Paraquat toxicity - Revision history

ClaireLewis at 00:22, 22 October 2020

2020-10-22T00:22:37Z

← Older revision		Revision as of 00:22, 22 October 2020
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	[[File:Paraquat tongue.jpg\|thumb\|Paraquat Tongue (Credit: wikitox.org)]]		[[File:Paraquat tongue.jpg\|thumb\|Paraquat Tongue (Credit: wikitox.org)]]

	Overall, pulmonary and renal toxicities predominate and are the primary cause of mortality. GI toxicity is nearly universal and is probably an ~~underrecognized~~ cause of mortality secondary to erosion and perforation.		Overall, pulmonary and renal toxicities predominate and are the primary cause of mortality. GI toxicity is nearly universal and is probably an under-recognized cause of mortality secondary to erosion and perforation.

	*Gastrointestinal: predominate early		*Gastrointestinal: predominate early
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	*[https://wikem.org/wiki/Ingested_foreign_body Foreign Body Ingestion]		*[https://wikem.org/wiki/Ingested_foreign_body Foreign Body Ingestion]

	===Oral Burns/Mucositis===		===Oral [[Burns]]/Mucositis===
	*[https://wikem.org/wiki/Burns Burns]		*[https://wikem.org/wiki/Burns Burns]
	*Infectious Causes		*Infectious Causes
	**Aphthous Ulcer		**[[Aphthous stomatitis\|Aphthous Ulcer
	**Herpes simplex infection		**[[Herpes simplex]] infection
	**Coxsackie virus		**[[Coxsackie virus]]
	**Tonsillitis		**Tonsillitis
	**Methotrexate/chemotherapy toxicity		**[[methotrexate toxicity\|Methotrexate]]/chemotherapy toxicity

	===Acute Dyspnea===		===Acute Dyspnea===
	*Primary Lung		{{SOB DDX}}
	**Pneumonia (bacterial and viral)
	**Pneumonitis
	**Pulmonary Embolism
	**Pneumothorax
	**Malignancy
	**Mucus plugging
	**Reactive airway disease
	**Aspiration
	**Pleural Effusion
	*Primary Cardiac
	**Congestive Heart Failure
	**Myocardial infarction
	**Valvular disease
	**Aortic Stenosis or regurgitation
	**Pericardial Effusion
	**Myocarditis/Pericarditis
	*Primary Metabolic
	**Sepsis
	**Metabolic Acidosis

	==Evaluation==		==Evaluation==
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	**CBC		**CBC
	**BMP		**BMP
	**LFTs and coagulation tests		**[[LFTs]] and coagulation tests
	**[[VBG]] or [[ABG]]		**[[VBG]] or [[ABG]]
	**[[UA]]: high concentrations of paraquat in the urine will cause it to appear blue		**[[UA]]: high concentrations of paraquat in the urine will cause it to appear blue
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	**[[CXR]]		**[[CXR]]
	**[[EKG]]		**[[EKG]]
	**consider CT if stable to evaluate for perforation/mediastinitis		**consider CT if stable to evaluate for perforation/[[mediastinitis]]

	===Diagnosis===		===Diagnosis===
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	==Management==		==Management==
	''Patients who present in extremis after an ingestion will not survive regardless of management and should be treated palliatively. ''		''Patients who present in extremis after an ingestion will not survive regardless of management and should be treated palliatively. Large >50mL ingestions of paraquat are universally fatal. Aggressive resuscitation is futile. ''
	===~~ABC's~~ ===		===Resuscitation===
	*Airway: consider early aggressive intubation for any respiratory distress or large (>100mL) ingestions		*Airway: consider early aggressive [[intubation]] for any respiratory distress or large (>100mL) ingestions
	*Breathing: [[CXR]], [[O2]]. Avoid aggressive oxygen therapy ~~if not necessary~~ due to increased free radical production		*Breathing: [[CXR]], [[O2]]
	*Circulation: may develop early shock and require aggressive inotropic support		**Avoid aggressive oxygen therapy unless severe [[hypoxia]] due to increased free radical production
			*Circulation: may develop early shock and require aggressive [[pressors\|inotropic]] support

	===Decontamination===		===Decontamination===
	*Paraquat is absorbed transdermally. Unprotected first responders and healthcare workers are at risk		*Paraquat is absorbed transdermally. Unprotected first responders and healthcare workers are at risk
	*Remove clothing and wash patient's skin if spillage or obvious skin involvement present		*Remove clothing and wash patient's skin if spillage or obvious skin involvement present
	*Consider activated charcoal or Fuller's Earth if within 1-2 hrs of ingestion		*Consider [[activated charcoal]] or Fuller's Earth if within 1-2 hrs of ingestion
	*Consider NG tube for administration of AC		*Consider [[NG tube]] for administration of [[activated charcoal]]
	**Must weigh risks as NGT placement can exacerbate caustic injury		**Must weigh risks as NGT placement can exacerbate caustic injury

	~~===Resuscitation===~~
	*Large >50mL ingestions of paraquat are universally fatal. Aggressive resuscitation is futile.
	*ABCs as noted above; avoid supplemental O2 unless severe hypoxia present

	===Supportive Care===		===Supportive Care===
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	===Antidotes/Additional Therapies===		===Antidotes/Additional Therapies===
	*Some centers administer [[glucocorticoids]] (typically [[dexamethasone]] 6mg-10mg IV q6h)		*Some centers administer [[glucocorticoids]] (typically [[dexamethasone]] 6mg-10mg IV q6h)
	*Consider [[NAC]], ~~Vit~~ C, other free radical scavengers in consultation with toxicologist or poison control		*Consider [[NAC]], vitamin C, other free radical scavengers in consultation with toxicologist or poison control
	*No role for extracorporeal elimination (hemodialysis~~, hemoperfusion~~, CRRT)		*No role for extracorporeal elimination ([[hemodialysis/Hemoperfusion]], CRRT)

	==Disposition==		==Disposition==
	*If small/trivial exposure and patient asymptomatic at 6 hours, unlikely to manifest a significant toxicity		*If small/trivial exposure and patient asymptomatic at 6 hours, unlikely to manifest a significant toxicity
	*Any ~~sympatomatic~~ exposure requires admission for close hemodynamic monitoring and supportive care		*Any symptomatic exposure requires admission for close hemodynamic monitoring and supportive care

	==See Also==		==See Also==

Rossdonaldson1: /* See Also */

2020-07-28T19:37:05Z

Rossdonaldson1: /* Disposition */

2020-07-18T11:33:48Z

Disposition

← Older revision		Revision as of 11:33, 18 July 2020
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	==Disposition==		==Disposition==
			*If small/trivial exposure and patient asymptomatic at 6 hours, unlikely to manifest a significant toxicity
	If small/trivial exposure and patient asymptomatic at 6 hours, unlikely to manifest a significant toxicity		*Any sympatomatic exposure requires admission for close hemodynamic monitoring and supportive care
	Any sympatomatic exposure requires admission for close hemodynamic monitoring and supportive care

	==See Also==		==See Also==

Rossdonaldson1: /* Diagnosis */

2020-07-18T11:33:22Z

Diagnosis

← Older revision		Revision as of 11:33, 18 July 2020
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	===Diagnosis===		===Diagnosis===
			*Based on urine test

	==Management==		==Management==

Rossdonaldson1: /* =Diagnosis */

2020-07-18T11:32:34Z

=Diagnosis

← Older revision		Revision as of 11:32, 18 July 2020
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	**consider CT if stable to evaluate for perforation/mediastinitis		**consider CT if stable to evaluate for perforation/mediastinitis

	===Diagnosis==		===Diagnosis===

	==Management==		==Management==

Rossdonaldson1: /* Evaluation */

2020-07-18T11:32:26Z

Evaluation

← Older revision		Revision as of 11:32, 18 July 2020
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	==Evaluation==		==Evaluation==
	===Workup===		===Workup===
	*CBC		*Labs
	*BMP		**CBC
	*LFTs and coagulation tests		**BMP
	*[[VBG]] or [[ABG]]		**LFTs and coagulation tests
	*[[UA]]: high concentrations of paraquat in the urine will cause it to appear blue		**[[VBG]] or [[ABG]]
	*Urine dithionate test:		**[[UA]]: high concentrations of paraquat in the urine will cause it to appear blue
	**Add 1cc of 1% sodium dithionate (hematology labs have this solution) to 10mL urine		**Urine dithionate test:
	**Blue color change indicates presence of paraquat		***Add 1cc of 1% sodium dithionate (hematology labs have this solution) to 10mL urine
			***Blue color change indicates presence of paraquat
			*Imaging
			**[[CXR]]
			**[[EKG]]
			**consider CT if stable to evaluate for perforation/mediastinitis

	===~~Diagnostics~~===		===Diagnosis==
	*[[CXR]]
	*[[EKG]]
	*consider CT if stable to evaluate for perforation/mediastinitis

	==Management==		==Management==

Rossdonaldson1: /* Evaluation */

2020-07-18T10:51:58Z

Evaluation

← Older revision		Revision as of 10:51, 18 July 2020
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	==Evaluation==		==Evaluation==
	===~~Laboratory Evaluation~~===		===Workup===
	*CBC		*CBC
	*BMP		*BMP

Rossdonaldson1 at 10:51, 18 July 2020

2020-07-18T10:51:32Z

← Older revision		Revision as of 10:51, 18 July 2020
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	==Evaluation==		==Evaluation==
	~~''Patients who present in extremis after an ingestion will not survive regardless of management and should be treated palliatively. ''~~
	===Laboratory Evaluation===		===Laboratory Evaluation===
	*CBC		*CBC
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	==Management==		==Management==
			''Patients who present in extremis after an ingestion will not survive regardless of management and should be treated palliatively. ''
	===ABC's ===		===ABC's ===
	*Airway: consider early aggressive intubation for any respiratory distress or large (>100mL) ingestions		*Airway: consider early aggressive intubation for any respiratory distress or large (>100mL) ingestions

Rossdonaldson1: /* Management */

2020-07-18T10:51:03Z

Management

← Older revision		Revision as of 10:51, 18 July 2020
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	==Management==		==Management==
			===ABC's ===
			*Airway: consider early aggressive intubation for any respiratory distress or large (>100mL) ingestions
			*Breathing: [[CXR]], [[O2]]. Avoid aggressive oxygen therapy if not necessary due to increased free radical production
			*Circulation: may develop early shock and require aggressive inotropic support

	Decontamination		===Decontamination===
	*Paraquat is absorbed transdermally. Unprotected first responders and healthcare workers are at risk		*Paraquat is absorbed transdermally. Unprotected first responders and healthcare workers are at risk
	*Remove clothing and wash patient's skin if spillage or obvious skin involvement present		*Remove clothing and wash patient's skin if spillage or obvious skin involvement present
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	**Must weigh risks as NGT placement can exacerbate caustic injury		**Must weigh risks as NGT placement can exacerbate caustic injury

	Resuscitation		===Resuscitation===
	*Large >50mL ingestions of paraquat are universally fatal. Aggressive resuscitation is futile.		*Large >50mL ingestions of paraquat are universally fatal. Aggressive resuscitation is futile.
	*ABCs as noted above; avoid supplemental O2 unless severe hypoxia present		*ABCs as noted above; avoid supplemental O2 unless severe hypoxia present

	Supportive Care		===Supportive Care===
	*IV fluids: patients often 2-3L fluid down		*IV fluids: patients often 2-3L fluid down
	*Pain control		*Pain control

	Antidotes/Additional Therapies		===Antidotes/Additional Therapies===
	*Some centers administer glucocorticoids (typically dexamethasone 6mg-10mg IV q6h)		*Some centers administer [[glucocorticoids]] (typically [[dexamethasone]] 6mg-10mg IV q6h)
	*Consider NAC, Vit C, other free radical scavengers in consultation with toxicologist or poison control		*Consider [[NAC]], Vit C, other free radical scavengers in consultation with toxicologist or poison control
	*No role for extracorporeal elimination (hemodialysis, hemoperfusion, CRRT)		*No role for extracorporeal elimination (hemodialysis, hemoperfusion, CRRT)

Rossdonaldson1: /* Evaluation */

2020-07-18T10:50:23Z

Evaluation

← Older revision		Revision as of 10:50, 18 July 2020
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	==Evaluation==		==Evaluation==
	''Patients who present in extremis after an ingestion will not survive regardless of management and should be treated palliatively. ''		''Patients who present in extremis after an ingestion will not survive regardless of management and should be treated palliatively. ''

	~~===ABC's ===~~
	*Airway: consider early aggressive intubation for any respiratory distress or large (>100mL) ingestions
	*Breathing: [[CXR]], [[O2]]. Avoid aggressive oxygen therapy if not necessary due to increased free radical production
	*Circulation: may develop early shock and require aggressive inotropic support

	===Laboratory Evaluation===		===Laboratory Evaluation===
	*CBC		*CBC

← Older revision		Revision as of 19:37, 28 July 2020
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	==See Also==		==See Also==
			*[[Toxicology (main)]]

	==External Links==		==External Links==