1 / 32

Toxicology conference

Toxicology conference. 2011.12.16 指導醫師：許景瑋醫師 報告者： fellow 1 潘恆之. P resentation. Patient Profile. Name: 趙 o 林 Sex: male Age: 39 years old Chart number: 8767453 He visited our emergent room on 2011/11/04. Chief Complaint. Acute onset of blurred vision lasts for one day. Present Illness.

ciara-crosby
Download Presentation

Toxicology conference

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Toxicology conference 2011.12.16 指導醫師：許景瑋醫師 報告者：fellow 1 潘恆之

  2. Presentation

  3. Patient Profile • Name: 趙o林 • Sex: male • Age: 39years old • Chart number: 8767453 • He visited our emergent room on 2011/11/04

  4. Chief Complaint • Acute onset of blurred vision lasts for one day.

  5. Present Illness • This 39 y/o gentleman denied hypertension, diabetes mellitus or other systemic diseases. • He had experienced intermittent nausea, vomiting , and progressive anorexia since 11/01. Acute onset of blurred vision , dizziness, headache were noted since 11/04 morning. Besides, he suffered from intermittent bloody stool for 1 years. • No dyspnea, orthopnea, urine output decrease, abdominal pain, chest pain, fever, chillness or cough. • He almost drinks every day. He often fogets to eat due to drunk. He drank 公賣局米酒 on 11/03 night.

  6. Past History • He denied significant systemic diseases, such as diabetes mellutis , hypertension, heart, kidney, or lung diseases. • Current medicine: nil

  7. Personal History • Allergy: no known allergy • Alcohol: he drinks 米酒 at least 1 bottle per day; betel-nut: denied; cigarette: 1 ppd/day since young age • Over-the-counter medication or chinese herb: denied

  8. Family History • No family history of diabetes mellutis, malignancy, heart, liver, kidney, or hereditary diseases.

  9. Physical Examination • Vital signs: T:36’C , P:116 bpm, R:17/min , BP:137/92 mmhg • General apperance: chronic ill looking • Consciousness: clear, GCS: E4V5M6 • HEENT: conjunctive: not pale, sclera: anicteric pupil: 3mm/3mm , light reflex: +/+, EOM: full/full • Chest: symmetric expansion , clear breathing sound • Heart: regular heart beat without murmur • Abdomen: soft and flat, normoactive bowel, no tenderness liver/spleen: impalpable, no palpable bladder • Extremity: free movement, no pitting edema • Digital rectal exam: yellowishy stool

  10. 11/04 Laboratory Data

  11. 11/04 Laboratory data • Osmo gap: • Serum Osm – calculated Osm ( 2 [Na] + [BUN]/2.8 + [glucose]/18 + [EtOH]/4.6) = 21.86 mOsm/kg => Anion gap: ?

  12. 11/04 Brain CT • Impression: subtle low attenuation in cerebellum and prominent cerebellar sulci. DDX: cerebral cortical atrophy or infarct, pleased clinical correlation.

  13. Impression • Metabolic acidosis with high osmolar gap, etiology? favor methanol intoxication related • Bloody stool, favor hemorrhoid related

  14. Plans • Closely monitor vital signs, mental status and consult ophthalmologist for thorough visual exam • Complete metabolic acidosis survey, please check anion gap, ketone, lactate, ethyl alcohol and urine AG • Suggest the patient take ethanol as antidote • Arrange hemodialysis for increasing methanol elimination • Follow up methanol level, blood Osm, and ABG • Give thiamine and watch out for alcohol withdrawal

  15. 11/05 Ocular Examination

  16. Laboratory data HD HD

  17. Other examination • 11/07 Sigmoidoscopy : Impression: No active bleeder. Colon polyp, R-S colon Mixed hemorrhoid. • 11/09 Brain MRI : Impression: Normal brain MR study.

  18. 11/09 Follow-up Ocular Examination • s/s : still blurred vision (ou) • VA: ou CF/50cm • RAPD: + (od) • clear corea, AC and lens (ou) • fundus: decreased hyperemia of the r’t disc, but disc margin is sl. blurred => Discharge and OPD follow-up !!

  19. Methanol poisoning

  20. Summary of exposure • Methanol are frequently found in high concentration in automotive antifreeze and de-icing solutions, windshield wiper fluid, solvent cleaners, fuels, other industrial products, and adulterant in homemade distillates. • Most serious poisonings occur following ingestion; inhalation and dermal exposures rarely cause toxicity. • Lethal dose – 1 g/kg Toxicity dose – 0.25ml/kg of 100% methanol (>8g) Threshold of treatment – 20~25mg/dL

  21. Methanol metabolism Toxicity Elimination Half life Kidney：3~5% Lung：12% 8 hr 51hr 1 ( Liver ) 33 ( Liver ) 6 20 hr Adult: 8.5 mg/dl/hr Child: 0.88 mg/dl/hr @

  22. Clinical features • Early toxicity(acute intoxication) CNS：sedation, disinhibition, ataxia, headache GI：abdominal pain, nausea, vomiting

  23. Clinical features • Late toxicity(severe metabolic acidosis develops 6-12 hours after exposure ) HEENT：Ocular toxicity CV: tachycardia, arrythmia, bradycardia (fatal poisoning), cardiac arrest, severe hypotension Respiratroy: tachypnea, sudden respiratory failure Neurologic: coma, seizure, basal ganglia necrosis with parkinsonian features, polyneuropathy, optic atrophy GI: abdominal pain, anorexia, nausea, vomiting, necortizing pancreatitis (severe poisoning)

  24. Clinical features GU: acute renal failure, hamaturia Acid-base: metabolic acidosis (concurrent ethanol ingestion may delay acidosis > 1 hr ) Electrolyte: hypomagnesemia, hypokalemia, hypophophatemia Musculoskeletal: rhabdomyolysis (severe poisoning) Reproductive: birth defects of CNS (ingested together with other solvents)  Keypoints of PE: Vital sign, mental status, pupuils, thorough visual exam

  25. Normal Relative afferent pupillary defect @

  26. Diagnostic testing • Finger sugar (rule out hypoglycemia, DKA, HHNK) • Arterial or venous blood gas , renal function, electrolytes, serum osmolality, methanol, ethanol , ethylene glycol, isopropanol concentration, lactate, acetaminophen and salicylate levels (to help determine diagnosis)  high anion gap? HCO3 <8 ? Osm gap > 10 ? mild elevated lactate levels? • ECG • Pregnancy test in women of childbearing age

  27. Treatment • Keep airway, breathing, circulation： * Endotracheal intubation if mental status change or respiratory failure  hyperventilated with large minute ventilations to prevent profound acidemia * IV crystalloid + vasopressors if hypotension

  28. Treatment • Decontamination : * GI – not very useful ( methanol is rapidly absorbed and binds poorly to activated charcoal). Gastric aspiration by NG tube within 60 mins of ingestion maybe useful. * Eye – irrigate with water for > 15 mins * Dermal – remove contaminated clothing and wash exposed area with soap and water

  29. Treatment • Medication : a. If PH < 7.3, give Sodium bicarbonate 1-2meq/kg bolus + 132 meq in 1L D5W run 150-250cc/hr b. Antidote – ADH inhibition (give as soon as possible) * Fomepizole – 15mg/kg iv loading + 10mg/kg q12h x 4 doses  Followed by 15mg/kg q12h if necessary * Ethanol – 8ml/kg of a 10% ethanol solution ivf loading + 1ml/kg/hr of 10% ethanol solution.  Titrate serum EtOH to 100 mg/dL or

  30. Treatment • Hemodialysis -- rapidly remove both methanol and its toxic acid metabolites (methanol half life 8 hrs  2.5 hrs) * Indication : a. Known methanol intoxication -- High anion gap metabolic acidosis -- End organ damage (visual changes) b. Suspected methanol intoxication -- Unexplained high anion gap metabolic acidosis + high plasma osmolar gap ( PH < 7.3 if strongly suspected, PH < 7.1 if weakly susected)

  31. Treatment • Cofactor therapy – combine with ADH inhibition Folinic acid (leucovorin) 50mg iv q4-6h or Folic acid 50mg IV q4-6h  increases clearance of formate • Admission criteria: acidosis, visual symptoms, or methanol > 25mg/dL

  32. Thanks for your listening

More Related