Wheat pill by dr sagheer part 2

WHEAT PILL WHEAT PILL POISONINGPOISONING

compositioncomposition

Chemical Composition Aluminium Chemical Composition Aluminium Phosphide 56% Inert ingrediants Phosphide 56% Inert ingrediants 44% Paraffin 44% Paraffin

USESUSES

Aluminium phosphide is an inorganic Aluminium phosphide is an inorganic phosphide used as an indoor phosphide used as an indoor fumigant at crop transport, storage fumigant at crop transport, storage and processing facilities. To control and processing facilities. To control insects and rodents As outdoor insects and rodents As outdoor fumigant for burrowing rodents and fumigant for burrowing rodents and mole control. mole control.

AvailabilityAvailability

It is available in the form of Pellets It is available in the form of Pellets Tablets Porous blister pack Sachet Tablets Porous blister pack Sachet Powder Fatal dose:- 0.15-0.5gm Powder Fatal dose:- 0.15-0.5gm  Celphos, Fumitoxin, Phostoxin,  Celphos, Fumitoxin, Phostoxin, and Quick Phos and Quick Phos

Mechanism Of ActionMechanism Of Action

Metal phosphide liberates phosphine Metal phosphide liberates phosphine gas after coming in contact with gas after coming in contact with moisture of grains or water or HCL moisture of grains or water or HCL of stomach after ingestion. Other of stomach after ingestion. Other gases liberated are Ammonia (NH3) gases liberated are Ammonia (NH3) Carbon dioxide (CO2) Carbon dioxide (CO2)

PathophysiologyPathophysiology It causes non-competitive inhibition of It causes non-competitive inhibition of

cytochrome c oxidase leading to cytochrome c oxidase leading to inhibition of mitochondrial oxidase inhibition of mitochondrial oxidase phosphorylation which in turn leads to phosphorylation which in turn leads to multiorgan dysfunction. Once absorbed multiorgan dysfunction. Once absorbed into the body phosphine can damage into the body phosphine can damage cell membrane and enzymes important cell membrane and enzymes important for respiration and metabolism like for respiration and metabolism like decrease in catalase and increase in decrease in catalase and increase in harmful enzymes like superoxide harmful enzymes like superoxide dismutase etc dismutase etc

It has been seen that phosphine causes It has been seen that phosphine causes decrease in Magnesium intracellularly and decrease in Magnesium intracellularly and its concentration increases extra cellularly. its concentration increases extra cellularly. When phosphine is inhaled,it can react with When phosphine is inhaled,it can react with moisture in the lungs to form phosphoric moisture in the lungs to form phosphoric acid which can cause blistering and edema acid which can cause blistering and edema leading to ARDS. It also causes the leading to ARDS. It also causes the denaturing of oxyhemoglobin leading to denaturing of oxyhemoglobin leading to decrease oxygen delivery to body tissues. decrease oxygen delivery to body tissues. Local trauma to the gastric tissues leading to Local trauma to the gastric tissues leading to gastritis. gastritis.

Symptoms & SignsSymptoms & Signs

G.I.T:- Thirst, nausea, vomiting, G.I.T:- Thirst, nausea, vomiting, burning epigastrium and abdominal burning epigastrium and abdominal cramps cramps

CVSCVS

Hypotension, shock, Hypotension, shock, brady/tachycardia, arrythmias, brady/tachycardia, arrythmias, myocarditis, congestive cardiac myocarditis, congestive cardiac failure and ultimately cardiac arrest.failure and ultimately cardiac arrest.

RESPIRATORYRESPIRATORY

Dyspnea, crackles, pulmonary Dyspnea, crackles, pulmonary edema (ARDS), chest tightnessedema (ARDS), chest tightness

HepatobillaryHepatobillary

Jaundice, tender hepatomegaly, Jaundice, tender hepatomegaly, raised transamines, raised transamines,

RenalRenal

Oliguria, proteinuria, hematuria,Oliguria, proteinuria, hematuria,

CNSCNS

Anxiety, apprehension, restlessness, Anxiety, apprehension, restlessness, dizzeness, impaired gaitdizzeness, impaired gait

METABOLIC CHANGESMETABOLIC CHANGES

Hypomagnesemia, Hypomagnesemia, Metabolic acidosisMetabolic acidosis

ManagementManagement

There is no specific antidote for There is no specific antidote for wheat pill(aluminium phosphide) wheat pill(aluminium phosphide) poisoning. Supportive measures are poisoning. Supportive measures are done till phosphine is excreted. done till phosphine is excreted. Brush all visible particles from Brush all visible particles from clothes, skin and hair. Thoroughly clothes, skin and hair. Thoroughly flush exposed skin and hair with flush exposed skin and hair with water for 3-5 mins,then wash with water for 3-5 mins,then wash with mild soap. mild soap.

If phosphine has been ingested, do not If phosphine has been ingested, do not induce emesis. Confirm the presence of induce emesis. Confirm the presence of wheat pill poisoning by the use of AgNO3 wheat pill poisoning by the use of AgNO3 (silver nitrate) or lead acetate paper. This (silver nitrate) or lead acetate paper. This can be done by placing silver nitrate paper can be done by placing silver nitrate paper in front of patient’s mouth and asking him or in front of patient’s mouth and asking him or her to exhale repeatedly,the color of the her to exhale repeatedly,the color of the paper will turn black in case of patient is paper will turn black in case of patient is phosphine gas positive. Further confirmation phosphine gas positive. Further confirmation can be done by placing ammonium can be done by placing ammonium molybdate solution on black turned paper molybdate solution on black turned paper and the colour will change to blueand the colour will change to blue

Gastric lavageGastric lavage

Is useful if done within 1-2 hrs gastric Is useful if done within 1-2 hrs gastric lavage with 1:1000 potassium lavage with 1:1000 potassium permegnate as it oxidezes phosphine to permegnate as it oxidezes phosphine to non toxic phosphate, till patient is non toxic phosphate, till patient is confirmed phosphine gas negative by confirmed phosphine gas negative by silver nitrate paper. Slurry or activated silver nitrate paper. Slurry or activated charcol at 1mg/kg (adult 60-90gm) charcol at 1mg/kg (adult 60-90gm) orally or through nasogastric tube. orally or through nasogastric tube. Mineral oil,olive oil or coconut oil may Mineral oil,olive oil or coconut oil may be used for gastric lavage.be used for gastric lavage.

COMPLICATIONS AND COMPLICATIONS AND TREATMENT TREATMENT

Cardiogenic ShockCardiogenic Shock:- Intravenous :- Intravenous fluids(3-4 litres of fluid out of which fluids(3-4 litres of fluid out of which 50% should be normal saline under 50% should be normal saline under CVP guidance) Dopamine CVP guidance) Dopamine (4-6ug/kg/min) with dobutamine to (4-6ug/kg/min) with dobutamine to keep the systolic blood pressure keep the systolic blood pressure above 100mmHg. above 100mmHg.

Intravenous hydrocortisone 200-Intravenous hydrocortisone 200-400mg after every 4-6hrs to be 400mg after every 4-6hrs to be administered- to reduce dose of administered- to reduce dose of dopamine To check capillary leakage dopamine To check capillary leakage in lungs To potentiate in lungs To potentiate responsiveness of shock to responsiveness of shock to endogenous catecholamines To endogenous catecholamines To compensate low levels of cortisol compensate low levels of cortisol found in cases with severe poisoningfound in cases with severe poisoning

Treatment of Arrhythmias:Treatment of Arrhythmias:

Arrhythmias can be treated by:Arrhythmias can be treated by: Administer amiodarone IV at 150 mg over 10 Administer amiodarone IV at 150 mg over 10

minutes. The dose depends upon the condition of minutes. The dose depends upon the condition of the patient.the patient.

Magnesium sulfate can also be used for the Magnesium sulfate can also be used for the management of supraventricular and ventricular management of supraventricular and ventricular arrhythmiasarrhythmias

due to its per-oxidant effect. Its IV doses include due to its per-oxidant effect. Its IV doses include 1 gm stat and then give 1 gm after every hour 1 gm stat and then give 1 gm after every hour up-to three consecutive hoursup-to three consecutive hours

. . Then 1 gm after 4 to 6 hours for maximum 5 Then 1 gm after 4 to 6 hours for maximum 5 days.days.

HypoxiaHypoxia:- Patent airway and oxygen :- Patent airway and oxygen inhalation through mask Assisted inhalation through mask Assisted ventilation if needed Monitor blood ventilation if needed Monitor blood gas analysisgas analysis

Adult respiratory distress syndrome:-Adult respiratory distress syndrome:- Oxygen is delivered through face mask at Oxygen is delivered through face mask at moderate flow rates of 5-10 litres/min. moderate flow rates of 5-10 litres/min. Mechanical support if needed Steps to Mechanical support if needed Steps to reduce systemic toxicity No agent of proven reduce systemic toxicity No agent of proven efficacy as it rapidly binds to enzymes efficacy as it rapidly binds to enzymes systems and produce cellular dysfunction. systems and produce cellular dysfunction. However Mg++ is thought to have anti However Mg++ is thought to have anti peroxidant, anti arrythmic, and membrane peroxidant, anti arrythmic, and membrane stabilizing effects.hence has been used with stabilizing effects.hence has been used with successsuccess

Dosage of MgSO4 Two regimens 1st: Dosage of MgSO4 Two regimens 1st: 1gm of MgsO4 IV stat Then 1gm every 1gm of MgsO4 IV stat Then 1gm every hour for next three hours Then 1 gm IV hour for next three hours Then 1 gm IV 4-6 hrly upto a maximum of 5 days 4-6 hrly upto a maximum of 5 days 2nd: MgSO4 3gm in 500ml D/W in first 2nd: MgSO4 3gm in 500ml D/W in first three hours Then MgSO4 6gm in three hours Then MgSO4 6gm in 500ml D/W for 24hrs starting from 500ml D/W for 24hrs starting from next day and continued for 3-5 days. next day and continued for 3-5 days. With this dose serum magnesium level With this dose serum magnesium level remains b/w 3.0-4.6 mEq/L which is remains b/w 3.0-4.6 mEq/L which is safe. safe.

METABOLIC ACIDOSISMETABOLIC ACIDOSIS

Intravenous sodium bicarbonate 50-100meq in Intravenous sodium bicarbonate 50-100meq in 1000ml N/Saline every 8 hrs to keep bicarbonate 1000ml N/Saline every 8 hrs to keep bicarbonate level around 18-20meq and pH above 7.1 Steps level around 18-20meq and pH above 7.1 Steps to increase Ph3 excretion Phosphine is excreted to increase Ph3 excretion Phosphine is excreted through breath and partially through urine Steps through breath and partially through urine Steps to enhance its excetion through urine Adequate to enhance its excetion through urine Adequate hydration Renal perfusion by IV fluids Low dose hydration Renal perfusion by IV fluids Low dose dopamine 4-6ug/kg/min Diuretics and dialysis are dopamine 4-6ug/kg/min Diuretics and dialysis are not employed due to hemodynamic not employed due to hemodynamic instability,howevr may be used if patient instability,howevr may be used if patient develops acute renal failure,severe acidosis or develops acute renal failure,severe acidosis or fluid overload and becomes hemodynamically fluid overload and becomes hemodynamically stable stable

Many studies have proved that enzyme Q10 is Many studies have proved that enzyme Q10 is protective in wheat pill poisoning against protective in wheat pill poisoning against cardic arrythmias, it is a anti oxidant, and cardic arrythmias, it is a anti oxidant, and also used in myalgias and arthalgias in also used in myalgias and arthalgias in cardiac and hypertensive patients using cardiac and hypertensive patients using statins therapy.statins therapy.

Trimetazidine(vastral MR): it is used in Trimetazidine(vastral MR): it is used in angina patients and it causes cellulal angina patients and it causes cellulal homeostasis by ensuring proper functioning homeostasis by ensuring proper functioning of ionic pump and transmembrane Na,k flow of ionic pump and transmembrane Na,k flow in patients with cellular hypoxia and ischemiain patients with cellular hypoxia and ischemia

Mortality (50-90%) Factors Mortality (50-90%) Factors Freshness of pills Dose consumed Freshness of pills Dose consumed Onset of symptoms Emptiness of Onset of symptoms Emptiness of stomach i.e vomiting etc Delay in stomach i.e vomiting etc Delay in arrival in hospital Delay in arrival in hospital Delay in institution of therapy Mortality institution of therapy Mortality Supportive therapy alone 70-100% Supportive therapy alone 70-100% Supportive therapy &MgSO4 25-Supportive therapy &MgSO4 25-45% 45%

questionsquestions

Gastric lavage should be done with?Gastric lavage should be done with? Egg yolkEgg yolk Olive oilOlive oil Coconut oilCoconut oil Potassium permagnatePotassium permagnate All of aboveAll of above

What gases formed after metabolim of What gases formed after metabolim of wheat pill?wheat pill?

Ammonia gasAmmonia gas

CO2CO2

PhosphenePhosphene

All of above All of above

How will you confirm presence of How will you confirm presence of wheat pill in the body?wheat pill in the body?

CBCCBC

ENDOSCOPYENDOSCOPY

SILVER NITRATESILVER NITRATE

HN3 MOLYBDATEHN3 MOLYBDATE

OPTIONS 3 &4OPTIONS 3 &4

THANKSTHANKS