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5/27/12

Herbicide Ingestion

By Mohd Feendi Bin Mohd Fauzi Yap


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Name : KS

43/I/male

RN: 774078

P/M : chronic alcoholic drinker >15years

chronic smoker

1st hospitalization


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P/W : alleged herbicide ingestion @11 amtoday.

Patient previously quarrelled with relative,ingested herbicide containing glyphosateisopropylamine and ammonium sulphate

Patient drank 100cc of herbicide and mixed it

with 1 bottle of beer

Vomited 2x, yellowish vomitus,

Feeling nausea

Central abdominal pain


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No SOB/ chest pain/ palpitation

No Diarrhea

No drop level of consciousness

No headache

No giddiness

No blurred vision

No other symptoms

Pt had intention to end his life, never had

suicidal attempt before


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Some questions to ponder:

What is our immediate management of thispatient if we are the one attending him?

How could we diagnose this patient from theinformation given.

What are the other signs and symptoms we

should look out for?

What are the other complications we shouldbe cautious of?

What are the investigations need to be done,articularl for monitorin ur ose?


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Physical Examinationalert, conscious, GCS full, hydration fairpink

not jaundicenot toxic looking

Mildly tachypneic

CRT < 2s

good pulse volume

Vital signs:- T 37.2BP 92/58

in ED PR 80RR 20

SpO294% NP O23L/MRepeated

BP : 88/61

PR: 90


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Throat: slightly injected

CVS S1S2 heard

no murmur

Lungs clear

Abdomen

central abdominal pain , mild epigastric

tenderness, no hepatosplenomegalyno pedal edema


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Investigation:

FBCBUSECREAT/LFTPT/APTTABGURINE PARAQUAT x 3 consecutive daysECGCHEST XRAY


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Treatment:For fluid resussitation IVD 4 pints NS/24HourIV Ranitidine 50 mg stat and TDSIV Maxalon 10mg stat and TDS

T. Activated charcoal 25mg QIDRT InsertionInsert CBDStrict I/O charting

Monitor BP and SpO2 hourlyTo inform if patient SOB/ Tachypneic/sudden drop of consciousness


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InvestigationIX 2/4 3/4 4/4

FBC

HB 14.6 14.0 13.2Leucocyte 9.1 8.6 8.8

Platelet 154 164 166

BUSE CREAT

Urea 4.8 5.6 7.4

Sodium 136 135 135

Potassium 3.7 4.0 4.1

Chloride 105 101 104

Creatinine 78 87 92

LFTTotal bilirubin 17.1 18.9 19.0

Total protein/ALP 77/66 77/66 74/58

Albumin/Globulin 38/39 38/39 36/35

ALT 61 62 58

Urine paraquat Day 1 (-) Day 2(-) Day 3 (-)


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ABG:

q ph 7.36

q CO2: 27

q O2: 90

q HCO3:18

ECG: SR, no acute ischemic changes

CXR : Clear lung field


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Herbicide poisoningDefinition

Herbicide poisoning is caused by inhaling,ingesting or otherwise absorbing substances thatare used for killing weeds and defoliating.Herbicides have been most often used foragricultural uses, in which poisoning can affectboth humans and animals.

(by Mosbys Medical Dictionary)


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What is Glyphosate?

GLYPHOSATE-broad spectrum,

-non-selective systemic herbicide.

-all grasses, sedges, broad- leaved weeds andwoody plants.

The chemical name of glyphosate is N-(phosphonomethyl) glycine.

While it can be described as an

organophosphorus compound glyphosate is


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CLINICAL EFFECTS


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Other effects

A variety of renal abnormalities occurincluding oliguria and occasional elevatedserum creatinine.

Cr in Our patient : 78 87 92

Liver enzymes may become abnormalalthough severe hepatitis is unusual.


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DETERMINATION OF SEVERITY


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Ingested dose

The ingestions of:

5-50 mL no symptoms or minor

gastrointestinal symptoms only.50-100 mL Moderate symptoms

100 mL or Severe symptoms

in our case patient drank 2 cups x 50mL ~100mL mixed with 1 bottle of beer


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Clinical grading of toxicity

From National Poison Center / Pusat Racun negara

(1-800-88-8099)

Mild-moderate toxicity :

mild throat pain, abdominal discomfort

Severe toxicity:

orogastro mucosal, ulceration,Hypotension,

Metabolic acidosis

source :


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source :http://curriculum.toxicology./Glyphosate)


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(source:http://www.prn.usm.my/mainsite/bulletin/toxicology/sun14.html)

Classification of toxicity:


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INVESTIGATIONS

Biochemistry

Patients should have serum electrolytes,creatinine, urea, liver function tests, glucoseand arterial blood gases.

ECG

Baseline then as indicated clinically.

Imaging


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TREATMENT

Treatment for minor exposures

In cases of dermal exposure remove allcontaminated clothing and flooding the skinsurface with water. Exposed skin is thenwashed with soap and water.

In eye exposures the exposed eyes shouldbe irrigated with copious amounts of water orsaline for at least 15 minutes


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Treatment for significant exposures

There is no available antidote for glyphosatepoisoning and treatment is largelysymptomatic.

In any significant ingestion exposure, theacute syndrome of glyphosate/ surfactant

toxicity may occur within the first 24 hours ofingestion and may progress rapidly.


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Prevention of absorption

Gastric lavage usually considered if nosignificant spontaneous vomiting has occurred.Gastric lavage may be very effective ifperformed within one to two hours post

ingestion.

Activated charcoal to absorb remaining

glyphosate.

Cathartics speed gastrointestinal transit time

and decrease the time that the drug orchemical is available for absor tion.


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Enhanced elimination

Glyphosate is excreted very well by thekidneys..Thus to increase the elimination ofthe glyphosate, adequate urine flow willensure the rapid elimination of the

glyphosate.


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Monitoring of the blood pressure


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Respiratory function

should be monitored closely

intubation with assisted ventilation may berequired

If pulmonary oedema occurs positive

respiratory pressure may be of value. Acidosis usually responds to bicarbonate

therapy but may on occasion be resistant.

GI Decontamination

Oral activated charcoal should only be given ifthe patient presents within 1 hour of

ingestion.


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,PROGNOSIS - FOLLOW

UPThere is the potential for long term lung injury if

significant ARDS occurs.


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~Thank You~

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