intoxicación por fosfato de aluminio
TRANSCRIPT
8/13/2019 Intoxicación por fosfato de aluminio
http://slidepdf.com/reader/full/intoxicacion-por-fosfato-de-aluminio 1/20
Intoxicación por fosfuro de
aluminio
8/13/2019 Intoxicación por fosfato de aluminio
http://slidepdf.com/reader/full/intoxicacion-por-fosfato-de-aluminio 2/20
Fosfuro de aluminioRodenticida altamente toxico de bajo costo
Veneno mitocondrial.
NO HAY ANTIDOTO.
Hay dos tipos de intoxicacion aguda:• Inhalacion indirecta• Ingestion directa
India 66.8% muertes no naturales causadas por envenenamiento suicida
Libera gas de fosfino se absorve rapidamente por:• Inhalacion• Piel• Via GI.
8/13/2019 Intoxicación por fosfato de aluminio
http://slidepdf.com/reader/full/intoxicacion-por-fosfato-de-aluminio 3/20
Gas fosfino
La mezcla de fosfato dealuminio y aire
produce gas fosfino(hidrogeno fosfado,trihidrido de fosforo,PH3) que es la formaactiva del pesticida
Se une alcitocromooxidasa ycambia las valencias
del componente hemde la hemoglobina.
Induce estrés oxidativo
Aumenta la liberacionde radicales libres
extramitocondriales
que produceperoxidacion lipidica ydesnaturalizacion de
las proteinas de lamembrana celular.
Disminuye la actividadde la actividad de la
colinesterasadependiendo de laconcectracion del
fosfato.
Reduce al glutation
(una de las principalesdefensasantioxidantes).
8/13/2019 Intoxicación por fosfato de aluminio
http://slidepdf.com/reader/full/intoxicacion-por-fosfato-de-aluminio 4/20
8/13/2019 Intoxicación por fosfato de aluminio
http://slidepdf.com/reader/full/intoxicacion-por-fosfato-de-aluminio 5/20
Toxicidad orgánicaDosis letal 0.5g
Síntomas tempranos
• Nauseas• Vomito• Dolor epigastrico y retroesternal• Disnea• Ansiedad• Agitacion
• Aliento a ajo.
Sigos de toxicidad fatal (90-100%):• Choque• Falla circulatoria periférica
Cambioshistopatologicos:• Congestion venosa central• Degeneracion de hepatocitos
• Infiltracion mononuclear• Adelgazamientos de alveolos
y dilatacion de capilares enpulmon
• Degeneracion de los granulosde Nissl en el cerebro
• Congestion glomerular e
intaparenquimatosa renal
8/13/2019 Intoxicación por fosfato de aluminio
http://slidepdf.com/reader/full/intoxicacion-por-fosfato-de-aluminio 6/20
Toxicidad
gastrointestinalSintomas tempranos hematemesis,
vomito y dolor epigastrico.
Endoscopia:
• Lesiones corrosivas dl esofago y estomago• Erosiones gastricas y duodenales severas.• Contracturas esofagicas o fistulas.• Dysphagia is a common late complication.
Se absorve In vitro como particulasmicroscopicas no hidrolizadas queinteractuan permanentemente con la hblibre, haemoglobin and haemoglobin inintact erythrocytes (rat and human) toproduce a haemichrome (amethaemoglobin derivative resulting fromdistorted protein conformation).
Potter et al. report that Heinz bodies (denaturedhaemoglobin aggregates) are formed whenphosphide concentration in vitro exceeds 1.25μ g mL-1.
Reports of in vivo phosphide poisoning showedintravascular complications such as haemolysisand methaemoglobinaemia, which support theinvolvement of erythrocytes in thebiotransformation of phosphine in humans.
Phosphine is excreted in the urine ashypophosphite and is also exhaled in theunchanged form.
8/13/2019 Intoxicación por fosfato de aluminio
http://slidepdf.com/reader/full/intoxicacion-por-fosfato-de-aluminio 7/20
Toxicidad hepática
Algunas veces se observa ictericia.• Puede ser una manifestacion of another
disturbances such as intravascular haemolysis.A more common finding is transient elevationof serum AST y ALT.
The main histopathological findings inthe liver at autopsy of fatal phosphinepoisoning include:• Cytoplasmic vacuolisation of hepatocytes and
sinusoidal congestion.• Nuclear fragmentation and sinusoidal clusters
of polymorphonuclear leukocytes in the liver.
8/13/2019 Intoxicación por fosfato de aluminio
http://slidepdf.com/reader/full/intoxicacion-por-fosfato-de-aluminio 8/20
Toxicidad respiratoria
Taquipnea, dirsnea,crepitantes y roncus.
Respiratory distress
syndrome and othertypes of pulmonaryoedema are
common in adults,accompanied byprotein-rich orhaemorrhagic
pleural effusions.
8/13/2019 Intoxicación por fosfato de aluminio
http://slidepdf.com/reader/full/intoxicacion-por-fosfato-de-aluminio 9/20
Toxicidad cardiaca
Post-mortem reports heart failure, profound and refractory hypotension, heart congestion,subendocardial infarction or pericarditis, separation of myocardial fibres by oedema, fragmentation ofthe fibres, non-specific vacuolation of myocytes, focal necrosis, and neutrophil and eosinophil
infiltration.
Other signs and symptoms include: increased left ventricle, hypokinesia of the left ventricleand septum, akinesia, lower ejection fraction, severe hypotension, raised systemic venouspressure, normal pulmonary artery wedge pressure, inadequate systemic vasoconstriction,and electrocardiographic (ECG) abnormalities such as dysrhythmia, ST-T wave changes and
conduction defects.
Sinus tachycardia dominates in the first three to six hours of poisoning, followedby ST-T changes and conduction disturbances between hour 6 and twelve, and
then by arrhythmias.
Siwach et al. found ventricular tachycardia in 40 %, ventricular fibrillation in 23.3%, supraventricular tachycardia in 46.7 %, and atrial flutter/fibrillation in 20 % of
AlP-poisoned patients.
8/13/2019 Intoxicación por fosfato de aluminio
http://slidepdf.com/reader/full/intoxicacion-por-fosfato-de-aluminio 10/20
8/13/2019 Intoxicación por fosfato de aluminio
http://slidepdf.com/reader/full/intoxicacion-por-fosfato-de-aluminio 11/20
Tratamiento
• Treatment with magnesium sulphate has been reported to reducemortality by up to 50 %.
• Magnesium stabilises the cell membrane and acts as an anti-oxidant. Astudy published in 1994 compared treatments of AlP poisoned patientsand concluded that the survival rate of those who receivedsupplemental magnesium was not significantly better than of thosewho did not (42 % vs. 40 %, respectively).
• In contrast, in another case control study , magnesium improved
survival of patients who ingested high doses of AlP.• Moreover, a recent study on a rat model showed that 25Mg2 +-
carrying nanoparticle (25MgPMC16) significantly increased bloodpressure and heart rate of rats poisoned with AlP. This study alsodemonstrated that 25MgPMC16 increased intracardiac magnesiumlevels, reduced lipid peroxidation, and improved mitochondrial
function.
Suplemento de magnesio
8/13/2019 Intoxicación por fosfato de aluminio
http://slidepdf.com/reader/full/intoxicacion-por-fosfato-de-aluminio 12/20
Tratamiento
• Different studies in ratsand humans have revealedthat N-acetylcysteine canhelp as it replenishescellular glutathione andmagnesium, in addition to
its antioxidant properties.In rats exposed to AlP, N-acetylcysteine increasedsurvival time and reducedmyocardial oxidative injury
N acetil cisteina
• Some authors propose thata combination ofhyperinsulinaemia-euglycaemia andhyperventilationoxygenation is worthy of
more extensive evaluationas a therapy for AlPpoisoning
Hiperinsulinemia-euglicemia
8/13/2019 Intoxicación por fosfato de aluminio
http://slidepdf.com/reader/full/intoxicacion-por-fosfato-de-aluminio 13/20
TratamientoAceite de almendras y coco
• There are reports of the positive clinical effects of coconut oil against AlPpoisoning in humans. Its mechanism of action is unclear, but it may form aprotective layer around the gastric mucosa and prevent the absorption ofphosphine gas. In addition, coconut oil may dilute HCl in the stomach andreduce the breakdown of phosphide. Saidi and Shoajaie reported thatintragastric lavage with sweet almond oil considerably reduced the mortalityof rats poisoned with AlP. It also significantly lowered plasma cholinesteraselevels.
• The authors suggested that sweet almond oil should be given orallyimmediately after AlP ingestion, but this has yet to be confirmed in humans.
Oxigenacion hiperbarica
8/13/2019 Intoxicación por fosfato de aluminio
http://slidepdf.com/reader/full/intoxicacion-por-fosfato-de-aluminio 14/20
TratamientoNepal:
Lavado gastrico aceite vegetal.
Iran:
Lavado gastrico Solucion de permanganato de potasio
Administracion oral de sorbitol y aceite de coco.
Bicarbonato de sodio, Sulfato de magnesio, Gluconato de calcio IV.
8/13/2019 Intoxicación por fosfato de aluminio
http://slidepdf.com/reader/full/intoxicacion-por-fosfato-de-aluminio 15/20
Tratamiento
• Leakege of (IABP) is a good way to mechanicallysupport the heart, especially in toxic myocarditiswith refractory shock. Trimetazidine has also
proven itself effective recently in stoppingventricular ectopic beats and preservingoxidative metabolism. In addition, digoxin can beused to stabilise the left ventricular heart failure.
Hidroxietil starch
8/13/2019 Intoxicación por fosfato de aluminio
http://slidepdf.com/reader/full/intoxicacion-por-fosfato-de-aluminio 16/20
8/13/2019 Intoxicación por fosfato de aluminio
http://slidepdf.com/reader/full/intoxicacion-por-fosfato-de-aluminio 17/20
Tratamiento
Early diagnosis of organ damageis another important aspect in
the management, as AlPpoisoning affects virtually all
organs in the body. Acute lunginjury may need endotracheal
intubation and mechanicalventilation.
Cyanosis not responding tooxygen therapy may be a sign of
methaemoglobinaemia thatrequires therapy with intravenousmethylene blue (1% solution) inthe dose of 2 mg kg-1 of body
weight over fi ve minutes.
For metabolic acidosis,
intravenous sodium bicarbonateshould be considered, whereas
severe acidosis, volume overloador renal failure may require
haemodialysis.
However, haemodialysis isprobably not very effective in
removing phosphine.
8/13/2019 Intoxicación por fosfato de aluminio
http://slidepdf.com/reader/full/intoxicacion-por-fosfato-de-aluminio 18/20
PronosticoThe mortality in adults who haveingested 500 mg of AlP or over is
between 30% and 100 %. The higherthe blood phosphine, the higher the
mortality. Patients having bloodphosphine levels equal to or less than1.067±0.16 mg survived, and this dose
seems to be the lethal threshold ofphosphine toxicity.
Survival may increase if a verysmall amount of AlP is
ingested or the tablet hasexpired or was exposed to air.Vomiting and early supportivecare also increase the survival
rate.
Poor prognosis is indicated byhyperglycaemia, high simplified acute
physiology score (SAPS II),hypotension, acidosis, leukocytosis,
hyperuraemia, ECG abnormalities, highacute physiology and chronic health
evaluation score (APACHE II), lowGlasgow coma scale, acute renalfailure, low prothrombin rate,
hyperleukocytosis,methaemoglobinaemia, use of
vasoactive drugs, lack of vomiting afteringestion, and use of mechanical
ventilation.
8/13/2019 Intoxicación por fosfato de aluminio
http://slidepdf.com/reader/full/intoxicacion-por-fosfato-de-aluminio 19/20