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

我们报告了一名21个月大的小孩从外围中心转移到我们的拟除虫菊酯中毒,表现不典型。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于父母在家中呕吐而引起的吸入性肺炎,而不是毒素本身,尽管肺损伤的快速发展并不排除这种可能性。摄入后,他的意识水平下降,呼吸工作增加,并发展为急性呼吸窘迫综合征,败血性休克和多器官衰竭。在到达我们的单位后,他甚至在心肺复苏5分钟后立即出现了短暂的心脏骤停,并恢复了自发循环,这似乎更可能是在儿童转移过程中管理不当的结果。除抗生素和血管升压药外,他最初需要高频振荡通气和俯卧位,后来需要肺保护性常规通气。他的心肺状况逐渐改善,并在12天后成功拔管。其他器官系统也显示出完全恢复。即使在心脏骤停后几天进行的脑部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。他在三个月的随访中表现良好,没有神经功能缺损,运动耐受性良好,肾脏和肝脏功能正常。拟除虫菊酯中毒的非典型表现与严重的发病率有关,在儿童中似乎没有可靠的参数来确定同样的风险。考虑到没有特定的解毒剂,需要及时和积极的支持治疗才能获得良好的结果。该病例突出了摄入杀虫剂后儿科患者护理中的几个重要方面。首先,试图诱发呕吐,尤其是在医疗机构之外,不仅无效,而且非常危险,不应这样做。其次,不稳定的患者需要由经验丰富和训练有素的人员进行院内转移; 最后,应对这些复杂和非典型病例的管理应尽早在一个中心进行,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恢复和康复。

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