SHORT COMMUNICATION i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i BiologicalSciences (An i(An International Journal of Medical, Pharmaceutical, and Life Sciences) Journalhome: https://irrespub.com/biolsciences/index.php/1/index Paraquat poisoning: Death after oral intake Sudhanshu Bansal*, Abhishek Kumar Gangwar, Sofia Thomas Department of Pharmacy Practice, ISF College of Pharmacy, Moga, Punjab-142001, India. ARTICLEHISTORY ABSTRACT Received:15-01-2022 This case study describes an Indian male patient's death caused i Revised: i22-01-2022 by paraquat after oral consumption. A 20-year-old male patient Accepted:23-01-2022 i attended the emergency department. He had a major complaint Online: 25-01-2022 i of stomach disorders, vomiting, fatigue, and hypothermia. It was confirmed that he was transferred from a nearby hospital after KEYWORDS evaluating the situation. It was reported that paraquat poison had a systemic effect, and during the healing process, he was subject Poisoning Paraquat poisoning to multiple dialysis. This study will help doctors and clinicians to Pesticide poisoning respond quickly to paraquat poisoning and aid in the early Poisoning death recovery and maintenance of poisoning. Introduction frequent side effects of paraquat poisoning (1). The most frequent form of poisoning is oral consumption of paraquat. Death can result from Paraquat is a poisonous herbicide that comes in a lung injury or multiple organ failure. For diagnosis liquid form with a green tint and a strong odour that urine and plasma toxicity tests must be obtained. must be diluted before application. Paraquat Hemoperfusion is the safest treatment in the early herbicidal properties were first discovered in 1950, paraquat poisoning stages (2). and it became commercially available in 1962. Paraquat is the second most commonly used weed killer in the market, with a high risk of side effects. Paraquat poisoning can be classified into three categories- In comparison to unintended consumption, most poisoning cases occur in adults due to suicide attempts. Pulmonary edema, convulsions, heart 1. Moderate poisoning:- 20 mg paraquat ion failure, renal failure, and hepatic failure are the most per kg body weight) In which gastrointestinal effects are usually mild. *Addressforcorrespondence 2. Extreme poisoning:- 20-40mg paraquat ion i i per kg of body weight) Patients with acute Department of Pharmacy Practice, ISF College of renal failure are said to be in this group. Pharmacy, Moga, Punjab-142001, India. Acute lung injury and pulmonary fibrosis Email:[email protected] can occur concurrently. Death is estimated in 2 weeks. DOI: http://dx.doi.org/10.55006/biolsciences.2022.2101 3. Fulminant poisoning:- more than 40mg Published by IRResearch Publication; Bansal S et i i paraquat ion per kg body weight) multiple al © 2022 by Biological Sciences is licensed under CC BY organ failure leading to death within a few 4.0 hours or days (3). Bansal S iet ial i2022i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i Biological iSciences, i2022, iVol. i02(01) iPage i110-113 Case presentation treating paraquat ingestion. The strategies of prevention were as follow- A 20-year-old patient was admitted into the emergency ward of Medanta S.N. Super speciality Prevent gastrointestinal absorption hospital with the symptoms of gastrointestinal disturbances, vomiting, and hypothermia with a Treatment with cathartics, activated charcoal, history of poison intake. He was referred from the diatomaceous earths, and gastric lavage should be civil hospital Abohar Punjab, where he was considered as an intervention in patients who diagnosed with poisoning a substance used as present soon after ingestion to prevent absorption herbicide (paraquat). There was no previous history from the gastrointestinal tract. Gastric lavage of convulsions, ENT bleeds, or loss of accompanied by a dose of activated charcoal is the consciousness. The vital signs of the patient were most common treatment, despite the evidence for recorded from day first to till death indicated in the benefits of gastric lavage and charcoal being Table 1. On the other hand, systemic examination weak, with most research finding little benefit. like the respiratory system was clear and Treatments to minimize paraquat absorption should cardiovascular system normal S1S2 with no murmur be determined on a case-by-case basis, taking into sound. In central nervous system GCS 15/15, pupils account the possible amount of paraquat consumed bilaterally equally responding to light, soft and non- as well as the time after ingestion. Early gastric tender abdomen, his lips, nails, and fingertips were lavage and charcoal treatment could have resulted turned blue, and other observations can be seen in in overall decreased plasma paraquat absorption Table 2. In a previous hospital, he obtained gastric and a better clinical outcome in our patients, but this lavage and KMnO4. During dialysis on the same is unclear. day, he was hemodynamically and neurologically stable. He was also given the antioxidant N-acetyl Elimination of poison from the blood cysteine and other supportive medications. Metabolic acidosis with hyperlactatemia was discovered during the investigation. The next day, Hemoperfusion (HP), Haemodialysis (HD), and the patient began to experience hypotension and Continuous Venovenous Hemofiltration (CVVH) can oliguria. Due to worsening hemodynamic, he was all be used to extract paraquat from the blood. It has intubated and put on mechanical ventilatory been suggested that hemoperfusion, rather than support. Another hemodialysis session was hemodialysis, is a better way to extract paraquat completed on the next day of admission. The from the blood. Using hemoperfusion within 12 patient had chronic hypotension, and he went into hours of poisoning can reduce mortality. CVVH can cardiac arrest at about 12:30 a.m. on the fourth day improve survival, reduce the rate of organ of admission. Cardiopulmonary resuscitation (CPR) dysfunction, and enable patients to receive was conducted and as per the Advanced Cardiac additional treatments for a longer period of time. Life Support (ACLS) protocol; however, it was However, successful results were not consistently unable to resuscitate and declared dead. observed elsewhere whether hemodialysis or hemoperfusion is used alone or in combination. Despite this debate, it is prudent to begin an early Investigations trial of hemodialysis or hemoperfusion for 4 to 6 hours daily, understanding that care will be needed Paraquat poisoning was diagnosed, but no other for at least 2 to 3 weeks, if available and after abnormalities or deformities were discovered. His determining the likely amount of paraquat ingested. blood glucose and thyroid hormone levels were not predicted on the test. Another investigation, such as A variety of alternative therapies urine and chest x-ray, was considered fine. His family denied other examinations due to a lack of time and resources. Several other treatments have been introduced for acute paraquat poisoning, including the use of the immuno-suppressant and antioxidant. The Treatment percentage of patients who received immune suppressant action (Cyclophosphamide, There are currently no universally accepted Metaphosphate, Vitamin E, and Vitamin C) had treatment recommendations for paraquat higher survival rates as compared to those who poisoning. Mainly prevention of gastrointestinal received it alone Without limiting the amount of absorption and increased elimination of paraquat oxygen. High concentrations of paraquat may from the blood, and alternative therapies such as further damage the body organism and lead to immunotherapy and antioxidants are all options for oxygen free radical species production. Although Copyright © 2021 IR Research Publication - All Rights Reserved Bansal S iet ial i2022i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i Biological iSciences, i2022, iVol. i02(01) iPage i110-113 Table 1. Vitals of patient from day of admission till death. Day Vitals Blood Pulse Respiratory Spo 2 pressure(mmHg) rate(beats/minute) rate(breath/minute) First Day 78/44 40 20 96% Second Day 75/44 48 20 90% Third Day 70/39 36 18 84% Fourth Day 67/35 30 12 79% Table 2. Laboratory observations. Parameter Observed Value Normal Range First Day Second Third-Day Fourth Day Day Hemoglobin(male) 10.6 g.dL 9.9 g.dL 9.1g.dL 9.1 g.dL 14-18g/dL Red blood cells 2.18 2.0 2.1 2.1 4.7- 6.1cells/mcL Total Leukocyte 13.26 18.26 19.86 19.86 4.5-11.0 x109/L count Neutrophils 94.8% 79.6% 78.6% 79.0% 45-75% Platelets 75000 72600 70300 68000 1.5-4.0 Lakh/cumm Blood Urea 272.5mg/dL 288.5mg/dL 287.5mg/dL 298.5mg/dL 15-45mg/dL Sr Uric Acid 4.5 4.0 4.2 4.2 2.4-7.0mg/dL SGOT 82.7 79.7 79.9 79.0 5-40unit/liter SGPT 115.1 122.3 132.3 133.9 7-56unit/liter Bilirubin Total 1.32 1.82 1.99 1.99 0.3-1.2mg/dL Haematocrit(male) 37.9 36.6 34.6 30.2 41-50% Table 3. Treatment chat of patient. Date Brand Generic Name Route of Frequency Dose Name Administration Inj Dalacin Clindamycin IV/IM TDS 600mg Inj Meropenem IV/IM TDS 500mg Meromac 18-9- Inj Pantaprazole IV/IM BDS 40mg Pantocid sodium 2020 Inj Emset Ondansetron IV/IM TDS 4mg Inj Calcium Gluconate IV/IM TDS 100mg/ml Calcium To Gluconate Inj KCL Potassium Chloride IV/IM STAT 20meq 20-9- Inj Dexamethasona IV/IM TDS 8mg Dexona 2020 Copyright © 2021 IR Research Publication - All Rights Reserved Bansal S iet ial i2022i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i Biological iSciences, i2022, iVol. i02(01) iPage i110-113 the effectiveness of immunosuppressant therapy Patient’s perspective and consent has been disputed. As for some, but not all anti- inflammatory medications prevent the development Not Applicable as the patient is dead of oxygen-radical. The mechanism by which this occurs is unclear. However, this decrease in anti- Contribution of authors radical agent production may increase paraquat absorption. There is insufficient data to support the SB: Data collection, and SB, ST, and AKG: Major use of Vitamin C or any other antioxidants such as contributor in writing and drafting the manuscript. deferoxamine (4). Treatment chart can be seen in Table 3. Acknowledgments Outcome and follow-up The authors express their gratitude to Dr. Arun Kalra H.O.D Medicine, Medanta S.N Super-specialty Paraquat poisoning is an uncommon but deadly Hospital for his great vision and support. clinical manifestation. There are currently no universally accepted recommendations for treating paraquat poisoning patients. Although there is little Conflicts of interests evidence for successful treatment of paraquat toxicity, early treatment with gastric lavage, The authors declare no potential conflicts of interest charcoal, or diatomaceous earths may be beneficial regarding the research, authorship, and/or in reducing absorption. Hemoperfusion, publication of this article. hemodialysis can be used to reduce paraquat levels in the blood after they have been absorbed. References Immunosuppressant and antioxidant therapies are two alternative therapies that may be used in the 1. Saravu K, Sekhar S, Pai A, Barkur AS, Rajesh treatment of paraquat poisoning. The patient in our V, Earla JR. Paraquat - A deadly poison: case was not able to achieve a better result. Report of a case and review. Indian Journal Vomiting and early gastric lavage/charcoal can of Critical Care Medicine. 2013 reduce paraquat absorption. May;17(3):182–4. 2. Rao R, Bhat R, Pathadka S, Chenji SK, Dsouza Discussion S. Golden hours in severe paraquat poisoning-the role of early haemoperfusion Vomiting was the most common symptom, followed therapy. Journal of Clinical and Diagnostic by changes in sensorium, oral ulceration, dyspnea, Research. 2017 Feb 1;11(2):OC06–8. and loose stools. Paraquat has renal and hepatic 3. Agarwal R, Srinivas R, Aggarwal A N, Gupta effects throughout the body. Failure, pulmonary D. Experience with paraquat poisoning in a edema and fibrosis, cardiac failure, shock, respiratory intensive care unit in North India. convulsions, and multi-organ failure are just some of Singapore Med Journal. 2006;47(12). the conditions that can occur. 4. Sarah A, Mario G, Alice MB, Kristin BH, Anthony G, Michelle M, et al. Paraquat Learning points/take-home messages Poisoning: Survival after Oral Ingestion. Journal of Family Medicine and Disease • The most common cause of death was a Prevention. 2019 Jul 20;5(4). delay in admission to the hospital. Due to a lack of a complete medical history and the lack of diagnostic tests, • Diagnosis may be difficult. In the previous hospital, the patient had already gone through various treatment protocols. • The patient in this situation was going from hemodialysis daily, but due to multiple organ failures, we were unable to save him from this lethal poison. • Finally, it is recommended that make every effort to get to the hospital as soon as possible. Copyright © 2021 IR Research Publication - All Rights Reserved