![]() On Day 3 of admission, the haemoglobin was 10.8g/dL, and there was some improvement of methaemoglobin which decreased to 1.7%. Ionotropic support in the form of norepinephrine infusion had to be started to maintain a MAP >65 mm Hg. ![]() ascorbic acid 300mg and N-Acetylcysteine (NAC) 1.2 gm daily was started. methylene blue 75mg (1.5mg/kg) was prescribed on Day 2 of admission after checking for G6PD status. Her haemoglobin increased to 12.5g/dL after 5 units packed red cell transfusion. Her methaemoglobin levels were falling with first day reading of 11.1%, which decreased to 2.2% on second day. Subsequently, after haemodialysis her acidosis improved with post-dialysis ABG suggestive of pH of 7.440, pO 2 of 63.3 mm Hg, HCO 3 of 23.3, BE of -0.5mmol/L. Haemodialysis was done in view of severe metabolic acidosis and acute renal failure. Post-intubation Blood Gas Analysis showed severe metabolic acidosis with a pH of 6.917, HCO 3 of 7.7, BE of -24.7mmol/L, pO 2 of 114.8 mm Hg, lactates of 9.7 with methaemoglobin of 11.1%. Renal functions were deranged with BUN of 70mg/dL and serum creatinine of 4.2mg/dL. Liver function tests were deranged with elevated liver enzymes (SGOT of 420). Intravascular haemolysis was suggested by clinical jaundice and total bilirubin measuring 5.30mg/dL with indirect hyperbilirubinaemia and urine bilirubin positive. There was leukocytosis with marked neutrophilia (Total Leukocyte Count of 86,000/μL with 80% neutrophils), platelet count =5,92,000 and deranged coagulation profile with INR =3.28. Initial investigations revealed severe anaemia with haemoglobin of 3.3g/dL and haematocrit of 9.1%. Gastric lavage was not done with activated charcoal in view of late presentation. Endotracheal tube got filled with pink frothy sputum soon after intubation which was suggestive of pulmonary oedema. Subsequently, the patient was intubated and put on full ventilatory support. She was admitted to the Intensive Care Unit (ICU) for further management. ABG was done which was suggestive of severe metabolic acidosis with a pH of 7.059, HCO3 of 2.9 and a BE of -25.1mmol/L with a methaemoglobin of 11.1%. ![]() Pupils were bilaterally normal size reacting to light.įoley’s catheterization was done and urine was black-coloured. On neurological examination, there was no focal neurological deficit. Clinically she was afebrile, had a pulse rate of 117/minute, BP 110/70 mm Hg, respiratory rate 30/minute, spo 2 75% on oxygen at 6 l/min via simple face mask. On the third day, she was referred to our hospital for further management. She complained of vomiting and decreased urine output a few hours after the ingestion and was taken to a local hospital for treatment. She did not have any past medical history. Early prehospital contact with the Poison Control Center and ED prenotification in poisoned patients is encouraged.ĮMS methemoglobinemia methylene blue out-of-hospital cardiac arrest poisoning sodium nitrite.A 29-year-old female patient presented 72 hours after oral ingestion of 8 naphthalene balls with suicidal intent. EMS professionals should consider sodium nitrite toxicity in patients with a suspected overdose who present with a cyanotic appearance, pulse oximetry that remains around 85% despite oxygen, and dark brown blood seen on venipuncture. ![]() In the Emergency Department (ED), she received methylene blue and packed red cells but could not be resuscitated despite a prolonged effort. The patient decompensated rapidly into a bradycardic arrest during transport despite intubation, push-dose epinephrine, and intravenous fluid resuscitation. The patient was hypotensive and cyanotic upon EMS arrival. A 17-year-old female reportedly drank approximately one tablespoon of sodium nitrite in a self-harm attempt. We report a case of an intentional fatal overdose of sodium nitrite. The majority of reports on sodium nitrite poisonings have been the result of unintentional exposures. Clinical manifestations can include cyanosis, hypoxia, altered consciousness, dysrhythmias, and death. Sodium nitrite is a powerful oxidizing agent that causes hypotension and limits oxygen transport and delivery in the body through the formation of methemoglobin. ![]()
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