Iron and stings l.jpg
This presentation is the property of its rightful owner.
Sponsored Links
1 / 50

IRON and STINGS PowerPoint PPT Presentation


  • 110 Views
  • Uploaded on
  • Presentation posted in: General

IRON and STINGS. Rob Hall Dr. M. Yarema June 20th, 2002. IRON recognize dx explain pathophysiology know how, when and why to treat. STINGS know the basic management of bee/wasp/fire ant stings know the approach to management of marine bites, stings, and nematocysts envenomations. GOALS.

Download Presentation

IRON and STINGS

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Iron and stings l.jpg

IRON and STINGS

Rob Hall

Dr. M. Yarema

June 20th, 2002


Goals l.jpg

IRON

recognize dx

explain pathophysiology

know how, when and why to treat

STINGS

know the basic management of bee/wasp/fire ant stings

know the approach to management of marine bites, stings, and nematocysts envenomations

GOALS


She got into my pills l.jpg

She got into my pills……..

  • 3yo female - 10 kg

  • 5 pills of Ferrrous sulphate 325 mg gone

  • Presents early vomiting blood

  • Are you worried?

  • What if it was 10 pills?


Toxic ingestions l.jpg

Toxic Ingestions

  • Depends on ELEMENTAL IRON

  • Look up % elemental iron in ingested tab

  • Ferrous sulphate (20% elemental Fe + 10kg child)

    • 325 mg X 0.20 = 65 mg elemental Fe

    • 65 mg X 5 pills = 325 mg ----> 32 mg/kg

    • 65 mg X 10 pills = 650 mg ----> 65 mg/kg


Toxicity l.jpg

TOXICITY

  • Elemental FePeak []Toxicity

    • < 20 mg/kg< 30 umol/Lnone

    • 20 - 40 mg/kg30 - 60 mild

    • 40 - 60 mg/kg60 - 90 mod

    • > 60 mg/kg> 90 umol/L severe


Local toxicity l.jpg

LOCAL TOXICITY

  • Direct GI corrosive/irritant

  • Nausea, vomiting, abdominal pain, diarrhea, hematemasis, melena, hematochezia

  • Must consider on ddx of gastroenteritis, GI bleed in peds


Systemic toxicity l.jpg

SYSTEMIC TOXICITY

  • Coagulopathy (inhibits thrombin formation)

  • Liver toxicity (periportal necrosis)

  • Increased Anion Gap Metabolic Acidosis

    • Inhibits oxidative phosphylation ---> lactate

    • Direct negative ionotropy ---> lactate

    • Direct vasodilation ---> lactate

  • MUST be on ddx of SHOCK and AGMA NYD


What causes the increased agma in fe overdose l.jpg

What causes the increased AGMA in Fe overdose?

  • Fe 2+ ----------------> Fe 3+ and Hydrogen

  • Anerobic metabolism ---------> lactate

  • Hypovolemia from V/D --------> lactate

  • Hypovolemia from GIB ---------> lactate

  • -ve Ionotropy ---------------> lactate

  • Vasodilation ----------------> lactate


Five stages l.jpg

FIVE STAGES

  • STAGE I (< 6hrs): GI signs symptoms

  • STAGE II (6 - 24hrs): Latent period

  • STAGE III (variable): Systemic toxicity

  • STAGE IV (2-3 days): Liver failure

  • STAGE V (weeks): Gastric outlet obstruction


Complications l.jpg

Complications

  • Yersinsia enterocolitica

    • Noted increased rates of infection

    • Iron as a growth factor

    • Increases with deferoxamine use

    • Abdo pain, fever, diarrhea, sepsis


Slide11 l.jpg

LABS

  • ? WBC > 15 and Glucose > 7.5

    • may be a bad sign but not reliable

  • Increased AGMA

    • remember ddx: AMUDPILECAT

  • TIBC

    • theoretical reassurance if Fe level less than TIBC b/c enough transferrin around to bind

    • NOT reliable; DO NOT USE or MEASURE


Iron levels l.jpg

IRON LEVELS

  • Measure at 2 - 6 hrs (Peak 4hrs usually)

  • Repeat levels to catch peak (?)

  • Normal is 14 - 32 umol/L

  • Goes down town; turn around in 2hrs but must notify lab of STAT order

  • Levels used to help guide therapy

  • Falsely lowered in presence of deferoxamine thus must do before


Slide13 l.jpg

Radiopaque

Liquids and chewables are NOT radiopaque

Absence on AXR does NOT r/o ingestion

Ddx of radiopaque ingestant

C ca carbonate, chloral hydrate

Hheavy metals (iron, zinc, ba, Li, bisthmus)

Iiron

P KCl, Play-doh

Pphenothiazines

Eenteric coated pills

Ddental amalgan

AXR


Decontamination l.jpg

DECONTAMINATION

  • NO ipecac

  • Doesn’t bind charcoal

  • Gastric Lavage

    • Indicated if visible in stomach on AXR

    • Water or saline NOT bicarb, phosphosoda, Mg

  • Whole Bowel Irrigation

    • Indicated if visible past stomach on AXR


Deferoxamine l.jpg

DEFEROXAMINE

  • Specific iron chelator

  • Derived from Streptomyces pilosus

  • Ferric iron + deferoxamine -----------------> ferrioxamine (colors urine red/brown)

  • Chelates free iron in blood and intracellular


Deferoxamine16 l.jpg

DEFEROXAMINE

  • Administration

    • iv > im > po

    • iv indicated

    • goal is 15 mg/kg/hr

    • start at ? 5 mg/kg/hr and increase to target


Deferoxamine17 l.jpg

DEFEROXAMINE

  • Adverse Effects

    • Hypotension with rapid administration

    • ARDS (more common with higher doses, longer administrations > 24hrs)

    • Increased Yersinsia infections

    • Ocular and Ototoxicity have been reported with chronic administration

    • Deferoxamine is NOT contraindicated in pregnancy


Deferoxamine challenge l.jpg

DEFEROXAMINE CHALLENGE

  • 90 mg/kg im and see if urine color changes

  • +ve = urine color change -----------> tx

  • -ve = no urine color change --------->no tx

  • Problems

    • shown to be UNRELIABLE

    • DO NOT use as sole determinant for basis of treatment


Vin rose l.jpg

Vin Rose’


Deferoxamine20 l.jpg

DEFEROXAMINE

  • Indications for use

    • Ingestion of > 60 mg/kg

    • Iron level > 90 umol/L

    • Systemic toxicity: hypotension, coma, AGMA, seizures

  • Discontinuation (generally at 24hrs)

    • Clinically well

    • AGMA resolved

    • No further urine color change


Other mx l.jpg

OTHER Mx

  • Deferiprone

    • Oral active iron chelator

    • Used in chronic setting; being looked at with acute ingestions

  • CAVH

    • Infuse deferoxamine on arterial side; dog studies

    • Essentially experimental at this point


Disposition l.jpg

DISPOSITION

  • Asymptomatic after 6 - 8 hrs rules out significant ingestion and d/c home

  • Management of moderate to severe ingestions depends on …….

    • Clinical assessment: hx, physical, labs

    • Amount ingested: > 60 mg/kg is bad

    • Iron level: > 90 umol/L is bad


Approach l.jpg

APPROACH


Slide24 l.jpg

MILD

  • < 20 mg/kg and asymptomatic

  • Management

    • Observe 6-8 hrs

    • D/C if asymptomatic

    • No iron levels necessary


Moderate l.jpg

MODERATE

  • 20 - 60 mg/kg or unknown + “mild”GI s/s

  • Order AXR and Fe level (2-6hr)

  • Consider Gastric lavage or WBI

  • Fe level < 60 or 60 - 90 and asymptomatic -------> observe 6 - 8 hours and d/c if well

  • Fe level > 90 or 60 - 90 and symptomatic -------> treat as severe


Severe l.jpg

SEVERE

  • > 60 mg/kg, severe GI s/s, AGMA, shock

  • AXR, Fe level, baseline urine

  • Gastric lavage or WBI based on AXR

  • Start Deferoxamine: target is 15 mg/kg/hr

  • Discontinue Deferoxamine when……

    • Clinically well

    • AGMA resolved

    • No further urine color change


The goods on iron l.jpg

The GOODs on IRON

  • LOCAL and SYSTEMIC toxicity: 5 stages

  • Asymptomatic at 6hrs r/o sign. ingestion

  • Consider with gastro, GIB, AGMA, shock

  • Absence of pills on AXR does NOT r/o

  • Rx based on clinical status, amount ingested, and iron levels

  • Don’t wait for iron level if toxic


Hymenoptera l.jpg

HYMENOPTERA

  • Nasty arthropods: bee, wasp, hornet, yellow jacket, fire ants

  • 2nd most common cause of anaphylactic deaths

  • Killer Bees: “normal” bees with a mean streak (not more toxic, just more aggressive)


Hymenoptera reactions l.jpg

HYMENOPTERA REACTIONS

  • Local

    • pain, erythema, edema, swelling, itching

    • lasts hours to days; looks like infection

  • Toxic

    • N/V/D, lightheaded, syncope, H/A, fever, muscle spasms (NO urticaria or bronchospasm)

    • Due to toxic nature of venom NOT anaphylaxis

    • Lasts few hours to 2-3 days


Hymenoptera reactions30 l.jpg

HYMENOPTERA REACTIONS

  • Allergic/Anaphylactic

    • Urticarial rash ------------> full anaphylaxis

  • Delayed Reaction

    • Serum sickness at 10 - 14 days: fever, malaise, H/A, lymphadenopathy, polyarthritis, urticaria

    • Often not associated with sting by patient

  • Usual Reactions

    • Encephalitis, GBS, neuritis, vasculitis


Hymenoptera mx l.jpg

HYMENOPTERA - Mx

  • First Aid

    • Ice bag to site, remove stinger, epipen prn

  • Local Wound care in ED

    • Ice, remove stinger, tourniquet, limb down, can inject 0.1 ml of 1:1000 epi into site

  • Further Mx will depend on severity

    • Local reaction, allergic reaction, anaphylactic reaction


Ed management l.jpg

ED Management

  • Local Reaction

    • Local wound care, benadryl po, ibuprofen po

    • Observe 1hr, d/c if well

  • Urticarial Reaction

    • Local wound care, benadryl po, ibuprofen po

    • Observe 2-3 hrs, d/c if well

    • Educate, bracelet, Epipen Rx, allergist referral, Rx with benadryl +/- steroid


Ed management33 l.jpg

ED Management

  • Anaphylaxis

    • Epinephrine sc, im, iv

    • Benadryl iv

    • IV fluids

    • Ranitidine +/- Cimetidine

    • Ventolin +/- Racemic epi neb

    • Methylprednisone

    • Local wound care

    • Admit


Marine envenomations l.jpg

MARINE ENVENOMATIONS

  • 2000 species of venemous marine animals

  • General Mx

    • Remove from water: drowning MCC of death

    • Local wound care

    • ? Specific antivenom

    • Be prepared to manage anaphylaxis


Three mechanisms of envenomation l.jpg

Three Mechanisms of Envenomation


Bites l.jpg

Octopi

Local wound care: irrigate, debride, dress, tetanus, analgesia

Blue - ringed Octopus can be lethal (tetrodotoxin like venom)

BITES


Bites37 l.jpg

Seasnakes

50 species, all toxic, 7 fatal

Most bites do not result in envenomation b/c fangs short/loose ---> poor delivery of venom

Local wound care + polyvalent sea snake antivenom

BITES


Nematocysts l.jpg

NEMATOCYSTS

  • Nematocyst = spring - loaded venom gland that suddenly everts and delivers venom

  • Often located on tentacles

  • Remain functional after animals death

  • May still be “loaded”when in skin

  • Local reaction, allergic reaction, toxic reaction (N/V/D, CP, cramps, SOB, paralysis, cardiorespiratory collapse)


Nematocysts39 l.jpg

NEMATOCYSTS

  • General Mx

    • Cut off tentacles

    • Inactivate nematocysts: VINEGAR

    • Remove nematocyts: credit card scrape

    • Antihistamine, analgesia

    • Antivenom only exists for seawasp


Nematocysts40 l.jpg

Jellyfish

Usually only local reaction

Remove tentacle, vinegar, credit card scrape, antihistamine, analgesia

NEMATOCYSTS


Nematocysts41 l.jpg

NEMATOCYSTS


Nematocysts42 l.jpg

NEMATOCYSTS

  • Box Jellyfish (Seawasp)

    • Australia, Indian ocean

    • MOST deadly of all envenomating marine life

    • 25% fatality rate; more deaths than sharks!

    • One box can kill 10 humans

    • Cardioresp arrest within minutes

    • Mx: ABCs, remove tentacles, VINEGAR, credit card scrape, ANTIVENOM (Chironex)


Nematocysts43 l.jpg

NEMATOCYSTS


Nematocyts l.jpg

NEMATOCYTS

  • Portuguese Man -o - war

    • Southern US coast line

    • Not a true jellyfish

    • Usually only local reaction

    • Potential for full CV collapse

    • Many deaths reported

    • Mx: ABCs, remove tentacles, vinegar, credit card scrape, NO antivenom exists


Stings l.jpg

STINGS

  • Stinger = specialized apparatus that punctures skin and delivers venom

  • Mx

    • Remove stinger (? Xray to r/o stinger in tissue)

    • Irrigate copiously, tetanus, analgesia

    • HOT WATER for 30 - 90 min (inactivates the heat labile venom; hot as possible)

    • Antivenom exists for stonefish stings


Stings46 l.jpg

Starfish

Most nonvenomous

Crown - of - thorns: severe local reaction

STINGS


Stings47 l.jpg

Sea Urchins

Toxic coated spines

Severity depends on species

Usually only local reaction

Imbedded spines problematic

STINGS


Stings48 l.jpg

Stingray

Barbs on tail

Stepped on in shallow water

Tail spines ---> laceration

Stinger: local +/- systemic rxn (N/V/D, cramps, CP, SOB)

Remove stinger, irrigate, HOT water, tetanus, abx to cover vibrio

STINGS


Stings49 l.jpg

Bony fish (Lionfish, Stonefish)

Venomous spins on fins

Stepped on or handled

Will attack b/f swimming away

Severe local rxn: pain, swelling

Systemic rxn: N/V/D, syncope, SOB, paralysis, CV collapse

ANTIVENOM exists

STINGS


The goods on marine envenomations l.jpg

The Goods on Marine Envenomations


  • Login