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MAEM 1213

Objektif
1. Menyatakan definisi keracunan paraquat.
2. Menyatakan ciri-ciri klinikal keracunan
paraquat.
3. Menerangkan ujian makmal keracunan
paraquat.
4. Menghuraikan pengendalian keracunan
paraquat.

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Definisi
 Bahan toksik iaitu racun rumpai paraquat yang
memasuki badan melalui ingesi, resapan
(absorption), mukosa mata atau inhalasi dan
seterusnya menyebabkan kesan setempat atau
sistemik.

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Paraquat
 Nama Kimia: 1,1'-DIMETHYL-4',4'-BIPYRIDILIUM
DICHLORIDE Formula (C12 H14 N2 CL2) Molecular weight
257.16
 "Redox Cycling" adalah tindakbalas utama yang berlaku
dalam keracunan paraquat.
 In anaerobic conditions the paraquat cation can be reduced by
NADPH-dependant microsomal flavoprotein reductase to form
the reduced radical. This then reacts with molecular oxygen to
reform the paraquat cation and the superoxide ion.
 Paraquat will then continue to cycle from its oxidized to
reduced form with the electrons and oxygen. Paraquat is
thought to cause cell death by lipid peroxidation or NADPH
depletion, as in the lung where there is selective accumulation
(Smith, 1987).
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Risiko pendedahan kepada paraquat
 Bergantung kepada cara racun masuk ke badan.
 Organ terlibat: paru-paru, ginjal, hati dan otot
jantung.
a) Ingesi jumlah banyak – kegagalan pelbagai organ
dan kematian.
b) Ingesi jumlah sederhana – kegagalan renal dan/atau
infiltrasi masif dan fibrosis paru-paru. Boleh
menyebabkan kematian.
c) Pendedahan setempat – kerosakan pada mambran
mukosa, kulit & mata.
d) Pendedahan sedikit – tiada kesan yang teruk.
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Ingesi racun
a) Dos rendah(<20 mg paraquat ion per kg bdwt= 10mls
of a 20 to 24% concentrate)
 Asimptomatik atau menyebabkan muntah atau
diarrhoea.
 Pesakit sembuh sepenuhnya tapi ujian fungsi paru-paru
menunjukkan sedikit kekurangan.

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Ingesi racun
b) Dos sederhana(20 - 40 mg paraquat ion per kgbdwt
= 10 to 20 mLs of 20 to 24% concentrate)
 Peringkat awal - disfungsi renal & hati
 Kerosakan mukosa - sloughing mambran mukosa
mulut.
 Berlaku sesak nafas selepas beberapa hari.
 Krepitasi & tanda radiologi kerosakan paru-paru.
Fungsi renal kembali normal.
 Massive pulmonary fibrosis - progressive dyspnoea &
kematian dalam 2-4 minggu selepas ingesi.

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Ciri-ciri klinikal setempat
Mata- ulserasi kornea & konjunctiva, lakrimasi
Kulit- iritasi, lepuh, ulserasi
Inhalasi – epistaxis, sakit kerongkong, sakit dada,
hemoptysis, dispnea dan edema pulmonari.
Ingesi – loya , muntah ,cirit birit (berdarah peringkat
akhir), ulserasi (bibir, lidah dan gusi, esophagus) &
perforasi esophagus

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Ciri-ciri klinikal sistemik
Dos sederhana;
 Dispnoea
Dos tinggi;
 Kegagalan renal – acute tubular necrosis
 Asidosis metabolik
 Pulmonari edema dalam beberapa jam
 Fibrosis Pulmonari & kegagalan pernafasan (sehingga 6
minggu)
 Jantung – aritmia kardiak– kegagalan sirkulasi
 CNS - Konvulsi , kelemahan otot, kebingungan, koma
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Ciri-ciri klinikal
Selepas 3-4 hari
Ulser berlaku di mulut
Nekrosis hepatocellular & kegagalan renal akut –
oliguria
Minggu kedua
Fibrosis pulmonari & edema berlaku

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Ciri-ciri klinikal
Keracunan ringan
Asimptometik atau muntah & cirit
Pulih dengan sedikit kesan pada kapasiti vital
Keracunan sederhana
Muntah & loya teruk
Ulserasi orofarink serta kerosakan organ

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Investigasi
 Blood and urine for paraquat analysis (10 and 20 mls).
 A rapid urine spot test can confirm the presence of
paraquat.
The samples not be put into glass containers of any type as
paraquat ion is absorbed by glass. A plastic heparinized tube
is suitable for blood and a plastic sterile universal container is
suitable for urine.
 BUSE & Sr creatinine
 Full blood count
 Liver function tests
 ABG & CXR
 ECG
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Pengendalian Keracunan Paraquat
1. Rawatan sokongan
2. Keluarkan semua racun –lavaj/aspirasi
3. Lambatkan serapan baki racun dengan fuller’earth
4. Meningkatkan eliminasi racun - forced diuresis,
dialisis
5. Rawatan komplikasi

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Prahospital
1. Tanggalkan pakaian yang dicemari paraquat
2. Basuh kulit yang terkena racun dengan air yang
banyak & sabun.
3. Jika kena mata – irigasi dengan saline
4. Rujuk segera mangsa ke hospital.

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Hospital
1. Keluarkan racun
 Masukkan tiub nasogastrik – keluarkan racun
dengan kaedah lavaj atau aspirasi
2. Halang penyerapan usus – beri oral
absorbent dan dulang setiap 4 jam.
 Activated charcoal 1-2g/kg
 Fuller’ Earth (1 – 2g/kg in 15% aqueous
suspension) atau
 Bentonite (1 – 2g/kg in 7% aqueous slurry)

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Lavaj Gaster

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Activated charcoal

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Hospital
3. Percepatkan eliminasi racun;
 Beri purgatif - Manitol 200ml (20%) melalui tiub
nasogastrik selepas MgSO4 20ml /H
 Forced Diuresis – jika ginjal ok
 Utk kekal isipadu urinari 12 – 16L / 24jam
 1st hour – 500cc D5
 2nd hour – 500cc D5 + 1 g KCL

 3rd hour – 500cc N/S + 1 g KCL

 IV Lasix (Frusemide) 20 mg 4-6 jam


 Haemodilisis / Charcoal Haemoperfusion segera dan
diteruskan selama 6 – 8jam.
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Dialysis

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Hospital
 Rawatan bantuan / sokongan
 O2 – kontraindikasi bagi kes yang tidak mengalami
masalah pernafasan. Tetapi jika melibatkan kegagalan
pernafasan – intubasi & O2.
 Rawat konvulsi
 Rawat metabolik asidosis – I/V sodium bicarbonate
 Rawat dehidrasi – I/V normal saline
 Rawat komplikasi pulmonari – IV dexamethasone atau
cyclophosphamide
 Pemberian analgesik jenis opiod– penahan sakit (ulser)

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Komplikasi
 Ulser gastric
 Kegagalan Renal
 Kegagalan hepar
 Edema pulmonari
 Kegagalan pernafasan
 Fibrosis Pulmonari

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Case report
 A 34-year-old woman was admitted to the
emergency room of Chulalongkorn Hospital,
Bangkok, Thailand, 4 hours after ingesting about
20 mL of 24% paraquat (Gramoxone), with
suicidal intent.
 She experienced nausea and vomiting shortly after
ingestion and was brought to the hospital by her
relatives. In the emergency room she reported sore
throat and epigastric pain, but denied any
shortness of breath or any difficulties breathing.

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Case report
 She reported no underlying medical problems, and had
been working at a farm, where she had access to herbicides.
 Physical examination in the emergency room revealed an
alert, fully conscious woman in no acute distress, with
blood pressure 100/50 mm Hg, heart rate 110 beats/min,
respiratory rate 16 breaths/min, and temperature 65.5° C.
 Her blood oxygen saturation (measured via pulse oximetry
while breathing room air) was 95%.
 Her oral mucosa was erythematous and edematous. Both
lungs were clear to auscultation.
 The remainder of physical examination was unremarkable.

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Case report
 Initial complete blood count, electrolyte, and liver function
tests were within normal ranges. A chest radiograph was
clear, without definite infiltrates, and the cardiac contour
was normal (Fig. 1).
 Electrocardiogram revealed sinus tachycardia. Urine
dithionite test was strongly positive, confirming the
presence of paraquat. We obtained a blood level for
paraquat, and the patient was given 100 g of activated
charcoal plus 100 mL of 70% sorbitol via nasogastric tube.
 We started administering intravenous fluid, and the
patient was admitted to the medical intensive care unit for
close observation and further evaluation.

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Fig. 1

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Case report
 After admission the patient was given a repeated
dose of activated charcoal and sorbital. Other
supportive treatments included intravenous fluids
and analgesics to control her epigastric pain.
 In the following 24 hours, the patient experienced
increasing epigastric pain, severe dysphagia, and
progressive shortness of breath.
 A subsequent chest radiograph revealed bilateral
lower-lobe and perihilar infiltration.

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Case report
 Blood chemistries on day 2 revealed elevated blood
urea nitrogen, creatinine, and liver enzymes.
 Her arterial blood gas values on day 2 were pH :
7.48, PaCO2 : 32 mm Hg, and PaO2 : 56 mm Hg.
 She required increasing supplemental oxygen to
keep her oxygen saturation above 88%.
 On day 3 the chest radiograph revealed bilateral
infiltrates, pneumomediastinum, and
pneumopericardium (Fig. 2).

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Fig. 2

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Case report
 She became increasingly hypoxemic and required
intubation and mechanical ventilation. Her renal
function deteriorated, with markedly increased
blood urea nitrogen and creatinine levels, and her
urine output decreased.
 Hemodialysis was started. Progressive multiple-
organ failure ensued, and she died on day 4 after
admission.
 Her initial blood paraquat level at 6 hours after
ingestion was 1.98 g/mL.

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