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The child presents with classic signs (and history) of carbon monoxide (CO) exposure. Pulse oximetry is unreliable in CO poisoning, although newer instruments may distinguish between carboxyhemoglobin (CO-Hgb) and oxyhemoglo-bin. Institute the ABCDs of poisoning (see Chapter 58). Immediate high-flow oxygen is mandatory and should be administered via a tight-fitting face mask or endotracheal catheter. A blood sample for blood gases and carboxyhemo-globin content should be obtained. If the CO-Hgb is greater than 50%, hyperbaric oxygen treatment (if available) may be considered. The electrocardiogram should be continuously monitored for arrhythmias. Anticonvulsant drugs may be required if seizures occur. Neurologic damage due to CO exposure may be subtle and long-lasting; the child should be followed for years if necessary. The fetus is particularly sus-ceptible to hypoxia, and if the mother is pregnant, her blood gases and CO-Hgb should be measured. If the latter is high, hyperbaric oxygen therapy should be considered.
Michael J. Kosnett, MD, MPH
Following Sunday morning services, 27 people attended a church social where coffee, baked goods, and sandwiches were served. Within 15–60 minutes, 13 people developed vomiting and abdominal discomfort, accompanied over the next several hours by nonbloody diarrhea. Within 12 hours, seven of these individuals were hospitalized with ongoing gastrointestinal symptoms, hypotension, and anion gap metabolic acidosis. Fluid resuscitation and pressors were accompanied by adequate urine output. What diagnoses should be considered? What tests should be conducted, and what therapy should be considered?
Some metals such as iron are essential for life, whereas others such as lead are present in all organisms but serve no useful biologic purpose. Some of the oldest diseases of humans can be traced to heavy metal poisoning associated with metal mining, refining, and use. Even with the present recognition of the hazards of heavy metals, the incidence of intoxication remains significant, and the need for preventive strategies and effective therapy remains high. Toxic heavy metals interfere with the function of essential cations, cause enzyme inhibition, generate oxidative stress, alter gene expression, and perturb cell signaling. As a result, multisystem signs and symptoms are a hallmark of heavy metal intoxication.
When intoxication occurs, chelator molecules (from chela “claw”), or their in vivo biotransformation products, may be used to bind the metal and facilitate its excretion from the body. Chelator drugs are discussed in the second part of this chapter.