Urinary alkalization and urinary acidification in poisoning

 

尿液鹼化原理是毒物從經由腎臟排除, 毒物為弱酸性的情況, 分佈於細胞外液並且protein binding不強. (像NSAID與protein binding強就無用)

 尿液鹼化適應症:

l  中重度salicylate毒性未達hemodialysis程度

(水楊酸中毒血液透析適應症: https://twmmhedpc.blogspot.com/2019/12/poison-hemodialysis-is-helpful.html

l  Phenobarbital (多劑量activated charcoal較優)[1].

 

l  Chlorophenoxy herbicides (2-4-dichlorophenoxyacetic acid and mecoprop): 須高尿流量 600 mL/h 較有效 [2, 3], forced diuresis 也是有幫忙的[4]

 

l  Chlorpropamide: supportive care/IV dextrose normally sufficient.

 

l  Toxicities of High-Dose Methotrexate [5]

 

尿液鹼化禁忌症

l  本來患者狀況fluid就overload

l  Renal impairment: CKD, uremia.

l  本來血鉀就很低(Uncorrected hypokalemia), 避免低血鉀引發VT [6] 最好keep 血鉀在4—4.5 mEq/L [7] 
 

尿液鹼化併發症:

l  Hypokalemia.

l  Volume overload.

l  鹼血症(Alkalemia);

l  輕度Hypocalcemia
 

尿液鹼化做法:

NaHCO₃^- 1 amp in N/S 1 BT run 125 ml, 有uremia, CHF, CKD 需調整滴速 [8]

1–2 mEq/kg IV bolus followed by 2 mEq/kg per h IV infusion

Sodium bicarbonate 4 amps in D5W 500ml run 250 mL/hr. (可以加20 mEq of potassium chloride避免低血鉀)

Keep urine output of 1 to 2 mL/kg per hour

 

尿液鹼化監測

urine pH 每 15 to 30分測尿的pH 保持7.5 to 8.5.

尿液鹼化曾用於Brazil 與 Iran的organophosphate poisoning 但並無有效實證。[9], 另抗發炎製劑Diflunisal和NSAID 也是無效 [10].

 

尿液酸化

urinary acidification 可以增加弱鹼的移除(包括 amphetamines和phencyclidine), 但產生的相關危險性(例如 rhabdomyolysis) 往往超過尿液酸化原本的好處.  

尿液酸化對MAOI的移除是無效的[4]

REFERENCES

 

[1]: Lindberg MC, Cunningham A, Lindberg NH. Acute phenobarbital intoxication. South Med J. 1992;85(8):803–807. doi:10.1097/00007611-199208000-00004

 

[2]: Bradberry SM, Proudfoot AT, Vale JA. Poisoning due to chlorophenoxy herbicides. Toxicol Rev. 2004;23(2):65–73. doi:10.2165/00139709-200423020-00001

 

[3]: Roberts DM, Buckley NA. Urinary alkalinisation for acute chlorophenoxy herbicide poisoning. Cochrane Database Syst Rev. 2007;(1):CD005488. Published 2007 Jan 24. doi: 10.1002/14651858.CD005488.pub2

 

[4]: Tintinalli’s Emergency Medicine, 8th ed. P.1227

 

[5]: Howard SC, McCormick J, Pui CH, Buddington RK, Harvey RD. Preventing and Managing Toxicities of High-Dose Methotrexate. Oncologist. 2016;21(12):1471–1482. doi:10.1634/theoncologist.2015-0164

 

[6] Tsai IH, Su YJ. Thyrotoxic periodic paralysis with ventricular tachycardia. J Electrocardiol. 2019; 54:93–95. doi: 10.1016/j.jelectrocard.2019.04.001

 

[7] Tintinalli’s Emergency Medicine, 8th ed. P.1268.

 

[8]. Table 176-2. Tintinalli’s Emergency Medicine, 8^th ed. P.1208 -1212.

 

[9]. Tintinalli’s Emergency Medicine, 8th ed. P.1320.

 

[10]: Balali-Mood M, Prescott LF. Failure of alkaline diuresis to enhance diflunisal elimination. Br J Clin Pharmacol. 1980;10(2):163–165. doi:10.1111/j.1365-2125. 1980.tb01734.x

 

 

-- edited 11th Jan, 2020 Yu-Jang Su.

血液灌注 charcoal hemoperfusion

可由活性炭血液灌注(charcoal hemoperfusion)排除之毒物:

Barbiturates [1]

 
Carbamazepine[2] 

Glutethimide[3]

 

Paraquat[4] 

Star Fruit [5]

 

Theophylline用hemoperfusion效果比hemodialysis好 [6]
 

Valproic acid.[7]

REFERENCES

 
1.      急性中毒救命術 急診醫學會 三版, p.378

2.      Peces R, Azorín S, Peces C, Selgas R. Tratamiento con hemoperfusión prolongada en la intoxicación aguda por carbamazepina [Extended hemoperfusion in the treatment of acute carbamazepine intoxication]. Nefrologia. 2010;30(1):127–130. doi:10.3265/Nefrologia.pre2010.Jan.10217

3. Peces R, Azorín S, Peces C, Selgas R. Tratamiento con hemoperfusión prolongada en la intoxicación aguda por carbamazepina [Extended hemoperfusion in the treatment of acute carbamazepine intoxication]. Nefrologia. 2010;30(1):127–130. doi:10.3265/Nefrologia.pre2010.Jan.10217

4 .Nasr Isfahani S, Farajzadegan Z, Sabzghabaee AM, Rahimi A, Samasamshariat S, Eizadi-Mood N. Does hemoperfusion in combination with other treatments reduce the mortality of patients with paraquat poisoning more than hemoperfusion alone: A systematic review with meta-analysis. J Res Med Sci. 2019;24:2. Published 2019 Jan 31. doi:10.4103/jrms.JRMS_478_18

5. Chan CK, Li R, Shum HP, et al. Star fruit intoxication successfully treated by charcoal haemoperfusion and intensive haemofiltration. Hong Kong Med J. 2009;15(2):149–152.

6. Shannon MW. Comparative efficacy of hemodialysis and hemoperfusion in severe theophylline intoxication. Acad Emerg Med. 1997;4(7):674–678. doi:10.1111/j.1553-2712.1997.tb03758.x

7. Peces R, Fernández EJ, Sánchez RJ, Peces C, Montero A, Selgas R. Tratamiento con hemoperfusión de la intoxicación aguda por ácido valproico [Hemoperfusion in the treatment of acute valproic acid intoxication]. Nefrologia. 2007;27(3):370–373.

-- edited 24th Dec, 2019 Yu-Jang Su.

 

Poison, Hemodialysis is helpful

可血液透析(hemodialysis):急性中毒 consult Nephrologist  
Acetaminophen (paracetamol level >900 mg/L) [1, 2]

Barbiturates (>100 mg/dL) [1, 3]

Carbamazepine (serum levels >40 mg/L or hemodynamic instability). [1, 4]

Lithium (3--4.0 mEq/L with serious symptoms) [5].

Metformin (lactate >15 mmol/L and ABG pH < 7.0 with shock or organ failure) [1, 6]

Methanol (50 mg/dL) and Ethylene glycol (50 mg/dL) [7].

Mushroom, Amanita [8]

Salicylates (>100 mg/dL, AKI, lung edema, AMS, hepatic failure, coagulopathy.) [9]

Theophylline (level >100 mg/L) with acute overdose

Theophylline level >60 mg/L) with chronic toxicity

severe toxicity – dysrhythmia, hypotension or seizures. [10].

Valproic acid (> 700mcg/ml) [11]

 REFERENCES

1.      https://www.dynamed.com/management/dialysis-for-acute-poisonings

2.      Serjeant L, Evans J, Sampaziotis F, Petchey WG. Haemodialysis in acute paracetamol poisoning. BMJ Case Rep. 2017;2017:bcr2016218667. Published 2017 Jan 17. doi:10.1136/bcr-2016-218667

3.      https://emedicine.medscape.com/article/813155-followup

4.      https://litfl.com/carbamazepine-toxicity-tox-library/

5.      http://www.tsim.org.tw/journal/jour12-5/P12_241.PDF

6.      https://www.hindawi.com/journals/cricc/2018/3868051/

7.      急診醫學會 AILS第三版，p. 258

8.      Warden CR, Benjamin DR. Acute renal failure associated with suspected Amanita smithiana mushroom ingestions: a case series. Acad Emerg Med. 1998;5(8):808–812. doi:10.1111/j.1553-2712.1998.tb02508.x

9.      急診醫學會 AILS第三版，p. 348

10.  https://litfl.com/theophylline-tox-library/

11.  Nasa P, Sehrawat D, Kansal S, Chawla R. Effectiveness of hemodialysis in a case of severe valproate overdose. Indian J Crit Care Med. 2011 Apr;15(2):120-2. doi: 10.4103/0972-5229.83020. PMID: 21814378; PMCID: PMC3145297.

-- edited 21th December 2019, Yu-Jang Su.

常用解毒劑 Antidotes

常用解毒劑Antidotes

 
Amyl nitrite (inhalation), Sodium nitrite (IVD)-- Cyanide, H2S

 Inhalation 30 secs, for 3 minutes.

 3% sodium nitrite (max. 10 ml. IVD 2—5 minutes.) (child: 0.2 ml/kg)

 Sodium thiosulfate (max. 12.5gm, child: 1.65ml./kg) IV. [1]

 

Anti-venom Snake bite – snake bite

 (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).

 (H)龜殼花 總量1—4 vials. 視病況需要調整用量

   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)

 (N)雨傘節 總量1—4 vials. 視病況需要調整用量

 鎖鏈蛇 總量1—4 vials. 視病況需要調整用量[2].

 

Atropine-- Organophosphate/Carbamate

 2—4mg IV/ 10—15 minutes視病況追加 (child:0.05mg/kg) [3]. 

(ex: Atropine 8 amps + N/S run 125 c.c./hr) 

 

Chelators: DMPS -- As, Hg, Cu, Gold, Cr, Cd.

  劑型 250mg/5 ml/amp. 100mg/tab

  Dose: 5mg/kb IM/IV, 1^st day q6h—q8h; 2^nd day q8h—q12h; 3^rd day: q12h—q24h [4].

 

Calcium- HF: 局部接觸, 可以用calcium gluconate 軟膏局部塗抹. 若為吞服(swallowing), 則需靜脈注射calcium gluconate, 口服calcium carbonate powder, milk. 注意metabolic acidosis [5].

 

Cyanide kit – Cyanide

  Inhalation 30 secs, for 3 minutes.

  3% sodium nitrite (max. 10 ml. IVD 2—5 minutes.) (child: 0.2 ml/kg)

  Sodium thiosulfate (max. 12.5gm, child: 1.65ml./kg) IV.

 

Deferoxamine-- Iron

  Acute iron poisoning

  Adult Dose: 1000 mg, IM or IV stat. (maximum IV rate: 15 mg/kg/hour)

Maintenance dose: 500 mg, IM or IV, q4h , for 2 doses; 追加500 mg doses q4—q12h 依臨床病況需要

  Maximum dose: 6000 mg / day [6].

 

Digibind-- Digoxin

  Indication: arrhythmia with hemodynamic change.

服用 digoxin 總量（mg）X 0.8÷0.5 mg=所需 Digibind 瓶數[7].

  急性中毒可以先給2 vials, IVD; 慢性中毒可以先給1 vial, 1 hr後視病況需要再給[8].

 

EDTA (Ethylenediamine tetraacetic acid)—Lead, Cd

  1-2 g/d (25-50 mg/kg/day) IVD/ IM (divided into 2 doses) *2-5days [9].

 

Ethanol-- Methanol, Ethylene glycol

  For 20% ethanol, loading 4ml/kg, maintain 0.4—0.8ml/kg/hr, to maintain serum ethanol concentration of 100-200 mg/dL [10].

 

Fomepizole-- Methanol, Ethylene glycol  劑型: 1 g/ml，1.5 ml/vial

  10—20 mg/kg/day * 3—5 days [11].

 

Glucagon -- β-blockers, CCB

  0.05—0.15mg/kg IVD > 1 minute, 1—5 mg/ hr IVD [12].

 

Hydroxocobalamin—Cyanide, to form Vitamin B12.

  5 gm or 70 mg/kg IVD 30 minutes [13].

 

Methylene blue--Methemoglobinemia

  1—2 mg/kg IVD [14].

 

N-Acetylcysteine--Acetaminophen

   NAC PO, 140 mg/kg, 70 mg /kg q4h* 17 times.

　 NAC IV, 150 mg /kg for 15 to 60 minutes,

12.5 mg /kg /hr * 4-hours, then    

6.25 mg /kg/hr * 16 hours [15].

 

Naloxone-- Opioids

  1—5 amps stat. repeated doses of waking up dose * 1/2 to 2/3 if necessary [16].

 

Oxygen—CO

  100% oxygen

  HBO when AMS, cardiac ischemia, pH<7.1, HbCO> 25%, and pregnancy with HbCO> 20% [17].

 

Pralidoxime  -- Organophosphate

 1—2 gm stat. in adult. Then 8mg/kg/hr or 2 gm for 30 minutes. 0.5—1 gm/hr 依病況調整[18, 19].

 Child: 20 to 50 mg/kg (maximum 2gm/dose) IVD over 15 to 30 minutes

      Then IV pump with 10 to 20 mg/kg/hour [18, 19].

      (ex: PAM 3--4 amps IVD st. > 30 minutes and 4 amps +N/S run 125 c.c./hr) 

 

Pyridoxine-- Isoniazid (INH) poisoning

1 g of pyridoxine intravenously for 1 gram of isoniazid (known to have been ingested) (至多52gm) 用50 c.c. N/S or dextrose 稀釋 (rate of 1 g/min) IVD > 5 minutes.

4–5 g IV and repeat q 5–20 minutes as needed:若吃的INH量不知道的時候 [20].

 

Sodium. Bicarbonate --Salicylate

  1—2 mEq/kg to keep urine pH 7.5—8 [21].

 

Sodium. Thiosulfate --Cyanide

  Sodium thiosulfate (max. 12.5gm, child: 1.65ml./kg) IV.

 

Succimer (Dimercaptosuccinic acid), DMSA-- 是用於Pb, As, Hg中毒[22].

  Pb: Lead Poisoning: 10 mg/kg PO q8hr * 5 days;

then 10 mg/kg/dose q12hr *14 days;

not to exceed 500 mg/dose. 

  As: Arsenic Poisoning: 300 mg PO q6hr * 3 days

     直到urinary arsenic <50 mcg/L

  Hg: Mercury Intoxication: 15mg/kg [23].

 

Vitamin K1 --Warfarin. Rodenticides

1—10mg, IM/SC better than IV to keep INR less than 5 [24].

 

REFERENCES

1.      急診醫學會. 急性中毒救命術, 第三版p. 295

2.      2019 International Conference for Poison Control and Research Development. Nov 15—17, 2019, Taipei. Taiwan.

3.      急診醫學會. 急性中毒救命術, 第三版p. 69

4.      衛服部 全國解毒劑儲備網http://www.pcc-vghtpe.tw/antidote/page_detail.asp?cid=6&nid=20

5.      Su YJ, Lu LH, Choi WM, Chang KS. Survival after a massive hydrofluoric acid ingestion with ECG changes [published correction appears in Am J Emerg Med. 2009 Jan;27(1):126.]. Am J Emerg Med. 2001;19(5):458–460. doi:10.1053/ajem.2001.24503

6.      https://www.drugs.com/dosage/deferoxamine.html#Usual_Adult_Dose_for_Iron_Poisoning___Acute

7.      http://www.pcc-vghtpe.tw/antidote/file/pdf/%E6%AF%9B%E5%9C%B0%E9%BB%83%E4%B8%AD%E6%AF%92%E8%A7%A3%E6%AF%92%E5%8A%91.pdf

8.      Chan BS, Buckley NA. Digoxin-specific antibody fragments in the treatment of digoxin toxicity. Clin Toxicol (Phila). 2014;52(8):824–836. doi:10.3109/15563650.2014.943907

9.      http://www.pcc-vghtpe.tw/antidote/page_detail.asp?cid=6&nid=20

10.  https://mdpoison.com/media/SOP/mdpoisoncom/ToxTidbits/2013/June%202013%20ToxTidbits.pdf

11.  急診醫學會. 急性中毒救命術, 第三版p. 260

12.  急診醫學會. 急性中毒救命術, 第三版p. 354

13.  急診醫學會. 急性中毒救命術, 第三版p. 296

14.  急診醫學會. 急性中毒救命術, 第三版p. 284

15.  Heard KJ. Acetylcysteine for acetaminophen poisoning. N Engl J Med. 2008;359(3):285–292. doi:10.1056/NEJMct0708278

16.  Clarke SF, Dargan PI, Jones AL. Naloxone in opioid poisoning: walking the tightrope. Emerg Med J. 2005;22(9):612–616. doi:10.1136/emj.2003.009613

17.  急診醫學會. 急性中毒救命術, 第三版p. 312—13.

18.  https://www.drugs.com/dosage/pralidoxime.html#Usual_Adult_Dose_for_Organophosphate_Poisoning

19.  急診醫學會. 急性中毒救命術, 第三版p. 60

20.  https://accessmedicine.mhmedical.com/content.aspx?bookid=391&sectionid=42070045

21.  急診醫學會. 急性中毒救命術, 第三版p. 348

22.  https://reference.medscape.com/drug/chemet-succimer-343751

23.  https://www.biolab.co.uk/docs/dmsaprov.pdf

24.  Hirsh J. Reversal of the anticoagulant effects of warfarin by vitamin K1. Chest. 1998;114(6):1505–1508. doi:10.1378/chest.114.6.1505

-- edited 21th December 2019, Yu-Jang Su.