Herbicide Ingestion

By Mohd Feendi Bin Mohd Fauzi Yap Click to edit Master subtitle style

5/27/12

 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 am

today.

Patient previously quarrelled with relative,

ingested herbicide containing glyphosate isopropylamine and ammonium sulphate

Patient drank 100cc of herbicide and mixed it

with 1 bottle of beer

Vomited 2x, yellowish vomitus, Feeling nausea
5/27/12 Central abdominal pain

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
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attempt before

Some questions to ponder:

What is our immediate management of this patient if we are the one attending him?
How could we diagnose this patient from the

information given.

What are the other signs and symptoms we

should look out for?

What are the other complications we should

be cautious of?

What are the investigations need to be done,

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particularly for monitoring purpose?

Physical Examination
alert, conscious, GCS full, hydration fair pink
Vital signs:- T 37.2 BP 92/58 not jaundice in ED PR 80 not toxic looking RR 20 SpO2 Mildly tachypneic 94% NP O2 CRT < 2s 3L/M

good pulse volume Repeated BP : 88/61 5/27/12 PR: 90

 Throat: slightly injected CVS S1S2 heard

no murmur
Lungs clear Abdomen
central abdominal pain , mild epigastric

tenderness, no hepatosplenomegaly

no pedal edema

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Investigation:
FBC BUSECREAT/LFT PT/APTT ABG URINE PARAQUAT x 3 consecutive days ECG CHEST XRAY

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For fluid resussitation IVD 4 pints NS/24

Treatment:

Hour IV Ranitidine 50 mg stat and TDS IV Maxalon 10mg stat and TDS T. Activated charcoal 25mg QID RT Insertion Insert CBD Strict I/O charting Monitor BP and SpO2 hourly To inform if patient SOB/ Tachypneic/ sudden drop of consciousness
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Investigation
IX FBC HB Leucocyte Platelet BUSE CREAT Urea Sodium Potassium Chloride Creatinine LFT Total bilirubin Total protein/ALP Albumin/Globulin ALT Urine paraquat 5/27/12 2/4 14.6 9.1 154 4.8 136 3.7 105 78 17.1 77/66 38/39 61 Day 1 (-) 3/4 14.0 8.6 164 5.6 135 4.0 101 87 18.9 77/66 38/39 62 Day 2(-) 4/4 13.2 8.8 166 7.4 135 4.1 104 92 19.0 74/58 36/35 58 Day 3 (-)

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 poisoning
Definition Herbicide poisoning is caused by inhaling,

ingesting or otherwise absorbing substances that are used for killing weeds and defoliating. Herbicides have been most often used for agricultural uses, in which poisoning can affect both humans and animals.
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(by Mosbys Medical Dictionary)

GLYPHOSATE

What is Glyphosate?
-broad spectrum, -non-selective systemic herbicide.

-all grasses, sedges, broad- leaved weeds and woody plants.

The chemical name of glyphosate is N-

(phosphonomethyl) glycine.
While it can be described as an
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compound glyphosate is

CLINICAL EFFECTS

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Other effects
A variety of renal abnormalities occur

including oliguria and occasional elevated serum creatinine. Cr in Our patient : 78 87 92

Liver enzymes may become abnormal

although 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. Moderate symptoms Severe symptoms

50-100 mL 100 mL or

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

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(source:http://www.prn.usm.my/mainsite/bulletin/toxicology/sun 14.html)

Classification of toxicity:

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INVESTIGATIONS
Biochemistry Patients should have serum electrolytes,

creatinine, urea, liver function tests, glucose and arterial blood gases.

ECG Baseline then as indicated clinically.

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TREATMENT
Treatment for minor exposures

In cases of dermal exposureremove all contaminated clothing and flooding the skin surface with water. Exposed skin is then washed with soap and water.

In eye exposures the exposed eyes should

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be irrigated with copious amounts of water or saline for at least 15 minutes

Treatment for significant exposures

There is no available antidote for glyphosate

poisoning and treatment is largely symptomatic.

In any significant ingestion exposure, the

acute syndrome of glyphosate/ surfactant toxicity may occur within the first 24 hours of ingestion and may progress rapidly.

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Prevention of absorption Gastric lavage usually considered if no

significant spontaneous vomiting has occurred. Gastric lavage may be very effective if performed within one to two hours post ingestion.

Activated charcoal to absorb remaining

glyphosate.

Cathartics speed gastrointestinal transit time

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and decrease the time that the drug or chemical is available for absorption.

Enhanced elimination Glyphosate is excreted very well by the

kidneys..Thus to increase the elimination of the glyphosate, adequate urine flow will ensure 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 be

required

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 if

the patient presents within 1 hour of 5/27/12 ingestion.

LATE COMPLICATIONS, PROGNOSIS - FOLLOW UP

There is the potential for long term lung injury if significant ARDS occurs.

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~Thank You~

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