Problem 6 Hendra Wijaya

Problem 6emergency medicineHendra wijaya405090006

Winai Wananukul, Ramathibodi Poison CenterEpidemiology of Toxic Exposure(May 2000 - April 2001)

Winai Wananukul, Ramathibodi Poison CenterClassification of Insecticide Exposure

Organophosphate andCarbamate Poisoning

Winai Wananukul, Ramathibodi Poison CenterWhat is Acute Organophosphate & Carbamate Poisoning ?State of Acetylcholine ExcessIt is a combination ofMuscarinic receptorNicotinic receptorCNS (unspecified)

Winai Wananukul, Ramathibodi Poison Center

Winai Wananukul, Ramathibodi Poison CenterOrganophosphate VS. Carbamate PoisoningReversible vs. Irreversible InhibitionReversible vs. Irreversible clinical poisoningTime of clinical courseBlood brain barrier penetrationCNS symptoms (after exclude hypoxic effects)

Winai Wananukul, Ramathibodi Poison Center

Winai Wananukul, Ramathibodi Poison CenterClinical course after acute poisoningCholinergic ExcessOthers (than cholinergic excess)Intermediate syndromeDelayed neuropathyArrthymias

Winai Wananukul, Ramathibodi Poison Center

Winai Wananukul, Ramathibodi Poison CenterDiagnosis of Organophosphate or Carbamate Poisoning:Clinical DiagnosisLaboratoryRed cell cholinesterasePlasma (Pseudo, Butyryl (Bu)) cholinesterase

Winai Wananukul, Ramathibodi Poison Center

Winai Wananukul, Ramathibodi Poison CenterManagement of OP & CB PoisoningSupportive CareVital signsRespiration: secretion block and airway obstructionrespiratory motor weaknessSeizureSpecific Treatment

Winai Wananukul, Ramathibodi Poison Center

AirwaySkinParenteralGI.CirculationTissues &OrgansIon TrappingRAC.DecontaminationIncrease EliminationAntidotesHemodialysis, Hemoperfusion

TOXICANTIDOTES

Muscarinic EffectsHeart rateSweating SecretionPupilsAtropine

AChE InhibitionsNicotinicMuscarinic2 PAM

Nicotinic EffectsMotor Power

+ (Muscarinic Effects)2 PAM

Winai Wananukul, Ramathibodi Poison CenterIntermediate SyndromeDevelop only after some acute organophosphate poisoning Mechanism: unknownnot directly relate to acetylcholine excessClinical Manifestation:Proximal muscle weaknessBulbar palsy

Winai Wananukul, Ramathibodi Poison Center

Winai Wananukul, Ramathibodi Poison CenterIntermediate SyndromeSpontaneous recover in 2 -3 weeks after developTreatmentSupportive care, especially respiratory careNote: this condition must be differentiated from Aged Acetylcholinesterase

Winai Wananukul, Ramathibodi Poison Center

Winai Wananukul, Ramathibodi Poison CenterChronic Organophosphate PoisoningClinical Features:Delay polyneuropathyNeuropsychiatric disorderDiagnosisClinical diagnosis, by suspicious & exclusionInvestigation?? PlasmacholinesteraseTreatmentNot established

Winai Wananukul, Ramathibodi Poison Center

Organochlorine Poisoning

Winai Wananukul, Ramathibodi Poison CenterClassification of OrganochlorineDichlorodiphenylethanesDDTMethoxychlorHexachlorocyclohexaneLindaneCyclodienesAldrinChlordane DieldrinEndrinEndosulphanHepatochlorChlordecone (kepone)Mirex

Winai Wananukul, Ramathibodi Poison Center

Winai Wananukul, Ramathibodi Poison CenterAcute Organochlorine PoisoningProdomal symptoms: tremor, ataxia, quick involuntary jerk (myoclonus) dizziness, confusion Paresthesia of month, nausea, vomiting

Winai Wananukul, Ramathibodi Poison Center

Winai Wananukul, Ramathibodi Poison CenterAcute Organochlorine PoisoningThe typical presentation: Status epilepticus Followed by: Respiratory failureCardiac arrhythmias Rhabdomyolysis & acute renal failure

Winai Wananukul, Ramathibodi Poison Center

Winai Wananukul, Ramathibodi Poison CenterAcute Organochlorine PoisoningTreatment:Control seizure as the same way as Status epilepticusBenzodiazepinesPhenobarbitalPhenytoinPrevent complications

Winai Wananukul, Ramathibodi Poison Center

Winai Wananukul, Ramathibodi Poison CenterDiagnosis of Organocholine PoisoningClinical DiagnosisHistory of exposureClinical features of repeated seizureLaboratory TestPlasma levelSubcutaneous fat level

Winai Wananukul, Ramathibodi Poison Center

Winai Wananukul, Ramathibodi Poison CenterSubacute Organochlorine PoisoningHyperexcitability stage: TachycardiaTremor Hyperreflexia TreatmentSymptomatic Px: AnxiolyticEnhance Elimination : Cholestyramine

Winai Wananukul, Ramathibodi Poison Center

Winai Wananukul, Ramathibodi Poison CenterChronic Organochlorine PoisoningOrganochlorine insecticides interfere with endocrine and reproductive systems. People who working with the insecticides have low sperm count and motility, infertility and abortion. The insecticides have also been reported to be carcinogenic to animals.

Winai Wananukul, Ramathibodi Poison Center

Principles of ManagementKeep the phone numbers of your doctor, hospital & emergency medical system near the phone.Removal of the patient from the site of poisoning.Initial resuscitation and stabilization.Symptomatic and supportive measures.Removal of unabsorbed poisons- from GI tract or from skin, eye.Hastening the elimination of absorbed poisons.Use of specific antidote if available Disposition of the patient with advice for prevention.

Initial resuscitation stabilizationIncludes airway- proper positioning head tilt and chin lift, suction of secretions from oropharynx, falling back of tongue is prevented by suitable airway tube.Breathing- oxygen via a mask, when gag/cough reflects is absent- ET tube inserted. if necessary positive pressure ventilation with ABG monitoring, respiratory stimulants for severe respiratory depression.Circulation- proper IV access, maintenance of fluid & electrolyte balance, IV drugs for treatment.

ContinuedManagement of hypothermia- cover with a blanket, thermo neutral environment maintenance, pre warmed IV fluids and inspired gases.Management of pulmonary edema- administer 100% oxygen, intermittent positive pressure ventilation, IV aminophylline(5-8mg/kg), IV frusemide(1-2 mg/kg).

Syrup of ipecac may be used for inducing emesis in children older than 6 months in a single dose of 10 mL for 6-12 months age, and 15 mL for children above 1 year of age. The dose may be repeated in 20 minutes for those more than 1 year of age.Induction of vomiting is contraindicatied in corrosive or kerosene poisoning and in comatose patients or those with absent gag reflex.

Gastric Lavage. If the vomiting does not occur quickly, gastric lavage should be done promptly to remove the poison. In a symptomatic but alert patient with minor ingestion, activated charcoal alone by mouth is sufficient for gastrointestinal decontamination

Pyrethroid Poisoning

Winai Wananukul, Ramathibodi Poison CenterClassification of Pyrethrins & PyrethroidsPyrethrinsCinerin ICinerin IIJustmolin IJusmolin IIPyrethrin IPyrethrin IIPyrethrum extract Type I PyrethroidsAllethrin BioallethrinCismethrinKadethrinPermethrinPhenothrinResmethrinTetramethrinType II PyrethroidsCyhalothrinCypermethrinCyphenothrinDeltamethrinFenpropenthrin FenvalerateFluvalinate

Winai Wananukul, Ramathibodi Poison Center

Winai Wananukul, Ramathibodi Poison CenterPyrethroids ExposureDirect ToxicHypersensitivityAllergic rhinitisBronchitisBronchial asthmaAnaphylactic shockLocal IrritationContact dermatitisCorneal abrasion

Winai Wananukul, Ramathibodi Poison Center

Winai Wananukul, Ramathibodi Poison CenterPyrethroid Poisoning: InsectThe type I syndrome (caused by type I pyrethroids): fine tremorreflex hyperexcitabilitysympathetic activation The type II syndrome (caused by type II pyrethroids):salivationcoarse tremorchoreoathetosiareflex hyperexcitabilitysympathetic activation, and seizure

Winai Wananukul, Ramathibodi Poison Center

Winai Wananukul, Ramathibodi Poison CenterPyrethroid Poisoning: HumanUsually mild Common: nausea and vomiting after ingestion of pyrethroids.Sever Cases: drowsiness, seizure and coma ( In patient exposed to large amount of pyrethroids, especially the product used in agriculture in higher concentration)Death from pyrethroid poisoning is rare.

Winai Wananukul, Ramathibodi Poison Center

Winai Wananukul, Ramathibodi Poison CenterDiagnosis of Pyrethroid PoisoningClinical DiagnosisLaboratory TestNone

Winai Wananukul, Ramathibodi Poison Center

Winai Wananukul, Ramathibodi Poison CenterManagement of Pyrethroid PoisoningHypersensitivity: Adrenaline CorticosteroidsBronchodilatorsAntihistamineDirect Toxic:Supportive treatment

Winai Wananukul, Ramathibodi Poison Center

1FOOD POISONINGWhat is Food PoisoningFood poisoning is an acute illness, usually of sudden onset, brought about by eating contaminated or poisonous food. The symptoms normally include abdominal pain, diarrhoea, nausea, vomiting and fever.It may be caused by:-bacteria or their toxinschemicals including metalsplants or fishvirusesmycotoxins

2 Type of Bacteria :There are two type of bacteria that cause major problems in the food industry:Spoilage bacteria - responsible for the decomposition of food.Pathogenic bacteria - responsible for causing illness such as dysentery, typhoid and food poisoning.

3The Main Food Poisoning Bacteria

Type of food poisoning

Where the bacteria come from

Onset time

Symptoms

Salmonella

Raw meat, eggs, poultry, animals

6 - 72 hours

Abdominal pains, diarrhoea, fever, vomiting, dehydration

Clostridium perfringens

Raw meat, soil, excreta, insects

8 - 72 hours

Abdominal pain, diarrhoea

Staphylococcus aureus

Skin, nose, boils, cuts, raw milk

1 - 6 hours

Vomiting, abdominal pains, lower than normal temperature

6Incidents of Food Poisoning in PDO

Date

Place

People Affected

Type of Food Poisoning

Source

June '98

Marmul

23

Salmonellosis

Unknown

April '99

Fahud

12

Shigellosis

Unknown

April '99

RAH Club

32

Shigellosis

Unknown

May '01

Toco Camp Saih Rawl

75

Salmonellosis

Unknown

7 High-Risk FoodsCooked poultryCooked meatsDairy produce (milk, cream, etc.)Soups, sauces and stocksShellfish, sea foodCooked riceDishes containing eggs.

8 Low-Risk Foods

Dried or pickled FoodsChemically-preserved foodsFoods with high sugar contentFood with high salt content

9 Environmental Sources-Water -Food-borne diseases are also carried bycontaminated water. -Soil - Dust and dirty is made up from soil. It is easily blown on to food after being carried into the kitchen on clothes and shoes, soil contains the food poisoning bacterium clostridium perfringens as well as many others.-Insects - Insects carry bacteria on their bodies. Crawling insects such as cockroaches, beetles and flies.-Kitchen surfaces & Utensils

10 Ten Main Reasons for Outbreak of Food Poisoning1.Food prepared too far in advance, and stored at warm temperature.2.Cooling food too slowly prior to refrigeration.3.Not reheating food to high enough temperatures to destroy food poisoning bacteria.4.The use of cooked food contaminated with food poisoning bacteria.5. Under cooking.6.Not thawing frozen poultry and meat for sufficient length of time.

11 Ten Main Reasons for Outbreak of Food Poisoning (Cont.)

7. Cross-contamination from raw food to cooked food. 8. Storing hot food below 63C.9. Infected food handlers.10. Use of leftovers.

12 Control Measures:-Cook food thoroughlyHandle food as little as possibleTry not to prepare food in advanceKeep food covered at all timesStore food at safe temperatures below 5C or above 63C.Do not keep food in the temperature (5C to 63C danger zone) Keep raw and cooked foods separate.Avoid re-heating food.

13 Control Measures (cont.)Prevent dry foods from becoming moist.Dispose waste food and other rubbish carefully.Keep bins covered.Keep all animals and insects away from food places.Keep everything as clean as possible.Seek advice if you feel ill, especially if you are suffering from diarrhoea or vomiting.

Finally, Never Forget:

Good Food Handling Practices are the Most Important Aspect of Food Hygiene.

Get the Practices Right, Keep them Right, and you should Achieve Food Safety.14

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