We are reporting a case of pyrethroid poisoning with atypical presentation in a 21-month-old toddler who was transferred to us from a peripheral center. Signs and symptoms at presentation were predominantly of cardiopulmonary dysfunction contrary to more common presenting features of gastrointestinal and neurological impairment. The reason for this seems to be the aspiration pneumonitis as a consequence of vomiting induced by parents at home, rather than the toxin itself even though a rather rapid progression of lung injury does not rule out the possibility. He had developed decreased level of consciousness and increased work of breathing after ingestion, which had progressed to Acute Respiratory Distress Syndrome, septic shock, and multi organ failure. He even had a brief cardiac arrest with Return of Spontaneous Circulation after 5 min of cardiopulmonary resuscitation, immediately after arrival at our unit, which seemed more likely to be a consequence of inappropriate management during transfer of the child. In addition to antibiotics and vasopressors, he required high frequency oscillatory ventilation and prone positioning initially, and lung-protective conventional ventilation later. His cardiopulmonary status improved gradually and he was successfully extubated after 12 days. Other organ systems also showed complete recovery. Even though Magnetic Resonance Imaging of brain done a few days after cardiac arrest showed features suggestive of hypoxic-ischemic encephalopathy he showed complete neurological recovery. He was thriving well at three-month follow-up with no neurological deficits, good exercise tolerance, and normal renal and liver function. Atypical presentation of pyrethroid poisoning is associated with significant morbidities and there seems to no reliable parameters in children to identify the risk of the same. Considering that there is no specific antidote, prompt, and aggressive supportive therapy is necessary for a favorable outcome. This case highlights several important aspects in the care of the pediatric patient after ingestion of insecticides. First, attempt to induce emesis, especially outside of a healthcare facility is not only ineffective but also highly dangerous, and should not be done. Second, unstable patients require inter and intrahospital transfer by experienced and trained personnel; and lastly, management for these complex and atypical cases should be done as early as possible in a center which is equipped to provide high level of circulatory and ventilatory support while prioritizing neuro-protective measures, and neurologic recovery and rehabilitation.

译文

:我们正在报告一例21岁大的婴儿中从典型的外围中心转移给我们的拟除虫菊酯中毒事件。表现时的体征和症状主要是心肺功能障碍,与胃肠道和神经功能障碍的更常见表现特征相反。造成这种情况的原因似乎是由父母在家中引起的呕吐引起的吸入性肺炎,而不是毒素本身,即使肺损伤的迅速发展并不排除了这种可能性。摄入后,他的意识水平下降,呼吸工作增加,已发展为急性呼吸窘迫综合症,败血性休克和多器官衰竭。他在到达我们单位后立即进行了5分钟的心肺复苏,甚至在短暂的心脏骤停后恢复了自发性循环,这似乎更可能是由于孩子转移过程中处理不当造成的。除了抗生素和血管升压药外,他还需要高频振荡通气和俯卧位,之后需要常规的肺保护通气。他的心肺状态逐渐好转,并在12天后成功拔管。其他器官系统也显示出完全恢复。即使心脏骤停后几天进行的脑磁共振成像显示出提示缺氧缺血性脑病的特征,他仍显示出完全的神经功能恢复。在三个月的随访中,他表现良好,没有神经功能缺损,良好的运动耐受性以及正常的肾和肝功能。拟除虫菊酯中毒的非典型表现与高发病率相关,儿童中似乎没有可靠的参数可确定其危险性。考虑到没有特定的解毒剂,迅速而积极的支持疗法对于取得良好的结果是必要的。该病例突出显示了在摄入杀虫剂后对小儿患者进行护理的几个重要方面。首先,尝试引起呕吐,尤其是在医疗机构外部进行呕吐,不仅效果不佳,而且非常危险,因此不应该这样做。其次,不稳定的患者需要经验丰富且训练有素的人员进行医院内部和医院之间的转移;最后,应对这些复杂和非典型病例的治疗应尽早在中心进行,该中心应提供高水平的循环和通气支持,同时优先考虑神经保护措施以及神经系统的恢复和康复。

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