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硫化氫沼氣中毒導致急性腎衰竭 , 乳酸中毒及 突發性心肺停止. 潘恆之 , 林杰樑 , 顏宗海. Acute Renal Failure, Lactic acidosis, and Sudden Collapse following Hydrogen Sulfide Sewer Gas Poisoning. 林口長庚紀念醫院 腎臟系 臨床毒物科. Patient's Profiles. Case 2 Age : 34 Gender: male Ethnic: Filipino Marital status : married - PowerPoint PPT Presentation
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ACUTE RENAL FAILURE, LACTIC ACIDOSIS, AND SUDDEN COLLAPSE
FOLLOWINGHYDROGEN SULFIDE SEWER GAS
POISONING潘恆之 , 林杰樑 , 顏宗海
硫化氫沼氣中毒導致急性腎衰竭 , 乳酸中毒及突發性心肺停止
林口長庚紀念醫院 腎臟系 臨床毒物科
Patient's ProfilesCase 1Age: 28Gender: maleEthnic: Filipino Marital status: marriedOccupation: worker
Case 2Age: 34Gender: maleEthnic: Filipino Marital status: marriedOccupation: worker
Present Illness Two otherwise healthy, Filipino
workers from a poultry meat-processing factory suffered sudden loss of consciousness while cleaning pig slotted floors.
Case 1 (28 y/o male) -- Physical examination Vital signs: T: 35.8 ℃ P: 0 bpm R: 0 cpm
BP: 0/0 mmHg GENERAL APPEARANCE: pale and cyanotic,
foul odor CONSCIOUSNESS: E 1 V 1 M 1 HEENT: sclera: anicteric, conjunctiva: not pale pupil size L/R: 6/6 (mm), cyanotic lips NECK: supple, no jugular vein engorgement CHEST: no breathing sounds HEART: no heart sounds ABDOMEN: soft and flat, hypoactive bowel
sounds EXTREMITIES: freely movable, no pitting
edema
血液WBC 8700 1/µLHemoglobin 13.4 g/dL
MCV 91.6 fLPlatelets 289K 1/µLSegment 70 %Lymphocyte 22 %
Eosinophil 4 %
PT (INR) 1.0APTT 23.8 sec
生化 Fasting sugar 133 mg/dL
ALT 96 U/LBUN 22.1 mg/dLCreatinine 1.50 mg/dLeGFR 53 mL/min/1.73㎡Na 149 mEq/LK 6.4 mEq/LCl 103 mEq/LCa 8.1 mg/dLP 2.4 mg/dLMg 1.7 mEq/LCK-MB 3.9 ng/mLTroponin-I 0.01 ng/mLLactate 24.2 mg/dLFree-T4 1.38 ng/dLTSH 0.77 µIU/mLCortisol 22.3 µg/dLO2HB 63.6 %COHB 1.2 %METHB 0.3 %O2CT 64.9 %
動脈血PH 6.799PCO2 90.0 mmHgPO2 69.3 mmHgHCO3 13.7 mm/LSBE - 20.9 mm/LSa% 60.5 %
Lab data (28 y/o male)
Course (28 y/o male)
An out-of-hospital cardiac arrest victim Blood tests revealed hypoxemia,
hypercapnia, acute renal failure, lactate acidosis and hyperkalemia
Electrocardiogram showed asystole CPCR failure
Vital signs: T: 33.0 ℃ P: 131 bpm R: 6 cpm BP: 77/51 mmHg
GENERAL APPEARANCE: acute-ill looking, foul odor
CONSCIOUSNESS: E 2 V 1 M 4 HEENT: sclera: anicteric, conjunctiva: not pale pupil size L/R: 3/3 (mm), throat: not injected NECK: supple, no jugular vein engorgement CHEST: respiratory pattern: slow and shallow breathing sound: clear HEART: rapid heart beat without murmurs ABDOMEN: Soft and flat, normoactive bowel
sounds, no local tenderness, no rebounding pain EXTREMITIES: freely movable, symmetric
peripheral pulse
Case 2 (34 y/o male) -- Physical examination
血液WBC 9500 1/µLHemoglobin 14.4 g/dL
MCV 83.8 fLPlatelets 162K 1/µLSegment 57.9 %Lymphocyte 37.6 %
Eosinophil 1.8 %
PT (INR) 1.0APTT 23.8 sec
生化 Fasting sugar 119 mg/dL
ALT 41 U/LBUN 18.1 mg/dLCreatinine 1.54 mg/dLeGFR 52 mL/min/
1.73㎡Na 138 mEq/LK 3.1 mEq/LCl 101 mEq/LCa 8.7 mg/dLP 3.1 mg/dLMg 1.7 mEq/LCK-MB 5.1 ng/mLTroponin-I 0.017 ng/mLLactate 23.8 mg/dLFree-T4 1.36 ng/dLTSH 0.69 µIU/mLCortisol 50.3 µg/dLO2 HB % 70.3 %CO HB % 0.9 %MET HB % 7.2 %O2 CT 78.3 %
動脈血PH 6.979PCO2 84.1 mmHgPO2 51.9 mmHgHCO3 19.3 mm/LSBE -12.3 mm/LSa% 73.8 %
Lab data (34 y/o male)
CXR (34 y/o male) EKG (34 y/o male)
Course (34 y/o male)
Day 1, at ER
Day 1, in ICU
Intubation with mechanical ventilator support
N/S challenge, Norepinephrine run 30 µg/min
Give amyl nitrite 1pc inhalation and 3% sodium nitrite 10ml iv drip for 20 mins
Brain CT: no evidence of ICH or structural lesions
Day 2, in ICU Consciousness: confused and
disoriented
Ga
Course (34 y/o male)
Day 4, in ICU
Day 5, at ordinary ward Aspiration pneumonia => give empiric antibiotics: Ceftazidime 2g q8h
Day 16, at ordinary ward Consciousness clear Discharge
Extubation EEG: diffuse cortical dysfunction
Introduction Hydrogen sulfide (H2S) is a colorless
toxic gas that has strong odor of “rotten eggs”
H2S poisoning usually occurs by inhalation
Discussion
~ Woodall GM et al, Inhal Toxicol. 2005;17:593-639
Source Organic 1. Incomplete oxidation of sulfur compounds 2. Bacterial degradation of sulfur compounds Inorganic, mainly industrial 1. Petroleum industry -- contamination or by-product 2. Chemical industry -- reactant for production of chemicals 3. Production of heavy water 4. Metal refining
~ Tee L. Guidotti , International Journal of Toxicology. 2010, 29:569-581
Knock down !!
Apnea !!
~ Doujaiji B et al, Ann Saudi Med. 2010;30:76-80
Symptoms 0.05 ppm
(airbone concentration)
Pungent smell mimicking “rotten egg”
0.1 ppm Anosmia50-150
ppmParalysis, conjunctivitis
250 ppm Photophobia, pulmonary edema250-500
ppmHeadache, nausea, vomiting, confusion, tachycardia, hypotension
500-750 ppm
Respiratory arrest
750-1000 ppm
Knocked down (central neurotoxicity)
> 1000 ppm
Dying immediately within a breath
~ Tee L. Guidotti , International Journal of Toxicology. 2010, 29:569-581
Diagnosis Measurement of blood sulfide in acute emergencies is of little clinical value. History of hydrogen sulfide exposure Odor of hydrogen sulfide Serum BUN, Cr, electrolyte, glucose,
CPK, blood gas & serum lactate ECG & Chest X-ray CT scan
~ Milby HT et al, American Journal of Industrial Medicine. 1999, 35:192-195
Treatment
~ Gregorakos L et al, Angiology. 1995, 46:1123-1131
Antidote – Nitrite Salt Nitrite salt oxidizes
the Fe2+ of hemoglobin to Fe3+, deriving Met-Hb
Met-Hb competes with the Fe3+ of cytochrome oxidase and protects it from oxidization by H2S
Keep the Met-Hb level < 25% with a concern of hypoxemia from methemoglobinemia
Oxy-Hb
Met-Hb
Sulfa-MetHb
Oxy-Hb + SO2
H2S
Amyl nitrite, Sodium nitrite
cyt c2+cyt c3+
cyt a2+cyt a3+
cyt a32+cyt a3
3+
H2O2+ 2H+ 2H2O
~ Smith RP et al, Ann Rev Toxicol. 1976, 16:189Mitochondria
Blood
Nitrite KitAmyl nitrite
• If spontaneous breathing remains,
give amyl nitrite inhalation every 3 min until sodium nitrite is ready
Sodium nitrite
• Dissolve 0.6g sodium nitrite to 20 ml of water ( 3% solution)
• IV 10ml of the 3% sodium nitrite solution > 20 mins
~ Morii et al, Journal of Occupational Medicine and Toxicology. 2010, 5:28
Highlights Hydrogen sulfide poisoning is a
relatively uncommon and frequently lethal hazard
Toxidrome : 1. odor perception followed by olfactory paralysis 2. burning eyes 3. pulmonary edema 4. knock down Foul odor Keep Airway, breath, circulation,
O2 100% Antidote : Amyl nitrite 、 Sodium
nitrite
THANKS FOR YOUR LISTENING!!
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