Case presentation

(Paraquat poisoning)
Ngu Ing Soon

Patients Biodata
Name

: Christinia

Date of birth

: 1/1/1987 (26 YO)

Gender

: Female

Race

: Indonesian

Occupation

: H/W

Marital status

: Married

Date of admission

: 4/9/13

Chief Complaint
Allerged drinking paraquat at 7pm on
4/9/13.

History of Presenting Illness

Drank 1 mouthful of paraquat (~10 -15ml) after
quarreling with her husband. (paraquat was
readily available at her hs)
Husband suspected her of having affair with other
man (Husband was under alcohol influence)
She became impulsive and drank paraquat
Her mind was full of anger at that time
She did not have pre-planned suicidal
plan/ideation
Denied taking other drugs at the same time.

History of Presenting Illness

Post-paraquat ingestion
Vomited x4 after ingestion of paraquat
Greenish vomitus, not blood-stained

No abd pain/diarrhoea
No SOB/chest pain/dizziness
No sore throat, oral ulcers
No LOC
No dysuria
Prior to that, no depressive & psychotic
symptoms.

History of Presenting Illness

Went to KK Selangau at ? Time
Patient was alert
GCS: 15/15
V/S: BP 130/90
PR - 84
SpO2 99 -100% under room air
Lungs were clear
CVS: DRNM
Abd: soft, non-tender

History of Presenting Illness

Managed with

Gastric lavage
IVD one pint N/S
CBD insertion
Activated charcoal 50g stat
Remove and change clothes

Upon admission to the ward, she

claimed she regretted for her action.
No more suicidal thought.

Family History
No family history of mental illness or
suicidal attempt

Social History
She was married for 7 years
No major relationship crisis but claimed
having frequent quarrel with her husband
over trivial matters, esp. suspecting her of
having affair for 2 mths.
Completed primary 6 education
Worked as a salesgirl for 3 yrs, then
stopped after married.
Currently staying with husband & 3
children.

In A&E

pH: 7.386
PO2: 118.4
PCO2: 34.6
BE: -3.9
HCO3: 21.2
(Metabolic acidosis)
Gastric lavage & urine: positive for
paraquat

Physical Examination

Alert, pink
GCS: 15/15 (orientated to T/P/P)
PV good, regular
Vomitus noted brownish in colour
Urine was clear
CVS: DRNM
Abd soft, non-tender
Lungs clear, A/E equal
No pedal oedema

Mx in the Ward
Cont charcoal 25 g 4 hourly
IVD 3 L/day, all N/S
Fuller 300 mL stat, then 20 mL hourly until
diarrhoea
IV pantoprazole 40 mg OD
IV lasix 20mg stat then tds
4-hrly V/S @ SpO2 monitoring
Keep NPO
HGT tds
Strict I/O charting

Progress in Ward
5/9/13 (D1)
Vomiting x2, blackish watery stool x3
(total BO x6), sore throat
No abd pain, oral ulcer, SOB, dysuria
Start on IV methylprednisolone infusion
(1g/day) over 1 hour x 3/7
IVI cyclophosphamide 850mg OD in 1
pint N/S over 4 H x 2/7
Allow orally

Progress in Ward
6/9/13 (D2)
No active complaint
No abd pain, oral ulcers, sore throat
O/E:
Lungs clear
Abd soft, non-tender
No oral ulcers, throat N

Mx:
Off NG, charcoal, fullers earth
Allow soft diet
Cont methylprednisolone & cyclophosphamide

Progress in Ward
8/9/13 (D4)

Patient was asymptomatic

V/S stable
Afebrile
VBG: improving HCO3 (from 21.2 to 22.7)
Mx:
T. Dexamethasone 8 mg tds (after completed
methyprednisolone)
T. calcium carbonate 500 mg BD
Add 0.5 g KCL in each pint of N/S (K+: 2.9)

Serial Ix Charting
4/9/13
FBC

5/9/13

6/9/13

7/9/13

8/9/13

9/9/13

132/2.9/
88/29.8

136/3.4/
92/31.9

13.4/10.8/192

Creat

63

98

219

343

BUSE

141/4.1/
104/48

139/3.5/
95/6.3

133/3.7/
85/16.3

133/3.0/
89/24.6

172/163

92/159

201/195

CA/PO4

2.19/1.55

1.97/1.74

CorrCA

2.07

1.95

Urine
paraquat

+ve

-ve

-ve

-ve

Input

4500

4700

4650

5050

4500

Urine
output

2050

2550

2850

2300

3200

AST/ALT

Serial Ix Charting
400
350
300
250
Creatinine
AST
Column1

200
150
100
50
0
41373

41403

41434

41464

Ngu Ing Soon

Organophosphate

Effects of OP

Effects of OP

Effects of OP

Paralysis in OP Poisoning
Type 1

Type 2

Type 3

Paralysis in OP Poisoning
Type 1

Type 2

Type 3

Acute paralysis secondary to

continued depolarization at the
neuromuscular junction.

Paralysis in OP Poisoning
Type 1

Type 2

Type 3

Intermediate syndrome

Develop
24-96
hours
after
resolution
of
acute
organophosphate
poisoning
symptoms
Syndrome involves weakness of
proximal muscle groups, neck, and
trunk, with relative sparing of distal
muscle groups.
Syndrome persists for 4-18 days

Paralysis in OP Poisoning
Type 1

Type 2

Type 3

Organophosphate-induced delayed
polyneuropathy (OPIDP)
Occurs 2-3 weeks after exposure to
large doses
Distal muscle weakness with
relative sparing of the neck muscles,
cranial nerves, and proximal muscle
groups
Recovery can take up to 12 months

Organophosphate Poisoning Grading

Criteria (Bardin et al., 1994)
Poisoning
Mild

Severe

Life threatening

Signs/Symptoms
Normal level of
consciousness
Mild secretions
Few fasciculations
Altered level of
consciousness
Copious secretions
Generalized fasciculations
Suicide attempt
Stupor

Ix
Cholinesterase activity in plasma &
in red blood cells reduced (Do not
wait for cholinesterase results before
initiating Rx)
Urine toxicology screen
FBC, BUSE, creat, blood glucose
CXR, ECG
ABG

Management
Remove contaminated clothing, wash
skin & mucous membrane with copious
amount of water
Gastric lavage (if presentation is within
1 hr) followed by activated charcoal
Cont lavage until returning fluid free
from odour of poison

Adequate oxygenation
Normal saline or D5%

Management

Adequate Atropinisation
Drying of tracheobronchial secretion
(most important)
Dry mouth
Flushing
Heart rate >120
Dilated pupils

Paraquat

Paraquat

Extent of Poisoning

Amount
Route
Duration of exposure
Persons health condition at the time
of the exposure.

Paraquat Effects
First 24 hours
Gastrointestinal effects.
Leading to oesophageal & gastric erosions as well as burns in
the mouth and throat. (corrosive effects - similar to that
observed with alkali ingestion.)

24-72 hours
Hepatocellular injury
Acute tubular necrosis

72-96 hours
Pulmonary fibrosis (d/t selective accumulation in lung
tissues)

Paraquat Effects
Multi-organ failure in fulminant poisoning (IF
more than 5-10 g of paraquat is ingested)
Acute renal failure
Hepatic necrosis
Myocardial necrosis
Acute pneumonia
Internal hemorrhages
Pulmonary fibrosis
Death

Determinants of severity
Oesophageal and gastric erosions
Complicatio
ns
Renal failure
Ingestion of more than one mouthful
of 20% concentrate
Development of pulmonary opacities
on chest X-ray
Decreasing lung volumes on
spirometry
Paraquat concentration > 3-5 mg/L

Ix
Gastric lavage/aspirate, urine & blood for
toxicology screening
Gastric lavage/aspirate & urine for
paraquat
Urine for paraquat daily x 3/7
Urinary sodium dithionite test
BUSE daily
FBC, LFT, Creat & CXR every 3 days
ABG

Prognostic factors

s-creatinine
s-protein
s-potassium, bicarbonate
plasma Paraquat concentration
SIPP [time to treatment since
ingestion of paraquat x serum
paraquat at admission (g/ml)]

SIPP
SIPP by Sawadaet al. (Applicable up to
200 H)
SIPP scores

Prediction

<10

Survival

10-50

Death from lung ibrosis

>50

Death from circulatory

failure

GI Decontamination
300 ml of Fullers earth (15% suspension)
via NG tube as soon as possible,
Then 20 ml of Fullers earth every hour
until diarrhoea & PR Fullers earth
Or
Activated charcoal 50 g stat & 25 g 4 hrly
for several days.
Mg sulphate (Mist alba) 30 ml every 4 hr
until diarrhoea & passage of Fullers earth

Hemodialysis/Charcoal
Hemoperfusion
Useful if started within 5-7 hrs of
ingestion (before distribution of
paraquat into tissues especially the
lungs).
The greatest paraquat conc. Is found
in the lungs & the concentration
peaks in 5-7 hrs post-ingestion.
Repeated HP is not helpful.

Other Mx
IV fluid 4-5 L/day (NS and D5%) x 1st
24 hr, then 3L/day orally or IV for
several days
K+ supplement (depending on BUSE)
Frusemide 40 mg bd IV or oral
O2 - avoided unless PaO2 falls to <60
mmHg

References
Sarawak Handbook of Medical Emergencies (3rd Edition)
emergency.cdc.gov/agent/paraquat/basics/facts.asp
http://www.slideshare.net/kiriekozanegawa/organophospha
te-poisoning-9447532?from_search=9
http://www.slideshare.net/fowzreal/organophosphatepoisoning-and-management?from_search=3
http://ceycollphysicians.org/images/ccp%20paraquat
%20pre.pdf
http://emedicine.medscape.com/
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2659600/tabl
e/T1/

Thank You