SummaryA 28-year-old male ingested 75 g of arsenic trioxide in a successful suicide attempt. The presentation, management and postmortem jndings are presented and discussed.
Key wordsPoisoning, acute; arsenic.
Case historyA 28-year-old self-employed analytical chemist attempted suicide by drinking a bottle of vodka and ingesting 75 g of arsenic trioxide. He fell asleep in his laboratory, awoke 4 hours later and admitted himself to hospital.On admission he was vomiting profusely and had copious watery diarrhoea. He had some abdominal discomfort, but there was no evidence of gastrointestinal bleeding. On examination he was alert and cooperative, but shocked (blood pressure 85/60 mmHg, pulse 100 beats/minute). His chest was clear, and his abdomen soft with bowel sounds; he had absent knee jerks, but good limb power and flexor plantar responses.Initial blood results showed that he was haemoconcentrated (haemoglobin 17.9 g/dlitre, haematocrit 0.57/litre) with normal urea, creatinine and electrolytes. Blood gases on air revealed a metabolic acidosis (Pao, 12.9 kPa, Paco, 3.7 kPa, base deficit 11 mmol/litre). His chest X ray showed a radiopaque substance in the stomach.Intravenous fluids were given, a urinary catheter inserted, and his stomach was washed out. Large volumes of saline were given via a nasogastric tube to purge the bowel. A suspension of activated charcoal was given to bind any unabsorbed arsenic. DMSA (2, 3-dimercaptosuccinic acid) capsules were brought by courier from the National Poisons Information Service and given orally. However, the patient vomited these and later dimercaprol was given intramuscularly.The patient was transferred to the Intensive Care Unit after initial resuscitation. Over the next 11 hours he remained alert, but continued to lose large amounts of body fluids. His central venous pressure was maintained between 0 and 9 cmH,O above the midaxillary line with 1 litre/hour of intravenous fluids (50% colloid, 50% crystalloid), with added potassium chloride (total 180 mmol). His urine output fell. A Swan Ganz catheter confirmed adequate left heart filling pressures (pulmonary artery wedge pressure 12 mmHg). Dopamine (at 2 lg/kg/minute) was given but the urine output failed to improve (27 mI/ hour), and his creatinine rose to 304 lmol/litre. He became more acidotic and was given aliquots of 8.4% sodium bicarbonate solution. His temperature rose to 38.4"C per axilla.The patient was transferred to a centre with dialysis facilities because of deteriorating renal' function. He remained alert and cooperative during the transfer, which took an hour. He had stopped vomiting and had an unquenchable thirst. His systolic blood pressure fell and was only maintained between 65 and 75 mmHg by three pressurised infusion lines. His breathing became progressively more acidotic and he was unable to move his legs, although sensation remained intact.Sixteen hours after ingestion, having had no previous arrhythmia, the patient developed a bradycardia and then asystole. He died despite attempted resuscitation....
