2

6 . 10400

POISON & DRUG

INFORMATION BULLETIN

April-June 2005 Vol.13, No.2

- .. 2548

13 2

....

15

( 4)
Paraquat...................................................................
ToCase Conference...........................................................................

17
20

Paraquat poisoning
......................................................................

23

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(Ramathibodi Poison Center)
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: 0-2354-7272, 0-2201-1083
Hotline : 1367
: 0-2201-1084
Email : poisrequest@hotmail.com
URL : www.ra.mahidol.ac.th/poisoncenter/

( 24 )
1.



Internet
2.

3.

4.

4. (Poison and Drug

Information Bulletin)
3

page 14

3 100 /, 150 / 2
250 /3 1

....................................................................................................
. ................................................................................................
.................................
/ .........................................................
. ................ ...............
:
1 100
2 150
3 250
3

80 1 ( )

.

026-4-01398-4

................

()

P&D Information Bulletin / Vol. 13, No. 2, 2005

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(4)

..

(Cannabis)

(Hashish)
(Hashish oil)

cannabinoids

delta-9-tetrahydrocannabinol (THC)

15
4

pneumomediastinum pneumothorax

Cannabis
Tetrahydrocannabinol (THC)

page 15


metabolites THC
THC
28
3
ibuprofen naproxen
fenobrufen

panic, anxiety, paranoid, depression, personality disorder psychosis
Flashback

Withdrawal syndrome


Medical complications
1.

postural hypotension
tolerance

2.
hydrocarbon
benzopyrenes


3.
cannabinoids
NK cell
monocyte


cannabinoids alveolar
macrophage
4.



THC gonadotropin releasing hormone

page 16

sex hormones

5.
premature labor, abruption placenta
fetal alcohol syndrome



10

1. Anonymous. Cannabis. Erowid. Availble at http://

www.erowid.org//plants/cannabis/cannabis.shtml. Accessed
June 2, 2004.
2. Otten EJ. Marijuana. In Goldfrank LR, Flomenbaum NE,
Lewin NA, Howland MA, Hoffman RS, Nelson LS, eds.
Goldfranks Toxicologic Emergency. 7th ed. New York;
McGrow-Hill:1054-8.
3. Frishman WH. Del Vecchio A. Sanal S. Ismail A. Cardiovascular manifestations of substance abuse: part 2: alcohol, amphetamines, heroin, cannabis, and caffeine. Heart
Disease 2003;5:253-71.
4. Sidney S. Cardiovascular consequences of marijuana use.
J Clin Pharmacol 2002;42:64S-70S.
5. Jones RT. Cardiovascular system effects of marijuana. J
Clin Pharmacol 2002;42:58S-63S.
6. Khalsa JH. Genser S. Francis H. Martin B. Clinical
consequences of marijuana. J Clin Pharmacol 2002;42:7S10S.
7. Shih WJ. Carmona JJ. Coupal JJ. Lee JK. Marked lung
uptake of Tc-99m HMPAO in a polysubstance-abusing
marijuana and tobacco smoker. Clin Nuclear Med
1996;21(2):156.
8. Cabral GA. Dove Pettit DA. Drugs and immunity:
cannabinoids and their role in decreased resistance to
infectious disease. J Neuroimmunol 1998;83:116-23.
9. Napiorkowski B. Lester BM. Freier MC. Brunner S.
Dietz L. Nadra A. Oh W. Effects of in utero substance
exposure on infant neurobehavior. Pediatrics 1996;98:71-5.
10. Tronick EZ. Frank DA. Cabral H. Mirochnick M.
Zuckerman B. Late dose-response effects of prenatal cocaine
exposure on newborn neurobehavioral performance. Pediatrics. 1996;98:76-83.

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PARAQUAT

..

Paraquat bipyridyl
-

Paraquat

paraquat
( 7 3
- 2542, 33-36)

Paraquat
paraquat
paraquat

paraquat
paraquat
( 1)
1 paraquat

Paraquat + O2

Tissue injury
Gastrointestinal symptoms
Acute tubular necrosis
Hepatocellular damage
Lung fibrosis

paraquat caustic
paraquat
oxygen nascent oxygen
oxidize
20% 10-15 ml

paraquat
paraquat

24
paraquat

patch
rupture esophagus
pneumomediastinum, pneumothorax subcutaneous emphysema
1-4
systemic paraquat acute tubular necrosis
uremia
hepatocellular damage SGOT,
SGPT 3-14
progressive respiratory failure pulmonary hemorrhage, pulmonary
edema fibrosis 3
60 ml
onset
1.
paraquat
1.
2.
3.
4. paraquat
5.

page 17

multiple organ failure coma 3 paraquat

esophageal perforation ventricular arrhythmias
24-48
hemolysis methemoglobinemia
paraquat
( 1)
paraquat 27.6%
15 ml
50 ml paraquat 5 g/ml
( 2) 24 0.1 g/ml
WBC 10,000
2 paraquat

paraquat ( 2)
( 3)

oxygen
paraquat paraquat
gastric lavage
gastric lavage Kayexalate (100 gm 1000 ml) paraquat
paraquat Kayexalate
paraquat
Fullers earth (60 gm/bottle) 150 gm 1 L
2 paraquat
I. Prevent absorption (principle treatment)
1. Gastric lavage with Kayexalate solution (100 g in NSS 1,000 ml)
2. Fullers earth (60 g/bottle)
15% (2.5 bottles in water 1,000 ml) solution single dose
3. MOM 30 ml every 6 hours until diarrhea
II. Increase elimination
1. Forces diuresis
5% N/S 1,000 ml IV up to 250 ml/hr to assure urine output of 3 ml/min
and administration of furosemide 20 mg IV qid
2. Hemodialysis/Hemoperfusion as indicated
III. Modification of tissue toxicities (marginal benefit)
1. Modulate inflammatory responses
Cyclophosphamide 5 mg/kg/day intravenously, devided to every 8 hr
Dexamethasone 10 mg IV q 8 hr
Chlorpheniramine 4 mg 1 tab oral qid
2. Prevent oxidation
Vitamin C (500mg/amp) 6 gm/day IV
Vitamin E (400 i.u./tab) 2 tabs qid
N-acetylcysteine (300 mg/amp) 50 mg/kg every 8 hr

page 18

P&D Information Bulletin / Vol. 13, No. 2, 2005

poisoning. Hum Toxicol 1987; 6: 57-62.

3. Bismuth C, Scherrmann JM, Garnier R, et al. Elimination of paraquat. Hum Toxicol 1987; 6: 63-67.
4. Dasta JF. Paraquat poisoning: a review. Am J Hosp Pharm
1978; 35: 1368-1372.
5. Fisher HK, Humphries M, Bails R. Paraquat poisoning:
recovery from renal and pulmonary damage. Ann Intern Med
1971; 75: 731-736.
6. Hampson EC, Pond SM. Failure of hemoperfusion and
hemodialysis to prevent death in paraquat poisoning. A retrospective review of 42 patients. Med Toxicol Adverse Drug
Exp 1988; 3: 64-71.
7. Hart TB, Nevitt A, Whitehead A. A new statistical approach to the prognostic significance of plasma paraquat
concentrations. Lancet 1984; 24: 1222-1223.
8. Kaojarern SK, Ongphiphadhanakul B. Predicting outcomes
in paraquat poisoning. Vet Hum Toxicol 1991; 33: 115-118.
9. Lindenschmidt RC, Seling WM. Patterson CE et al. Histamine actions in paraquat induced lung injury. Am Rew
Respir Dis 1986; 133: 274-8.
10. Meredith TJ, Vale JA. Treatment of paraquat poisoning
in man: methods to prevent absorption. Hum Toxicol 1987;
6: 49-55.
11. Okonek S, Weilemann LS, Majdanzic J, et al. Successful
treatment of paraquat poisoning: activated charcoal per os
and continuous hemoperfusion. Clin Toxicol 1982; 19: 807819.
12. Proudfoot AT, Stewart MS, Levitt T, et al. Paraquat poisoning: significance of plasma-paraquat concentrations.
Lancet. 1979; 18: 330-332.
13. Saenghirunvattana S, Sermswan A, Piratchvej V,
Rochanawutanon M, Kaojarern S, Rattanaenya T. Effects of
lung irradiation on mice following paraquat intoxication.
Chest 101; 3: 833-5.
14. Sequential bilateral lung transplantation for paraquat poisoning. A case report. The Toronto Lung Transplant group.
J Thorac cardiovasc Surg 1985; 89: 734-742.
15. Tungsanga K, Sitprija V, Suvanpha R, et al. Paraquat
poisoning: experience in fourteen patients. J Med Ass Thailand. 1981; 64: 215-222.
16. Webb DB, William WV, Davies BH, et al. Resolution after
radiotherapy of severe pulmonary damage due to paraquat
poisoning, Br Med J. 1984; 288: 1259-1260.
17. Wright N, Yeoman WB, Hale KA. Assessment of severity
of paraquat poisoning. Br Med J. 1976; August 5: 396.

18. Yamshita M, Naito H, Takagi S. The effectiveness of

1. Addo E, Poon-King T. Leucocyte suppression in Kayexalate as an absorbent of paraquat: experimental and
treatmemt of 72 patients with paraquat poisoning. Lancet clinical studies. Hum Toxicol 1987; 6: 89-90.
1986; 17: 1117-1120.
2. Bateman DN. Pharmacological treatments of paraquat
7.5% bentonite 100-150 gm MOM
30 ml 6

inactivate paraquat Fullers
earth

forced diuresis 250 ml/hr

furosemide urine 3
ml/min paraquat

paraquat

paraquat hemoperfusion
3
multiple organ failure hemoperfusion 1-2 3
hemoperfusion

paraquat


pulmonary edema necrotizing pneumonitis

pulmonary fibrosis
anti-inflammatory dexamethasone 5 mg IV 6 cytotoxic
cyclophosphamide 5 mg/kg/day
8 controlled trial
(lung radiation) fibroblast
fibrosis
paraquat oxidant
anti-oxidants vitamin C,
vitamin E, niacin, N-acetylcysteine

page 19

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ToCase Conference
..

21 34
CC: 2-3 . 1
PI: .
PE:

1. Phosphinic acid glyphosate

2. Bipyridylium paraquat
3. Chlorophenoxy compound 2,4-D
4. Chloroacetanilide alachlor, butachlor





-

1.

4-24

0.51 /.

Hart TB. Lancet 1984;2 (8413) :1222-3.

page 20

P&D Information Bulletin / Vol. 13, No. 2, 2005

 92% ()

2.
34

dithionite
Cesarean Section
24 cyclophosphamide dexamethasone
apgar score 9,10

(Navy bule) Respiratory Distress Syndrome
10 /. 3
(Pale bule) 11 .

1 /.
11

4
3.
, 0.51 /.
70WBC
90% 1.74
/.






.

dinithionite CBC:
WBC 10,940/ml


WBC

?

sodium dithionite test

page 21


1. Proudfoot AT, Stewart MS, Levitt T, Widdop B. Paraquat
poisoning: significance of plasma-paraquat concentrations.
Lancet 1979;2(8138):330-2.
2. Hart TB, Nevitt A, Whitehead A. A new statistical
approach to the prognostic significance of plasma paraquat
concentrations. Lancet 1984;2(8413):1222-3.
3. Scherrmann JM, Houze P, Bismuth C, Bourdon R.
Prognostic value of plasma and urine paraquat concentration.
Hum Toxicol 1987;6(1):91-3.
4. Kaojarern S, Ongphiphadhanakul B. Predicting outcomes
in paraquat poisonings. Vet Hum Toxicol 1991;33(2):115-8.
5. Bus JS, Preache MM, Cagen SZ, et al. Fetal toxicity and
distribution of paraquat and diquat in mice and rats. Toxicol
Appl Pharmacol 1975;33(3):450-60.
6. Musson FA, Porter CA. Effect of ingestion of paraquat on
a 20-week gestation fetus. Postgrad Med J 1982;58(685):731-2.
7. Prasarnphanich T, Chinawong P, Somlaw S, Kosalwat N.
Neonatal paraquat poisoning: a case report. J Med Assoc Thai
1988;71(12):694-8.
8. Talbot AR, Fu CC, Hsieh MF. Paraquat intoxication
during pregnancy: a report of 9 cases. Vet Hum Toxicol
1988;30(1):12-7.

(reduction)
(sodium dithionite)
1. (sodium hydroxide)
10 pH
9 ( (sodium bicarbonate)
) A ()
2. 1 (spatula)
B
()
:



10
3.



4.
2 /

fullers earth
18
287 10500
0-2631-2140

page 22

P&D Information Bulletin / Vol. 13, No. 2, 2005

 (Insect

Repellents)

(HOUSEHOLD PRODUCTS)

1. (hair color, dye)
2. (permanent hair waving)
3. (hair straightener, rebounding)

3
1. cuticle

2. cortex

3. medulla

(hair color, dye)

1.
1.1 (vegetable dyes)
(henna)

G-6-PD deficiency

hemolysis, anemia, reticulocytosis, indirect hyperbilirubinemia

p-phenylenediamine (PPD)

1.2 (metallic dyes) sulfur, silver nitrate lead acetate

headache, abdominal clamp, muscle weakness lead acetate

peripheral motor polyneuropathy, anemia, kidney injury
1.3 (compound dyes)

2.


2
1 (oxidative
hair dyes) diaminophenols, methylphenylene diamine
p-phenylenediamine (PPD)

PPD (aniline derivatives)

- pharynx
dyspnea, cyanosis, airway obstruction respiratory failure intravascular hemolysis
methemoglobinemia

PPD 0.2% PPD
4%
2

hydrogen peroxide 6% hydrogen peroxide

page 23

 (hair waving)
(hair straightener, rebounding)

1. / reduce disulfide cross

linkages (S-S cross linkages) free-SH

potassium / sodium hydroxide ammonia thioglycolic
pH 9.5 (9.2-9.8)
thioglyoclate ammonium thioglycolate
5.5-7%
2.
-SH S-S cross linkages
sodium / potassium bromate 10-25%

potassium bromate 2% sodium
bromate 10%

(dilution)

120-240 120
-
activated charcoal

3.
methemoglobinemia 1% methylene blue (
7 4)

1. Poisindex staff editorial [Toxicology Information on CDROM]. Henna, Lead acetate, Paraphenylenediamine, Hydrogen peroxide, Thioglycolate, Bromate, Sodium hydroxide,
Propylene glycol. Poisindex system. Volume 124. Colorado:
Micromedex:Inc, 2005
2. A guide to the safe use of salon hair products: materail
safety datasheets.Available from
URL : http:// www.greatvistachemicals.com/agrochemicals/
pyrida ben.html
3. Available from URL : http://webdb.dmsc.
/ moph.go.th/ifc_cosmetic/a_ch_ 1_001c. asp?info_id=13
(corrosive alkaline)
bromate 1 1/2 -2

hypotension respiratory depression, tachycardia, pulmonary edema, lethargy, restlessness, coma, seizure acute oliguria
renal failure 2-3 acetonuria, albuminuria hematuria
bromate renal tumor

1.

15

2.
( 1 )

page 24

P&D Information Bulletin / Vol. 13, No. 2, 2005