EMERGENCY ROOM

PROBLEM CASE
Dr Sidra Mumtaz
Resident II
Emergency Department
National Institute of Child Health,
Karachi
PRESENTING COMPLAINTS

 15 year old boy, weighing 45kg, resident of lines area, saddar, no

known comorbids, came with complaints of:

 Ingestion of unknown poison 1 hour ago

 Drowsiness for 30 min
 Abdominal pain, nausea and vomiting for 30 min
HISTORY

 HOPC
 PAST HISTORY
 FAMILY HISTORY
 BIRTH HISTORY
 DEVELOPMENTAL HISTORY
 IMMUNIZATION HISTORY
 FEEDING HISTORY
 PERSONAL HISTORY
 SOCIOECONOMIC HISTORY
Emergency Approach to
patient
PALS GUIDELINES
 Initial impression

Consciousness Disoriented

Breathing fast breathing

Color Normal
 Identify: Acute Life Threatening Event
 Call for help
Monitor attached
Oxygen
Maintain IV line
 “PRIMARY ASSESMENT”

 Evaluate:
 Airway: maintained with high flow oxygen
 Breathing:

Respiratory rate chest movements Ausculttion Oxygen

and pattern and air entry saturation

Fast breathing, 50 B/L symmetrical B/L equal air 98% on oxygen

breaths/min chest rise entry, clear ,no
added sounds
 Circulation

heart rate pulses CRT Bp

and rhythm

HR palpable 02 sec 110/70mmHg

:160/min, (good
Normal central and
rhythm peripheral
pulses
  Disability:

AVPU scale Pupil size and RBS

response to light

Disoriented bilaterally equal and 111 mg/dl

reactive to light
 Exposure:

Temperature Skin

Warm no scratches, bruises or any scar

mark found
 SECONDARY ASSESSMENT

SIGN AND SYMPTOMS Drowsy with incomprehensible verbal

response, Abdominal pain and vomiting
ALLERGIES Nil
MEDICATION Not given
PAST MEDICAL HISTORY Was in usual state of health

LAST MEAL Breakfast before leaving home

EVENT POISON 1 hour back

 Primary Assessment
EVALUATION IDENTIFICATION INTERVENTION

AIRWAY Clear Airway intact Properly positioned

BREATHING RR 50breaths/min Tachypnea High flow O2 attached

Irregular breathing pattern,
Bilateral equal air entry with
SpO2 96%

CIRCULATION Sinus tachycardia 160bpm Tachycardia I/V line maintained

CRT ~2sec
Normal volume pulse
BP 110/70 mmHg

DISABILITY AVPU Drowsiness Maintenance fluid started

ALOC with incomprehensible
verbal response, Pupils BERL
RBS 111mg/dl

EXPOSURE Temperature 98F Afebrile N/A

SYSTEMIC EXAMINATION

 HEENT: Normal
 Respiratory Exam: B/L clear+ equal air entry with tachypnea
 CVS: S1+S2+0, tachycardia
 CNS: Drowsy, GCS 12/15 [E=3, V=4, M=5], reflexes normal,
tone normal, power 5/5
 Abdomen: soft, slightly tender, no mass, no visceromegaly
 Limbs: Normal
 Back and spine: Normal
Differential diagnosis
 PROVISIONAL
DIAGNOSIS

 Poisoning/Suicide
 Organophosphate Poisoning
 Rodenticide Poisoning(RAT POISON)
 Opoid Poisoning
Management in ER
Emergency response activated
Airway maintained
Oxygen inhalation via face mask
IV fluids started
NPO, NG passed
Blood samples collected (ABGs, RBS, PT/APTT, LFTS, CBC,
UCE)
ECG monitor attached
Foleys passed to monitor IO
Gastric lavage done and activated charcoal given in ER.
MLO done
 GCS and Fits monitored
Patient was admitted to PICU and kept under observation.
 After 2-3 hours his friend called his
attendants that he went to buy rat poison
from market with him
Reassessment

 Pulse: 87 beats/min
 Blood Pressure: 105/75 mmHg
 Respiratory Rate: 35 breaths/min
 Temperature: Afebrile
ABGs

pH 7.38
pCO2 35.8
pO2 118.6
HCO3 21.4
SO2 98.9
 CBC
Hemoglobin 15 gm/dl
Red cell count 5.34 x 106 /L
Haematocrit 49.8 %
MCV 94.2 fl
MCH 28.6 pg
MCHC 30.7 %
Total leukocyte count 19.6 x 109 /L
Absolute leukocyte count 15.28

Neutrophils 78 %
Lymphocytes 20 %
Platelets 303 x 109 /L
 UCE
TEST RESULT

Urea 21mg/dL

Creatinine 0.7 mg/dL

ELECTROLYTES

Sodium 144 mEq/L

Potassium 3.6 mEq/L

Chloride 106

RBS 111
 LFTs

TB 0.45
DB 0.10
SGPT 20
Alk Phos 139
PT/APTT

PT 14
APTT 34
FINAL DIAGNOSIS

 RODENTICIDE POISONING (RAT

POISONING)
DISCUSSION
RODENTICIDE POISONING

 Rodenticides are a heterogeneous group of

compounds that exhibit markedly different
toxicities to humans and rodents. They are among
the most toxic substances regularly found in
homes. The varieties of rodenticides used over the
years are legion. Before the mid-
20th century, heavy metals (arsenic, thallium)
were the often-used agents. Since the mid-20th
century, anticoagulant substances have been the
mainstays of rodenticide products.
 classification
 Inorganic preparations:
 Barium carbonate, phosphorous ,Thallium , Zn phosphide
 Organic preparations:
 Flouro acetate compounds
 Convulsants:
 Strychnine
 Anti coagulants:
 First generation : warfarin , coumatetrayl
 Second generation : Brodifacoum , Difenacoum
 Others:
 Arsenic , Bromethalin , Endrin , Sodium fluoro acetate and
Zyklon.
 Mechanism of action

 Zinc phosphide:
 It is a single dose fast acting rodenticide.
 Death occurs with in 1-3days after ingestion.
 MOA: Acid in the stomach reacts with the phosphide to yield
toxic phosphine gas which is a potent pulmonary toxicant.
Calciferols:
 MOA: On ingestion in toxic doses these affect calcium
and phosphate homeostasis causing hypercalcemia.
 On accumulation in stomach , kidney , lungs , blood
vessels and heart are all calcified/mineralised.
 It has a synergistic effect with anticoagulant , thereby
increasing the chances of death and decrease in the
time involved.
Anti coagulants:
 After ingestion of lethal dose , it effectively blocks the
vit-k cycle , resulting in inability to produce essential
blood clotting factors mainly factors II and VII.
 This is the preferred type of rat bait , as the antidote is
available i.e, Vit-K.
 Clinical features
WITH ZINC PHOSPHIDE:
 Via Inhalation : Cough, Nausea ,Vomiting, Headache Fatigue.
 Via Ingestion: Abdominal pain , Cough , Diarrhea , Dizziness ,
Shortness of breath , Unconsciousness , Nausea , Vomiting
Uncoordinated movements.
WITH WARFARIN:
 Do not have onset symptoms , which might manifest days later.
 Hematuria
 Bloody diarrhea
 Extensive Bruising
 Epistaxis
 Hematemesis
 Low Blood pressure
 Confusion , Lethargy , Altered mental status
 Shock
 With Warfarin: Pin point Purplish red spots
WITH CALCIFEROLS:
 Nausea , Vomiting , Anorexia , Fatigue , Itching and Weakness.
 Acute Intoxication: Polyneuropathy.
 Chronic Intoxication: Extreme depression , Apathy , Confusion , Fatigue.
WITH BARIUM:
 Nausea , Weakness , Abdominal pain.
 WITH THALLIUM
 Acute GI distress , Anorexia , Myalgia , Painful
neuropathy and hair loss.
WITH STRYCHNINE:
 Anxiety , Generalized seizure like appearance without
loss of consciousness , Muscle twitching , Facial
grimacing.
WITH ARSENIC:
 Nausea , Vomiting , Bloody diarrhea and garlic taste in
mouth.
 MANAGEMENT: APPROACH
 Complete blood count
 PT
 INR
 Activated PTT
 BT
 Platelet count
 Lab verification of Brodifacoum , Difenacoum.
 CPK
 LA
 Blood test for arsenic & Thallium
 Treatment
 Secure airway and place IV lines in Haemodynamically unstable patients.
 ACTIVATED CHARCOAL is used as soon as possible to prevent further
systemic absorption of ingested toxin.
 GI EVACUATION in cases of huge over dosage and in which the patient
presents early to an emergency facility.
 ZINC PHOSPHIDE:
 -Supportive therapy remains the only available form as there is no
specific antidote.
 -Gastric lavage to reduce the release of toxic phosphine.
 -Patients with severe respiratory compromise require endotracheal
intubation for ventilatory support.
 -Severe haemolysis from phosphine gas may require exchange
transfusion of RBCs.
 ANTICOAUGULANTS:
 If no coagulopathy is found in the setting of an
anticoagulant exposure ,prophylactic treatment with
Vit-K is absolutely contraindicated.
 If a coagulopathy is documented , Vit-K therapy is
suggested.
 Patients who present with life threatening
haemorrhage , in addition to Vit-K, Prothrombin
complex conc. and/or fresh frozen plasma may be
needed to reverse anti coagulation