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Wednesday, June 27, 2007

Ethanol,Methanol and Ethylene glycol poisoning

Ethanol
Overdose of ethanol (ethyl alcohol or"alcohol") is very common. Alcohol potentiates the CNS-depressant effect of many drugs. It initially causes disinhibition and later ataxia, dizziness, dysarthria, and drowsiness. In severe poisoning may be coma with respiratory depression, hypotension, hypothermia, and a metabolic acidosis. Hypoglycemia is a particular problem in a children and may occur after some hours. Death may result from respiratory failure or aspiration of vomit.

For an adult, the fatal dose of ethanol alone is 300-500ML absolute alcohol. Whisky and gin usually contain 40-50% ethanol. Rarely alcohol intoxication cause lactic acidosis (Especially with the patient with liver diseases or taking biquanide hypoglicaemic drug) or ketoacidosis (due to dehydration and hypoglicaemia in alcohol).

Treat Supportively:
  • Maintain clear airway and adequate ventilation
  • Check blood glucose every 1-2 hours in severe poisoning
  • Emergency measurement of blood ethanol is rarely helpful
  • Correct hypoglicaemia with glucose not with glucagon
  • Look sign for injury, especially head injury
  • Gastric lavage and activated charcoal are ineffective in ethanol intoxication
  • Do not give fructose
Mehanol Poisoning
Methanol is used as a solvent and in antifreeze. Ingestion of >60ML of methanol (in Adult) may cause fatal poisoning, the toxic effect due to the metabolites formaldehide and formid acid. Methylated spirits is a mixture of ethanol and water with only 5% ethanol and toxicity is almost entirely due to ethanol.

Clninical features
Methanol initially cause only mild transient drowsiness. Serious toxicity develops after a latent period of 8-36 hours with vomiting, abdominal pain, headache, dizziness, blurring of vision and drowsiness leading to coma. There is a severe metabolic acidosis, hyperglicaemia, and increase serum amylase. survivor may be blind due to optic nerve damage and Parkinsonian Problem.

Management
  • Provide gastric lavage less than 1 hour since ingestion
  • Measure ABG (Analys Blood Gas), U&E, blood glucose, and plasma methanol
  • correct metabolic acidosis to keep arterial pH > 7,2 large amount of bicarbonate may be needed and hypernatremia may be occur.
  • Give methanol orally as whisky, gin or vodka (adult 125-150mL, child 2mL/kg) and then intravenous infusion (dose as for ethylene glycol)
  • Give folinic acid (30 mg IV every 6 hours)
  • In severe poisoning refer to ITU for haemodialysis and possibly IPPV
Ethylene glycol poisoning
Ethylene glicol is used mainly as antifreeze. The minimum fatal dose adult=100mL. Toxic effect due to metabolites, including glycolaldehyde and oxalid acid. ethanol blocks metabolism of ethylene glycol, preventing toxicity.

Clinical Features
In the first 12 hours after ingestion the victim look drunk, but does not smell of alcohol. Aaxia, disarthria, nausea, vomiting, and sometimes haematemesis occur, followed by convulsion, coma and severe metabolic acidosis. From 12-24 hours post ingestionthere is hyperventilation, tachycardia, pulmonary oedema, cardiac arrhythmias and cardiac failure. Hypocalcaemia may be severe. Acute tubular necrosis and renal failure occur at 24-72 hours. Cranial nerve palsies may be develop.

Management
  • Perform gastric lavage
  • Measure ABG, U&E, calcium and plasma ethylene glycol
  • Correct metabolic acidosis to keep arterial pH >7.2 large amount of bicarbonate may be needed and hypernattraemia may occur
  • Give ethanol orally as whisky, gin, or vodka (adult 125-150mL, child 2ml/kg) followed by intravenous infusion (IVI)of ethanol, preferably as 5% solution in dextrose, initial IV adult dose is 12g ethanol per hour, increase for alcoholic during haemodialysis and adjusted to maintain blod ethanol at 1gr/lt
  • correct severe hypocalcaemia with calcium gluconate (10mL of 10% slowly IV)
  • In severe poisoning, haemodialysis is required, with frequent measurement of blood ethlylene glycol and ethanol concentrations.
  • Ventialation may be needed if pulmonary oedema develops

Source
Oxford Handbook of Accident and emergency medicine

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Monday, June 11, 2007

Botulism

Do you always buy preserved food? I think many people in modern style to do the simple way to buy some food and preserved food is ones choices because it's easy to serve and cook but you have to pay attention look at the expire date, check the seal is broken or not and take preserved food with longer of the expire date to avoid foodborne that cause intoxication. Either intoxication or infection follows eating tinned or preserved food contaminated with Clostridium Botulinum spores, cases involved sausage, tinned salmon, hazelnut yoghurt and other food. Clostridium Botulinum cause illness called BOTULISM. There are seven recognized types of botulism. Four of these (types A, B, E and rarely F) cause human botulism. Types C, D and E cause illness in mammals, birds and fish.

Sign and Symptoms
The symptoms is appear within 12 to 36 hours (within a minimum and maximum range of four hours to eight days) after exposure. Initial symptoms may be mainly Gastrointestinal problem such as nausea, vomiting, abdominal discomfort, dryness of the mouth or neurological such as dizziness, blured vision, diplopia. Later problem include dysarthria, dysphagia, muscle weakness or paralysis, constipation and urinary retention, respiratory falure and sudden death. There is no fever and no loss of consciousness.

Prevention
To prevent from botulism you have to be good food preparation (particularly preservation) practices and hygiene, cook well done, because the botulism toxin able to destroyed by high temperatures, check the expire date of food product, do not use any food if the food was expired date already. Commercial heat pasteurization (vacuum packed pasteurized products, hot smoked products) may not be sufficient to kill all spores and therefore safety of these products must be based on preventing growth and toxin production. Keep it any preserved food in refrigerator. Refrigeration temperatures combined with salt content and/or acidic conditions will prevent the growth or formation of toxin. If exposure to the toxin via an aerosol is suspected, in order to prevent additional exposure to the patient and health care providers, the clothing of the patient must be removed and stored in plastic bags until it can be washed with soap and water.

Treatment
The respiratory failure and paralysis that occur with severe botulism may require a patient to be on a breathing machine (ventilator) for weeks, plus intensive medical and nursing care. After several weeks, the paralysis slowly improves. If diagnosed early, foodborne and wound botulism can be treated with an antitoxin which blocks the action of toxin circulating in the blood. This can prevent patients from worsening, but recovery still takes many weeks

Sources:
  1. CDC
  2. WHO


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Wednesday, June 06, 2007

Accident Investigation

Around the world accident is frequently happened, many accident such as cars accident, trains accident, aircrafts accident, ships accident, worker accident in workplace . We know that the accident is unplanned, unpredictable, undesirable even like that we can understanding to know what cause of factors contributed by Accident Investigation. Accident Investigation is tool used to find out what kind of the accident, Who is get accident, when is accident happen, where is accident happen, Why the accident happen, and How can accident happen. It useful to reduce and avoid any similar accident happen in the future. Remember Five's W and (one H) question to explore accident happen.
Several reasons to investigate in a workplace accident include:
  1. most importantly, to find out the cause of accidents and to prevent similar accidents in the future.
  2. to fulfill any legal requirements.
  3. to determine the cost of an accident.
  4. to determine compliance with applicable safety regulations.
  5. to process workers' compensation claims.
Who should do the accident Investigation?
In most cases, the supervisor should help investigate the event. Other members of the team can include:
  • employees with knowledge of the work.
  • safety officer.
  • health and safety committee.
  • union representative, if applicable.
  • employees with experience in investigations.
  • "outside" expert.
  • representative from local government.
Why look for the "root cause"?
An investigator who believes that accidents are caused by unsafe conditions will likely try to uncover conditions as causes. On the other hand, one who believes they are caused by unsafe acts will attempt to find the human errors that are causes. Therefore, it is necessary to examine some underlying factors in a chain of events that ends in an accident.

The important point is that even in the most seemingly straightforward accidents, seldom, if ever, is there only a single cause. For example, an "investigation" which concludes that an accident was due to worker carelessness, and goes no further, fails to seek answers to several important questions such as:
  • Was the worker distracted? If yes, why was the worker distracted?
  • Was a safe work procedure being followed? If not, why not?
  • Were safety devices in order? If not, why not?
  • Was the worker trained? If not, why not?
What are the steps involved in investigating an accident?
The accident investigation process involves the following steps:
  • Report the accident occurrence to a designated person within the organization.
  • Provide first aid and medical care to injured person(s) and prevent further injuries or damage.
  • Investigate the accident.
  • Identify the causes.
  • Report the findings.
  • Develop a plan for corrective action.
  • Implement the plan.
  • Evaluate the effectiveness of the corrective.
Accident Investigate Approach
As with most other tasks, skill in conducting effective accident investigations improves with experience. A good basic approach is to find out what caused the accident and what can be done to prevent or minimize the chances of a similar accident occurring. Some suggestions that may help supervisors get the facts and reach a conclusion include:
  • Maintain objectivity throughout the investigation. Its purpose is to find the cause of the accident, not to assign blame for its occurrence.
  • Check the accident site and circumstances thoroughly before anything is changed.
  • Discuss the accident with the injured person, but only after first aid or medical treatment has been given (see Section A1, Work-Related Injuries and Illnesses). Also talk with anyone who witnessed the accident and those familiar with conditions immediately before and after it occurred.
  • Be thorough. Small details may point to the real cause.
  • Reconstruct the events that resulted in the accident, considering all possible causes. Determine unsafe conditions or actions that separately or in combination were contributing factors.
What To Do With The Results

Supervisors should take action to control or eliminate the conditions that caused the accident once these have been conclusively identified. EHS can provide assistance in determining the level of action that may be necessary, such as the following:
  • When equipment changes or safeguards are necessary, supervisors should discuss specific recommendations with Department management;
  • When an operation can be changed to eliminate the hazard, supervisors should make the change if it is within their authority, or seek the necessary approval from Department management;
  • If unsafe acts by workers are involved, ensure that the worker is properly trained and that training is followed. All others involved in similar operations should be trained as well.
Roles and Responsibilities
Department
  • Ensure accidents involving their operations or workers are investigated.
  • Ensure corrective actions are taken.
Supervisors
  • Particpate in incident investigations.
  • Take corrective actions.
EHS
  • Investigate incidents promptly and thoroughly.
  • Issue accident investigation reports.
  • Provide training in investigation methods and techniques when requested.
Individual
  • Cooperate with supervisors and others during investigations
References:
web.princeton.edu
www.ccohs.ca


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