Metals

Ruck

Normal Lead Level

0 is the goal - no safe level of lead

no normal level however usually 2-3

no action level

Who gets lead poisoning?

anyone who is exposed to lead

Sources of Lead

*you don’t absorb lead through the skin*

herbal/natural/folk remedies

• often contaminated with heavy metals

• •Ayurvedic, alternative medicine, Sindoor

  • bought and sold by weight

lead in soil

hobbies - painting, pottery, stained glass, ammunition, gun ranges

occupations - construction workers, remodelers, plumbers, painters

lead dust brought into home

• children exposed

homes before 1978

•Cosmetics

•Imported Food

•Water

Lead Exposure side effects

n/v → actue ingestations

most lead poisoning are chronic or acute on chronic

brain damage

neurodevelopmental delays

especially in children and even in-utero

• hearing loss

• lower of IQ

• ADHD - decreased attention

• underperformance at school

• learning and behavioral disorders

• seizures

slow growth - short stature

adults

seizures

anemia

anorexia

constipation

hypertension

sexual dysufnction

motor neuropathy

anything seen in adults can be seen in a child na vice vera

may are unresverible

What should be done is lead exposure is detected?

A blood lead test is the best way to determine if someone has been exposed to lead

A child with lead poisoning may not have visible signs or symptoms.

• Parents can talk to their child’s healthcare provider about getting a blood lead test if their child may have been exposed

When should a lead test be done?

+age, how many?

Children should get 2 lead tests

•ages 12 and 24 months

•ages 24–72 months if there is no record of ever being tested

• When there is a suspected exposure

  • Eating non nutritional substances

    • Pica

•Live or spend time in a house or building built before 1978.

• Are from low-income households.

  • Often related to housing

• Are immigrants, refugees, or recently adopted from less developed countries?

• Live or spend time with someone who works with lead.

  • Construction workers

• Live or spend time with someone who has hobbies that expose them to lead

Lead Tox. General Management

+outpatient - who qualifies, inpatient - levels, therapy, child vs adult

outpatient treatment

• patients who have lead levels below the range that is considered potentially encephalopathogenic ( < 60 μg/dL)

  –Who can be kept away from further lead exposure

separation from the source! = best treatment

nurse from the local/regional health department is supposed to contact the family for any lead > 3.5

Drug therapy for leads > 45 (> in the adult)

• The child will generally be hospitalized to start therapy - abdominal oil want no lead in gut

• Clear gut of lead with polyethylene glycol before chelation therapy

• Chelation

• Remains in hospital until lead falls significantly AND there is a lead-safe home to go to. 

Treatment - Symptomatic Patients

+agent, levels, indication, moa, place in therapy, efficacy

•BLL <44

• Routine chelation is not indicated

• Separation from source

• Prior to chelation

  • Child is separated from lead

    • Lead free environment

    • No lead in gut

    • Abdominal x-ray

      • Whole bowel irrigation if needed

• Some data shows

  • Chelation might enhance absorption of residual gut lead

Place in therapy

• Seriously symptomatic

  • Risk vs benefit of treating with lead in gut agent used

not a “cure-all” for lead poisoning

• Chelation is a “chemical process in which a substance is used to bind molecules, such as metals or minerals, and hold them tightly so that they can be removed”

• not very efficient

  • Removes only a small portion of the body's burden

    •incapable of dramatically decreasing the body burden of lead

    –only several milligrams of lead are eliminated during chelation

–Still unproven is the exact effect of cognition, behavior, learning

Treatment - Asymptomatic Patients

+agents, levels, place in therapy

lead tox. BLL 45-69

Gold standard w/this level: Oral succimer 

• comes in 100 mg capsules - can be opened and sprinkled on applesauce

– Q8H (not TID) x 5 days then  Q12 H (not BID) for 14 days

*always suggest rounding up*

OR

CaNa2EDTA (Calcium Di-Sodum EDTA)

• continuous infusion

• DO NOT CONFUSE WITH edeatate disodium → electrolyte abnormalities (no longer on market in US)

*both used in levels over 69*

Dimercaprol (BAL)

therapy for lead tox outside US

not available in US

• not an option

Ecephalopath treatment in Lead tox.

CaNa2EDTA + oral succimer

Succimer

+indication, moa, ADRs, administration, major cancer, make sure…?

lead toxicity w/ BLL: 45-69

• no benefit noted on measures of cognition, neuropsychistricc function, or behavior

moa: orally active chelator

administration: 100 mg - round up doses

hard to give to patients that are unconscious - adheres to NG tube

• Cannot be placed into solution or suspension

  • Place on top of apple source if needed

    • DO NOT place in medicine cup

ADRs

»Transient increases in AST and ALT

»Flatulence, diarrhea and abdominal pain

»Chills, fever and rash

»Anaphylaxis (rare)

Major concern with its outpatient use is continued lead exposure → increased lead toxicity

Make sure:

»lead free home

»parent has Rx for succimer

»parent brings in medication prior to child being discharged

»Parent demonstrated medication administration

page 22 -31 (maybe just read through

Clinical Manifestations of Lead Poisoning in children

+severity and blood level

the higher the level the greater the risk

level of >45 worse

When is damage from lead posisoning permanent?

we dont know with the neurologic sequlae

• treatment can prevent from getting worse

certain conditions (anemia, constipation) with reverse with treatment

Lead blood levels as low as 10μg/dL is associated with?

Blood lead levels as low as 10μg/dL, which do not cause distinctive symptoms, are associated with decreased intelligence and impaired neurobehavioral development.

Calcium Disodium (CaNa2EDTA)

+indication, administration, ADRs

indication: severe lead poisoning

• used in less sever cases when succorer is not an option

• administration: bioavailability: <5% → IV use only

ADRs - greater concentrations

• thrombophlebitis (vein wall inflammation)

• renal toxicity caused by lead in the kidneys during excretion

Disodium EDTA

can lead to life-threatening hypocalcemia and death

hypocalcemia is no longer a concern with CaNa2EDTA

When to use chelators?

BLL over 45!!!!

dont use to diagnose!! (will come out in urine so its understandable urine will be high) 54:30

no chelation mobilization tests!!!

• given to help mobilize a metal

• given prior to a lab test to show how much metal in your body will come out

• no place in “clinical medicine” today

  • no use for diagnosing ANY heavy metal exposure

Potential Causes for rebound

“rebound phenomenon”

• non-adherence

• inadequate treatment

• re-exposure

• enhanced absorption post chelation therapy

“Rebound Phenomenon”

> 80 % of a body burden of lead is not in the plasma compartment

• it is not available for chelation

• chelation only lowers soft tissue lead

• once chelation is stopped, lead may rebound from the other compartments

• Not unexpected for the lead level after 2 weeks of drug-free period to approach the original pre-treatment level

  • If this occurs, repeat chelation is suggested.

Thallium tox manifestation

parathesia - a sensation of the skin that may feel like numbness progressing to severe pain to the point of refusing to move legs

Thallium

+ADME, mechanism of toxicity and manifestations,

Thallium is rapidly absorbed

• Dermal

• Inhalation

• GI: 90% bioavailability

mechanism of toxicity:

• Behaves biologically similar to potassium

  • because both have similar ionic radii

  • cell membranes cannot differentiate between thallous (Tl⁺¹) and potassium (K⁺) ions

  • thallous ions accumulate in areas with high potassium concentrations

    • Central and peripheral nervous system

    • Liver

    • Muscle

Prussian Blue (Radiogardase)

National Stockpile

thallium antidote

•RX

•stockpiled for emergencies (Strategic National Stockpile)

•Available via the state’s public health officials

• FDA approved

• Orally

  • ion exchanger

  • interferes with the enterohepatic recirculation of thallium

    • exchanging potassium ions  for thallium ions in the GI tract

GI manifestations in thallium tox

+timeline, symptoms

Abdominal pain (most common),  nausea, vomiting = 3-4 hours post-exposure

Diarrhea or constipation (decreased GI motility) = scute stage

Rarely: blood in vomitus/stool = acute stage

Neurologic Manifestations in thallium tox

+timeline, manifestations

• Usually appear 2 to 5 days after exposure

neurologic sequalae

• Severe painful, ascending sensory neuropathy (2–5 days)

  • paresthesias are present in the lower extremities (especially the soles of the feet)

  • Even weight of bedsheet is painful

• Distal motor weakness, lower limb predominance

• Ataxia, tremor, seizures, insomnia, coma

• Cognitive/psychotic effects: confusion, delirium, agitation, depression

Dermatologic & Hair/Nail Changes in Thallium tox

+timeline, manifestations

• Diffuse alopecia (2–3 weeks)

  • Sometimes the first sign of chronic exposures

  • Approximately 10 days and is maximal within 1 month

• Mees’ lines (nail transverse white lines, 3–4 weeks)

• Palmar erythema, scaling, pustular eruptions

• Optional: diagram showing timeline of hair loss progression

Ocular and CV Manifestations in Thallium tox.

Ocular

•Diplopia, abnormal color vision, ptosis

•Toxic optic neuropathy and lens changes

•Include an icon or schematic of the eye to anchor visual understanding

CV - thallium moves like K+

•Tachycardia, hypertension, pleuritic chest discomfort

•Rare severe outcomes: multi-organ involvement

Thallium toc diagnosis

No specific lab test

•Many present days to weeks after exposure

•X-ray of suspected food

•High index of suspicion

Established by demonstrating elevated thallium concentrations in various body fluids or organs

•Hair

•Nails

•feces

•Saliva

•CSF

•Blood

•urine

Treatment of Thallium Poisoning

Separation from the source

• GI decontamination

  • orgostatic or nasogastric lavage

    • if no spontaneous emesis and present within 1 to 2 hours after ingestion

  • multiple dose AC

    • interrupts enteropathic recirculation (even inhaled or dermal)

  • Whole-bowel irrigation with polyethylene glycol

    • for large ingestions or the presence of radiopaque material on abdominal radiographs

Symptoms of Mercury Toxicity

dysesthesias (distorted, unpleasant, or painful sensations)

weakness of her upper extremities

condition progresses to dysarthria, blurry vision, and gait unsteadiness, leading to hospital admission

• Progressed to agitated delerium

What toxin can you find in fish and skin lightening products?

Mercury

small amount of liquid mercury not really toxic

inhalation = dangerous

• do not heat up