medical emergency

2.  Super-vasmol poisoning is emerging as a
major cause of suicidal poisoning in India…as
it is a cheap ,freely available hair dye
 It contains potential toxins like PPD which can
result in multiorgan dysfunction

3. The main important constituent is
 PPD(paraphenylene diamine)- <4%
Other constituents are
 Propylene glycol
 Resorcinol
 EDTA Sodium
 Ceto stearyl alcohol
 Sodium lauryl sulphate
 Liquid paraffin
 Preservatives and water

4.  PPD(paraphenylene diamine):it is the major toxin
among all constituents
 PPD metabolised by CYP450 to form
BRANDOWASKI’S BASE
It is an anaphylactic,highly toxic
and strongly mutagenic
The lethal dose is 7 to 10 gms..
But 3gms is sufficient to cause systemic
complications

5. It produces both local and systemic effects.
Systemic effects occurs in two phases:
 Phase 1
Acute presentation (4-6hrs):cervicofacial
edema,airway obstruction,gastritis and severe
vomiting.
 Phase 2
Subacute presentation withARF,rhabdomyolysis
and hemolysis.
Hepatitis.
Hyperkelemia,hypocalcemia,hyperphosphatemia.
Severe metabolic acidosis

6.  Even 5 to 10 ml super vasmol can cause
laryngeal edema due to direct toxic effect of
PPD on membranes..
 No specific antidote available for PPD,hence
management is only symptomatic &
supportive .
 Development of pneumothorax is reported
following laryngeal edema
Intense inspiratory effort secondary to
laryngeal edema leading to overdistension of
alveoli.

7. Local effects of PPD:
• Skin iritation
• Contact dermatitis
• Chemosis,lacrimation and exopthalmous
• Permanent blindness

8.  Chronic hair dye use is associated with non-
Hodgkin’s lymphoma,multiple myeloma,acute
leukemia,and bladder cancer

9.  Resorcinol-
it causes methemoglobinemia and
renal toxicity
 EDTA sodium-
it causes hypocalcemia
 Propylene glycol-
it is ass. with hyperosmolarity, CNS depression,
arrythmias
it is nephotoxic and results in high anion
gap metabolic acidosis and acute renal failure.

10.  In addition to these a few hair dyes also
contain Lead acetate and Bismuth sulphate
which causes CKD and Acute interstitial
nephritis respectively..

11. 1.Angioedema or Cervicofacial edema:
 Early manifestation (within 4-6 hours) include
respiratory distress due to swelling of upper
airway and angioedema
 Angioedema is immunologically
mediated,anatomically limited,nonpitting edema.
 It is an abrupt swelling of the dermis and
subcutis

12.  STAGING OF ANGIOEDEMA:
This is to predict airway risk at presentation.
Stage 1 - Facial and lip edema
Stage 2 - soft palate edema
Stage 3 - Lingual edema
Stage 4 - Laryngeal edema

13. 2.RHABDOMYOLYSIS:
 Symptoms are back pain,limb
pain,generalised myalgias
 Acute muscle necrosis is the cause for
tenderness and local edema of muscles

14.  The initial sign of rhabdomyolysis is the
appearance of cola-colored urine
 There is dissolution of striated muscle fibres, with
leakage of muscle Enzymes,myoglobin,
potassium,calcium and other intracellular
constituents.
 CK levels are the most sensitive indicators of
myocyte injury.

15. 3.RENAL FAILURE:
 It testifies to the severity of intoxication.
 The causes are
Toxic injury
Myoglobinuria
Hemoglobinuria
Hypovolemia
Propylene glycol is also a nephrotoxic

16. 4.MYOCARDITIS:
It is due to rhabdomyolysis of myocardium
It is reported in 15% of cases with mortality
rate of 29%.
Ventricular arrythmias,sudden cardiac death
5.Neurological:convulsions

17. Cause of death:
Respiratory obstuction
Renal failure
Arrythmias
ARDS

18.  Treatment is aimed at rapid identification of
potentially life-threatening complications and
prevention of renal failure
 GASTRIC LAVAGE: is useful if the
patient presents within 1 hour of ingestion but
contraindicated if airway protective reflex is lost.
 Airway protection is the most important
consideration with laryngeaal edema…it should
be ensured with timely endotracheal intubation
or tracheostomy.

19.  Steroids – hydrocortisone 200mg stat f/b
100mg every 6th hourly.
If not responded to hydrocortisone ,
methyl prednisolone 125mg iv infusion given
6th hourly

20.  In the event of life threatening reaction
involving urticaria with angioedema or
laryngeal edema Epinephrine may be neded
to stabilise the patient

21.  Aggressive fluid resuscitation
with isotonic fluids to restore the renal
perfusion and increase renal flow is necessary
to prevent AKI

22.  Dialysis support may be life saving when
oliguria develops.
 Myocarditis requires continous cardiac
monitoring in order to timely intervene life-
threatening arrythmias and sudden cardiac
death.

23.  Alkaline diuresis- using isotonic
saline,sodium bicarbonate and diuretics
 Sodabicarb 20meq 8th hourly

24.  In conclusion,hair dye poisoning is a life-
threatening emergency which requires
emergency resuscitation and aggressive
management of anaphylaxis
 Preventing renal failure is a very important
goal,since its occurrence is associated with
high mortality and increase in ICU stay
 The time of development of renal failure is
uncertain and hence all patients should be
monitored in hospital for renal failure
complications…