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潘恆之 , 林杰樑 , 顏宗海

硫化氫沼氣中毒導致急性腎衰竭 , 乳酸中毒及 突發性心肺停止. 潘恆之 , 林杰樑 , 顏宗海. Acute Renal Failure, Lactic acidosis, and Sudden Collapse following Hydrogen Sulfide Sewer Gas Poisoning. 林口長庚紀念醫院 腎臟系 臨床毒物科. Patient's Profiles. Case 2 Age : 34 Gender: male Ethnic: Filipino Marital status : married

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潘恆之 , 林杰樑 , 顏宗海

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  1. 硫化氫沼氣中毒導致急性腎衰竭, 乳酸中毒及突發性心肺停止 潘恆之, 林杰樑, 顏宗海 Acute Renal Failure, Lactic acidosis, and Sudden Collapse followingHydrogen Sulfide Sewer Gas Poisoning 林口長庚紀念醫院 腎臟系 臨床毒物科

  2. Patient's Profiles • Case 2 • Age: 34 • Gender: male • Ethnic: Filipino • Marital status: married • Occupation: worker • Case 1 • Age: 28 • Gender: male • Ethnic: Filipino • Marital status: married • Occupation: worker

  3. Present Illness • Two otherwise healthy, Filipino workers from a poultry meat-processing factory suffered sudden loss of consciousness while cleaning pig slotted floors.

  4. Case 1(28 y/o male) -- Physical examination • Vital signs: T: 35.8 ℃ P: 0 bpm R: 0 cpm BP: 0/0 mmHg • GENERAL APPEARANCE:pale and cyanotic, foul odor • CONSCIOUSNESS: E 1 V 1 M 1 • HEENT: sclera: anicteric, conjunctiva: not pale pupil size L/R: 6/6(mm), cyanotic lips • NECK: supple, no jugular vein engorgement • CHEST: no breathing sounds • HEART: no heart sounds • ABDOMEN: soft and flat, hypoactive bowel sounds • EXTREMITIES: freely movable, no pitting edema

  5. Lab data(28 y/o male)

  6. Course (28 y/o male) • An out-of-hospital cardiac arrest victim • Blood tests revealed hypoxemia, hypercapnia, acute renal failure, lactate acidosis and hyperkalemia • Electrocardiogram showed asystole • CPCR failure

  7. Case 2(34 y/o male) -- Physical examination • Vital signs: T: 33.0 ℃ P: 131 bpm R: 6 cpm BP: 77/51 mmHg • GENERAL APPEARANCE:acute-ill looking, foul odor • CONSCIOUSNESS: E 2V 1 M 4 • HEENT: sclera: anicteric, conjunctiva: not pale pupil size L/R: 3/3 (mm), throat: not injected • NECK: supple, no jugular vein engorgement • CHEST: respiratory pattern: slow and shallow breathing sound: clear • HEART: rapid heart beat without murmurs • ABDOMEN: Soft and flat, normoactive bowel sounds, no local tenderness, no rebounding pain • EXTREMITIES: freely movable, symmetric peripheral pulse

  8. Lab data (34 y/o male)

  9. CXR (34 y/o male) EKG (34 y/o male)

  10. Course (34 y/o male) G a Day 1, at ER • Intubationwith mechanical ventilator support • N/S challenge, Norepinephrine run 30 µg/min • Give amyl nitrite 1pc inhalation and 3% sodium nitrite 10ml iv drip for 20 mins Day 1, in ICU • Brain CT: no evidence of ICH or structural lesions Day 2, in ICU • Consciousness: confused and disoriented

  11. Course (34 y/o male) Day 4, in ICU • Extubation • EEG: diffuse cortical dysfunction • Aspiration pneumonia => give empiric antibiotics: Ceftazidime2g q8h Day 5, at ordinary ward Day 16, at ordinary ward • Consciousness clear • Discharge

  12. Discussion Introduction • Hydrogen sulfide (H2S) is a colorless toxic gas that has strong odor of “rotten eggs” • H2S poisoning usually occurs by inhalation ~ Woodall GM et al, Inhal Toxicol. 2005;17:593-639

  13. Source • Organic 1. Incomplete oxidation of sulfur compounds 2. Bacterial degradation of sulfur compounds • Inorganic, mainly industrial 1. Petroleum industry -- contamination or by-product 2. Chemical industry -- reactant for production of chemicals 3. Production of heavy water 4. Metal refining ~ Tee L. Guidotti , International Journal of Toxicology. 2010, 29:569-581

  14. Apnea !! Knock down !! ~ Doujaiji B et al, Ann Saudi Med. 2010;30:76-80

  15. Symptoms ~ Tee L. Guidotti , International Journal of Toxicology. 2010, 29:569-581

  16. Diagnosis • Measurement of blood sulfide in acute emergencies is of little clinical value. • History of hydrogen sulfide exposure • Odor of hydrogen sulfide • Serum BUN, Cr, electrolyte, glucose, CPK, blood gas & serum lactate • ECG & Chest X-ray • CT scan ~ Milby HT et al, American Journal of Industrial Medicine. 1999, 35:192-195

  17. Treatment ~ Gregorakos L et al, Angiology. 1995, 46:1123-1131

  18. Antidote – Nitrite Salt • Nitrite salt oxidizes the Fe2+ of hemoglobin to Fe3+, deriving Met-Hb • Met-Hb competes with the Fe3+ of cytochrome oxidase and protects it from oxidization by H2S • Keep the Met-Hb level < 25% with a concern of hypoxemiafrom methemoglobinemia cyt c3+ cyt c2+ Oxy-Hb Amyl nitrite, Sodium nitrite cyt a3+ cyt a2+ Met-Hb H2S cyt a33+ cyt a32+ Sulfa-MetHb H2O2 + 2H+ 2H2O Oxy-Hb + SO2 Blood Mitochondria ~ Smith RP et al, Ann Rev Toxicol. 1976, 16:189

  19. Nitrite Kit ~ Morii et al, Journal of Occupational Medicine and Toxicology. 2010, 5:28

  20. Highlights • Hydrogen sulfide poisoning is a relatively uncommon and frequently lethal hazard • Toxidrome： 1. odor perception followed by olfactory paralysis 2. burning eyes 3. pulmonary edema 4. knock down • Foul odor • Keep Airway, breath, circulation, O2 100% • Antidote：Amyl nitrite、Sodium nitrite

  21. Thanks for your listening!!

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