Lead
Lead Management
HF
Button batteries
100
Why do you need to get a whole blood lead level and not plasma?
99% of circulating lead in blood is bound to red blood cells (erythrocytes), with only ~1% present in plasma.
100
A child swallowed a bullet. What investigations are needed, what is the management?
- Stat BLL
- Xray chest/abdo
- Endoscopic removal (if elevated lead level and depending on where on xray) and start WBI along with serial lead levels
100
What electrolyte abnormalities can occur with hydrofluoric acid exposure? (at least 2)
- Hypocalcemia
- Hypomagnesemia
- Hyperkalemia
100
What are some symptoms of a button battery ingestion (name 3)?
airway obstruction, abnormal respiration, drooling, difficulty swallowing, vomiting, chest pain, abdominal pain, decreased appetite, refusal to eat, coughing or choking with eating or drinking.
200
What is the process for getting a lead level stat?
- Ordering stat and calling lab (precision labs edmonton runs them once per week).
200
Without chelation, do we expect lead levels to decreases quickly, why or why not?
- Significant tissues and bone distribution (70% in children, 95% in adults)
- Half life from bone is 23 years, soft tissue is 40 days, and blood is 30 days
200
How would you treat a dermal hydrofluoric acid exposure? (investigations and management)
- ical or calcium and albumin
- VBG, other electrolytes (Mg, Na, K, Cl, CO2), BUN, creatinine
- Water irrigation (15-20 min), IV calcium, IV Mg, 2.5% calcium gluconate gel
200
What is photo A and B depicting
- A = button battery with halo sign
- B = coin
300
If a detectable level is found, but is below the threshold for chelation, what is the management, are there any resources that can be used to help guide this?
- May need to refer to public health/occupation health if source is unknown
- Continue to observe with follow up levels while removing source as per CDC
300
Name a lead chelator
- Succimer/DMSA (PO) - SAP, some hospitals have supply
- CaNa-EDTA (calcium disodium edetate)
- DMPS (dimercaptopropane sulfonate)
300
Name a product/solution which contains HF
- Rust removers, metal pickling solution, glass/ceramic etchant, wheel cleaner, used to dissolve silica in geology/mining
300
What are you priority investigations with a suspected/witnessed button battery?
Xrays - Chest (AP/Lat), Neck (AP/lat), Abdo (supine)
CBC, type and screen/crossmatch, coags
400
What are some potential lead exposures? (Name 3)
- House paint or ceramics older than 1980
- Bullets (often firing range)
- Aryuvedic medications
- Contaminated substances of abuse
- Ingestions (fishing weights, intentional)
- Water pipes
400
At what lead level is chelation considered?
Those patients with even mild symptoms and BLL >2.41 umol/L or BLL >3.38 umol/L
400
If a patient with HF exposure immediately went into pulseless vfib on presentation, how would you manage?
- Start ACLS
- Administer 10% calcium gluconate 60 mL every 10 minutes until return of spontaneous circulation
400
If a witnessed button battery occurs at home, in addition to calling 911 what could be recommended?
Is there a population you would not give that to?
Why does it work?
Honey 10mL Q10 mins x 6 doses
?Not for children < 1 years old (can use sucralfate as alternative)
Can generate electrical current producing hydroxide ions which creates highly alkaline environment (pH>12) = liquefactive necrosis. Honey is a weak acid and has a viscous barrier effect.
500
Name at least 2 symptoms for lead toxicity in:
Mild (BLL at 0.97 - 2.41 umol/L)
Moderate (BLL at 2.41 - 3.38 umol/L)
Or
Severe ( BLL at >3.38 umol/L)
Mild = CNS: Fatigue, somnolence, moodiness, anhedonia, decreased cognition, MISC: Hypertension
Moderate = CNS: Headache, memory loss, decreased libido, insomnia, PNS: Ascending peripheral symmetric motor polyneuropathy, GI: Metallic taste, abdominal pain, anorexia, constipation, vomiting, HEME: Mild anemia, MISC: Saturnine gout, myalgias, muscular weakness, artrhalgias
Severe: CNS: Encephalopathy, coma, seizures, delirium, focal motor disturbances, headaches, cerebral edema, optic neuritis / vision loss, increased ICP, PNS: Foot drop, wrist drop, GI: Abdominal pain / colic, vomiting, HEME: Anemia with evidence of basophilic stippling, CVS (Rare): Ventricular dysrhythmias due to prolongation of QRS and QTc
500
Name 3 adverse effects of lead chelation
Neutropenia, GI upset, metallic taste, sulfur smelling secretions, mild transaminitis, pruritis and rash (Can be zinc related)
500
A BSA above what predicts systemic effects?
>2.5%
500
If your patient had a witnessed gastric button battery ingestion that was 20mm in size and was asymptomatic, what would be your management?
Observe and repeat xray in 48h, if still present would recommend endoscopy