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

 

 

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

Aconitum poisoning

Substance

Aconitum 烏頭鹼

本草備藥:  

烏頭: 母. 川烏(四川) , 草烏(野生). 

附子: 附生者

側子: 連生者 

天雄: 形狀細長者

烏喙:形狀兩歧者

五物同出異名 

Common name or Trade name

今中醫中藥所使用附子為烏頭Aconitum carmichaeli Debx.的子根經中藥炮製切片而成

川烏為 烏頭Aconitum carmichaeli Debx.的乾燥母根

草烏為 北烏頭Aconitum kusnezoffii Reichb.的乾燥塊根。[1]

Involving system

-          Mechanism: aconite alkaloids are the fast voltage-gated sodium channel and cause persistent activation. [2]

 

Presentation

-          Altered mental status. [3]

-          Shock [3]

-          Cardiac arrhythmia. [3];

-       BVT, Bidirectional Ventricular Tachycardia:  

-          ventricular dysrhythmia (83%); ventricular fibrillation (23%); Torsade De pointes (9.2%). [2]

-       Bradycardia with hypotension:  (activation of the ventromedial nucleus of the hypothalamus.)

-          Death. [3]

 

Antidote and Treatment

-          Procainamide 100mg IV direct q5 minutes to a maximum of 1 g then maintenance infusion 2 - 6mg/min. (class Ia)

-          Mexiletine 200mg q8h. (class Ia)

-          Amiodarone 150mg stat. then 6支泡500 cc D5W run 34cc/ hr * 6hrs (class III)

then run 17cc/hr.* 18 hrs.

-          CPCR (23%) [3]

-          ECMO [2]

-          Hemoperfusion [2].

 

 

Disposition

Mortality rate: 15% [3]

MICU or CCU if hemodynamic changes/arrhythmia.

 

References

 

[1] Ref: http://yibian.hopto.org/esay/?eno=29

[2]. Coulson JM, Caparrotta TM, Thompson JP. The management of ventricular dysrhythmia in aconite poisoning. Clin Toxicol (Phila). 2017;55(5):313–321. doi:10.1080/15563650.2017.1291944

[3]. 2019 International Conference for Poison Control and Research Development.

 

-- March 19, 2020  

 

-- April 12, 2023   revised. by  Yu-Jang Su.