Difficulties in Management of Occupational Exposure in Our
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96 CASE REPORT OLGU SUNUMU Difficulties in Management of Occupational Exposure in Our Country: A Case Report Ülkemizde Mesleksel Maruziyet Durumunun Yönetilmesinde Yaşanan Güçlükler: Bir Olgu Sunumu Serkan YILMAZ, Murat PEKDEMİR, Elif YAKA Department of Emergency Medicine, Kocaeli University Faculty of Medicine, Kocaeli, Turkey SUMMARY ÖZET Occupational exposure to hazardous materials is a serious problem Mesleki maruziyet gelişmekte olan ülkelerde, ciddi ancak yete- in developing countries. Unfortunately, the different presentations rince kayıtlara geçirilememiş bir sorundur. Sıklıkla nonspesifik result in nonspecific clinical syndromes, making diagnosis difficult. semptomlarla başvuran bu hastaların tanı ve tedavisinde birçok We discuss lessons learned during the assessment and treatment güçlük yaşanmaktadır. Bu makale, bir mesleki maruziyet vaka- of occupational exposure in two industrial workers. Two employees sının değerlendirmesi sırasında elde edilen deneyimlerin payla- of a facility that manufactures plastic floor covering were admit- şılması amacıyla hazırlanmıştır. Plastik yer döşemeleri üretimin- ted to the emergency department with complaints including in- de çalışan iki işçi yürüyememe, uyuşukluk ve baş dönmesi, bilinç ability to ambulate, lethargy and dizziness. It was thought that the bulanıklığı gibi yakınmalarla acil servise başvurdu. Her iki hasta- patients’ neurological symptoms resulted from toxic encephalitis da da nörolojik semptomlara yol açan toksik ensefalit ve direnç- and refractory hypokalemia due to renal medullary damage. No li hipokalemiye yol açan renal medüller hasar düşünüldü. Gerek material safety data sheets were available for consultation, and the fabrikada kullanılan maddelere dair kayıtlara ulaşılamaması ve authorities at the manufacturing facility were unable to provide fabrika yetkilerinden bilgi alınamaması, gerekse hızlı bir şekilde reliable information about the material involved. On-site exposure olay yeri toksikolojik değerlendirmesinin yapılmaması nedeniyle evaluation was not performed and these conditions made the ex- act etiology of the patients’ condition unclear. It was thought that etyolojiye kesin olarak karar verilemedi. Fabrikada çözücü olarak toluene, which was used as a solvent during the manufacture of vi- kullanılan toluenin klinik tablodan sorumlu olabileceği düşünül- nyl fluoride, could be responsible for the existing clinical condition. dü. Şüpheli kimyasal ajanlara maruz kalma nedeniyle başvuran Both patients were treated symptomatically and discharged with hastaların değerlendirilmesi sırasında birçok güçlük yaşanmak- minor cognitive impairment, which was assessed during follow-up. tadır. Sanayide kullanılan kimyasallar ile ilgili bilgilerin ulaşılabi- Various difficulties were experienced during the management of lir olması, bu konuda ulusal bir veritabanı hazırlanması, toksiko- patients suffered from occupational exposure. Material safety data lojik olay yeri değerlendirmesinin hızlı ve etkin şekilde yapılma- sheets for industrial chemicals should be available at manufactur- sı bu hastalarının doğru değerlendirilebilmelerine yardımcı ola- ing plants. On-site exposure evaluation would be useful for more caktır. accurate assessment of exposed patients. Key words: Emergency treatment; occupational exposure; toluene. Anahtar sözcükler: Acil tedavi; mesleksel temas; toluen. Submitted (Geliş tarihi): July 9, 2011 Accepted (Kabul tarihi): January 19, 2012 Published online (Online baskı): March 5, 2012 Correspondence (İletişim): Serkan Yılmaz, M.D. Kocaeli Üniversitesi Tıp Fakültesi Hastanesi, Acil Tıp Anabilim Dalı, 41380 Kocaeli, Turkey e-mail (e-posta): [email protected] Türkiye Acil Tıp Dergisi - Tr J Emerg Med 2012;12(2):96-98 doi: 10.5505/1304.7361.2012.71601 Yılmaz S et al. Difficulties in Management of Occupational Exposure in Our Country 97 Introduction as toluene, benzene, or xylene. Based on the history of the Occupational exposure is a serious but poorly documented industrial plant, the presence of more than one affected problem, especially in developing countries. Unfortunately, patient, and laboratory and MRI results, it was thought that the different presentations result in nonspecific clinical syn- toxic encephalitis might be responsible for the neurologic dromes that make diagnosis difficult. We discuss the lessons symptoms; and that renal tubular damage might be respon- learned during the assessment and treatment of occupa- sible for the hypokalemia and mild acidosis following indus- tional exposure in two industrial workers. trial exposure. No information on the exposure agents was available to confirm our diagnosis. The patients were hospi- talized with conservative therapy comprising supplemental Case Report oxygen, KCl infusion for four days at a rate of 100 mEq/day, Two males (aged 39 and 34 years) employed a plastic floor and sodium bicarbonate 5 mEq/kg IV infusion over 8 hours cover manufacturing facility were admitted to the emergen- for two days. cy department (ED). Both complained of generalized weak- The symptoms improved after the third day. Hypokalemia ness, leg-muscle cramps, inability to ambulate, lethargy, and and metabolic acidosis were completely resolved at the dizziness. They were placed in an isolation room following end of the fourth day. Both patients were discharged from admittance. the hospital six days after the admission. On follow-up one The patients had been employed at the factory for 13 and 11 month later, both patients showed slight cognitive abnor- years, respectively, which mainly produces vinyl fluoride. It malities presented with minimal attention and memory defi- was found that no similar event had previously occurred to cit. any of the patients at the plant and none of those patients had a medical history relevant to the current complaints. Discussion Initial evaluation indicated that the patients were not fully Disorientation, lethargy hypokalemia, and metabolic acido- oriented or cooperative, and had slurred speech. Vital signs sis were present in our patients. This prompted us to think were within normal limits (first patient: heart rate 74 bpm, that toluene, which was used in the plant, may have been respiratory rate 18, blood pressure 119/65 mmHg, tempera- responsible for the existing clinical condition. We also con- ture 36.7°C, and oxygen saturation 99% on room air; second cluded that toxic encephalitis resulted in the patients’ neu- patient: heart rate 82 bpm, respiratory rate 17, blood pres- rological symptoms; and that renal tubular damage caused sure 127/72 mmHg, temperature 36.4°C, and oxygen satu- hypokalemia and mild acidosis. ration 98% on room air). Motor and sensory examination, reflexes, and cerebellar functions were also normal. All other Toluene (methylbenzene, toluol, phenylmethane) is an aro- systemic examination results were normal. matic hydrocarbon (C7H8) commonly used as an industrial solvent in paints, coatings, thinners, inks, detergents, phar- Initial laboratory examination revealed hypokalemia (K+= maceuticals, etc. It can be released in trace amounts from 1.9 mEq/l and 2.1 mEq/l) and mild metabolic acidosis (ar- some plastics.[1] Toluene is found in gasoline, acrylic paints, terial blood gasses: pH=7.32, pCO2=43, pO2=64, HCO3¯=18, varnishes, lacquers, paint thinners, adhesives, glues, rubber AG=16, SO2=99% for the first patient; pH=7.30, pCO2=44, cement, airplane glue, and shoe polish. At room tempera- pO2=61, HCO3¯=15, AG=18, SO2=98% for the second). The ture, it is a colorless, sweet-smelling, and volatile liquid. The ECGs were normal. Toxic drug screening for tetrahydrocan- principal effect of toluene exposure is central nervous sys- nabinol, amphetamines, methamphetamines, barbiturates, tem (CNS) depression including euphoria, hallucinations, benzodiazepines, cocaine, opiates, tricyclic antidepressants, delusions, tinnitus, dizziness, confusion, headache, vertigo, phencyclidine, and methadone was negative. seizures, ataxia, stupor, and coma.[2] Toluene has direct nega- tive effects on cardiac automaticity and conduction, and can The patients remained clinically stable and underwent cra- sensitize the myocardium to circulating catecholamines. Pul- nial computed tomography (CT), which was interpreted as monary effects include bronchospasm, asphyxia, acute lung normal. Magnetic resonance imaging (MRI) with turbo spin echo (TSE) T2-weighted and FLAIR (fluid attenuated inver- injury (ALI), and aspiration pneumonitis. Toluene can affect sion recovery) images showed damage to white matter skeletal muscles directly, resulting in rhabdomyolysis and structures and subcortical regions. myoglobinemia. Metabolic acidosis, hypokalemia, hematu- ria, proteinuria, distal renal-tubular acidosis, and pyuria have The apparently lipid-dependent distribution of MRI images been reported in chronic toluene toxicity, although these appeared to correlate with the common symptoms and effects have usually been reversible.[3] Patients with acute signs of industrial exposure to an organic neurotoxic such toluene poisoning may present with a range of pulmonary 98 Türkiye Acil Tıp Dergisi - Tr J Emerg Med 2012;12(2):96-98 and CNS symptoms depending on duration and route of ex- of initiating an investigation to resolve this issue. Unfortu- posure, and the level of toluene in the air or liquid. nately, since such investigations would require several days to complete, they provide no help in the assessment of pa- Toxicological risk assessment should be routinely performed tients in emergency situations.