A 5-year-old boy ingested approximately 5 mouthfuls of shampoo 30 minutes prior to arriving at the hospital. Upon arrival, he reported slight tongue numbness but felt well otherwise with no vomiting, dyspnea, or abdominal pain. Shampoo contains surfactants like nonionic surfactants which are condensation products of fatty alcohols and ethylene oxide that can cause minor oral irritation but are generally considered low toxicity at normal usage amounts.

1. Common Toxicology sukit wipusattaya Emergency Medicine

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. Case PI : 6 ชั่วโมงก่อน กินน้ํายาล้างห้องน้ำ “เป็ดโปร” ประมาณ 50 ml. หลังกินมีอาการแสบคอมาก และปวดท้องโดยเฉพาะบริเวณลิ้นปี่ 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

4. Acid Sulfuric acid Hydrochloric acid Hydrofluoric acid Formic acid Acetic acid

5. Alkali Sodium hydroxide Calcium hydroxide Lithium hydroxide Ammonium hydroxide Sodium hypochlorite Sodium tripolyphosphate

6. determinants of damaging potential Volume Concentration Physical state pH

7. Alkali burn Liquefaction necrosis Protein dissolution, collagen destruction, fat saponification and cell membrane emulsification Facilitate penetration of the alkali often injure oropharynx and proximal esophagus

8. Liquefaction necrosis

9. Coagulation necrosis protein precipitation and eschar formation tend to be protective against deep injury Acid Ingestion

10. Pathology Ingestion: Squamous epithelium Erythema, edema, erosion, ulcer Lowest tensile strength of the esophagus: Day 3-14 Collagen organization and epithelial repair in months Shortening and dysmotility Increase risk of squamous cell CA x 20-40

11. Clinical manifestations Drooling --> oropharyngeal injury Odynophagia ,dysphagia --> esophageal injury Abdominal pain,GI bleed --> stomach injury Dysphonia,stridor,resp distress --> laryngotracheal injury Retrosternal chest pain --> mediastinitis Signs of complication: GI hemorrhage Laryngeal involvement Esophageal perforation

12. TREATMENT Initial Stabilization Clinical Evaluation Decontamination Diagnostic tests Enhance Elimination Specific antidotes Supportive care

13. Initial stabilization Personal protective equipment Airway: indications for early intubation Stridor Dyspnea Oropharyngeal obstruction Blind nasotracheal intubation is contraindicated

14. Clinical Evaluation History type and amount of caustic ingested intentional or unintentional ingestion Physical examination determine hemodynamic stability etiology of shock (GI bleed , volume deplete) examine peritoneal sign & mediastinitis examine eye & skin

15. Decontamination contraindicated No role of dilution or neutralization

16. Diagnostic test arterial blood gas electrolyte liver function complete blood count coagulation profile calcium & magnesium ( HF acid) Chest x-ray EKG

17. Enhance elimination No role of enhance elimination

18. Antidote Some agents need specific antidote Hydrofluoric acid Phenol : calcium gluconate : isopropyl alcohol : ethyleneglycol

19. Hydrofluoric acid

20. Hydrofluoric acid 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) +

21. Supportive care Endoscopy Benefits: treatment plan, disposition and prognosis Timing: 4-6 hours post-ingestion: avoid underestimation Not later than 48 hours post-ingestion Indications: All intentional ingestion Presence of symptom or sign of corrosive injury

22. Grade 0: Normal Grade I: Mucosal edema or hyperemia Grade II: Ulceration IIa: superficial ulceration IIb: deep discrete or superficial ulceration Grade III: Necrosis IIIa: small, scattered areas of necrosis IIIb: extensive necrosis Grading of Esophageal injury

23. Pathologic severity of injury

24. Management Mild gastroesophageal injury Supportivetreamentonly Moderate to Severe (significant)gastroesophageal injury Supportivetreatment Endosccopyforevaluationtheinjury Parenteralnutrion(TPN,PPN) – +steroid Observe for its complication GI Bleeding GI perferation Infection

25. Supportive care Corticosteroid Aim: minimizing stricture in second degree (II, IIb) burns with plans for dilation Controversial issues

26. Disposition Grade 0 – I can be discharge if tolerate well to eating and drinking Grade IIb-III need ICU admission.

27. Question ผู้ป่วยชาย 30 ปี chronic alcohol drinking น้ำหนัก 50 kg 30 นาทีก่อนมาโรงพยาบาล กิน paracetamol 10 เม็ด ท่านจะให้การรักษาแก่ผู้ป่วยอย่างไรต่อไป

28. Acetaminophen

29. Paracetamol Sulfation Glucuronidation CYP2E1 Renal excretion NAPQI Reduced glutathione + CYP2E1 NAPQI

30. Clinical symptoms Stage I : 0.5-24 hrs nausea, vomiting Stage II : 24-72 hrs RUQ pain , liver enzyme , bilirubin , prolong PT Stage III : 72-96 hrs jaundice, hepatic encephalopathy , renal failure Stage IV : 96 hrs -2 wks recovery phase

31. Diagnosis History of ingestion > 150 mg/kg Exception chronic alcohol inducible agent : phenytoin, phenobarbital, isoniazid eating disorder e.g. anorexia nervosa, starvation Serum paracetamol level (normogram) at 4-24 hr

32. Overdose estimation: amount > 150 mg/kg

34. Treatment Paracetamal level N-acetylcysteine

35. NAC therapy : Routes of administration Oral : 18 doses over ~70 hours 140 mg/kg for loading 70 mg/kg for maintenance every 4 hours x 17 doses Vomiting Intravenous : ~ 21 hours 150 mg/kg in 1 hours 50 mg/kg in 4 hours 100 mg/kg in 16 hours Anaphylactoid reaction

36. Management of Anaphylactoid reactions from IV NAC Flushing: continue treatment Urticaria: Diphenhydramine 50 mg IV Continue treatment Angioedema Stop NAC Diphenhydramine 50 mg IV Restart if no symptoms after 1 hour

39. Disposition Follow up LFT at 48 hrs , PT BUN/Cr at day 7 If liver enzyme >1000 PT , BUN/Cr NAC 150 mg/kg/day until clinical improve , PT normal

40. ผู้ป่วยรายใดที่กิน paracent 10 เม็ดแล้วอาจไม่ต้องให้ acetylcysteine - chronic alcohol - acute alcohol - seizure on phenytoin - TB on IRZE - starvation

41. Case ผู้ป่วยชายอายุ 47 ปี มาด้วยอาการหมดสติ ไม่ค่อยรู้สึกตัว ตรวจร่างกายพบ RR=8 , BP=80/50 , PR=60 T=36 O2sat = 85% E1V1M5 , pupil 1mm SRTL , lung clear , absent bowel sound , no sweating , DTX=141

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

43. Opioid

44. Opioid 1.Natural derived from opium Morphine, Codeine 2.Semi-synthetics Heroin 3.Synthetics Fentanyl, Meperidine, Methadone Diphenoxylate (Lomotil)

45. Opioid Toxidrome CNS depression Miosis Respiratory depression Miosis hypoventilation hypothermia CNS depression Bradycardia ,hypotension Ileus Hyporeflexia Needle mark

46. Treatment Initial Stabilization Clinical Evaluation Decontamination Diagnostic tests Enhance Elimination Specific antidotes Supportive care urine toxicology Naloxone

47. Initial stabilization Airway : oral airway , bag-mask valve , ETT Breathing : Improve oxygenation Circulation : Hypotension : typically orthostatic --> supine , rise legs R/O hypoglycemia, hypoxia, hypothermia cardiac monitoring

48. Decontamination No role of ipecac syrup NG lavage : not necessary Activated charcoal 1 gm/kg in moderate to large dose after ingestion within 1 hr Sustained release product (Oxycodone) , body packer --> whole-bowel irrigation

49. Enhance elimination No role of cathartic alone Multiple dose activated charcoal may be useful in Lomotil overdose no role of dialysis (due to large volume distribution)

50. Naloxone Opioid antagonist : reverses almost all adverse effects mediated through opioid receptors Empiric use may assist in diagnosis Can administered IV , IM , ETT Onset of action (iv) 1-2 mins Duration of action 20-90 mins

51. Naloxone Repeat dose q 2-3 min until respiratory is reversed maximum dose of 10 mg Dosage Minimal resp depression Markly resp depression Opioid dependent 0.2 mg iv 2 mg iv Non-opioid dependent 0.4 mg iv

52. Case ผู้ป่วยชายอายุ 50 ปี มาด้วยอาการหมดสติ ไม่ค่อยรู้สึกตัว PE : RR=14 , BP=120/80 , PR=60 T=36 O2sat = 92% a man with drownsiness , hypersalivation heart : regular lung : wheezing and rhonchi both lung abdomen : hyperactive bowel sound extremities: sweating E2V2M5 , pupil 1 mm SRTL

53. Organophosphate/Carbamate Organophosphate : parathion, malathion Carbamate : methamyl, methyl carbamate

54. Inhibit acetylcholine esterase enzyme

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

58. Treatment plasma cholinesterase level , gastric content atropine , 2-PAM Initial Stabilization Clinical Evaluation Decontamination Diagnostic tests Enhance Elimination Specific antidotes Supportive care

59. Atropine Atropine 0.02 - 0.05 mg/kg (1-3 mg) q 5 min until Control of mucous membrane hypersecretion Airway clear May require 200 - 500 mg in 1st hr Not active at nicotinic sites

60. Pralidoxime (2-PAM) Pralidoxime 1-2 g bolus (20-50 mg/kg) Then 500 mg/hr (10-25 mg/kg/hr) Monitor clinical and AChE level

61. Paraquat Trade name: Gramoxone Herboxone Dextron Color: Blue - green

62. Toxicodynamic Mechanism PQ 2+ PQ + NADP + NADPH O 2 . PQ reductase Pentose phosphate pathway Cell death : (lung , liver , kidney) O 2

63. Oropharyngeal ulceration and corrosion

64. Ocular injury

65. Clinical symptoms GI : like corrosive agent Cardiovascular : Hypovolemia, shock, dysrhythmias Renal : acute tubular necrosis , renal failure Hepatobilliary : hepatitis , hepatic necrosis Respiratory : mediastinitis, pneumothorax, hemoptysis, pulmonary edema, and hemorrhage, pulmonary fibrosis

66. Paraquat Lung Day 1 Day 28

67. Treatment No oxygen until PaO2<50 , resp distress lavage , fuller’s earth urine for paraquat hemoperfusion Initial Stabilization Clinical Evaluation Decontamination Diagnostic tests Enhance Elimination Specific antidotes Supportive care

68. Investigations Serum paraquat level Urine paraquat level Bedside : 1% Na-dithionate in NaOH 2 ml + urine 10 ml (blue = positive = paraquat 1 ppm) BUN, Cr, UA, arterial blood gas, pulmonary function test

69. alkaline sodium dithionate Paraquat

70. - antioxidant: Vit C, Vit E, NAC - Immunosuppressive Cyclophosphamide 5mg/kg/day IV Dexamethazone 10 mg IV q 8 hrs Specific treatment

71. Case เด็กผู้ชาย 5 ปี CC. กินแชมพู 30 นาทีก่อนมาโรงพยาบาล PI. 30 นาที ก่อนมารพ . ผู้ป่วยกินแชมพูสระผมประมาณ 5 อึก หลังกินมีอาการปวดชาลิ้นเล็กน้อย มารดาพยายามล้วงคอผู้ให้อาเจียน แต่ไม่อาเจียน จึงมารพ . ผู้ป่วยรู้สึกตัวดี ไม่สำลัก ไม่ปวดท้อง อาการอื่นปกติ PH. ไม่มีโรคประจำตัวใดๆ ไม่เคยแพ้ยาใดๆ

72. ผลิตภัณฑ์ทำความสะอาด (cleaner) ทำความสะอาดร่างกาย สบู่อาบน้ํา แชมพูสระผม ทําความสะอาดเสื้อผ้า ผงซักฟอก นํ้ายาซักผ้าน้ำยาขจัดคราบ ทําความสะอาดอื่นๆ ทั่วไป น้ำยาล้างจาน น้ำยาทำความสะอาดพื้น

73. Detergent Surfactant Builder

74. Surfactant Nonionic surfactant Anionic surfactant Cationic surfactant 3

75. Nonionic surfactant Condensation products of fatty alcohols + ethylene oxide Alkyl phenol polyglycol Alkylphenyl polyethoxyethanol Alkylpolyethoxylates Ethoxylated alcohols Nonoxynol PEG stearates Polyalkaline glycol, fatty acid alkanolamide amide Polyethylene glycol alkyl aryl ethers Polyoxyethylene alkyl ethers

76. Anionic surfactant Sodium, potassium, or ammonium salts of fatty acids Alkyl sulfonate Alkylbenzene sulfonates Alkyl sulfate Dialkyl sulfosuccinate Linear alkylate sulfonate Phosphorylated hydrocarbons Sulfonated hydrocarbons

77. Cationic surfactant Pyridinium compounds Cetalkonium chloride Cetrimide Cetrimonium bromide Cetylpyridinium chloride Stearalkonium chloride Quaternary ammonium compounds Benzalkonium chloride Benzethonium chloride Quinolinium compound Dequalinium chloride

78. Example Sodium lauryl ether sulfate 14% w/w Sodium lauryl sulfate 6%w/w

79. Sodiumdodecylbenzenesulphonate 6.7%w/w Nonyl phenol ethoxylated 9% w/w Sodium lauryl ether sulfate 5% w/w Example

80. Sodium lauryl ether sulfate 2.12% w/w Sodium dodecyl benzene sulphonate 14.88% w/w Example

81. Example C12-C15 alcohol ethoxylated 1.2% w/w Sodium lauryl ether sulfate 3.92% w/w

82. Example Alkoxylated linear alcohol 8%w/w

83. Anionic surfactant -Sodium linearalkyl benzenesulfonate -Polyoxyethylene alkyl ether Sodium tripolyphosphate Zeolite Sodium carboxymethyl cellulose Fluorescer Example

84. Example Dialkyl Dimethyl Ammonium Chloride

85. Builder sodium phosphate sodium carbonate sodium metasilicate

86. Symptoms Nonionic / Anionic surfactant mild irritation mild GI symptoms : N/V , abdominal pain --> dehydrate Cationic surfactant like corrosive agent upper airway edema , respiratory distress hypotension, metabolic acidosis, CNS depression

87. GASTROINTESTINAL Nausea, vomiting diarrhea --> metabolic alkalosis Oral, pharyngeal,esophageal burns Esophageal stricture irritation of mucous membranes

88. 1. ผลิตภัณฑ์ความสะอาดร่างกาย (toilet articles and cosmetics): แชมพูสระผม , สบู่อาบน้ํา , ครีม / โฟมล้างหน้า : nonionic and anionic surfactant ครีมนวดผม : cationic detergent 2. ผลิตภัณฑ์ซักผ้า (laundry products): ผงซักฟอก , น้ำยาซักผ้า : nonionic and anionic surfactant น้ำยาปรับผ้านุ่ม : cationic detergent น้ำยาขจัดคราบไคล : anionic surfactant 3. ผลิตภัณฑ์ล้างจาน (dishwashings): น้ำยาล้างจาน , น้ำยาล้างขวดนม : nonionic and anionic detergent น้ำยาล้างจาน ( เครื่อง ) : cationic detergent 4. น้ำยาทําความสะอาดพื้น (floor cleaners) : nonionic and anionic detergent 5. น้ำ ยาทําความสะอาดห้องนํา้บางสูตร (toilet cleaners) : nonionic, anionic and cationic 6. น้ํายาทําความสะอาดเอนกประสงค์ (All-purpose cleaner) : nonionic, anionic and cationic

89. Additive enzyme carboxymethyl cellulose flourescent whitening agent เช่น Pyrazolines, Coumarins corrosion inhibitor เช่น sodium silicate preservative corrosive fragrance

90. TREATMENT Initial Stabilization Clinical Evaluation Decontamination Diagnostic tests Enhance Elimination Specific antidotes Supportive care

91. Initial Stabilization Airway Management Administer 100% humidified supplemental oxygen, Administer inhaled beta adrenergic agonists if bronchospasm Monitor for evidence of respiratory distress (stridor, retractions, coughing, tachypnea)  ET tube

92. Decontamination Eye exposure Remove contact lenses & irrigate eyes with copious amounts of room temp 0.9%NSS or water for >15 mins. If irritation, pain, swelling, lacrimation, photophobia persist after 15 mins of irrigation  ophthalmologic examination Dermal exposure remove contaminated clothing and jewelry irrigate exposed area with copious amounts of water Inhalation exposure Move patient from the toxic environment to fresh air

93. Nonionic or anionic is generally self-limiting requiring no treatment maybe dilute with 120 - 240 ml of water or milk Cationic detergent should treat as corrosive agent Do not induce vomiting If signs or symptoms of esophageal irritation or burns are present, consider endoscopy Activated charcoal - unnecessary

94. Supportive care Treat dermal irritation / burns with standard topical drug Dermal hypersensitivity reactions  Rx. with systemic / topical corticosteroids / antihistamines

95. Summary No activated charcoal Nonionic / anionic surfactant dilution by water/milk may NG lavage improve in 24 hr Cationic surfactant treat as corrosive agent --> endoscopic

96. Case ผู้ป่วยหญิงไทยโสด อายุ 20 ปี ปฏิเสธโรคประจำตัว CC: พ่นยาไบกอน (spray) ฉีดยุงเข้าปาก 3 ครั้ง 5 นาทีก่อนมารพ . PI: 5 นาทีก่อนทะเลาะกับแฟน จึงนำ สเปรย์ฉีดยุงยี่ห้อไบกอนสีเหลืองมาฉีดเข้าปาก 3 ครั้ง แฟนนำส่งรพ . ทันที PE: WNL มีกลิ่นยา บริเวณปาก

98. Pyrethrines & Pyrethroids Pyrethrins : compounds extracted from chrysanthemums Pyrethroids : synthetic derivatives of pyrethrins greater chemical stability Type II pyrethroid Contain a cyano substituent More toxic formulation Potential danger to human Common as aerosals in automate insect spray Less toxic and safer than other compound

99. Pyrethrum cinerin I cinerin II jasmolin I jasmolin II pyrethrin I (methy group) pyrethrin II (ester group) type I (no cyano(nitrile group)

100. Toxicodynamics affect sodium channel in nerve cell depolarization and hyperexcitability Type I pyrethroid briefer , repetitive nerve discharge Type II longer repetitive nerve discharge inhibit Cl in GABA receptor --> seizure allergic : true IgE-mediated anaphylatic

102. Pyrethrines Pyretrum extract Pyrethrine I Pyretrhrine II Cinerin I Cinerin II Jasmolin I Jasmolin II Pyrethroids Allethine Barthrine Bioallethrine Bioresmethrine Cismethrine Cymethrine Cypermethrine Decamethrine Deltamethrine Fenothrin Fenvalerate Furamethrine tetramethrin

103. ยาจุดกันยุงและผลิตภัณฑ์กันยุงใชักับเครื่องไฟฟ้า

104. Mechanism of toxicity 1. Hypersensitivity immediate rhinitis and bronchial hyperreactivity uncertain mechanisms 2. Increase sodium influx into neurons Increase neurotransmitter release

105. Clinical manifestation Allergic and hypersensitivity Allergic rhinitis Contact dermatitis Asthma Anaphylactoid Dermal and systemic manifestations Abdominal pain, nausea, vomiting within 10 minutes to 1 hours Paresthesia, numbness: onset hours, duration: less than 24 hours Weakness and muscle fasciculation Seizure In cases of ingestion, beware of hydrocarbon pneumonitis

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

107. Gastrointestinal salivation , N/V , abdominal pain , diarrhea Liver effected due to prolong hypoxemia Genitourinary effected due to prolong hypoxemia

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

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

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

111. Treatment Typical GI decontamination Be careful in case of hydrocarbon media Treat allergic symptoms with antihistamine Symptomatic Observe for 6 hrs and d/c if asymptomatic

112. SAD PERSONS score S ex (male) = 1 A ge less than 19 or greater than 45 years = 1 D epression (patient admits to depression or decreased concentration, sleep, appetite and/or libido = 2 P revious suicide attempt or psychiatric care = 1 E xcessive alcohol or drug use = 1 R ational thinking loss: psychosis, organic brain syndrome = 2 S eparated, divorced, or widowed = 1 O rganized plan or serious attempt = 2 N o social support = 1 S ickness, chronic disease = 1 1 - 2 points low risk, 3-5 points moderate risk, 7-10 high risk