大量砒霜攝取導致之急性腎衰竭及死亡 Acute Renal Failure and Mortality Following Massive Arsenic Trioxide Ingestion. 侯羿州 , 林杰樑 , 顏宗海 Yi-Chou Hou, Ja-Liang Lin, Tzung-Hai Yen 林口長庚紀念醫院 腎臟系 臨床毒物科 Chang Gung Memorial Hospital, Linkou department, Taoyun, Taiwan. Patient Information. Age: 57-year-old Gender: male - PowerPoint PPT Presentation
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大量砒霜攝取導致之急性腎衰竭及死亡大量砒霜攝取導致之急性腎衰竭及死亡Acute Renal Failure and Mortality Acute Renal Failure and Mortality Following Massive Arsenic Trioxide Following Massive Arsenic Trioxide IngestionIngestion
Age: 57-year-oldGender: maleOccupation: Teacher (chemistry)Marital status: married
ChiefChief ComplaintComplaintIngestion of 30 grams of asrsenics
trioxides ( 砒霜 ).
Present IllnessPresent Illness 14:00 on 12/30- his colleagues
found him taking 30 grams of arsenic trioxide ( 砒霜 ).
Excessive salivation and epigastralgia with persistent vomiting.
Shortness of breath and abdominal pain occurred concurrently.
15:30-he was referred to our ER.
Physical ExaminationPhysical ExaminationT:37℃ P:80 beats/min R:16times /min BP:116/81mmHg Consciousness: Clear, E 4 V 5 M 6 HEENT: Sclera: not icteric; Conjunctiva: not pale Oral cavity : intact oral mucosa Chest: Symmetric expansion. Bilateral clear breathing sounds.Heart: regular heart beat without murmur.Abdomen: Soft and flat. No tenderness. No hepatosplenomegaly. Extremities: No pitting pitting edema.
Laboratory (16:13)Laboratory (16:13)
WBC(/uL) 11800 BUN(mg/dL) N/A
Hb(g/dL) 15.3 Cr(mg/dL) 1.4
MCV(fL) 87.5 Na(meq/L) 137
RDW(%) 13.5 T. Bil(mg/dL) 1.0
Platelet(uL) 179000 K(meq/L) 3.7
Seg(%) 91.4 ALT(U/L) 103
PT INR N/AUric
acid(mg/dL)5.7
aPTT N/A Sugar( mg/dL) 144
Sinus Tachycardia
15:30-Arrived at CGMH ERDecontamination, Gastric lavage, IVF supportCheck Arsenic level
17:00-Contacted with 台北榮總解毒劑中心 for antidote.
21:00-Respiratory distress, hypoxic respiratory failure and shock occurred.
Fluid resuscitation(1000ml) and high dose norepinephrine were prescribed for shock.
Arterial blood gasArterial blood gas beforebefore intubationintubation(21:00)(21:00)
22:20-endotracheal intubation with mechanical ventilator support.Transfer to ICU.Continue fluid resuscitation with high dose inotropic agents for shock status1st 2,3- dimercaptol propanesulfonic acid (DMPS) 250mg IVF at 23:30(9hrs).
toxic metals derived from the natural environment.
Most common form: 5+, 3+, 3- Organic : with hydrogen and
oxygenInorganic: with Sulfur, chloride or oxygen
Inorganic arsenics is toxic. Postgrad Med J 2003
79: 391-396
ArsenicsArsenics As2O3: most common form in
environment, especially in water, soil or seafood, color pigments.
Murder weapons with sugar used by ancient Chinese.
Treatment of acute myelogenous leukemia -M3: (relapse status after ATRA).
Cosmetic products, <5ppm.
Postgrad Med J 2003 79 391-396
PharmacokineticsPharmacokinetics
Absorbed rapidly from GI tract with 100% bioavailability.
Rapid redistribution from blood (half life 1 hr.)
Inorganic arsenic can be either methylated to form monomethylarsonic acid or dimethylated as in dimethylarsinic acid.
K.Jonova: Journal of Applied.
Toxicology. 2011; 31: 95–107
The methylation of inorganic arsenic has been considered to be a detoxification mechanism
Clearance from bloodPhase 1: from serum to tissue (90%, 30 mins)Phase 2: to tissue (RBC, 10%)Phase 3: from tissues and RBC into plasma then renal elimination.