Lead poisoning (Saturnism)

In lead poisoning, often initially minimal symptoms can subsequently lead to acute encephalopathy or irreversible organ impairment and usually result in cognitive deficits in children. The diagnosis is based on the concentration of lead in whole blood. Treatment includes cessation of exposure to lead and sometimes the use of chelation therapy with succimer or sodium calcium edetate, with orithiolum.

Lead paint was widely used until the 1960s, to a lesser extent in the early 1970s and stopped using by 1978. Thus, lead paint still presents some danger in old houses. Lead poisoning is usually associated with swallowing fallen off, peeling pieces of lead-containing paint. During home repair, patients may be exposed to a significant amount of the sprayed lead that accumulates in the air during preparation of the surface for repainting. On lead-free products that are not coated with ceramics, usually outside the United States, lead can be leached, especially when the product comes in contact with acidic substances (for example, fruits, colas, tomatoes, wine cider). The source of poisoning can be lead-contaminated homemade whiskey or alternative drugs, as well as randomly found in the stomach or tissues of foreign lead objects (for example, bullets or fishing sinkers). Bullets in soft tissues can increase the lead content in the blood, but this process takes years. Professional impact is possible in the manufacture of batteries and recycling of rubbish, bronze, copper, glass, pipe cutting, soldering and welding, melting, when working with earthenware or dyes. Some ethnic cosmetics and imported medicinal herbs contain lead and can cause massive outbreaks of lead poisoning in visitors. Pairs of leaded gasoline (not found in the US), inhaled toxics, contain lead and can cause poisoning.

[1], [2], [3],

Symptoms of lead poisoning (Saturnism)

Lead poisoning - most often a chronic condition, may not cause acute symptoms. With or without acute symptoms, poisoning ultimately has irreversible effects (eg, cognitive deficits, peripheral neuropathy, progressive renal failure).

The risk of cognitive impairment increases when the concentration of lead in whole blood over a long period of time is 10 μg / dL (0.48 μmol / L), although it can be at lower concentrations. Other symptoms (eg, abdominal cramps, left side pain, constipation, tremor, mood changes) are possible with lead concentration in the blood> 50 μg / dL (> 2.4 μmol / L). Encephalopathy develops at lead concentration in the blood> 100 μg / dl (> 4.8 μmol / l).

In children, acute lead poisoning can cause irritability, decreased attention and acute encephalopathy. The edema of the brain develops after 1-5 days, causing permanent severe vomiting, ataxic gait, changes in consciousness, convulsive syndrome of severe course and to whom. Encephalopathy can be preceded by several weeks of irritability and decreased gaming activity. Chronic lead poisoning in children can cause oligophrenia, seizures, aggressive behavior, developmental lag, chronic abdominal pain and anemia.

For adults with professional poisoning, the development of symptoms (for example, personality changes, headache, abdominal pain, neuropathy) is characteristic in a few weeks or later. Encephalopathy is not typical.

Children and adults may have anemia, because lead interferes with the normal formation of hemoglobin. In children and adults who inhale tetra-ethyl- or tetra-methyl lead (from leaded gasoline), in addition to the more characteristic symptoms of lead poisoning, the addition of toxic psychosis is possible.

Symptoms and treatment of typical complications

Poisoning	Symptoms	Treatment
Anticholinesterase inhibitors	Angioedema, arterial hypotension	Activated carbon; supportive treatment; with angioneurotic edema - epinephrine, antihistamines or glucocorticoids are probably effective
Acephate	See FOS	-
Paracetamol	See paracetamol poisoning in the appropriate section.
Acetanilide Aniline dyes and oils Chloroaniline Fenacetin (acetophenethidine, phenylacetamide)	Cyanosis due to the formation of meth- and sulfgemoglobin, dyspnoea, general weakness, dizziness, angina pectoris, rash, vomiting, delirium, oppression, insufficiency of respiration and circulation	Ingestion: activated charcoal, then - as if inhaled. Skin contact: undress and rinse with soap and water, then as if inhaled. Inhalation: O 2, respiratory support; blood transfusion; with expressed cyanosis, a solution of methylene blue (methylthioninium chloride) at a dose of 1 -2 mg / kg intravenously
Acetic acid	Low concentration: moderate irritation of mucous membranes. High concentration: see poisoning with caustic substances	Supportive treatment with washing and dilution
Acetone Ketones Adhesives or cements for toy models Solvents of nail polish	Ingestion: As with inhalation, with the exception of direct action on the lungs. Inhalation: bronchial irritation, pneumonia (congestion and pulmonary edema, weakened breathing, dyspnoea), intoxication, stupor, ketosis, cardiac arrhythmias	Remove from the source, respiratory support 0 and infusion therapy, correction of metabolic acidosis
Acetonitrile Cosmetic pads for nails	It is converted into cyanide, the symptoms characteristic of cyanide poisoning develop	See cyanides
Acetophenetidine	See acetanilide	-
Acetylene gas	See carbon monoxide	-
Acetisalicylic acid	See poisoning with acetylsalicylic acid and other salicylates in the appropriate section
Acids and alkalis	See separate types of acids and alkalis (for example, boric acid, fluorides) and poisoning with caustic substances or in contact with skin and eyes in the appropriate section
Adhesives or cements for toy models	See acetone, benzene (toluene), refined petroleum products	-
Ethyl alcohol (ethanol) Brandy Whiskey Other strong alcoholic beverages	Emotional lability, impaired coordination, hot flashes, nausea, vomiting, impaired consciousness from stupor to coma, respiratory depression	Supportive treatment, intravenous glucose to prevent hypoglycemia
Isopropyl alcohol Alcohol cleaners	Dizziness, discoordination of movements, violation of the level of consciousness from stupor to coma, gastroenteritis, hemorrhagic gastritis, arterial hypotension, without retinal damage or acidosis	Supportive treatment, intravenous glucose, correction of dehydration and electrolyte disorders; with gastritis - blockers of H1-receptors intravenously or inhibitors of H, K -ATPase
Alcohol methyl (methanol, wood alcohol) Antifreeze Solvent paints Lucky	High toxicity when taking 60-250 ml in adults or 8-10 ml (2 teaspoons) in children; latency period 12-18 hours; headache, weakness, spasms of calf muscles, dizziness, convulsions, retinal damage, twilight vision, acidosis, weakening of breathing	Fomepisol (15 mg / kg, then 10 mg / kg every 12 hours); alternative treatment: 10% ethanol solution with 5% glucose solution or with 0.9% sodium chloride solution intravenously; a loading dose of ethanol of 10 ml / kg for an hour, then 1 -2 ml / kg per hour to maintain a blood ethanol concentration of 100 mg / dL (22 mmol / l); hemodialysis (radical treatment)

Diagnosis of lead poisoning (Saturnism)

Lead poisoning should be suspected in a patient with characteristic symptoms, but such symptoms are often blurred and the diagnosis often lags. The examination includes a clinical blood test and determination of the concentration of plasma electrolytes, urea nitrogen, creatinine and plasma glucose, as well as the concentration of lead in the blood. Radiography of the abdominal cavity is performed to detect radiopaque lead particles. Children make radiographs of long tubular bones. Horizontal lead bands on the metaphysis indicating insufficient reproduction of erythrocytes and an increase in calcium deposition in the ossification zones of children's bones are signs of lead poisoning or other heavy metals, although these signs are not absolute. Normocytic or microcytic anemia involves poisoning with sync, especially when the amount of reticulocytes is increased or with increased granularity of basophils in the blood. However, the specificity of these tests is also limited. The diagnosis is reliable if lead concentrations in the blood are> 10 μg / dl.

Since the measurement of lead concentration in the blood is not always possible and expensive, other preliminary or screening tests can be used to detect lead poisoning. The capillary blood test for lead is an accurate, inexpensive and rapid study. However, all positive test results should preferably be confirmed by measuring the concentration of lead in the blood. Measurement of protoporphyrin erythrocytes (also referred to as zinc protoporphyrin or free protoporphyrin of erythrocytes) is often inaccurate and rarely used.

The lead mobilization test with EDTA (CaNa-EDTA), previously used for diagnosis and treatment, is considered by most toxicologists to be obsolete and usually not used.

[4], [5], [6], [7], [8],

Treatment of lead poisoning (Saturnism)

All patients should be isolated from the source of lead. If the pieces of lead are visible on the roentgenogram of the abdominal cavity, the entire intestine is flushed with an electrolyte solution containing polyethylene glycol at a rate of 1000-2000 ml / h for adults or 25-40 ml / kg per hour for children until repeated radiography reveals the absence residues of lead. If the poison was caused by a bullet, it is surgically removed. Children with a lead concentration in the blood> 70 μg / dl (> 3.40 μmol / L) and all patients with neurologic symptoms should be hospitalized. Patients with acute encephalopathy are hospitalized in the intensive care unit.

Chelation drugs [for example, succimer (meso-2,3-dimercaptosuccinic acid), sodium calcium edetate, unitiol] are prescribed to bind lead to forms that can be removed from the body. Chelation should be supervised by an experienced toxicologist. Chelation is indicated for adults with symptoms of poisoning and lead concentration in blood> 70 μg / dL and children with encephalopathy or lead concentration> 45 μg / dl (> 2.15 μmol / l). Hepatic and renal impairment is a relative contraindication for chelating drugs. Chelation drugs should not be given to patients who still have contact with lead, because chelation can increase absorption of lead in the digestive tract. Chelation allows you to remove only a relatively small amount of metal. If the content of lead in the body is large, it may require repeated repetition of this procedure for many years.

Patients with encephalopathy are treated with unithiol at a dose of 75 mg / m (or 4 mg / kg) intramuscularly every 4 hours and 1000-1500 mg / m sodium calcium edetate intravenously once a day. The first dose of sodium edetate calcium should be administered no earlier than 4 hours after the first injection of unithiol to prevent lead from entering the brain. The introduction of unithiol can be stopped after several doses depending on the concentration of lead and the severity of the symptoms. The combined treatment of Unitiol sodium calcium edetate is carried out for 5 days, followed by a 3-day wash. Then the indications for prolonged chelation are reviewed.

Patients without encephalopathy are usually prescribed a succimer at a dose of 10 mg / kg orally every 8 hours for 5 days, then 10 mg / kg orally every 12 hours for 14 days. If symptoms persist, such patients can alternatively be treated for 5 days with unithiolom 50 mg / m deep intramuscularly every 4 hours plus sodium calcium edetate 1000 mg / m intravenously once a day.

Uniothiol, due to the threat of vomiting, is given together with parenteral or oral administration of fluids. Unitiol may also cause severe pain at the injection site, numerous systemic symptoms and, in patients with glucose-6-phosphate dehydrogenase deficiency, moderate or severe acute intravascular hemolysis. This drug should not be administered together with iron supplements. Uniothiol is made from peanut derivatives, and therefore it is not used in patients with peanut allergy or suspected of having it.

Sodium calcium edetat can cause thrombophlebitis, for the prevention of which the drug is administered intravenously, and not intramuscularly, at a concentration of less than 0.5%. Before the beginning of the treatment of sodium calcium, the edetate should be checked in the normal state of the urinary tract. Severe reactions to sodium calcium edetate include kidney failure, proteinuria, microhematuria, fever and diarrhea. Renal intoxication depends on the dose and in most cases is reversible. The adverse effects of calcium edetate sodium are most likely due to zinc depletion.

Common adverse effects of succimer include skin rashes, gastrointestinal symptoms (eg, anorexia, nausea, vomiting, diarrhea, metallic taste in the mouth) and a temporary increase in the activity of liver enzymes.

Patients with a lead concentration in the blood> 10 μg / dl should be carefully examined, their parents or their parents should be informed about the means of protection against lead.

Prevention of lead poisoning (Saturnism)

In patients at risk, the concentration of lead in the blood should be measured regularly. Measures that reduce the risk of household poisoning include regular washing of hands, children's toys, nipples and surfaces in the home. Drinking water, indoor paint (except for buildings built after 1978) and ceramic products made outside the US should be checked for lead content. People working with lead must use appropriate personal protective equipment, change shoes and clothes before returning home and must take a shower before going to bed.