Chloroquine poisoning

Substance

Chloroquine

Common name or Trade name, used in

-          Chloroquine is a derivative of 4-aminoquinoline [1]

-          toxic dose > 20mg/kg [2]

-          fatal when > 5 gm [3]

-          Used in the malaria prophylaxis [1]

-          treatment of malaria, some connective tissue diseases, COVID-19 infection [1, 4]

 

Involving system

-          cardiovascular system [2].

-          altered mental status [2]

-          apnea, hyperventilation [2]

-          quinidine-like action [2].

-          negative inotropic action [2]

 

Presentation

-          Seizure [1]

-          Ventricular fibrillation [1]

-          QRS widening [5]

-          QTc prolongation [1]

-          Shock [5]

-          Cardiovascular collapse. [5] OHCA (15%) [6]

Antidote and Treatment

-          IVF + adrenalin, ACLS [5, 7]

-          NaHCO3 –

-          mechanical ventilation if respiratory failure [5, 7].

-          intravenous administration of diazepam and epinephrine [5]

-          diazepam dose (1 mg/kg) [7, 8] stat and 5—10mg/hrs. * 48 hours. Mechanism: increased chloroquine concentration in the blood, but decreased it in the heart muscle [2].

-          ECMO [5]

Disposition

-          MICU if hemodynamic change/ AMS [5]

-          overall mortality for all degrees of intoxication: 8.4% to 10% [6, 7]. 

References

 

[1] Ciszowski K, Winnik L, Groszek B, Kłys M, Kołodziej J. Ostre zatrucie chlorochina--rzadkie, ale zawsze powazne: opis przypadków i przeglad literatury [Acute chloroquine intoxication--rare, but always serious: case reports and literature review]. Przegl Lek. 2005;62(6):501–507.

[2]. Rajah A. The use of diazepam in chloroquine poisoning. Anaesthesia. 1990;45(11):955–957. doi:10.1111/j.1365-2044.1990.tb14629.x

[3] Riou B, Barriot P, Rimailho A, Baud FJ. Treatment of severe chloroquine poisoning. N Engl J Med. 1988;318(1):1–6. doi:10.1056/NEJM198801073180101

[4] Hu TY, Frieman M, Wolfram J. Insights from nanomedicine into chloroquine efficacy against COVID-19 [published online ahead of print, 2020 Mar 23]. Nat Nanotechnol. 2020;10.1038/s41565-020-0674-9. doi:10.1038/s41565-020-0674-9

[5] Bagate F, Radu C, Mekontso Dessap A, de Prost N. Early extracorporeal membrane oxygenation for cardiovascular failure in a patient with massive chloroquine poisoning. Am J Emerg Med. 2017;35(2):. doi: 10.1016/j.ajem.2016.08.058

[6] Clemessy JL, Taboulet P, Hoffman JR, et al. Treatment of acute chloroquine poisoning: a 5-year experience. Crit Care Med. 1996;24(7):1189–1195. doi:10.1097/00003246-199607000-00021

[7] Clemessy JL, Lapostolle F, Borron SW, Baud FJ. Intoxication aiguë à la chloroquine [Acute chloroquine poisoning]. Presse Med. 1996;25(31):1435–1439.

[8]. Altrock G, Lange A, Münster P. Akute Chloroquin-Intoxikation [Acute chloroquine poisoning]. Dtsch Med Wochenschr. 1997;122(8):225–228. doi:10.1055/s-2008-1047601

 

-- 26th March, 2020  Yu-Jang Su

 

 

Organophosphate poisoning

Substance

Organophosphate

Commonly used as insecticides

Common name or Trade name

磷酸酯或有機磷

Involving system

-Mechanism: They bind to acetylcholinesterase (AChE), also known as red blood cell (RBC) acetylcholinesterase, and render this enzyme non-functional [1]

-Aging: After some period of time, the acetylcholinesterase-organophosphorus compound undergoes a conformational change, known as "aging," which renders the enzyme irreversibly resistant to reactivation by an antidotal oxime [2]
- possible poisoning: decreased > 50% plasma cholinesterase or RBC cholinesterase 
- severe poisoning:  decreased > 90% plasma cholinesterase or RBC cholinesterase 

Presentation

SLUDGE/BBB – Salivation, Lacrimation, Urination, Defecation, Gastric Emesis, 

                            Bronchorrhea, Bronchospasm, Bradycardia

DUMBELS – Defecation, Urination, Miosis, Bronchorrhea/Bronchospasm/Bradycardia, 

                      Emesis, Lacrimation, Salivation [3] 

 
Antidote and Treatment

- GI decontamination: poisoning less than 1 hour

- activated charcoal 1gm/Kg BW.

- Atropine: 1 to 3 mg IV for adults and 0.05 mg/kg IV for children

If no effect is noted, the dose should be doubled every three to five minutes until pulmonary muscarinic signs and symptoms are alleviated [4]

- Pralidoxime: 30 mg/kg in adults, and 25 to 50 mg/kg for children, Pralidoxime should NOT be administered without concurrent atropine in order to prevent worsening symptoms due to transient oxime-induced acetylcholinesterase inhibition [5]

Disposition

Endotracheal intubation if the respiratory failure or markedly depressed mental status

Admission to the intensive care unit if hemodynamic  changes / AMS / respiratory failure.

References

[1] Khurana D, Prabhakar S. Organophosphorus intoxication. Arch Neurol 2000; 57:600.

[2] Eddleston M, Szinicz L, Eyer P, Buckley N. Oximes in acute organophosphorus pesticide poisoning: a systematic review of clinical trials. QJM 2002; 95:275.

[3] Sidell FR. Clinical effects of organophosphorus cholinesterase inhibitors. J Appl Toxicol 1994; 14:111.

[4] Konickx LA, Bingham K, Eddleston M. Is oxygen required before atropine administration in organophosphorus or carbamate pesticide poisoning? - A cohort study. Clin Toxicol (Phila) 2014; 52:531.

[5] Johnson MK, Jacobsen D, Meredith TJ, et al. Evaluation of antidotes for poisoning by organophosphorus pesticides. Emerg Med 2000; 12:22.

--20^th, March 2020 Sheng-Teck Tan, Yu-Jang Su

Glyphosate

Substance

Glyphosate
Common name or Trade name

年年春, 農達, 好過春, 家家春, 治草春, 日產春, 好伯春

 

 

Involving system and Presentation

 

-          Mucosa damage. Pain in throat. (Glyphosate pH=4.8). nausea/ vomiting.

-          Lung edema. Dyspnea, GI bleeding.

-          Acute lung injury (ALI) including acute respiratory distress syndrome (ARDS). [1]

-          liver injury. [1]

-          Organ damage by products containing glyphosate isopropylamine or ammonium salts, and polyoxyethyleneamine (POEA) as a surfactant. [1, 2]

-          Hyperkalemia. [1]

-          Arrhythmia. [1]

-          Cardiac arrest. [1]

Antidote and Treatment

-          Supportive

-          continuous veno-venous hemodiafiltration / Hemoperfusion.[3, 4]

-          ECMO. [5]

 

Disposition and Outcome

-          Independent risk factors for 30-day mortality: elevated lactate, age >59 years, corrected QT interval >495 ms and potassium >5.5 mmol/L. [6]

-          fatality rate: 12.5%. [6]

 

References

 

[1] Kamijo Y, Takai M, Sakamoto T. A multicenter retrospective survey of poisoning after ingestion of herbicides containing glyphosate potassium salt or other glyphosate salts in Japan. Clin Toxicol (Phila). 2016;54(2):147–151. doi:10.3109/15563650.2015.1121271.

[2]. 2019 International Conference for Poison Control and Research Development. 2019; Nov 15—17, p.265

[3] Ozaki T, Sofue T, Kuroda Y. Severe Glyphosate-Surfactant Intoxication Successfully Treated With Continuous Hemodiafiltration and Direct Hemoperfusion: Case Report. Ther Apher Dial. 2017;21(3):296–297. doi:10.1111/1744-9987.12565

[4]. Knežević V, Božić D, Budošan I, Čelić D, Milošević A, Mitić I. Srp Arh Celok Lek. 2012;140(9-10):648–652. doi:10.2298/sarh1210648k

[5]. Wang D, Zhang G, Zhang W, Luo J, Zhu L, Hu J. Successful extracorporeal membrane oxygenation support for severe acute diquat and glyphosate poisoning: A case report. Medicine (Baltimore). 2019;98(6):e14414. doi:10.1097/MD.0000000000014414

[6] Kim YH, Lee JH, Cho KW, et al. Prognostic Factors in Emergency Department Patients with Glyphosate Surfactant Intoxication: Point-of-Care Lactate Testing. Basic Clin Pharmacol Toxicol. 2016;119(6):604–610. doi:10.1111/bcpt.12624

 

--20^th, March, 2020  Yu-Jang Su

Snake bite

Substance

Protobothrops mucrosquamatus (龜殼花) 50% [1]

Trimeresurus stejnegeri Schmidt (赤尾青竹絲) 7% [1]

Deinagkistrodon acutus (百步蛇)

Bungarus multicinctus (雨傘節)

Naja atra (眼鏡蛇)

Daboia siamensis (鎖鏈蛇)

Common name or Trade name

 
龜殼花 -- 烙鐵頭 ,筍殼班, 老鼠蛇, 惡烏子

赤尾青竹絲 -- 赤尾鮐, 青竹蛇, 青竹鏢

 

百步蛇 -- 尖吻蝮, 尖吻蝮蛇, 五步蛇, 蘄蛇

雨傘節 -- 寸白蛇, 台灣環蛇, 中國環蛇, 過基甲, 過基峽, 簸箕甲, 手巾蛇, 銀

腳帶, 銀環蛇, 金錢蛇, 銀蛇, 花扇柄, 雨傘柄, 小白藥蛇, 台灣克雷特.

 

眼鏡蛇 -- 飯匙倩, 飯匙銃, 飯鏟頭, 膨頸蛇, 五毒蛇.

 
鎖鏈蛇 -- 七步紅

 

Involving system and Presentation

 

Hematotoxic – hours to days, up to 3 days. [2]

Neurotoxic – minutes to hours. (less than 12 hours.) [2].

 

Dry bite (10%) in a Thailand report. [3]

龜殼花, 赤尾青竹絲, 百步蛇 – pain, ecchymosis with swelling, bullae formation

百步蛇 – coagulopathy. Bleeding tendency. Epistaxis. DIC.

雨傘節, 眼鏡蛇 - lethargy，numbness rather than ecchymosis / swelling，weakness/ paralysis, diplopia, blurred vision, ptosis, dysarthria. Drooling, respiratory failure.

眼鏡蛇—severe painful, swelling, tissue necrosis, rhabdomyolysis.  

鎖鏈蛇 – ecchymosis, swelling, bullae formation. Hemolysis, and rhabdomyolysis, acute renal failure, lung edema.   

Antidote and Treatment

(H)青竹絲 總量1—4 vials. 視病況需要調整用量 (大部份1 vial, 轉診來的3vials,有開刀的 3 vials). 平均2.8 Vials. [1]

 (H)龜殼花 總量4.5 vials. 視病況需要調整用量. [1]


   百步蛇 總量1—4 vials. 視病況需要調整用量


 
 (N)眼鏡蛇 總量6—12vials 視病況需要調整用量(大部份1vial, 轉診來的4.5vials有開刀的 8.5 vials) , weakness就開始給 [2]
 
 (N)雨傘節 總量1—4 vials. 視病況需要調整用量, weakness就開始給 [2]

 鎖鏈蛇 總量1—4 vials. 視病況需要調整用量


 
Disposition and Outcome

 
Comparment syndrome 13.6%. [1]

Surgical intervention 22% [1]

Adverse drug reaction to antivenom reaches 3—53% in a Thailand report. [3].

Admission if symptoms progressive although/ even antivenom administrated.

If hemodynamic change / AMS : admit to ICU.

References

 

[1] 2019 International Conference for Poison Control and Research Development. 2019; Nov 15—17, p.191.

 

[2]. 2019 International Conference for Poison Control and Research Development. 2019; Nov 15—17, p.211--6.

 

[3] 2019 International Conference for Poison Control and Research Development. 2019; Nov 15—17, p.205.

-- 20th, March, 2020. Yu-Jang Su