li>Anionic surfactant   -Sodium linearalkyl benzenesulfonate   -Polyoxyethylene alkyl ether </li></ul><ul><ul><li>Sod...
Example <ul><li>Dialkyl Dimethyl Ammonium Chloride  </li></ul>
Builder <ul><li>sodium phosphate </li></ul><ul><li>sodium carbonate </li></ul><ul><li>sodium metasilicate  </li></ul>
Symptoms <ul><ul><li>Nonionic / Anionic  surfactant  </li></ul></ul><ul><ul><ul><li>mild irritation </li></ul></ul></ul><u...
GASTROINTESTINAL <ul><li>Nausea, vomiting  diarrhea --> metabolic alkalosis </li></ul><ul><li>Oral, pharyngeal,esophageal ...
<ul><li>1.  ผลิตภัณฑ์ความสะอาดร่างกาย  (toilet articles and cosmetics):  </li></ul><ul><ul><li>แชมพูสระผม ,  สบู่อาบน้ํา ,...
Additive  <ul><li>enzyme  </li></ul><ul><li>carboxymethyl cellulose  </li></ul><ul><li>flourescent whitening agent  เช่น  ...
TREATMENT <ul><li>Initial Stabilization </li></ul><ul><li>Clinical Evaluation </li></ul><ul><li>Decontamination </li></ul>...
Initial Stabilization <ul><li>Airway Management </li></ul><ul><li>Administer 100% humidified supplemental oxygen, </li></u...
Decontamination <ul><li>Eye exposure </li></ul><ul><ul><li>Remove contact lenses & irrigate eyes with copious amounts of r...
<ul><li>Nonionic or anionic   is generally self-limiting </li></ul><ul><ul><ul><li>requiring  no treatment </li></ul></ul>...
Supportive care <ul><li>Treat dermal irritation / burns with standard topical drug </li></ul><ul><li>Dermal hypersensitivi...
Summary <ul><li>No activated charcoal </li></ul><ul><li>Nonionic / anionic surfactant </li></ul><ul><ul><li>dilution by wa...
Case  <ul><li>ผู้ป่วยหญิงไทยโสด อายุ  20  ปี  ปฏิเสธโรคประจำตัว </li></ul><ul><li>CC:  พ่นยาไบกอน (spray)  ฉีดยุงเข้าปาก  ...
 
Pyrethrines & Pyrethroids <ul><li>Pyrethrins : compounds extracted from chrysanthemums </li></ul><ul><li>Pyrethroids : syn...
<ul><li>Pyrethrum </li></ul><ul><ul><li>cinerin I </li></ul></ul><ul><ul><li>cinerin II </li></ul></ul><ul><ul><li>jasmoli...
Toxicodynamics <ul><li>affect sodium channel in nerve cell </li></ul><ul><li>depolarization and hyperexcitability </li></u...
 
Pyrethrines <ul><li>Pyretrum extract </li></ul><ul><li>Pyrethrine I </li></ul><ul><li>Pyretrhrine II </li></ul><ul><li>Cin...
ยาจุดกันยุงและผลิตภัณฑ์กันยุงใชักับเครื่องไฟฟ้า
Mechanism of toxicity <ul><li>1. Hypersensitivity </li></ul><ul><ul><li>immediate rhinitis and bronchial hyperreactivity <...
Clinical manifestation <ul><li>Allergic and hypersensitivity </li></ul><ul><ul><li>Allergic rhinitis </li></ul></ul><ul><u...
Respiratory mildly irritate  rhinitis , bronchitis , bronchospasm , asthma Cardiovascular not direct effect Nervous type I...
Gastrointestinal  salivation , N/V , abdominal pain , diarrhea Liver effected due to prolong hypoxemia Genitourinary effec...
Decontamination Respiratory Remove from source adequate ventilation with 100% oxygen inhaled beta-agonist Skin remove all ...
Primary survey and resuscitation Airway open airway , intubate if necessary Breathing adequate oxygenation  high flow O2 1...
Poisoning treatment paradigm Alter Absorption Remove from the poison Antidote non Basic continue reassess ABC treat anaphy...
Treatment <ul><li>Typical GI decontamination </li></ul><ul><li>Be careful in case of hydrocarbon media </li></ul><ul><li>T...
SAD PERSONS score <ul><li>S ex (male) = 1 </li></ul><ul><li>A ge less than 19 or greater than 45 years = 1 </li></ul><ul><...
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Toxico for extern

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Toxico for extern

  1. 1. Common Toxicology sukit wipusattaya Emergency Medicine
  2. 2. Common poison exposure Ramathibodi Poison Center: 2001-2005 Ramathibodi Poison Center: 2001-2005 กลุ่ม จํานวน % สารป้องกันกำจัดศัตรูพืช (pesticides) 9,327 39.9 สารใช้ในบ้านเรือน (household products) 4,421 18.9 ยา (pharmaceutical products) 4,397 18.8 สารใช้ในงานอุตสาหกรรม (occupational products) 2,527 10.9 พืชมีพิษ (plant toxins/poisonous plants) 977 4.2 สัตว์มีพิษ (poisonous animals) 621 2.7 รวม 23,368
  3. 3. Case <ul><li>PI : 6 ชั่วโมงก่อน กินน้ํายาล้างห้องน้ำ “เป็ดโปร” ประมาณ 50 ml. หลังกินมีอาการแสบคอมาก และปวดท้องโดยเฉพาะบริเวณลิ้นปี่ </li></ul><ul><li>PE : P 110/min, BP 90/60, RR 24/min, T 37.8 Erythema or soft palate and posterior pharynx, no stridor Lung : clear Abdomen : tender at epigastrium, no guarding or rigidity, normal bowel sound </li></ul>
  4. 4. Acid <ul><li>Sulfuric acid </li></ul><ul><li>Hydrochloric acid </li></ul><ul><li>Hydrofluoric acid </li></ul><ul><li>Formic acid </li></ul><ul><li>Acetic acid </li></ul>
  5. 5. Alkali <ul><li>Sodium hydroxide </li></ul><ul><li>Calcium hydroxide </li></ul><ul><li>Lithium hydroxide </li></ul><ul><li>Ammonium hydroxide </li></ul><ul><li>Sodium hypochlorite </li></ul><ul><li>Sodium tripolyphosphate </li></ul>
  6. 6. determinants of damaging potential <ul><li>Volume </li></ul><ul><li>Concentration </li></ul><ul><li>Physical state </li></ul><ul><li>pH </li></ul>
  7. 7. Alkali burn <ul><li>Liquefaction necrosis </li></ul><ul><li>Protein dissolution, collagen destruction, fat saponification and cell membrane emulsification </li></ul><ul><li>Facilitate penetration of the alkali </li></ul><ul><li>often injure oropharynx and proximal esophagus </li></ul>
  8. 8. Liquefaction necrosis
  9. 9. <ul><li>Coagulation necrosis </li></ul><ul><li>protein precipitation and eschar formation </li></ul><ul><li>tend to be protective against deep injury </li></ul>Acid Ingestion
  10. 10. Pathology <ul><li>Ingestion: </li></ul><ul><ul><li>Squamous epithelium </li></ul></ul><ul><ul><li>Erythema, edema, erosion, ulcer </li></ul></ul><ul><ul><li>Lowest tensile strength of the esophagus: Day 3-14 </li></ul></ul><ul><ul><li>Collagen organization and epithelial repair in months </li></ul></ul><ul><ul><li>Shortening and dysmotility </li></ul></ul><ul><ul><li>Increase risk of squamous cell CA x 20-40 </li></ul></ul>
  11. 11. Clinical manifestations <ul><li>Drooling --> oropharyngeal injury </li></ul><ul><li>Odynophagia ,dysphagia --> esophageal injury </li></ul><ul><li>Abdominal pain,GI bleed --> stomach injury </li></ul><ul><li>Dysphonia,stridor,resp distress --> laryngotracheal injury </li></ul><ul><li>Retrosternal chest pain --> mediastinitis </li></ul><ul><li>Signs of complication: </li></ul><ul><ul><li>GI hemorrhage </li></ul></ul><ul><ul><li>Laryngeal involvement </li></ul></ul><ul><ul><li>Esophageal perforation </li></ul></ul>
  12. 12. TREATMENT <ul><li>Initial Stabilization </li></ul><ul><li>Clinical Evaluation </li></ul><ul><li>Decontamination </li></ul><ul><li>Diagnostic tests </li></ul><ul><li>Enhance Elimination </li></ul><ul><li>Specific antidotes </li></ul><ul><li>Supportive care </li></ul>
  13. 13. Initial stabilization <ul><li>Personal protective equipment </li></ul><ul><li>Airway: indications for early intubation </li></ul><ul><ul><li>Stridor </li></ul></ul><ul><ul><li>Dyspnea </li></ul></ul><ul><ul><li>Oropharyngeal obstruction </li></ul></ul><ul><li>Blind nasotracheal intubation is contraindicated </li></ul>
  14. 14. Clinical Evaluation <ul><li>History </li></ul><ul><ul><li>type and amount of caustic ingested </li></ul></ul><ul><ul><li>intentional or unintentional ingestion </li></ul></ul><ul><li>Physical examination </li></ul><ul><ul><li>determine hemodynamic stability </li></ul></ul><ul><ul><ul><li>etiology of shock (GI bleed , volume deplete) </li></ul></ul></ul><ul><ul><li>examine peritoneal sign & mediastinitis </li></ul></ul><ul><ul><li>examine eye & skin </li></ul></ul>
  15. 15. Decontamination <ul><li>contraindicated </li></ul><ul><li>No role of dilution or neutralization </li></ul>
  16. 16. Diagnostic test <ul><li>arterial blood gas </li></ul><ul><li>electrolyte </li></ul><ul><li>liver function </li></ul><ul><li>complete blood count </li></ul><ul><li>coagulation profile </li></ul><ul><li>calcium & magnesium ( HF acid) </li></ul><ul><li>Chest x-ray </li></ul><ul><li>EKG </li></ul>
  17. 17. Enhance elimination <ul><li>No role of enhance elimination </li></ul>
  18. 18. Antidote <ul><li>Some agents need specific antidote </li></ul><ul><ul><li>Hydrofluoric acid </li></ul></ul><ul><ul><li>Phenol </li></ul></ul>: calcium gluconate : isopropyl alcohol : ethyleneglycol
  19. 19. Hydrofluoric acid
  20. 20. Hydrofluoric acid <ul><li>Apply 2.5% calcium gluconate gel (10% calcium gluconate 10 ml in KY gel 60 ml ) on skin until pain resolves (usually within 10 minutes) </li></ul>+
  21. 21. Supportive care <ul><li>Endoscopy </li></ul><ul><li>Benefits: treatment plan, disposition and prognosis </li></ul><ul><li>Timing: </li></ul><ul><ul><li>4-6 hours post-ingestion: avoid underestimation </li></ul></ul><ul><ul><li>Not later than 48 hours post-ingestion </li></ul></ul><ul><li>Indications: </li></ul><ul><ul><li>All intentional ingestion </li></ul></ul><ul><ul><li>Presence of symptom or sign of corrosive injury </li></ul></ul>
  22. 22. <ul><li>Grade 0: Normal </li></ul><ul><li>Grade I: Mucosal edema or hyperemia </li></ul><ul><li>Grade II: Ulceration </li></ul><ul><ul><li>IIa: superficial ulceration </li></ul></ul><ul><ul><li>IIb: deep discrete or superficial ulceration </li></ul></ul><ul><li>Grade III: Necrosis </li></ul><ul><ul><li>IIIa: small, scattered areas of necrosis </li></ul></ul><ul><ul><li>IIIb: extensive necrosis </li></ul></ul>Grading of Esophageal injury
  23. 23. Pathologic severity of injury
  24. 24. Management <ul><li>Mild gastroesophageal injury </li></ul><ul><ul><ul><li>Supportivetreamentonly </li></ul></ul></ul><ul><li>Moderate to Severe (significant)gastroesophageal injury </li></ul><ul><ul><li>Supportivetreatment </li></ul></ul><ul><ul><li>Endosccopyforevaluationtheinjury </li></ul></ul><ul><ul><li>Parenteralnutrion(TPN,PPN) </li></ul></ul><ul><ul><li>– +steroid </li></ul></ul><ul><ul><li>Observe for its complication </li></ul></ul><ul><ul><ul><ul><li>GI Bleeding </li></ul></ul></ul></ul><ul><ul><ul><ul><li>GI perferation </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Infection </li></ul></ul></ul></ul>
  25. 25. Supportive care <ul><li>Corticosteroid </li></ul><ul><li>Aim: minimizing stricture in second degree (II, IIb) burns with plans for dilation </li></ul><ul><li>Controversial issues </li></ul>
  26. 26. Disposition <ul><li>Grade 0 – I can be discharge if tolerate well to eating and drinking </li></ul><ul><li>Grade IIb-III need ICU admission. </li></ul>
  27. 27. Question <ul><li>ผู้ป่วยชาย 30 ปี chronic alcohol drinking น้ำหนัก 50 kg 30 นาทีก่อนมาโรงพยาบาล กิน paracetamol 10 เม็ด </li></ul><ul><li>ท่านจะให้การรักษาแก่ผู้ป่วยอย่างไรต่อไป </li></ul>
  28. 28. Acetaminophen
  29. 29. Paracetamol Sulfation Glucuronidation CYP2E1 Renal excretion NAPQI Reduced glutathione + CYP2E1 NAPQI
  30. 30. Clinical symptoms <ul><li>Stage I : 0.5-24 hrs </li></ul><ul><ul><ul><ul><li>nausea, vomiting </li></ul></ul></ul></ul><ul><li>Stage II : 24-72 hrs </li></ul><ul><ul><ul><li>RUQ pain , liver enzyme , bilirubin , prolong PT </li></ul></ul></ul><ul><li>Stage III : 72-96 hrs </li></ul><ul><ul><ul><li>jaundice, hepatic encephalopathy , renal failure </li></ul></ul></ul><ul><li>Stage IV : 96 hrs -2 wks </li></ul><ul><ul><ul><li>recovery phase </li></ul></ul></ul>
  31. 31. Diagnosis <ul><li>History of ingestion > 150 mg/kg </li></ul><ul><ul><li>Exception </li></ul></ul><ul><ul><ul><li>chronic alcohol </li></ul></ul></ul><ul><ul><ul><li>inducible agent : phenytoin, phenobarbital, isoniazid </li></ul></ul></ul><ul><ul><ul><li>eating disorder e.g. anorexia nervosa, starvation </li></ul></ul></ul><ul><li>Serum paracetamol level (normogram) </li></ul><ul><ul><ul><li>at 4-24 hr </li></ul></ul></ul>
  32. 32. Overdose estimation: amount > 150 mg/kg
  33. 34. Treatment Paracetamal level N-acetylcysteine
  34. 35. NAC therapy : Routes of administration <ul><li>Oral : 18 doses over ~70 hours </li></ul><ul><ul><li>140 mg/kg for loading </li></ul></ul><ul><ul><li>70 mg/kg for maintenance every 4 hours x 17 doses </li></ul></ul><ul><ul><li>Vomiting </li></ul></ul><ul><li>Intravenous : ~ 21 hours </li></ul><ul><ul><li>150 mg/kg in 1 hours </li></ul></ul><ul><ul><li>50 mg/kg in 4 hours </li></ul></ul><ul><ul><li>100 mg/kg in 16 hours </li></ul></ul><ul><ul><li>Anaphylactoid reaction </li></ul></ul>
  35. 36. Management of Anaphylactoid reactions from IV NAC <ul><li>Flushing: continue treatment </li></ul><ul><li>Urticaria: </li></ul><ul><ul><li>Diphenhydramine 50 mg IV </li></ul></ul><ul><ul><li>Continue treatment </li></ul></ul><ul><li>Angioedema </li></ul><ul><ul><li>Stop NAC </li></ul></ul><ul><ul><li>Diphenhydramine 50 mg IV </li></ul></ul><ul><ul><li>Restart if no symptoms after 1 hour </li></ul></ul>
  36. 39. Disposition <ul><li>Follow up </li></ul><ul><li>LFT at 48 hrs , PT </li></ul><ul><li>BUN/Cr at day 7 </li></ul><ul><li>If liver enzyme >1000 </li></ul><ul><li>PT , BUN/Cr </li></ul><ul><li>NAC 150 mg/kg/day </li></ul><ul><li>until clinical improve , PT normal </li></ul>
  37. 40. ผู้ป่วยรายใดที่กิน paracent 10 เม็ดแล้วอาจไม่ต้องให้ acetylcysteine <ul><li>- chronic alcohol </li></ul><ul><li>- acute alcohol </li></ul><ul><li>- seizure on phenytoin </li></ul><ul><li>- TB on IRZE </li></ul><ul><li>- starvation </li></ul>
  38. 41. Case <ul><li>ผู้ป่วยชายอายุ 47 ปี มาด้วยอาการหมดสติ ไม่ค่อยรู้สึกตัว ตรวจร่างกายพบ RR=8 , BP=80/50 , PR=60 T=36 O2sat = 85% E1V1M5 , pupil 1mm SRTL , </li></ul><ul><li>lung clear , absent bowel sound , no sweating , DTX=141 </li></ul>
  39. 42. Suspected CNS Suppression Intoxication Anticholinergic sign Respiratory Suppress Constrict pupil dilate pupil Phenothizine TCA Benzodiazepine Opioid Barbiturate Yes Yes Yes Yes No No No No
  40. 43. Opioid
  41. 44. Opioid <ul><li>1.Natural derived from opium </li></ul><ul><ul><ul><li>Morphine, Codeine </li></ul></ul></ul><ul><li>2.Semi-synthetics </li></ul><ul><ul><ul><li>Heroin </li></ul></ul></ul><ul><li>3.Synthetics </li></ul><ul><ul><ul><li>Fentanyl, Meperidine, Methadone </li></ul></ul></ul><ul><ul><li>Diphenoxylate (Lomotil) </li></ul></ul>
  42. 45. Opioid Toxidrome <ul><li>CNS depression </li></ul><ul><li>Miosis </li></ul><ul><li>Respiratory depression </li></ul>Miosis hypoventilation hypothermia CNS depression Bradycardia ,hypotension Ileus Hyporeflexia Needle mark
  43. 46. Treatment <ul><li>Initial Stabilization </li></ul><ul><li>Clinical Evaluation </li></ul><ul><li>Decontamination </li></ul><ul><li>Diagnostic tests </li></ul><ul><li>Enhance Elimination </li></ul><ul><li>Specific antidotes </li></ul><ul><li>Supportive care </li></ul>urine toxicology Naloxone
  44. 47. Initial stabilization <ul><li>Airway : oral airway , bag-mask valve , ETT </li></ul><ul><li>Breathing : Improve oxygenation </li></ul><ul><li>Circulation : </li></ul><ul><ul><ul><li>Hypotension : typically orthostatic --> supine , rise legs </li></ul></ul></ul><ul><li>R/O hypoglycemia, hypoxia, hypothermia </li></ul><ul><li>cardiac monitoring </li></ul>
  45. 48. Decontamination <ul><li>No role of ipecac syrup </li></ul><ul><li>NG lavage : not necessary </li></ul><ul><li>Activated charcoal 1 gm/kg in moderate to large dose after ingestion within 1 hr </li></ul><ul><li>Sustained release product (Oxycodone) , body packer --> whole-bowel irrigation </li></ul>
  46. 49. Enhance elimination <ul><li>No role of cathartic alone </li></ul><ul><li>Multiple dose activated charcoal may be useful in Lomotil overdose </li></ul><ul><li>no role of dialysis (due to large volume distribution) </li></ul>
  47. 50. <ul><li>Naloxone </li></ul><ul><li>Opioid antagonist : reverses almost all adverse effects mediated through opioid receptors </li></ul><ul><li>Empiric use may assist in diagnosis </li></ul><ul><li>Can administered IV , IM , ETT </li></ul><ul><li>Onset of action (iv) 1-2 mins </li></ul><ul><li>Duration of action 20-90 mins </li></ul>
  48. 51. Naloxone <ul><li>Repeat dose q 2-3 min until </li></ul><ul><ul><ul><li>respiratory is reversed </li></ul></ul></ul><ul><ul><ul><li>maximum dose of 10 mg </li></ul></ul></ul>Dosage Minimal resp depression Markly resp depression Opioid dependent 0.2 mg iv 2 mg iv Non-opioid dependent 0.4 mg iv
  49. 52. Case <ul><li>ผู้ป่วยชายอายุ 50 ปี มาด้วยอาการหมดสติ ไม่ค่อยรู้สึกตัว </li></ul><ul><li>PE : RR=14 , BP=120/80 , PR=60 T=36 O2sat = 92% </li></ul><ul><li>a man with drownsiness , hypersalivation </li></ul><ul><li>heart : regular </li></ul><ul><li>lung : wheezing and rhonchi both lung </li></ul><ul><li>abdomen : hyperactive bowel sound </li></ul><ul><li>extremities: sweating </li></ul><ul><li>E2V2M5 , pupil 1 mm SRTL </li></ul>
  50. 53. Organophosphate/Carbamate <ul><li>Organophosphate : parathion, malathion </li></ul><ul><li>Carbamate : methamyl, methyl carbamate </li></ul>
  51. 54. Inhibit acetylcholine esterase enzyme
  52. 57. Sign and Symptom Mnemonics DUMBELS D – Diarrhea U – Urination M – Miosis B – bradycardia, bronchospasm, bronchorrhea E – Emesis L – Lacrimation S – Salivation Days of the Week: M – Mydriasis T – Tachycardia W – Weakness H – Hypertension F – Fasciculations
  53. 58. Treatment plasma cholinesterase level , gastric content atropine , 2-PAM <ul><li>Initial Stabilization </li></ul><ul><li>Clinical Evaluation </li></ul><ul><li>Decontamination </li></ul><ul><li>Diagnostic tests </li></ul><ul><li>Enhance Elimination </li></ul><ul><li>Specific antidotes </li></ul><ul><li>Supportive care </li></ul>
  54. 59. Atropine <ul><li>Atropine 0.02 - 0.05 mg/kg (1-3 mg) q 5 min until </li></ul><ul><ul><li>Control of mucous membrane hypersecretion </li></ul></ul><ul><ul><li>Airway clear </li></ul></ul><ul><li>May require 200 - 500 mg in 1st hr </li></ul><ul><li>Not active at nicotinic sites </li></ul>
  55. 60. Pralidoxime (2-PAM) <ul><li>Pralidoxime 1-2 g bolus (20-50 mg/kg) Then 500 mg/hr (10-25 mg/kg/hr) </li></ul><ul><li>Monitor clinical and AChE level </li></ul>
  56. 61. Paraquat Trade name: Gramoxone Herboxone Dextron Color: Blue - green
  57. 62. Toxicodynamic Mechanism PQ 2+ PQ + NADP + NADPH O 2 . PQ reductase Pentose phosphate pathway Cell death : (lung , liver , kidney) O 2
  58. 63. Oropharyngeal ulceration and corrosion
  59. 64. Ocular injury
  60. 65. Clinical symptoms <ul><li>GI : like corrosive agent </li></ul><ul><li>Cardiovascular : Hypovolemia, shock, dysrhythmias </li></ul><ul><li>Renal : acute tubular necrosis , renal failure </li></ul><ul><li>Hepatobilliary : hepatitis , hepatic necrosis </li></ul><ul><li>Respiratory : mediastinitis, pneumothorax, hemoptysis, pulmonary edema, and hemorrhage, pulmonary fibrosis </li></ul>
  61. 66. Paraquat Lung Day 1 Day 28
  62. 67. Treatment No oxygen until PaO2<50 , resp distress lavage , fuller’s earth urine for paraquat hemoperfusion <ul><li>Initial Stabilization </li></ul><ul><li>Clinical Evaluation </li></ul><ul><li>Decontamination </li></ul><ul><li>Diagnostic tests </li></ul><ul><li>Enhance Elimination </li></ul><ul><li>Specific antidotes </li></ul><ul><li>Supportive care </li></ul>
  63. 68. Investigations <ul><li>Serum paraquat level </li></ul><ul><li>Urine paraquat level </li></ul><ul><li>Bedside : 1% Na-dithionate in NaOH 2 ml + urine 10 ml (blue = positive = paraquat 1 ppm) </li></ul><ul><li>BUN, Cr, UA, arterial blood gas, pulmonary function test </li></ul>
  64. 69. alkaline sodium dithionate Paraquat
  65. 70. <ul><li>- antioxidant: Vit C, Vit E, NAC </li></ul><ul><li>- Immunosuppressive </li></ul><ul><li>Cyclophosphamide 5mg/kg/day IV </li></ul><ul><ul><li>Dexamethazone 10 mg IV q 8 hrs </li></ul></ul>Specific treatment
  66. 71. Case <ul><li>เด็กผู้ชาย 5 ปี </li></ul><ul><li>CC. กินแชมพู 30 นาทีก่อนมาโรงพยาบาล </li></ul><ul><li>PI. 30 นาที ก่อนมารพ . ผู้ป่วยกินแชมพูสระผมประมาณ 5 อึก หลังกินมีอาการปวดชาลิ้นเล็กน้อย มารดาพยายามล้วงคอผู้ให้อาเจียน แต่ไม่อาเจียน จึงมารพ . ผู้ป่วยรู้สึกตัวดี ไม่สำลัก ไม่ปวดท้อง อาการอื่นปกติ </li></ul><ul><li>PH. ไม่มีโรคประจำตัวใดๆ </li></ul><ul><li>ไม่เคยแพ้ยาใดๆ </li></ul>
  67. 72. ผลิตภัณฑ์ทำความสะอาด (cleaner) <ul><li>ทำความสะอาดร่างกาย </li></ul><ul><ul><li>สบู่อาบน้ํา </li></ul></ul><ul><ul><li>แชมพูสระผม </li></ul></ul><ul><li>ทําความสะอาดเสื้อผ้า </li></ul><ul><ul><li>ผงซักฟอก </li></ul></ul><ul><ul><li>นํ้ายาซักผ้าน้ำยาขจัดคราบ </li></ul></ul><ul><li>ทําความสะอาดอื่นๆ ทั่วไป </li></ul><ul><ul><li>น้ำยาล้างจาน </li></ul></ul><ul><ul><li>น้ำยาทำความสะอาดพื้น </li></ul></ul>
  68. 73. Detergent Surfactant Builder
  69. 74. Surfactant <ul><li>Nonionic surfactant </li></ul><ul><li>Anionic surfactant </li></ul><ul><li>Cationic surfactant </li></ul>3
  70. 75. Nonionic surfactant <ul><li>Condensation products of fatty alcohols + ethylene oxide </li></ul><ul><ul><li>Alkyl phenol polyglycol </li></ul></ul><ul><ul><li>Alkylphenyl polyethoxyethanol </li></ul></ul><ul><ul><li>Alkylpolyethoxylates </li></ul></ul><ul><ul><li>Ethoxylated alcohols </li></ul></ul><ul><ul><li>Nonoxynol </li></ul></ul><ul><ul><li>PEG stearates </li></ul></ul><ul><ul><li>Polyalkaline glycol, fatty acid alkanolamide amide </li></ul></ul><ul><ul><li>Polyethylene glycol alkyl aryl ethers </li></ul></ul><ul><ul><li>Polyoxyethylene alkyl ethers </li></ul></ul>
  71. 76. Anionic surfactant <ul><li>Sodium, potassium, or ammonium salts of fatty acids </li></ul><ul><ul><li>Alkyl sulfonate </li></ul></ul><ul><ul><li>Alkylbenzene sulfonates </li></ul></ul><ul><ul><li>Alkyl sulfate </li></ul></ul><ul><ul><li>Dialkyl sulfosuccinate </li></ul></ul><ul><ul><li>Linear alkylate sulfonate </li></ul></ul><ul><ul><li>Phosphorylated hydrocarbons </li></ul></ul><ul><ul><li>Sulfonated hydrocarbons </li></ul></ul>
  72. 77. Cationic surfactant <ul><li>Pyridinium compounds </li></ul><ul><ul><li>Cetalkonium chloride </li></ul></ul><ul><ul><li>Cetrimide </li></ul></ul><ul><ul><li>Cetrimonium bromide </li></ul></ul><ul><ul><li>Cetylpyridinium chloride </li></ul></ul><ul><ul><li>Stearalkonium chloride </li></ul></ul><ul><li>Quaternary ammonium compounds </li></ul><ul><ul><li>Benzalkonium chloride </li></ul></ul><ul><ul><li>Benzethonium chloride </li></ul></ul><ul><li>Quinolinium compound </li></ul><ul><ul><li>Dequalinium chloride </li></ul></ul>
  73. 78. Example <ul><li>Sodium lauryl ether sulfate 14% w/w </li></ul><ul><li>Sodium lauryl sulfate 6%w/w </li></ul>
  74. 79. <ul><li>Sodiumdodecylbenzenesulphonate 6.7%w/w </li></ul><ul><li>Nonyl phenol ethoxylated 9% w/w </li></ul><ul><li>Sodium lauryl ether sulfate 5% w/w </li></ul>Example
  75. 80. <ul><li>Sodium lauryl ether sulfate 2.12% w/w </li></ul><ul><li>Sodium dodecyl benzene sulphonate 14.88% w/w </li></ul>Example
  76. 81. Example <ul><li>C12-C15 alcohol ethoxylated 1.2% w/w </li></ul><ul><li>Sodium lauryl ether sulfate 3.92% w/w </li></ul>
  77. 82. Example <ul><li>Alkoxylated linear alcohol 8%w/w </li></ul>
  78. 83. <ul><li>Anionic surfactant -Sodium linearalkyl benzenesulfonate -Polyoxyethylene alkyl ether </li></ul><ul><ul><li>Sodium tripolyphosphate </li></ul></ul><ul><ul><li>Zeolite </li></ul></ul><ul><ul><li>Sodium carboxymethyl cellulose </li></ul></ul><ul><ul><li>Fluorescer </li></ul></ul>Example
  79. 84. Example <ul><li>Dialkyl Dimethyl Ammonium Chloride </li></ul>
  80. 85. Builder <ul><li>sodium phosphate </li></ul><ul><li>sodium carbonate </li></ul><ul><li>sodium metasilicate </li></ul>
  81. 86. Symptoms <ul><ul><li>Nonionic / Anionic surfactant </li></ul></ul><ul><ul><ul><li>mild irritation </li></ul></ul></ul><ul><ul><ul><li>mild GI symptoms : N/V , abdominal pain --> dehydrate </li></ul></ul></ul><ul><ul><li>Cationic surfactant </li></ul></ul><ul><ul><ul><li>like corrosive agent </li></ul></ul></ul><ul><ul><ul><li>upper airway edema , respiratory distress </li></ul></ul></ul><ul><ul><ul><li>hypotension, metabolic acidosis, CNS depression </li></ul></ul></ul>
  82. 87. GASTROINTESTINAL <ul><li>Nausea, vomiting diarrhea --> metabolic alkalosis </li></ul><ul><li>Oral, pharyngeal,esophageal burns </li></ul><ul><li>Esophageal stricture </li></ul><ul><li>irritation of mucous membranes </li></ul>
  83. 88. <ul><li>1. ผลิตภัณฑ์ความสะอาดร่างกาย (toilet articles and cosmetics): </li></ul><ul><ul><li>แชมพูสระผม , สบู่อาบน้ํา , ครีม / โฟมล้างหน้า : nonionic and anionic surfactant </li></ul></ul><ul><ul><li>ครีมนวดผม : cationic detergent </li></ul></ul><ul><li>2. ผลิตภัณฑ์ซักผ้า (laundry products): </li></ul><ul><li>ผงซักฟอก , น้ำยาซักผ้า : nonionic and anionic surfactant </li></ul><ul><li>น้ำยาปรับผ้านุ่ม : cationic detergent </li></ul><ul><li>น้ำยาขจัดคราบไคล : anionic surfactant </li></ul><ul><li>3. ผลิตภัณฑ์ล้างจาน (dishwashings): </li></ul><ul><ul><ul><ul><li>น้ำยาล้างจาน , น้ำยาล้างขวดนม : nonionic and anionic detergent </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>น้ำยาล้างจาน ( เครื่อง ) : cationic detergent </li></ul></ul></ul></ul></ul><ul><li>4. น้ำยาทําความสะอาดพื้น (floor cleaners) : nonionic and anionic detergent </li></ul><ul><li>5. น้ำ ยาทําความสะอาดห้องนํา้บางสูตร (toilet cleaners) : nonionic, anionic and cationic </li></ul><ul><li>6. น้ํายาทําความสะอาดเอนกประสงค์ (All-purpose cleaner) : nonionic, anionic and cationic </li></ul>
  84. 89. Additive <ul><li>enzyme </li></ul><ul><li>carboxymethyl cellulose </li></ul><ul><li>flourescent whitening agent เช่น Pyrazolines, Coumarins </li></ul><ul><li>corrosion inhibitor เช่น sodium silicate </li></ul><ul><li>preservative </li></ul><ul><li>corrosive </li></ul><ul><li>fragrance </li></ul>
  85. 90. TREATMENT <ul><li>Initial Stabilization </li></ul><ul><li>Clinical Evaluation </li></ul><ul><li>Decontamination </li></ul><ul><li>Diagnostic tests </li></ul><ul><li>Enhance Elimination </li></ul><ul><li>Specific antidotes </li></ul><ul><li>Supportive care </li></ul>
  86. 91. Initial Stabilization <ul><li>Airway Management </li></ul><ul><li>Administer 100% humidified supplemental oxygen, </li></ul><ul><li>Administer inhaled beta adrenergic agonists if bronchospasm </li></ul><ul><li>Monitor for evidence of respiratory distress </li></ul><ul><li>(stridor, retractions, coughing, tachypnea)  ET tube </li></ul>
  87. 92. Decontamination <ul><li>Eye exposure </li></ul><ul><ul><li>Remove contact lenses & irrigate eyes with copious amounts of room temp 0.9%NSS or water for >15 mins. </li></ul></ul><ul><ul><li>If irritation, pain, swelling, lacrimation, photophobia persist after 15 mins of irrigation  ophthalmologic examination </li></ul></ul><ul><li>Dermal exposure </li></ul><ul><ul><li>remove contaminated clothing and jewelry </li></ul></ul><ul><ul><li>irrigate exposed area with copious amounts of water </li></ul></ul><ul><li>Inhalation exposure </li></ul><ul><ul><li>Move patient from the toxic environment to fresh air </li></ul></ul>
  88. 93. <ul><li>Nonionic or anionic is generally self-limiting </li></ul><ul><ul><ul><li>requiring no treatment </li></ul></ul></ul><ul><ul><ul><li>maybe dilute with 120 - 240 ml of water or milk </li></ul></ul></ul><ul><li>Cationic detergent should treat as corrosive agent </li></ul><ul><ul><ul><li>Do not induce vomiting </li></ul></ul></ul><ul><ul><ul><li>If signs or symptoms of esophageal irritation or burns are present, consider endoscopy </li></ul></ul></ul><ul><ul><ul><li>Activated charcoal - unnecessary </li></ul></ul></ul>
  89. 94. Supportive care <ul><li>Treat dermal irritation / burns with standard topical drug </li></ul><ul><li>Dermal hypersensitivity reactions  Rx. with systemic / topical corticosteroids / antihistamines </li></ul>
  90. 95. Summary <ul><li>No activated charcoal </li></ul><ul><li>Nonionic / anionic surfactant </li></ul><ul><ul><li>dilution by water/milk </li></ul></ul><ul><ul><li>may NG lavage </li></ul></ul><ul><ul><li>improve in 24 hr </li></ul></ul><ul><li>Cationic surfactant </li></ul><ul><ul><li>treat as corrosive agent --> endoscopic </li></ul></ul>
  91. 96. Case <ul><li>ผู้ป่วยหญิงไทยโสด อายุ 20 ปี ปฏิเสธโรคประจำตัว </li></ul><ul><li>CC: พ่นยาไบกอน (spray) ฉีดยุงเข้าปาก 3 ครั้ง 5 นาทีก่อนมารพ . </li></ul><ul><li>PI: 5 นาทีก่อนทะเลาะกับแฟน จึงนำ สเปรย์ฉีดยุงยี่ห้อไบกอนสีเหลืองมาฉีดเข้าปาก 3 ครั้ง แฟนนำส่งรพ . ทันที </li></ul><ul><li>PE: WNL </li></ul><ul><li>มีกลิ่นยา บริเวณปาก </li></ul>
  92. 98. Pyrethrines & Pyrethroids <ul><li>Pyrethrins : compounds extracted from chrysanthemums </li></ul><ul><li>Pyrethroids : synthetic derivatives of pyrethrins </li></ul><ul><ul><li>greater chemical stability </li></ul></ul><ul><li>Type II pyrethroid </li></ul><ul><ul><li>Contain a cyano substituent </li></ul></ul><ul><ul><li>More toxic formulation </li></ul></ul><ul><ul><li>Potential danger to human </li></ul></ul><ul><li>Common as aerosals in automate insect spray </li></ul><ul><li>Less toxic and safer than other compound </li></ul>
  93. 99. <ul><li>Pyrethrum </li></ul><ul><ul><li>cinerin I </li></ul></ul><ul><ul><li>cinerin II </li></ul></ul><ul><ul><li>jasmolin I </li></ul></ul><ul><ul><li>jasmolin II </li></ul></ul><ul><ul><li>pyrethrin I (methy group) </li></ul></ul><ul><ul><li>pyrethrin II (ester group) </li></ul></ul><ul><li>type I (no cyano(nitrile group) </li></ul>
  94. 100. Toxicodynamics <ul><li>affect sodium channel in nerve cell </li></ul><ul><li>depolarization and hyperexcitability </li></ul><ul><li>Type I pyrethroid </li></ul><ul><ul><li>briefer , repetitive nerve discharge </li></ul></ul><ul><li>Type II </li></ul><ul><ul><li>longer repetitive nerve discharge </li></ul></ul><ul><ul><li>inhibit Cl in GABA receptor --> seizure </li></ul></ul><ul><li>allergic : true IgE-mediated anaphylatic </li></ul>
  95. 102. Pyrethrines <ul><li>Pyretrum extract </li></ul><ul><li>Pyrethrine I </li></ul><ul><li>Pyretrhrine II </li></ul><ul><li>Cinerin I </li></ul><ul><li>Cinerin II </li></ul><ul><li>Jasmolin I </li></ul><ul><li>Jasmolin II </li></ul>Pyrethroids <ul><li>Allethine </li></ul><ul><li>Barthrine </li></ul><ul><li>Bioallethrine </li></ul><ul><li>Bioresmethrine </li></ul><ul><li>Cismethrine </li></ul><ul><li>Cymethrine </li></ul><ul><li>Cypermethrine </li></ul><ul><li>Decamethrine </li></ul><ul><li>Deltamethrine </li></ul><ul><li>Fenothrin </li></ul><ul><li>Fenvalerate </li></ul><ul><li>Furamethrine </li></ul><ul><li>tetramethrin </li></ul>
  96. 103. ยาจุดกันยุงและผลิตภัณฑ์กันยุงใชักับเครื่องไฟฟ้า
  97. 104. Mechanism of toxicity <ul><li>1. Hypersensitivity </li></ul><ul><ul><li>immediate rhinitis and bronchial hyperreactivity </li></ul></ul><ul><ul><li>uncertain mechanisms </li></ul></ul><ul><li>2. Increase sodium influx into neurons </li></ul><ul><ul><li>Increase neurotransmitter release </li></ul></ul>
  98. 105. Clinical manifestation <ul><li>Allergic and hypersensitivity </li></ul><ul><ul><li>Allergic rhinitis </li></ul></ul><ul><ul><li>Contact dermatitis </li></ul></ul><ul><ul><li>Asthma </li></ul></ul><ul><ul><li>Anaphylactoid </li></ul></ul><ul><li>Dermal and systemic manifestations </li></ul><ul><ul><li>Abdominal pain, nausea, vomiting within 10 minutes to 1 hours </li></ul></ul><ul><ul><li>Paresthesia, numbness: onset hours, duration: less than 24 hours </li></ul></ul><ul><ul><li>Weakness and muscle fasciculation </li></ul></ul><ul><ul><li>Seizure </li></ul></ul><ul><ul><li>In cases of ingestion, beware of hydrocarbon pneumonitis </li></ul></ul>
  99. 106. Respiratory mildly irritate rhinitis , bronchitis , bronchospasm , asthma Cardiovascular not direct effect Nervous type I : T-syndrome (tremor) type II : CS-syndrome ( choreoathetosis salivation seizure) skin & mucous membrane allergic contact dermatitis allergic conjunctivitis
  100. 107. Gastrointestinal salivation , N/V , abdominal pain , diarrhea Liver effected due to prolong hypoxemia Genitourinary effected due to prolong hypoxemia
  101. 108. Decontamination Respiratory Remove from source adequate ventilation with 100% oxygen inhaled beta-agonist Skin remove all contaminated clothing ,jewelry wash affected area with water and liquid detergent Eye irrigate with water at least 20 mins Morgan lenses with ophthamic local anesthetics
  102. 109. Primary survey and resuscitation Airway open airway , intubate if necessary Breathing adequate oxygenation high flow O2 15 LPM via nonrebreathing reservoir mask BMV in inadequate spontaneous ventilation endotracheal intubation Circulation cardiac monitoring , ALCL guideline start IV NSS Disability assess level of conscious continually IV diazepam if seizure despite adequate O2 and glucose Exposure undress and decontaminated
  103. 110. Poisoning treatment paradigm Alter Absorption Remove from the poison Antidote non Basic continue reassess ABC treat anaphylactic Change catabolism not applicable Enhance Elimination not applicable
  104. 111. Treatment <ul><li>Typical GI decontamination </li></ul><ul><li>Be careful in case of hydrocarbon media </li></ul><ul><li>Treat allergic symptoms with antihistamine </li></ul><ul><li>Symptomatic </li></ul><ul><li>Observe for 6 hrs and d/c if asymptomatic </li></ul>
  105. 112. SAD PERSONS score <ul><li>S ex (male) = 1 </li></ul><ul><li>A ge less than 19 or greater than 45 years = 1 </li></ul><ul><li>D epression (patient admits to depression or decreased concentration, sleep, appetite and/or libido = 2 </li></ul><ul><li>P revious suicide attempt or psychiatric care = 1 </li></ul><ul><li>E xcessive alcohol or drug use = 1 </li></ul><ul><li>R ational thinking loss: psychosis, organic brain syndrome = 2 </li></ul><ul><li>S eparated, divorced, or widowed = 1 </li></ul><ul><li>O rganized plan or serious attempt = 2 </li></ul><ul><li>N o social support = 1 </li></ul><ul><li>S ickness, chronic disease = 1 </li></ul><ul><li>1 - 2 points low risk, 3-5 points moderate risk, 7-10 high risk </li></ul>

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