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SATURNINE ENCEPHALOPATHY – TOXICOLOGICAL EMERGENCY IN CHILDREN AND ADOLESCENTS

Autor: Constantin Lupu Georgiana Golea
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Encefalopatia saturnină este o urgenţă medicală neuropsihică, reprezentând o manifestare acută datorată intoxicaţiei acute sau cronice cu plumb. Atingerea SNC se manifestă cu cefalee intensă predominant occipitală, insomnie, tremorul pleoapelor şi al mâinilor, halucinaţii, afazie, confuzie, delir, comă.

Descriem etapele tratamentului şi procedurile de recuperare în aceste cazuri.

Chronic and acute poisoning with lead products are quite common, with acute supratoxice cases that can be accidental or chronic. Knowing symptoms of saturnine poisoning is an obligation for all health professionals, emergency therapeutic measures with considerably greater importance than in subsequent periods.

The United States Agency for Toxic Substances and Disease Records, which classifies the hazards present in the toxic waste, depending on the frequency and severity of their toxicity, gives an indication of the importance of lead poisoning from other potential hazards by placing it in first place of the metal (Agency for Toxic Substances and Disease Registry, 2007).

In lead poisoning products we distinguish three groups of emergencies (Niculescu T, 1993):

Colic saturnine

Saturnine encephalopathy due to inorganic lead (minium red lead paints and other colors on common objects, especially on toys)

Acute intoxication saturnine due to lead organic compounds (tetraethyl lead in oil preparations as gasoline, diesel and kerosene)

A proper history guides us from the beginning to the possibility of contact with the patient’s lead product, so it is fair to think of emergencies for children and young people at the possibility of intoxication saturnine.

There are several clinical forms of these emergencies:

Saturnine colic is an acute manifestation of acute or chronic forms of poisoning with metallic lead, lead oxide or organic compounds of lead. It can be detected on young people who have consumed alcohol from distillation with metallic lead. Saturnine colic preceded by diarrhea alternating with constipation, asthenia, sweating, have suddenly by nausea, abdominal pain generalized or periumbilical atrocious supraacute, vomiting, headache and constipation absolute feces and gas (Niculescu T, 1993).

On examination we notice the patient: facies pale, sometimes subicter, the rifle cock position or prone, normal abdomen on palpation, sometimes bloated. Abdominal pain is reduced to deep palpation. There are two important cardiovascular symptoms: bradycardia around 50-60 beats / minute (one abdominal colic bradycardia) and hypertension during colic.

As neurological emergency medical laboratory tests are required since blood lead, indicating values ​​above 70 mg% delta acid – amino – levulinic urinary significantly increased to over 20 mg ‰. Increase over the 2.5 mg to porfirinobilinogenului urinary ‰, over 8 to 10 mg / l, brandy proves ingesting contaminated with lead. Marked increase in the number of red blood cells with basophilic granulation (over 5000 / one million red blood cells) is also a significant indicator of lead poisoning (GF Nordberg, 2007).

Saturnine encephalopathy by inorganic lead due to pathological and pathophysiological changes of cerebral vessels and capillaries that induce CNS injury. Encephalopathy can start with abdominal colic saturnine, clinical symptomatic triad consisting of convulsions, delirium and coma. Onset is a prodromal state of fatigue, digestive disorders and shortly install occipital headache, insomnia, depressed mood, agitation, tremor eyelids and hands, then aphasia and confusion. It may progress to coma. Saturnine encephalopathy characteristic disturbances are considered: hemianopsia or convulsions (Niculescu T, 1993).

Biological effect indicators are high values ​​of blood lead and delta acid – amino – levulinic and increasing the number of red blood cells with basophilic granulations. CSF presents intense increase intrathecal pressure without increasing the lead – zinc Rahi (GF Nordberg, 2007).

Acute saturnine encephalopathy caused by tetraethyl lead. This organic compound of lead has direct toxic action on the CNS (not by altering vascular). Children accidentally exposed by inhalation or consumption of leaded gasoline may suffer from mild, medium or severe encephalopathy (always mild evolve towards worsening).

The clinical picture of the tetraethyl lead encephalopathy consists of headache, insufficient sleep, muscle twitching, muscle and tongue tingling with sensation specific “hair on the tongue” transition to serious forms of disorientation, confusion, visual hallucinations, audition and olfaction delusional state.

Tetraethyl lead poisoning on children can occur in mechanical workshops in car leaking gas, sometimes by playing, and many other instances of contact with petrol fumes. Children and young people who inhale volatile substances and / or acetone, use and leaded gasoline as a substitute substances “bag”. Sometimes volatile substances combine with these spirits, or living in shelters (rooms or spaces Underground) with permanent open spirit that creates an atmosphere saturated fumes in those spaces. These procedures create a fund of chronic intoxication with petrol vapor dependence, which can worsen and users presents with pathognomonic sign of hair sensation on the tongue (Niculescu T, 1993).

Clinic is found hypothermia (temperature must be monitored closely), hypotension, bradycardia, generalized tremors and frequent attempts autolysis. Evolution is often fatal in 2-5 days, and the developments non-fatal mental illness lasts 2-4 weeks, return to natural sleep is a favorable prognostic sign.

Laboratory indicators are conclusive: a marked increase blood lead and leaden (it is necessary to follow to implement urgent treatment).

Saturnine colic treatment: aims interruption of exposure, so the absorption of lead through emergency admission to hospital and administration Plegomazin (Largactil), which is the only drug that reduces and cancels saturnine colic pains. Note that this is a strong hypotensive, so walking may fall sick and injured. Administer ethylenediaminetetraacetic acid salt (edetamin) or other chelating (dimercaprol, penicillamine and succimer) to eliminate lead, accompanied by infusion and ingestion of fluids to help reduce lead levels. Chelation therapy is recommended for all children with higher blood lead nile of 55μg%. Chelation is also recommended for children, blood lead is between 25-55μg% if the total amount of lead excreted into the urine for 8 hours after a single dose of edetamin than 200 Hg / dl (GF Nordberg, 2007).

Saturnine encephalopathy stops contact with power lead and support is taken care of Plegomazin, chelation of lead under the control of renal function (recommended dimercaprol). It can be associated with phenobarbital but Largactilul spinal puncture is necessary to reduce CSF hypotension and ensure intake of plenty of fluids, plus vasodilator medication to prevent arterial spasms and brain capillaries (GF Nordberg, 2007).

All medical and hygienic-dietary measures take into account the intoxicated patient care that will not be left alone, avoid scopolamine and morphine Cloralhidratul and hospital room should be quiet, ventilated and illuminated uniformly.

Measures of medical emergency in child poisoning should be based on clinical neurotoxicologiei progress, so the precise knowledge of the diagnosis and treatment of emergency. The doctor who noticed first the intoxicated child must establish the most important emergency relief measures. If simple treatment measures are not neglected in the early symptoms and signs of intoxication can solve the positive future intoxicated.

Bibliography

  1. Niculescu T, 1993, Urgenţe medicale: Intoxicaţia profesională sau ocazională cu plumb, Jurnalul Medicinei Româneşti, Nr 7/8, Pag: 34-37
  2. Agency for Toxic Substances and Disease Registry (ATSDR). 2007.Toxicological profile for Lead. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service.
  3. Nordberg GF, Fowler BA, Nordberg M, Friberg LT, Handbook on the Toxicology of Metals – Third Edition, Elsevier, 2007