Two Filipino workers suffered sudden loss of consciousness while cleaning a pig farm. One worker was found to have no signs of life and could not be resuscitated. The other was conscious but confused upon arrival at the emergency room. Both workers exhibited signs of hypoxemia, hypercapnia, acute renal failure, and lactic acidosis. Their symptoms and exposure history were consistent with hydrogen sulfide poisoning from sewer gas. Nitrite salts such as amyl nitrite and sodium nitrite were administered as antidotes to oxidize hemoglobin and protect cytochrome oxidase from the toxic effects of hydrogen sulfide gas.

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. 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. Present Illness
 Two otherwise healthy, Filipino workers
from a poultry meat-processing factory
suffered sudden loss of consciousness
while cleaning pig slotted floors.

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. 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. 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.  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. 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. CXR (34 y/o male) EKG (34 y/o male)

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. 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. 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. 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. Knock
down !!
Apnea
!!
~ Doujaiji B et al, Ann Saudi Med. 2010;30:76-80

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. 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. Treatment
~ Gregorakos L et al, Angiology. 1995, 46:1123-1131

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. 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

21. 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

22. THANKS FOR
YOUR LISTENING!!