Trovanje korozivom - prikaz slučaja
Corrosive poisoning: Case report
aDom zdravlja Jagodina, Služba hitne medicinske pomoći bKlinički centar Niš, Klinika za endokrinologiju, dijabetes i bolesti metabolizma
e-adresa: milan_mdj@hotmail.com
Sažetak
Uvod: Kiseline su korozivni otrovi koji ekstrahuju vodu iz tkiva, koagulišu proteine i formiraju kisele albuminate, a hemoglobin pretvaraju u kiseli hematin. Na svetskoj mapi toksikologije, Srbija se svrstava u zemlje koje imaju visok procenat trovanja kausticima. U razvijenim zemljama intoksikacija korozivima je izuzetno retka zbog nedostupnosti istih i zabranjene slobodne prodaje. Cilj rada: Ukazati na značaj, veličinu i učestalost korozivnih trovanja, prikazati fatalno trovanje esencijom, kao i model prehospitalnog i hospitalnog zbrinjavanja akutno otrovanog korozivom, i dati predlog mera za smanjenje ovih intoksikacija. Materijal i metode: Korišćena je istorija bolesti Klinike za endokrinologiju, dijabetes i bolesti metabolizma, Odeljenje za toksikologiju, KC Niš, kao i izveštaj sudsko-medicinske obdukcije Zavoda za sudsku medicinu Niš. Prikaz slučaja: Okolnosti trovanja: Pacijentkinja je u toku večeri 21. 02. 2014, oko 21h popila oko 200ml esencije, namerno, u cilju suicida, a zbog nesuglasica u porodici. Dovezena u prijemno-trijažno odeljenje Vranjske bolnice u 21:49h, svesna; dala je podatak o namernom samotrovanju, povraćala je; postavljen je urinarni kateter i dobijen hemoglobinurični urin. Prvi pokušaj suicida, dosad je nelečena psihijatrijski. Transportovana je u KC Niš u 00:35h, 22.2.2014. Pregledana je od strane ORL specijaliste i urađena je urgentna ezofagogastroduodenoskopija (EGDS). Objektivni status: odaje utisak teškog bolesnika sa PSS (poisoning severity scor) 4. Glava i vrat: koža oko usana hiperemična, sa opekotinama, usna duplja hiperemična, edematozna. Abdomen: bolno difuzno osetljiv na palpaciju, urin kesa 1500ml hemoglobinuričnog urina. Laboratorija: Gly: 39,9; Urea: 10,9-12,6; Crea: 133,0-167,3; Amy: 606,7; Acidobazni status pH: 7,19; BE: 18,9, HCO3: 10,3. Urgentna EGDS: U jednjaku, želucu, bulbusu duodenuma i postbulbarnom delu duodenuma sluzokoža lividno beličasta sa hiperemičnim plažama. Zaključak: Radi se o pacijentkinji koja je hospitalizovana nakon namerne intoksikacije korozivnim sredstvom (esencija) u teškom opštem stanju. Tokom hospitalizacije zbog insuficijencije respiratornih puteva urađena traheotomija. Dolazi do anurije i razvoja akutne bubrežne insuficijencije. I pored svih mera reanimacije, dolazi do letalnog ishoda 22. 02. 2014, u 01:40h. Makroskopski obdukcioni nalaz: Jezik mlitav, obložen prljavo-braonkastim naslagama, koje se lako skidaju. U jednjaku prisutna osrednja količina prljavo-mrko-braonkasto-tečnog sadržaja, njegova sluzokoža čitavom površinom mrko prebojena, istanjena, nedostajuće nadsluznice. U želucu prisutno oko 100 ml mrko-braonkasto-zelenkastokašastog sadržaja. Njegova sluzokoža zbrisanih nabora, natečena, sljuštene nadsluznice, gotovo u potpunosti mrko prebojena, mestimično sitno zrnasta. Zaključak: Akcenat treba staviti na mere prevencije. U zbrinjavanju intoksiciranog razlikujemo prehospitalne i hospitalne mere. Moguće komplikacije su u vidu strikture ezofagusa, stenoze pilorusa i karcinoma želuca ili jednjaka. Trovanje visoko koncentrovanom acetatnom kiselinom je i dalje veoma često i sa visokom stopom mortaliteta. Pacijenti koji su ingestirali veće količine kiseline i sa većim stepenom gastrointestinalnih oštećenja, pneumonije ili bubrežne slabosti, zahtevaju veći oprez jer su podložniji fatalnim komplikacijama.
Abstract
Introduction: Acids are corrosive compounds which extract water from the tissues, coagulate the proteins to form the acid of albumin and convert hemoglobin to the acid hematin. On the world map of toxicology, Serbia is considered to be the country with high percentage of caustic intoxication. In developed countries corrosive poisoning is extremely rare due to unavailability of the products and forbidden free sale. Aim: To highlight the importance, size and frequency of corrosive poisoning, to show fatal acetic acid ingestion and the model of pre-hospital and hospital care for acutely poisoned with corrosives, as well as suggest measures to reduce these intoxications. Material and methods: Case history was used of the Clinic for Endocrinology, Diabetes and Metabolism Disorders, Toxicology Department, Clinical Centre Niš and a forensic autopsy report of the Institute for Forensic Medicine Niš. Case report: The circumstances of poisoning: A female patient drank deliberately about 200ml of acetic acid at about 9 p.m. on 21st February 2014 with suicidal intentions due to disagreements in the family. She was brought conscious in Admission and Triage Department of the hospital in Vranje at 9:49 p.m., where she gave the information on the intentional self-intoxication. She vomited, a urinary catheter was placed and haematuria in the urine was obtained. It was the first suicide attempt, not treated psychiatrically so far. She was transported to the Clinical Centre Niš at 0:35 a.m. on 22nd February 2014. She was examined by an ENT specialist and submitted to urgent EGDS (esophagogastroduodenoscopy). Objective status: severe patient with PSS (poisoning severity score) 4. Hyperaemic skin around the lips, with burns, oral cavity hyperaemic, edematous. Abdomen: painfully sensitive to palpation diffusely, urine bag with 1500ml of the haematurian urine. Lab: Gly 39.9; Urea 10.9-12.6; Crea 133.0-167.3; Amy 606.7; Acid-base status pH 7.19; BE -18.9, HCO3 10.3. Urgent EGDS: In the esophagus, stomach, duodenal bulb and postbulbar duodenum, mucous membranes are livid whitish with hyperaemic parts. Conclusion: The female patient was hospitalized after intentional intoxication with corrosive substances (acetic acid) in the severely bad general condition. During hospitalization tracheotomy was performed due to respiratory failure and developed anuria leading to acute renal failure. Despite all resuscitation measures there was a lethal outcome at 1:40 a.m. on 22nd February 2014. Macroscopic autopsy findings: the tongue is flubby, covered with dirty-brownish deposits that are easily removed. Moderate amount of dirty-dark-brownish-liquid content is present in the esophagus, its mucous membranes darkly painted over the entire surface, thin, lacking its upper layer. About 100 cc of brown-greenishmushy content present in the stomach. Its mucosal folds deleted, swollen, peeling of the mucous membranes, almost completely darkly painted over, finely granular in places. Conclusion: Emphasis should be placed on preventive measures. The management of the intoxicated patient distinguishes pre-hospital and hospital measures. Possible complications include an esophageal stricture, stenosis of the pylorus and the esophagus, or gastric cancer. Highly concentrated acetic acid is still frequently ingested with a high mortality rate. Patients with higher grades of gastrointestinal injury, pneumonia, renal injury and higher amount of acid ingested should be more carefully monitored as they are more susceptible to develop fatal consequences.
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