Supervasmol

medical emergency

1. SUPERVASMOL POISONING

2. Super- vasmol poisoning is emerging as a major cause of suicidal poisoning in India…as it is a cheap ,freely available hair dye It contains potential toxins like PPD which can result in multiorgan dysfunction

3. The main important constituent is PPD( paraphenylene diamine )- <4% Other constituents are Propylene glycol Resorcinol EDTA Sodium Ceto stearyl alcohol Sodium lauryl sulphate Liquid paraffin Preservatives and water COMPONENTS OF HAIR DYE

4. PPD( paraphenylene diamine ): it is the major toxin among all constituents PPD metabolised by CYP450 to form BRANDOWASKI’S BASE It is an anaphylactic,highly toxic and strongly mutagenic The lethal dose is 7 to 10 gms .. But 3gms is sufficient to cause systemic complications

5. It produces both local and systemic effects. Systemic effects occurs in two phases: Phase 1 Acute presentation (4-6hrs): cervicofacial edema,airway obstruction,gastritis and severe vomiting. Phase 2 Subacute presentation withARF,rhabdomyolysis and hemolysis . Hepatitis. Hyperkelemia,hypocalcemia,hyperphosphatemia . Severe metabolic acidosis

6. Even 5 to 10 ml super vasmol can cause laryngeal edema due to direct toxic effect of PPD on membranes.. No specific antidote available for PPD,hence management is only symptomatic & supportive . Development of pneumothorax is reported following laryngeal edema Intense inspiratory effort secondary to laryngeal edema leading to overdistension of alveoli.

7. Local effects of PPD: Skin iritation Contact dermatitis Chemosis,lacrimation and exopthalmous Permanent blindness

8. Chronic hair dye use is associated with non-Hodgkin’s lymphoma,multiple myeloma,acute leukemia,and bladder cancer

9. Resorcinol- it causes methemoglobinemia and renal toxicity EDTA sodium- it causes hypocalcemia Propylene glycol- it is ass. with hyperosmolarity , CNS depression, arrythmias it is nephotoxic and results in high anion gap metabolic acidosis and acute renal failure.

10. In addition to these a few hair dyes also contain Lead acetate and Bismuth sulphate which causes CKD and Acute interstitial nephritis respectively..

11. 1.Angioedema or Cervicofacial edema : Early manifestation (within 4-6 hours) include respiratory distress due to swelling of upper airway and angioedema Angioedema is immunologically mediated,anatomically limited,nonpitting edema. It is an abrupt swelling of the dermis and subcutis CLINICAL FEATURES

12. STAGING OF ANGIOEDEMA : This is to predict airway risk at presentation. Stage 1 - Facial and lip edema Stage 2 - soft palate edema Stage 3 - Lingual edema Stage 4 - Laryngeal edema

13. 2. RHABDOMYOLYSIS: Symptoms are back pain,limb pain,generalised myalgias Acute muscle necrosis is the cause for tenderness and local edema of muscles

14. The initial sign of rhabdomyolysis is the appearance of cola-colored urine There is dissolution of striated muscle fibres , with leakage of muscle E nzymes,myoglobin , potassium,calcium and other intracellular constituents. CK levels are the most sensitive indicators of myocyte injury.

15. 3.RENAL FAILURE: It testifies to the severity of intoxication. The causes are Toxic injury Myoglobinuria Hemoglobinuria Hypovolemia Propylene glycol is also a nephrotoxic

16. 4. MYOCARDITIS : It is due to rhabdomyolysis of myocardium It is reported in 15% of cases with mortality rate of 29%. Ventricular arrythmias,sudden cardiac death 5.Neurological:convulsions

17. Cause of death : Respiratory obstuction Renal failure Arrythmias ARDS

18. Treatment is aimed at rapid identification of potentially life-threatening complications and prevention of renal failure GASTRIC LAVAGE: is useful if the patient presents within 1 hour of ingestion but contraindicated if airway protective reflex is lost. Airway protection is the most important consideration with laryngeaal edema…it should be ensured with timely endotracheal intubation or tracheostomy . MANAGEMENT

19. Steroids – hydrocortisone 200mg stat f/b 100mg every 6 th hourly. If not responded to hydrocortisone , methyl prednisolone 125mg iv infusion given 6 th hourly

20. In the event of life threatening reaction involving urticaria with angioedema or laryngeal edema Epinephrine may be neded to stabilise the patient

21. Aggressive fluid resuscitation with isotonic fluids to restore the renal perfusion and increase renal flow is necessary to prevent AKI

22. Dialysis support may be life saving when oliguria develops. Myocarditis requires continous cardiac monitoring in order to timely intervene life-threatening arrythmias and sudden cardiac death.

23. Alkaline diuresis - using isotonic saline,sodium bicarbonate and diuretics Sodabicarb 20meq 8 th hourly

24. In conclusion ,hair dye poisoning is a life-threatening emergency which requires emergency resuscitation and aggressive management of anaphylaxis Preventing renal failure is a very important goal,since its occurrence is associated with high mortality and increase in ICU stay The time of development of renal failure is uncertain and hence all patients should be monitored in hospital for renal failure complications…

25. Thank you