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Case Conference  December 15, 2007
[object Object],Case Conference   •  Chief complaint :  ซึมลง   10  นาทีก่อนมาโรงพยาบาล :  ผู้ป่วยหญิงไทยอายุ   25  ปี   , กทม . ประวัติจากมารดา   ผู้ป่วย
Present illness ,[object Object]
Past illness ,[object Object],[object Object],[object Object]
Physical examination ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Physical examination ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

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Interesting case

  • 1. Case Conference December 15, 2007
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  • 7. Problem list & differential diagnosis
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  • 11. EKG
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  • 19. 23/9/50 20.33 ( after injection of NaHCO3)
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  • 26. Drug with Na channel blockade property (membrane stabilizing effect) Amantadine Amitryptyline Amoxapine Carbamazepime Chloroquine Cocaine Imipramine Loxapine Maproyiline Nortryptyline Orphenadrine Phenothaizine Desipramine Diltiazem Diophenhydramine Encainide Flecainide Hygroxychloroquine Procainamide Propanolol Thioridazine Quinidine Quinine Verapamil Note; Many Na channels blocking agents also bind to K channels and prevent efflux: Phenothiazine, antihistamines, and type A antidysrhythmics (7)
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  • 34. Pathophysiology Severe chloroquine poisoning is usually associated with ingestions of 5 g or more in adults, or with serum concentrations exceeding 5 mg/L. Goldfrank_s_Toxicologic_Emergencies__8e_2006
  • 35. The cardiovascular effects QRS prolongation: block fast Na channel of perkinje fiber and his bundle  delay depolarization, QTc interval prolongation, increased U wave: in inhibit K efflux  delay repolarization Goldfrank_s_Toxicologic_Emergencies__8e_2006 Pathophysiology VT : delayed depolarization ที่ไม่พร้อมกันของเซลล์กล้ามเนื้อหัวใจที่ ventricle ทำให้เกิด reentry circuit และเกิดเป็น VT ตามมา Torsades depointes: prolong QT
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  • 37. Clinical Manifestations Symptoms usually occur within 1- 3 hours of ingestion Respiratory depression Hypotension Cardiovascular compromise Significant hypokalemia results from direct chloroquine-induced intracellular shifts . Goldfrank_s_Toxicologic_Emergencies__8e_2006
  • 38. The neurologic manifestations include CNS depression, dizziness, headache, and convulsions. Rarely. Clinical Manifestations Red blood cell (RBC) oxidant stress from chloroquine may result in hemolysis in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency Goldfrank_s_Toxicologic_Emergencies__8e_2006
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  • 40. Management Patients should receive early endotracheal intubation and mechanical ventilation : if arrhythmias, hypotension, seizures or significant CNS depression are present Inotropes may also be necessary : for hypotension unresponsive to a fluid challenge ( 1) thiopental was used to facilitate intubation, its use immediately preceded sudden cardiac arrest in 7 of 25 patients after chloroquine overdose.(1) 1. ABC epinephrine (0.25 mcg/kg/min) should be given IV with D 5 W, and adjusted incrementally until a systolic blood pressure greater than 100 mm Hg (1)
  • 41.
  • 42. 2. GI decontamination Management Orogastric lavage: within 1 hour after ingestion Activated charcoal : 1 g/kg Goldfrank_s_Toxicologic_Emergencies__8e_2006
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  • 44. If the QRS complex width is increased, sodium bicarbonate should be administered Management Goldfrank_s_Toxicologic_Emergencies__8e_2006 Chloroquine significant protein binding, and long terminal elimination half-lives, enhanced elimination procedures are not beneficial
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  • 53. Thank you For your attention Merry Christmas and Happy New Year 2008