ECG Changes on Poisoning / Intoxication

 ECG changes on poisoning/ intoxication

 

ECG	Substance	Date	Origin
Asystole	Lithium	1991	UK[1]
First degree AV block	Carbon monoxide Lithium	2013 2018	Riyadh[2] Taiwan[3] Kaohsiung Medical University Hospital
QRS complex widening	Hydrofluoric acid tricyclic antidepressant	2005 2016	USA [4] New Orleans[5] Spain [6]
QT interval prolongation	Hydrofluoric acid organophosphate	2005 2009	USA [4] Iran [7]
R wave in aVR ≥ 3 mm		2012	Spain [6]
Scooping of the T waves	Digoxin	2017	Lebanon[8]
Sinus bradycardia	Calcium channel blockade Beta-adrenergic receptor blockade
Sinus Dysfunction	Lithium	1995	Japan [9]
Tall T wave	Hydrofluoric acid	2001	Taiwan [10] MacKay Memorial Hospital.

 

References

1.      Ong AC, Handler CE. Sinus arrest and asystole due to severe lithium intoxication. Int J Cardiol. 1991 Mar;30(3):364-6. doi: 10.1016/0167-5273(91)90021-g. PMID: 2055679.

2.      Salih SB, Alenezi H, Alghamdi A. A case of first degree AV block in carbon monoxide poisoning patient. J Saudi Heart Assoc. 2013 Oct;25(4):255-9. doi: 10.1016/j.jsha.2013.05.004. PMID: 24198450; PMCID: PMC3818633.

3.      Chien SC, Liu KT, Wu YH. Lithium intoxication presenting as altered consciousness and arrhythmia with cardiogenic shock: A case report. Medicine (Baltimore). 2018 Nov;97(45):e13129. doi: 10.1097/MD.0000000000013129. PMID: 30407335; PMCID: PMC6250446.

 

4.      Holstege C, Baer A, Brady WJ. The electrocardiographic toxidrome: the ECG presentation of hydrofluoric acid ingestion. Am J Emerg Med. 2005 Mar;23(2):171-6. doi: 10.1016/j.ajem.2004.04.032. PMID: 15765339.

5.      Glancy DL. ECG Of the Month: Suicide. J La State Med Soc. 2016 Mar-Apr;168(2):66-7. Epub 2016 Apr 15. PMID: 27383860.

6.      Yates C, Manini AF. Utility of the electrocardiogram in drug overdose and poisoning: theoretical considerations and clinical implications. Curr Cardiol Rev. 2012 May;8(2):137-51. doi: 10.2174/157340312801784961. PMID: 22708912; PMCID: PMC3406273.

7.      Shadnia S, Okazi A, Akhlaghi N, Sasanian G, Abdollahi M. Prognostic value of long QT interval in acute and severe organophosphate poisoning. J Med Toxicol. 2009 Dec;5(4):196-9. doi: 10.1007/BF03178266. PMID: 19876851; PMCID: PMC3550412.

8.      Mansour MJ, Kalaoui M, Chammas E, Hamoui O, Fawaz T, AlJaroudi WA. Unusual digoxin toxicity with myocardial injury. J Electrocardiol. 2017 Nov-Dec;50(6):909-911. doi: 10.1016/j.jelectrocard.2017.07.013. Epub 2017 Jul 12. PMID: 28807352.

9.      Nakamura H, Takahashi F, Matsuzaka T, Tanaka H, Akashi N, Sato N, Kikuchi K. [A case of lithium induced sinus mode dysfunction]. Nihon Naika Gakkai Zasshi. 1995 Jan 10;84(1):127-9. Japanese. PMID: 7722356.

10.  Su YJ, Lu LH, Choi WM, Chang KS. Survival after a massive hydrofluoric acid ingestion with ECG changes. Am J Emerg Med. 2001 Sep;19(5):458-60. doi: 10.1053/ajem.2001.24503.

edited by Yu-Jang Su            

Theophylline Intoxication

 Substance

 -  theophylline intoxication.   

 -  (45.5%) had acute, (40.4%) had chronic, and (14.0%) had acute-on-therapeutic poisoning. [1]

Common name or Trade name

 -  definition: Therapeutic ranges are usually achieved between 10–20 μg/mL. Toxic effects are often seen above 20 μg/mL plasma concentrations. [2]

 

Involving system

-       Effect: diuretic, smooth muscle relaxant, cardiac, nervous system, and ventilator stimulant [2]

-       GI system: nausea, vomiting, gastrointestinal reflux [2]

-       Neuro: restlessness, and headache, convulsions (8.2%) [2, 3]

-       CV: severe cardiac arrhythmias (20.8%), hypotension (may result fromβ2-stimulated peripheral vasodilation) and even death occur at higher theophylline concentrations (usually 80–100 μg/mL). [1, 2]

 

Presentation 

-       severe cardiac arrhythmias, refractory hypotension, and convulsions [2]

-       Hypokalemia, hypercalcemia, hyperglycemia, and acidosis are metabolic disturbances that commonly occur after an acute overdose [2]

-       May complicate with Coma Blister. [4]

 

Antidote and Treatment

-       Gastrointestinal decontamination with activated charcoal. [2]

-       The use of beta-blockers is an acceptable approach to control tachydysrhythmias [2]

-       aggressive fluid administration + conventional vasopressors in cases of refractory hypotension.

-        

-       standard hemodialysis is a suitable alternative when severe theophylline toxicity [2].

Disposition 

-       Carefully DDx with a thyroid storm.  

-       4.2% fatality [D].  

REFERENCES

 [1]. Shannon M. Life-threatening events after theophylline overdose: a 10-year prospective analysis. Arch Intern Med. 1999 May 10;159(9):989-94. doi: 10.1001/archinte.159.9.989. PMID: 10326941.

 [2]. Aggelopoulou E, Tzortzis S, Tsiourantani F, Agrios I, Lazaridis K. Atrial Fibrillation and Shock: Unmasking Theophylline Toxicity. Med Princ Pract. 2018;27(4):387-391. doi: 10.1159/000490145. Epub 2018 Jun 22. PMID: 29936503; PMCID: PMC6170900.

[3]. Kopacz P, Kula K. Lethal poisoning with theophylline in the form of rectally administered tablets. Arch Med Sadowej Kryminol. 2014;64(3):158-64. doi: 10.5114/amsik.2014.48879. PMID: 25693173.

[4]. Tsokos M, Sperhake JP. Coma blisters in a case of fatal theophylline intoxication. Am J Forensic Med Pathol. 2002 Sep;23(3):292-4. doi: 10.1097/00000433-200209000-00019. PMID: 12198361.

 

edited by Yu-Jang Su            Dec 7, 2021

Pyrethrin, Pyrethroid Poisoning

 SUBSTANCE

-          Pyrethrin 除蟲菊精

-          Artificial: pyrethroid [1]

Common name or Trade name 

-          蚊香, 速必落, 滅飛, 拜貢, 克蟑[1]

 

Involving SYSTEM

-          delaying the closure of voltage-sensitive sodium channels. [1, 2]

-          Nearly 1% absorbed via skin [1]

-          GI discomfort [1, 2]

-          Airway irritative [1]

-          Bronchospasm [3]

-          Neurotoxic [2].

-          Cardiotoxic effects: prolonged bradycardia [2]

 

Presentation

-          Type I: T, tremor [1]

-          Tyee II: contains cyano-group, CS, choreoathetosis with salivation. [1]

-          Eye pain, tearing, and photophobia.[1]

-          Glasgow Coma Scale (GCS) <15 (33.9%) [4]

-          respiratory failure requiring ventilator care (17.9%) [4]

-          hypotension (10.7%), acute kidney injury (10.7%) [4]

-          pneumonia (7.1%) [4]

-          seizure (3.6%) and death (3.6%). [4]

 

Antidote and Treatment 

-          No antidote, supportive care. [1]

-          Using Bronchodilator when bronchospasm. [1, 5]

-          Decontamination [1]

-          Atropine improve the symptoms of type II pyrethrin related hypersecretion. [1]

-          Steroids, antihistamines and epinephrine PRN [5]

-          ACLS.

 

Disposition

-          Fatal dose when 10—100 gm. [1]

 

REFERENCES

1.      急診醫學會. 急性中毒救命術. 三版p.77—83.

2.      Shilpakar O, Karki B. Cypermethrin poisoning manifesting with prolonged bradycardia: A case report. Toxicol Rep. 2020 Dec 10;8:10-12. doi: 10.1016/j.toxrep.2020.12.005. PMID: 33364178; PMCID: PMC7750177.

3.      Wax PM, Hoffman RS. Fatality associated with inhalation of a pyrethrin shampoo. J Toxicol Clin Toxicol. 1994;32(4):457-60. doi: 10.3109/15563659409011049. PMID: 8057406.

4.      Cha YS, Kim H, Cho NH, Jung WJ, Kim YW, Kim TH, Kim OH, Cha KC, Lee KH, Hwang SO, Nelson LS. Pyrethroid poisoning: features and predictors of atypical presentations. Emerg Med J. 2014 Nov;31(11):899-903. doi: 10.1136/emermed-2013-202908. Epub 2013 Aug 19. PMID: 23959805.

5.      van den Bersselaar LR, van der Hoeven JG, de Jong B. Suicide after inhaling a pyrethrins containing insecticide spray. BMJ Case Rep. 2019 Apr 16;12(4):e227936. doi: 10.1136/bcr-2018-227936. PMID: 30996064; PMCID: PMC6506137.

edited by Yu-Jang Su    Nov 9, 2021. 

Bee Venom Poisoning

 

SUBSTANCE

   -Melittin and phospholipase A2, hyaluronidase, apamin, [1, 2, 3]

-           peptide 401 [3].

 

Common name or Trade name 

- Bees/wasps sting venom poisoning.

 

Involving SYSTEM

- Skin. 

-   Kidney:  Acute kidney injury: related to melittin attacking renal tubular epithelial cells (RTECs) [4, 5, 6, 7]

- acute respiratory failure, acute liver failure, rhabdomyolysis.

- 24.1% of hospitalized patients: Rhabdomyolysis [8]

-19.2% of hospitalized patients: hemolysis [8]

- liver injury in 30.1% of hospitalized patients [8].

- coagulopathy in 22.5% of hospitalized patients. [6, 8]

Presentation

-          Skin itching, painful. Systemic symptoms and signs when > 20 stings. [https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0083164]

-          Anaphylaxis. [9]

-          Skin necrosis. [10]

-          Angioedema [2]

-          Bronchospasm [2]

-          Shock [2]

-          wheezing

-          Gastrointestinal bleeding. [11]

-          DIC [2]

-          Coma [11]

 

Antidote and Treatment 

-          no antidote.

-Epinephrine 0.3 mg SC when anaphylactic shock. Bosmin 1 amp in N/S IV pump keep 30 c.c./hr.

- Tetanus toxoid [2].

- Ice packing, steroid ointment [2]

-Antihistamine [2]

- Steroid [2]

-Antibiotics when secondary infection. [2]

 

Disposition

 -76.9% of the hospitalized cases attacked 10 or > 10 stings with a mortality of 5.1%. [8]

-          4.4 % of hospitalized cases died of multi-organ injury [8]

-          1% of hospitalized cases died who were attacked less than 10 stings. [8]

-          Poor outcome when high creatinine level, shock, oliguria, and anemia [8].

REFERENCES

1.      Pillur Tamilarasu K, Shankar T, Kabi A. Unusual case of recurrent hypoglycaemia in multiple bee sting envenomation. BMJ Case Rep. 2021 Jul 26;14(7):e242440. doi: 10.1136/bcr-2021-242440. PMID: 34312127; PMCID: PMC8314743.

2.      急診醫學會. 急性中毒救命術.三版 p.191—197

3.      Silva GBD Junior, Vasconcelos AG Junior, Rocha AMT, Vasconcelos VR, Barros J Neto, Fujishima JS, Ferreira NB, Barros EJG, Daher EF. Acute kidney injury complicating bee stings - a review. Rev Inst Med Trop Sao Paulo. 2017 Jun 1;59:e25. doi: 10.1590/S1678-9946201759025. PMID: 28591253; PMCID: PMC5459532.

4.      Kim H, Hong JY, Jeon WJ, Baek SH, Ha IH. Bee Venom Melittin Protects against Cisplatin-Induced Acute Kidney Injury in Mice via the Regulation of M2 Macrophage Activation. Toxins (Basel). 2020 Sep 6;12(9):574. doi: 10.3390/toxins12090574. PMID: 32899913; PMCID: PMC7551791.

5.      Shu Y, Yang Y, Zhao Y, Ma L, Fu P, Wei T, Zhang L. Melittin Inducing the Apoptosis of Renal Tubule Epithelial Cells through Upregulation of Bax/Bcl-2 Expression and Activation of TNF-α Signaling Pathway. Biomed Res Int. 2019 May 29;2019:9450368. doi: 10.1155/2019/9450368. PMID: 31772938; PMCID: PMC6854966.

6.      Chen TH, Liao WT, Chen CS, Lin PC, Wu MY. An Envenoming Syndrome from Massive Vespa Stings Induces Multiple Organ Failure. Insects. 2020 Apr 2;11(4):219. doi: 10.3390/insects11040219. PMID: 32252275; PMCID: PMC7240471.

7.      Grisotto LS, Mendes GE, Castro I, Baptista MA, Alves VA, Yu L, Burdmann EA. Mechanisms of bee venom-induced acute renal failure. Toxicon. 2006 Jul;48(1):44-54. doi: 10.1016/j.toxicon.2006.04.016. Epub 2006 May 6. PMID: 16774771.

8.      Xie C, Xu S, Ding F, Xie M, Lv J, Yao J, Pan D, Sun Q, Liu C, Chen T, Li S, Wang W. Clinical features of severe wasp sting patients with dominantly toxic reaction: analysis of 1091 cases. PLoS One. 2013 Dec 31;8(12):e83164. doi: 10.1371/journal.pone.0083164. PMID: 24391743; PMCID: PMC3877022.

9.      Hughes RL. A Fatal Case of Acute Renal Failure From Envenoming Syndrome After Massive Bee Attack: A Case Report and Literature Review. Am J Forensic Med Pathol. 2019 Mar;40(1):52-57. doi: 10.1097/PAF.0000000000000451. PMID: 30531211.

10.  Toledo LFM, Moore DCBC, Caixeta DMDL, Salú MDS, Farias CVB, Azevedo ZMA. Multiple bee stings, multiple organs involved: a case report. Rev Soc Bras Med Trop. 2018 Jul-Aug;51(4):560-562.

11.  Iliev YT, Tufkova SG, Prancheva MG. A rare case of severe intoxication from multiple bee stings with a favorable outcome. Folia Med (Plovdiv). 2010 Jul-Sep;52(3):74-7. doi: 10.2478/v10153-010-0010-5. PMID: 21053677.

edited by Yu-Jang Su    Oct 30th, 2021.