Potassium permanganate poisoning is an acute or chronic intoxication caused by the ingestion of a xenobiotic by mouth, inhalation or transdermal method. It is characterized by the appearance of signs of chemical burns of the gastrointestinal tract, edema of the respiratory tract, multiple organ failure. It is diagnosed on the basis of anamnesis, clinical picture, information obtained with the help of instrumental studies (gastroscopy, bronchoscopy, contrast radiography). Specific treatment is the treatment of mucous membranes with ascorbic acid, tetacin—calcium or unithiol as a complexing compound.
T57.2 Poisoning with potassium permanganate and its compounds
Potassium permanganate (KMnO4) belongs to the category of cauterizing poisons, causes severe chemical damage to tissues. It is a strong oxidizer, in the body it is converted to caustic alkali, atomic oxygen, manganese dioxide. Chronic poisoning with this substance is common in young children, acute — in people with mental disabilities, workers of chemical enterprises and agricultural industries, where the substance is used as fertilizer. A dose of 0.3-0.5 g / kg of body weight is considered lethal for an adult. In a child, changes incompatible with life occur with the simultaneous consumption of 2.5-3 grams of the drug.
Chronic poisoning with potassium permanganate in young children is usually observed when they are bathing in concentrated solutions. The critical dose accumulates after 2-3 weeks. The greatest danger of baths with KMnO4 is for a child under the age of 1 year, whose skin has maximum sensitivity to chemical exposure. Other possible causes of pathology include:
- Accidental use. The concentrated solution looks like tea or Coca-Cola. Sometimes this becomes the reason for its erroneous use in food. The risk increases when storing the product in bottles from popular drinks. Children, mentally ill people, old people with reduced intellectual function are at risk.
- Suicide attempt. There are situations when potassium permanganate has been used for suicidal purposes. The victims took a saturated solution of the drug, which caused severe chemical burns, systemic damage to a number of organs. When using dry powder, damage to the upper gastrointestinal tract is usually detected.
- Inhalation of aerosols. Occurs when safety precautions are violated while working with fertilizers or using potassium permanganate as a chemical reagent. It can occur during industrial accidents, in which a toxicant in the form of an aerosol is sprayed through the air of the working area.
- Self-medication. Potassium permanganate is used in many recipes of folk and traditional medicine for the treatment of poisoning, gastric lavage, cauterization of skin defects. In most cases, the solution should be pale pink. Failure to comply with this recommendation leads to poisoning, accompanied by chemical burns.
The pathogenesis of acute processes is based on the defeat of the mucous and submucosal layers of the gastrointestinal tract. Coagulation necrosis, swelling and ulceration of tissues, hidden bleeding are formed. Possible perforation of the esophagus or stomach with the development of peritonitis. When a toxicant enters the respiratory tract, similar processes occur in the tissues of the oropharynx, trachea, bronchi. This leads to mechanical asphyxia, death of the patient from acute respiratory failure. An additional pathogenetic factor is a state of shock.
Systemic phenomena are caused by the accumulation of manganese and potassium in the body. In this case, Mn is deposited inside the kidneys, lungs, heart and central nervous system, disrupting their work. Its increased concentration in plasma is noted for an hour after absorption from the mucosa of the small intestine. Further, the amount of trace element in liquid media is normalized. The K+ content in the blood increases significantly, which has an additional negative effect on the functioning of the cardiovascular system.
Potassium permanganate poisoning is classified using several principles. There is a division by reasons (suicidal, accidental, domestic); by the ways of penetration of poison into the body (inhalation, percutaneous, enteral); by the presence of complications (with the development of edema of the respiratory tract, with perforation of the stomach, with the occurrence of traumatic shock). The most common criterion for systematization is the severity of the process:
- Easy. The symptoms are moderately pronounced, mainly the upper parts of the digestive apparatus, the oropharynx are affected. The inflammation is catarrhal-fibrinous, the pain syndrome is insignificant, does not require the use of narcotic analgesics. There is no threat to the victim’s life.
- Medium. The mouth, stomach, and esophagus are damaged. Exotoxic shock phenomena may occur. The inflammatory process acquires a catarrhal-serous character. The symptoms of moderate damage to the urinary and hepatobiliary systems are determined. When xenobiotic enters the respiratory throat, there is swelling with difficulty breathing. Consciousness is usually preserved.
- Heavy. There is a burn of the esophagus, stomach, oral cavity, small intestine. Perforation of the gastrointestinal tract may occur. Severe exotoxic shock is detected, a violation of consciousness up to coma. Inflammation of the ulcerative-necrotic type, kidney and liver damage before the occurrence of multiple organ failure is detected.
The formation of a characteristic clinical picture is noted. All symptoms can be divided into general and local signs. The local ones include the brown-purple color of the affected mucous membranes, their puffiness, the presence of bleeding erosions. Sometimes whole crystals of insoluble potassium permanganate are found inside the folds. Laryngoscopy shows a narrowing of the glottis, which is manifested by hoarseness, barking cough. Massive edema causes respiratory failure.
Mechanical asphyxia, which occurs as a result of low patency of the upper respiratory tract, is manifested by generalized cyanosis of the skin, pronounced inspiratory dyspnea, inclusion of intercostal muscles in the breathing process, inflating of the wings of the nose, anxiety. Trauma can also be accompanied by a shock clinic: a sharp decrease in blood pressure, tachycardia, pallor or marbling of the skin, a decrease in diuresis up to complete absence, centralization of blood circulation.
The list of common toxic effects that occur at the somatogenic stage of poisoning includes psychomotor agitation due to central nervous system damage, convulsions, general weakness, abdominal and chest pain, decreased muscle tone. Methemoglobinemia develops, exacerbating the severity of the condition. It is possible to form toxic hepatitis with the appearance of vomiting, pain in the right hypochondrium, skin exanthema. In acute renal failure, anuria, increased blood pressure, swelling, vomiting and nausea are detected.
Transdermal intake of poison in chronic poisoning leads to the appearance of inflammatory foci on the skin with black dots in the center. Microscopic examination reveals epithelial necrosis, zones of perivascular hemorrhages, exudation. Areas of lamellar peeling and deep cracks form on the skin. The remaining integuments are over-dried, the turgor is reduced, the color is dark or purple. All this is accompanied by certain signs of systemic damage.
At an early stage, poisoning with potassium permanganate causes the development of shock and suffocation. Shock occurs in severe and moderate poisoning in about 40% of cases. Severe asphyxia, provoked by swelling of the vocal cords, is diagnosed in 10-20% of victims. Moderate respiratory failure occurs in 30% of cases. At the somatogenic stage, multiple organ failure is a significant danger. With the defeat of three or more systems, the mortality rate is 70%.
Among the late complications developing at the healing stage is the formation of esophageal strictures with impaired patency. Such changes are detected after severe burns in 20-25% of patients, require surgical correction. Before the plastic surgery, a gastrostomy is applied to the patient, which allows liquid food to be injected directly into the stomach. In addition, there is a risk of gastrointestinal bleeding, which is detected at the stage of burn scab discharge. As a rule, this happens at 3-4 weeks of illness when the recommended diet is violated.
Diagnosis is carried out by an emergency medical doctor, a toxicologist or a resuscitator of the acute poisoning center. You may need to consult a surgeon, a combustiologist. An endoscopist is involved to conduct an instrumental examination. Differentiation with poisoning with other cauterizing poisons is necessarily carried out: acetic essence, caustic alkalis and hydrogen peroxide. Diagnostic search is implemented in the following areas:
- Physical examination. There are symptoms characteristic of poisoning with cauterizing liquids. During auscultation, harsh or wheezing breathing, wheezing may be heard. Systolic blood pressure rises to 150-180 mm Hg. Against the background of shock, this indicator drops to 60-40 mm or becomes undetectable. In the somatic period, an increase in the liver is detected by percussion.
- Instrumental examination. At the initial stage of diagnosis, gastroscopy is indicated. The volume of the lesion, the presence or absence of bleeding, perforation is determined. Abdominal radiography is performed to detect free fluid. It is necessary to register an ECG, which usually shows a change in the shape and height of the T wave corresponding to hyperkalemia.
- Laboratory examination. The blood potassium content exceeds 5.3 mmol/liter. The hemoglobin level decreases to a value of >132 g/l in men and >115 grams/liter in women. There is an accumulation of lactate of more than 2.4 mmol / l, a change in the activity of liver enzymes. With severe inflammation, there is an increase in the number of leukocytes. Respiratory failure leads to a decrease in SpO2 of less than 95%.
Severe poisoning requires a comprehensive approach to treatment. The period of stay in the hospital sometimes reaches 2 months, outpatient follow-up is carried out for 4-6 months. Sometimes the victim needs surgical or resuscitation assistance. With the timely initiation of therapy and the use of recommended methods, complete recovery can be achieved in 90% of cases. Hospitalization of the patient is carried out in a specialized toxicological center or medical facility, where there is an emergency surgery department, an ICU unit.
At the prehospital stage or immediately after delivery to the hospital, washing is carried out through a nasogastric probe. To do this, use a solution made by mixing 100 ml of 3% hydrogen peroxide, 250 ml of 3% acetic acid and 2 liters of cool water. The procedure is continued until the washing composition becomes clean. Visible mucous membranes are treated with ascorbic acid. Under the action of these agents, the toxicant is converted to harmless compounds. After the procedure, activated charcoal is injected at a dose of 1 g / 10 kg of weight.
Systemic treatment consists of the administration of complexing antidotes (tetacin-calcium, unithiol). A solution of ascorbic acid 5% in an amount of 50-100 ml / day is prescribed through the mouth. Analgesics, sometimes narcotic, are used for the purpose of anesthesia. To reduce the swelling of the mucous membranes, the victim is inhaled sodium bicarbonate with the addition of local anesthetics. Prevention of infectious complications requires the addition of broad-spectrum antibacterial agents to the treatment regimen.
With the development of shock, cardiovascular, respiratory and multiple organ failure, the patient is transferred to the intensive care unit, where active detoxification methods can be used: replacement blood transfusion, hemodialysis, forced diuresis. In case of shock, the patient is transferred to a ventilator, cardiotonics, glucocorticosteroid hormones, adrenaline are connected. Hypoxia caused by the closure of the respiratory tract requires the imposition of a tracheostomy.
Bleeding arising from ulcers of the esophagus and stomach is stopped with the use of hemostatic drugs. In the absence of the effect of conservative therapy, hemostasis is carried out by the endoscopic method. The damaged area is pricked with a solution of adrenaline or cauterized with colloidal silver. Convulsions are an indication for infusion of barbiturates, benzodiazepines and anxiolytics. It is necessary to monitor the patient’s condition around the clock with the use of an anesthesiological monitor.
It is required for non-stop bleeding, gastrointestinal perforation, volumetric intestinal necrosis, as well as at late stages of healing with formed strictures. In the first case, profuse or prolonged capillary hemorrhages occurring on a large area of the esophagus serve as an indication for intervention. Through holes in the wall of the digestive system are an indication for emergency surgery, since they are usually accompanied by the development of peritonitis, which creates an immediate threat to life. Without help, the mortality rate is 100%.
With the death of tissues, the need for surgical treatment is due to the functional failure of the digestive system and endotoxicosis, which occurs when the products of the decay of the intestinal wall are released into the blood. Strictures that interfere with the passage of food are eliminated in cases when the narrowing reaches 40-50%. Lesser degrees of stenosis make it possible to refuse surgical correction if the patient observes certain restrictions in food.
Prohibitions at the recovery stage mainly relate to nutrition. In the first 2-3 days, fasting or parenteral infusion of protein-lipid mixtures, glucose is recommended. Further feeding is carried out with cold liquid porridges, broths. Their introduction is carried out fractional 5-6 times / day in small portions. By the end of the first week, the patient is allowed to consume enveloping porridges and broths based on rice, crushed cereals. The temperature of the dishes should not exceed 20-25 ° C. Failure to comply with this rule increases the risk of bleeding.
The restoration of the diet is carried out for a long time, for 6 months or more. After discharge from the hospital, it is allowed to use mashed potatoes cooled down to 30 ° C, mashed meat, boiled fish, any soups, porridges. More solid foods (bread, cheese, untreated meat) are introduced into the diet only after the scab has completely disappeared and wounds have healed. Until the moment of full recovery, the intake of alcohol, spicy, pickled, traumatic esophageal varieties of food is prohibited.
Prognosis and prevention
Mild and moderate potassium permanganate poisoning has a favorable prognosis. The number of life-threatening complications does not exceed 2-5%. The indicator increases sharply with severe burns associated with damage to the intestines, respiratory tract. Certain complications that pose a vital risk are noted in 80-90% of cases. The total mortality rate in case of potassium permanganate damage reaches 30%. The prognosis worsens with an increase in the time elapsed from the moment of taking the toxicant to the beginning of therapeutic measures.
Prevention of poisoning with potassium permanganate consists in storing a chemical substance out of the reach of children, the elderly and patients with a psychiatric diagnosis. It is strictly forbidden to keep the solution in food containers. For bathing children, a minimum concentration of the product is used. The water should be pale pink, not purple or black. When working with the drug at work or at home, it is recommended to use closed clothing and personal respiratory protection (mask, respirator, gas mask).