Alkaline Diuresis and Pre-emptive Hemodialysis as Treatment for 2, 4-Dicholorophenoxy Acid Herbicide Intoxication

Abstract

Introduction: Chlorophenoxy herbicides poisoning is very rare. It is used widely to control broad-leaved weeds. 2, 4-D is a Chlorphenoxy herbicide which has no antidote. The mission of this case report is to emphasize the role of accurate diagnosis and management of 2, 4-D herbicide intoxication. Case Report: 19 year old male was admitted 6h after the deliberate ingestion of the contents of a half bottle (300 ml) of weedkiller named Dallas contents of which were 59% w/w 2,4-D acid tech, 30% w/w Di-methylamine. Soon after ingestion the patient gave history of vomiting, after which patient became unconscious. On examination, RR was 35/min with a saturation of 90% on room air requiring 5-6L/min of oxygen. The pupils were small, 1.5 mm in diameter, reactive. Arterial blood analysis showed mild Metabolic acidosis. Gastric aspiration and lavage were performed. Patient was unresponsive to deep painful stimulus. He was sweating profusely with a temperature of 39 degree Celsius. Patient was electively intubated for airway protection. Patient was admitted in the ICU. The total leukocyte counts were 17000/cmm. Liver function and kidney function tests were within normal limits. CPK total was 3150. Over the next 7 hours, patient’s condition worsened and the blood pressure started dropping to 80/50 mmHg. Patient was started on vasopressor support. Alkaline diuresis was started by giving 1 meq/kg sodium bicarbonate in 0.9% normal saline, 100 ml iv within the  next 30 minutes and then added  with 75meq of sodium bicarbonate and 25 meq of potassium in 500 ml 5% dextrose within 8 hours. Inj Furosemide 20 mg was given every 12hours intravenously. On the second day, patient’s laboratory investigations showed a rising trend in TLC, creatinine rose to 2.4 mg/dl from 1.1mg/dl on the day of admission. Patient’s metabolic acidosis also worsened.  Patient’s output dropped to 5-10 ml/hr. Patient was then taken on Haemodialysis. Patient’s urine output improved and GCS also improved. Three cycles of haemodialysis were done, the TLC showed a falling trend with normalising creatinine, metabolic acidosis also improved; pH normalised and patient was extubated on the fourth day. Patient was then shifted to ward and discharged subsequently on clinical improvement. Conclusion: 2,4-Dimethylamine intoxication is uncommon, doesn’t have an antidote with very  high morbidity and mortality. Alkaline diuresis as a life-saving treatment  and must  be supplemented by  other  therapies  including decontamination  of  the  gastrointestinal  system, initial  emergency  resuscitation  and supportive treatment with  haemodialysis as and when required.