LEAD POISONING

Sources 1. Industrial exposure: painting, printing, welding, projectiles 2. Non industrial exposure: - Drinking water from lead pipe. - Environmental: from leaded gasoline, motor vehicle, exhausts - ingestion - dermal - inhalation stored in bones and teeth - bile - sweat - urine 1. Interfering with enzymes of heme synthesis i) inhibition of delta-aminolevulinic acid (ALA)dehydratase block conversion of delta-aminolevulinic acid toporphobilinogen. ii) interfering with coproporphyrinogen decarboxylaseblock conversion of copro-porphyrinogento protoporphyrin iii) inhibition of the enzymeferrochelatase binds iron toprotoporhyrin forming hemoglobin 2. Interferes with the sodium-potassium ATPase pump Increase fragility and decreased survival of RBCs 3. Bone marrow attempts to compensate by: immature RBCs and Reticulocytes children adult mild Anorexia,occasional Metallic taste vomiting, irritability, in the mouth, lethargy, refusal to play. colicky muscle weakness, abdominal Learning disability or pain, regression constipation, limb pain and hypertension severe Slurred speech, anemia, persistent vomiting. peripheral neuropathy, stupor, paralysis, ataxia, convulsions and coma Renal failure, headache, memory loss, tremors, confusion, ataxia, stupor, convulsions and coma

MERCURY POISONING
Elemental Inorganic mercury chloride disinfecta nt Ingestion Renal toxicity Organic methyl/ethy l mercury aquatic food chain Ingestion concentrate d in the fetus

ARSENIC POISONING
- Pesticides, rodenticides, wood preservatives - Arsine gas (AsH3) is a by-product of the action of acids on arsenic

IRON POISONING

thermometer Inhalation Pulmonary toxicity Neurotoxicity

Toxicokinetic Absorption Metabolism Excretion Pathophysiology

inhalation, ingestion, and dermal binding to sulfhydryl groups inhibition of enzyme activity . mainly renal

Absorption: in a soluble state (ferrous form) Oxidized ferric state couples to transferrin (total iron-binding capacity) (TIBC). Transferrin becomes saturated (the amount of iron exceeds the TIBC) the iron molecules distribute themselves into cells ( mitochondria) alterations of mitochondrial function

Clinical manifestatio ns

Elemental mercury vapour (inhalation) - Cough, dyspnea, metal fume fever - chemical pneumonitis. - diarrhea -abdominal cramps CNS: neuropsychiatric disturbances (erethism); aggression Irritability emotional liability memory loss

Inorganic mercury (ingestion) - Stomatitis, esophageal erosions, nausea, vomiting, hematemesis, and severe abdominal cramp. - Dysentery and tenesmus (mercurial Dysentery). - Acute renal failure

Acute ingestion of arsenic: GI symptoms : - Vomiting, severe abdominal pain - profuse diarrhea (rice watery diarrhea) - A garlic odor of the breath and feces - hypotension - toxic encephalopathy with seizures and coma. - A peripheral neuropathy that is more sensory than motor inhaled arsine gas : - shortness of breath - abdominal pain - hyperkalemia - hemolytic anemia - Hemoglobinuria & Renal failure

First stage within 6 hours Nausea, vomiting Diarrhea, abdominal pain, GI hemorrhage Second stage 6-24 hours quiescent phase Third stage 12-48 hours Shock cardiovascular collapse Severe lethargy or coma. metabolic acidosis Renal insufficiency Hepatic damage jaundice -hypoglycemia Fourth stage 4-6 weeks gastric scarring pyloric strictures hepatic cirrhosis.

Investigation s

Laboratory findings : 1-Complete Blood Count (CBC): Anemia Reticulocytosis . Basophilic stippling of erythrocytes. Eosinophilia. 2- Serum lead level :(30-60 g/dl ) 3-elevated Erythrocyte protoporphyrin 4-Decreased Delta-aminolevulinate dehydratase activity (ALA-D) 5. Increased Urinary ALA and coproporphyrinogen level. II- Plain X-ray 1. Abdominal X-ray: Radio-opaque shadow 2. Long bones: Lead lines on the distal ends of growing bones 1- Removal from exposure 2- Gastric lavage with (local antidote) magnesium sulphate 3- Chelation therapy (physio antidote): - Penicillamine: in a dose of 20-40 mg/kg/24hr orally, in 4 divided doses for 5 days. -CaNa2- EDTA : in a dose of 20-30mg/kg / 24hr via continuous IV infusion for 3-5 days

1. Kidney function tests. 2. Arterial blood gases (ABGs) and chest X- ray are indicated after exposure to mercury vapor. 3. Whole blood & urine mercury levels represent acute inorganic and elemental mercury exposure

Routine: Complete blood count. Kidney function tests Liver function tests. Chest X-ray. ECG. Abdominal films : as arsenic is radiopaque Toxicological: Blood arsenic levels b) Urine levels are more accurate . c) Hair levels of arsenic may be confusing because of external contamination of the hair.

Routine : Serum electrolytes, renal function test. Arterial blood gases (ABGs), Liver function tests. Abdominal X-ray may reveal (Radioopaque shadow). Toxicological : Serum iron level, measured by Atomic Absorption Spectrophotometry (AAS). - >500 g /dl are definitively toxic. - normal serum iron level is 50-150 g /dl.

Treatment

1- Removal of the patient from further exposure especially with mercury vapor exposure 2- Care of respiration (A, B): Administration of oxygen or assisted ventilation. 3- Care of circulation (C): Treat hypotention in patients with inorganic mercury ingestions. 4- Decontamination : gastric lavage by local specific antidote sodium formaldehyde ( sulfoxylate). 5-Physiological antidotes =Chelators - D-Penicillamine : orally at a dose of 20 mg/kg/day, up to 1 g a day, in 4 divided doses for 5 days - Dimercaprol (BAL) :(I.M) 3-5 mg/kg every 4h for 48 hours, followed by 2.5-3.0 mg/kg every 6h for 48 hours and then 2.5-3.0 mg/kg every l2h for 7 days. - Dimercaptosuccinic acid (DMSA) - 3-dimercaptopropane-l-sulfonate (DMSP) ** EDTA is nephrotoxic in combination with mercury

1- Removal of the patient from further exposure. 2- Care of respiration . 3- Care of circulation : hypotension, cardiac arrhythmias 4- Gastric lavage: use the specific local antidote which is freshly prepared colloidal solution of ferric hydroxide 5- Chelation therapy: a) BAL : 2.5-5.0 mg/kg/dose IM every 4-6h for 48 hours, then every l2-24h for 10 days. b) Penicillamine : 20 mg/kg/day up to 1 g for 5 days

Care of respiration. Care of circulation . Decontamination: - Gastric lavage (do with caution) - Physiological antidote: Deferoxamine (desferal): - it binds the free circulating elemental iron - Dose: (parenterally) * In mild cases, the dose is 90 mg/kg IM up to a maximum of 1 g in children or 2 g in adults. * In severe cases, the patient requires the use of intravenous infusion. The recommended dose is 15 mg/kg/hr with the maximum daily dose up to 6gs total

lead encephalopathy Chelation therapy; initial single dose of BAL (3-5 mg/kg) I.M. followed in 4 hours by administration of CaNa2-EDTA (30mg/kg/24hr ) I.V infusion. BAL is then repeated every 4 hours in conjunction with CaNa2-EDTA infusion for 3-5 days. Seizures are treated with diazepam, phenytoin, or Phenobarbital