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Inhalational Poisoning. Rama B. Rao, MD Bellevue Hospital Center/NYU Medical Center New York City Poison Control Center. Classes. Simple asphyxiants Pulmonary irritants. Particulates Mitochondrial toxins. Simple Asphyxiants. Alveolar displacement O 2 Non-irritating

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inhalational poisoning

Inhalational Poisoning

Rama B. Rao, MD

Bellevue Hospital Center/NYU Medical Center

New York City Poison Control Center

classes
Classes
  • Simple asphyxiants
  • Pulmonary irritants
  • Particulates
  • Mitochondrial toxins
simple asphyxiants
Simple Asphyxiants
  • Alveolar displacement O2
  • Non-irritating
  • No direct mitochondrial toxicity
simple asphyxiants1
Simple Asphyxiants
  • Methane
  • Carbon dioxide (CO2)
  • Helium
  • Nitrogen
  • Nitrous oxide
simple asphyxiants symptoms
Simple Asphyxiants: Symptoms
  • Loss of consciousness
    • Minimal warning
    • Non-irritating
  • Sustained exposure
  • Hypoxia
  • Cardiovascular collapse
simple asphyxiants treatment
Simple Asphyxiants: Treatment
  • Safe rescue
  • 100% oxygen
  • Evaluation for other injuries
  • Supportive care
pulmonary irritants
Pulmonary Irritants
  • Can behave in part like simple asphyxiants
  • Mucosal irritation
    • Acid or base formation
    • Some free radical formation
pulmonary irritants water solubility
Pulmonary Irritants: Water Solubility
  • Highly water soluble:
    • Ammonia
    • Sulfur dioxide
    • Hydrogen chloride
    • Chloramine
  • Rapid onset
pulmonary irritants intermediate solubility
Pulmonary Irritants: Intermediate Solubility
  • Chlorine
    • Exposure better tolerated initially
    • Increased duration exposure
    • Subsequent acid formation in upper and lower airways
    • Delayed effects
      • Acute lung injury
pulmonary irritants low solubility
Pulmonary Irritants: Low Solubility
  • Include
    • Phosgene
    • Nitrogen dioxide
  • Prolonged exposure
  • Delayed
    • Pulmonary edema
    • Acute lung injury
pulmonary irritants treatment
Pulmonary Irritants: Treatment
  • Removal from exposure
  • Oxygen
  • Nebulized bronchodilators
  • For acid forming agents:
    • Nebulized sodium bicarbonate
      • 1 part NaHCO3 to 3 parts saline or water
      • Primarily for symptomatic relief
pulmonary irritants treatment1
Pulmonary Irritants: Treatment
  • Supportive care
  • Admission:
    • Severely symptomatic patients
    • Low and intermediate solubility exposures
  • Arrange follow-up
particulates and aspirants
Particulates and Aspirants
  • Gas exchange impaired
  • Supportive therapy
    • Intubation
    • ECMO
    • Bronchoaveolar lavage
  • Can be fatal in children
hydrocarbon aspiration
Hydrocarbon Aspiration
  • Surfactant disruption
  • Higher severity:
    • Agents
      • Low viscosity
      • Surface tension
      • High volatility
    • >30 mL exposures
hydrocarbon aspiration symptoms signs
Hydrocarbon Aspiration: Symptoms/Signs
  • Cough
  • Choking
  • Dyspnea
  • Rales
  • Hypoxia
  • May progress to ALI
hc aspiration management
HC Aspiration: Management
  • Assess for evidence of aspiration
    • Clinical
    • Radiographic
  • For asymptomatic patients without clinical evidence of aspiration
    • Observe 6 hours
    • Radiograph at 6 hours
    • Admit if signs or symptoms aspiration
mitochondrial toxins
Mitochondrial Toxins
  • Carbon monoxide
  • Cyanide
  • Hydrogen sulfide
carbon monoxide
Carbon Monoxide
  • Incomplete combustion
    • Fires
    • Vehicular exhaust
  • Methylene chloride
  • Leading cause of poisoning deaths in the U.S
toxicity co

100

75

Normal

50% COHb

% Saturation

50

50% Anemia

25

0

20

40

60

80

100

Tissue pO2 [mmHg]

Toxicity CO
  • Displacement O2
    • Alveoli
    • Hemoglobin binding sites (OCC)
  • Impaired O2
    • Delivery
    • Utilization
co poisoning acute signs and symptoms
CO Poisoning: Acute Signs and Symptoms
  • Headache
  • Myalgias
  • Dyspnea
  • Nausea, Vomiting
  • Loss of Consciousness
  • Chest pain
  • Hypotension
co toxicity delayed events
CO Toxicity: Delayed Events
  • Delayed neurological/

neuropsychiatric sequelae

  • 2-40 days post-exposure
  • Risks
    • Age
    • Loss of consciousness
slide32

Mitochondria

Blood

Muscle

CO + Hb

COHb

CO + Mb

COMb

CO + cytochrome oxidase

(1. displaces O

from Hb

(inhibits O

delivery to myocyte)

2

2

2. shifts O

dissociation curve)

2

Inhibits electron transport

¯

¯

BP and

CBF

Vasodilation

¯

ATP and O

utilization

­

2

N

+ O

2NO

cGMP

2

2

NOS

(endothelium, platelets)

-

CO-Platelets

O

and H

O

generation

2

2

2

Platelets

CO binds to heme-containing

NO

NMDA

-

ONOO

platelet proteins

activation

b

Affects

-integrins

2

PMNs adhere to vascular endothelium

Lipid peroxidation

PMNS

Proteases

Xanthine dehydrogenase Xanthine oxidase

Free radicals

(inhibitors: tungsten, allopurinol)

physiology co binding
Physiology: CO Binding
  • Myocardium
    • CV impairment  Hypotension
  • Hemoglobin
    • Decreased OCC  Functional Anemia
  • Platelets and PMN
    • Nitric oxide  Hypotension
    • Free radicals  Lipid Peroxidation
  • Mitochondria
    • Cytochrome oxidase  Lipid Peroxidation
    • Impaired e transport  Functional Hypoxia
carbon monoxide management
Carbon Monoxide: Management
  • 100% oxygen
    • Reduce half-life CO-Hb 6hr to 90 minutes
  • Assess for pregnancy
  • Note that pulse oximetry is inadequate
    • Oxygen saturation may appear artificially high
  • Assess for end organ damage
    • VS, ECG, symptomatology, neurological examination
carbon monoxide levels
Carbon Monoxide Levels
  • Venous sampling
  • > 10% abnormal
  • Levels correlate poorly with severity of exposurre
hyperbaric oxygen
Hyperbaric Oxygen
  • Decrease COHb half life
  • Displaces CO from tissues
  • Improves oxygen carrying capacity
  • Limits lipid peroxidation
  • Improves dissolved oxygen
hyperbaric oxygen1
Hyperbaric Oxygen
  • Variable outcomes in literature 2:
    • Definition of DNS
    • Timing and duration of therapy
    • Co-exposures
    • Inability to define equivalent exposures
    • Patient variability
hyperbaric oxygen2
Hyperbaric Oxygen

Weaver LK, et al: Hyperbaric oxygen for acute carbon monoxide poisoning. N Engl J Med 2002; 347:1057-67

hyperbaric oxygen indications
Hyperbaric Oxygen: Indications
  • Neurological damage
  • Cardiovascular events
  • Loss of Consciousness
  • Persistent symptoms
  • COHb > 25% ( some centers use >40%)
  • COHb > 15% in pregnant woman
  • Ideally within 6 hours of exposure
cyanide
Cyanide
  • Salts used in:
    • Electroplating
    • Mining extraction
    • Photography
    • Jewelry
  • Nitroprusside
  • Amygdalins

Jim Jones, The People’s Temple

cyanide1
Cyanide
  • Similar mechanism as CO
    • Mitochondrial toxin
  • Acute exposure
    • Rapid onset
    • Lactic acidosis
    • Vomiting, seizures, coma
cyanide2
Cyanide
  • Salts
  • Alkaline liquid
  • Gas
    • War
    • Combustion

Zyklon B, WWII Auschwitz

slide46

Cyanide Antidote Kit

Hemoglobin

Nitrites

Methemoglobin

Cyt a-a3

Mitochondria

Cyanide

Cyanomethemoglobin

Sodium Thiosulfate

Sodium

Thiocyanate

Rhodanese

treatment cyanide antidote kit
Treatment: Cyanide Antidote Kit
  • Known or suspected cyanide poisoning
  • Metabolic acidosis
  • End organ damage
nitrites for cn
Nitrites for CN

Caution

Caution if diagnosis is uncertain or if COHb is also suspected.

Can omit nitrites if uncertain exposure.

hydroxocobalamin kit
Hydroxocobalamin Kit
  • Sodium Thiosulfate 8 gm IV
  • Hydroxocobalamin 4 gm IV
  • Under investigation
  • Anaphylactoid reaction
  • May interfere with some lab assays