Emergency Medicine Book

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Lead Poisoning

Aka: Lead Poisoning, Lead Intoxication, Lead Toxicity
  1. Causes
    1. Home renovation or remodel
      1. Household dust
      2. Paint chips from lead-based paint
    2. Drinking water from lead pipes (or contaminated from lead solder, valves or fixtures)
    3. Industrial waste exposure (e.g. soil contaminated with lead)
    4. Residence near busy highway
    5. Tea Kettles
    6. Vinyl mini blinds
    7. Imported candy (e.g. Tamarind candy from Mexico stored in lead-contaminated ceramics)
    8. Imported eye cosmetics (e.g. Kohl or Surma from India, or other eye cosmetics from Pakistan)
    9. Imported Jewelry or Toys
    10. Parents with occupational exposure (i.e. Take-home exposures)
      1. Lead production or smelting
      2. Battery manufacturing
      3. Brass, copper or lead foundry
      4. Radiator repair
      5. Scrap handling
      6. Ship and bridge demolition
      7. Old painted metal welding
      8. Thermal paint stripping of old buildings
      9. Old paint sanding
      10. Lead soldering
      11. Ceramic glaze mixing
      12. Cable stripping
      13. Firing range staff
      14. Machining or grinding lead alloys
    11. Pica secondary to Anemia
      1. Eating lead paint or soil
    12. Herbal remedies containing lead
      1. See Lead-Containing Herbal Remedies
  2. Symptoms
    1. Anorexia
    2. Headache
    3. Abdominal Pain
    4. Nausea and Vomiting
    5. Constipation
  3. Signs
    1. Lead line in gums
    2. Papilledema
    3. Ocular palsy
    4. Wrist drop
    5. Foot drop
    6. Slurred speech
    7. Reflex changes
    8. Bradycardia
    9. Mental status changes
      1. Seizures
      2. Delirium
      3. Coma
  4. Labs: Screening
    1. Blood Lead Level
      1. See below for protocol
    2. Indications
      1. Previously universal screening was in place before 1997 in Uniited States
        1. Now screen child considered high risk or all children for whom risk is unknown or uncertain
      2. All Medicaid enrolled or eligible children (age 1-2 years or catch-up at age 36-72 months)
      3. All recent Immigrant Children on arrival and again in 3-6 months later (ages 6 months to 6 years old)
      4. High risk children
        1. Identified by state or local screening recommendations
        2. Child lives in, visits, or attends child care in a house built before 1950
        3. Child lives in, visits, or attends child care in a house built before 1978 undegoing renovation in last 6 months
        4. Child has sibling or playmate that has Lead Poisoning
  5. Labs: Advanced (indicated for lead level >20 mcg/dl or 0.97 umol/L)
    1. Peripheral Smear
      1. Stippled erythrocytes
    2. Complete Blood Count (CBC)
      1. Microcytic Anemia
      2. Leukocytosis
    3. Reticulocyte Count
    4. Urinalysis
    5. Comprehensive metabolic panel
    6. Iron Deficiency Anemia labs (TIBC, Ferritin)
  6. Labs: Other findings suggestive of Lead Toxicity
    1. Urine lead level elevated
    2. Urine microscopy of sediment or renal biopsy
      1. Acid-fast inclusion bodies in tubular nuclei
      2. Pathognomonic for Lead Poisoning
    3. Free Erythrocyte Protoporphyrin (FEP) > 0.6 umol/L
  7. Imaging
    1. Abdominal XRay
      1. Indicated for moderate, high or very high lead level of 20 mcg/dl or greater
      2. Identifies lead remaining in the intestinal tract (radiodense)
    2. Long bone XRay
      1. Epiphyseal lead line
  8. Protocol
    1. General
      1. Education should be done at all abnormal lead levels
    2. Lead level 10-14 mcg/dl (0.48 to 0.68 umol/L): Low Lead Toxicity level
      1. Lead level at 0 months
      2. Lead level at 3 months
      3. Lead level at 6-9 months
    3. Lead level 15-19 mcg/dl (0.72 to 0.92 umol/L): Low Lead Toxicity level
      1. Lead level at 0 months
      2. Lead level at 1-3 months
        1. If lead level still >15 mcg/dl proceed to follow lead level of 20-44 mcg/dl
        2. If lead level <15 mcg/dl, continue with education and observation
      3. Lead level at 3-6 months
    4. Lead level 20-44 mcg/dl (0.97 to 2.13 umol/L): Moderate Lead Toxicity level
      1. Lead level at 0 months
        1. Environmental investigation and lead hazard reduction
        2. Complete history, exam, lab, XRay as above
        3. Consider bowel Decontamination if ingestion suspected (consider abdominal XRay)
          1. Enemas used to clear retained lead products
      2. Lead level at 2-4 weeks
      3. Lead level at 1 month
    5. Lead level 45-69 mcg/dl (2.17 to 3.33 umol/L): High Lead Toxicity level
      1. Lead level at 0 months
        1. Includes measure done for lead level of 20-44 mcg/dl
      2. Lead level pre-chelation
        1. Outpatient Chelation therapy
      3. Lead level post-chelation
    6. Lead level >70 mcg/dl (>3.38 umol/L): Very high Lead Toxicity level
      1. Lead level at 0 months
        1. Includes measure done for lead level of 20-44 mcg/dl
        2. Immediate hospitalization for chelation therapy
      2. Lead level pre-chelation
        1. Inpatient chelation therapy
      3. Lead level post-chelation
  9. Management: Chronic lead chelation
    1. Precautions
      1. Consult toxicologist before using chelation
      2. Obtain labs and diagnostics as above before chelation
      3. Dosing regimens should be checked with toxicology
    2. First-Line
      1. Succimer or Chemet (Meso-2,3-dimercaptosuccinic acid or DMSA)
        1. Initial: 10 mg/kg (or 350 mg/m2) PO every 8 hours for 5 days
        2. Next: 10 mg/kg (or 350 mg/m2) PO every 12 hours for 14 days
    3. Other agents that have been used for lead chelation
      1. Edetate Disodium
        1. Dose: 0.5-1.0 g/m2/day
        2. Maximum: 1.5 grams per day
      2. Dimercaprol
        1. Dose: 12-24 mg/kg/day for 5 days
      3. Penicillamine
        1. Dose: 20-40 mg/kg/day for 3 to 6 months
        2. Maximum: 1 grams per day
    4. Efficacy
      1. Chelation not affective if lead <45 mcg/dl
      2. Dietrich (2004) Pediatrics 114:19-26 [PubMed]
  10. Management: Acute Lead Chelation
    1. Indications
      1. Acute encephalopathy (e.g. Seizures, Altered Mental Status) AND
      2. Lead Toxicity confirmed with whole blood lead level
    2. Chelation agents
      1. British anti-Lewisite (BAL)
        1. Administered intramuscular (IM)
        2. Contraindicated in peanut allergy and G6PD Deficiency
      2. Calcium Disodium EDTA
        1. Administered after BAL
        2. Poor CNS penetration
    3. Protocol
      1. Consult poison control
      2. First: British anti-Lewisite (BAL) IM (if not contraindicated)
      3. Next: Calcium Disodium EDTA IV given 4 hours after BAL
    4. References
      1. Swadron and Nordt in Herbert (2016) EM:Rap 16(6): 13-4
  11. Prognosis (Untreated)
    1. Aggressive and delinquent behavior
    2. Mental Retardation
    3. Language and cognitive deficits
    4. References
      1. Needlman (1996) JAMA 275:363-9 [PubMed]
  12. Prevention
    1. Precautions regarding drinking water from lead pipes
      1. Allow tap to flow for 30 seconds, then collect water
      2. Do not use hot water from tap for drinking
    2. Avoid living near highways or industrial plants
    3. Replace all lead paint with non-lead paints
      1. Carefully limit child's exposure during remodeling
      2. Carefully dispose of removed lead paint
  13. References
    1. (2005) Pediatrics 116(4): 1036-46 [PubMed]
    2. Chao (1993) Am Fam Physician 47:113-20 [PubMed]
    3. Dietrich (2004) Pediatrics 114(1): 19-26 [PubMed]
    4. Rogan (2001) N Engl J Med 344(19): 1421-6 [PubMed]
    5. Warniment (2010) Am Fam Physician 81(6): 751-60 [PubMed]

Lead Poisoning (C0023176)

Definition (MEDLINEPLUS)

Lead is a metal that occurs naturally in the earth's crust. Lead can be found in all parts of our environment. Much of it comes from human activities such as mining and manufacturing. Lead used to be in paint; older houses may still have lead paint. You could be exposed to lead by

  • Eating food or drinking water that contains lead. Water pipes in older homes may contain lead.
  • Working in a job where lead is used
  • Using lead in a hobby, such as making stained glass or lead-glazed pottery
  • Using folk remedies such as herbs or foods that contain lead

Breathing air, drinking water, eating food, or swallowing or touching dirt that contains lead can cause many health problems. Lead can affect almost every organ and system in your body. In adults, lead can increase blood pressure and cause infertility, nerve disorders, and muscle and joint pain. It can also make you irritable and affect your ability to concentrate and remember.

Lead is especially dangerous for children. A child who swallows large amounts of lead may develop anemia, severe stomachache, muscle weakness, and brain damage. Even at low levels, lead can affect a child's mental and physical growth.

Agency for Toxic Substances Disease Registry

Definition (CSP) poisoning due to absorption or ingestion of lead or one of its salts; symptoms include loss of appetite, weight loss, colic, constipation, insomnia, headache, dizziness, irritability, moderate hypertension, albuminuria, anemia, encephalopathy, and peripheral neuropathy leading to paralysis.
Concepts Injury or Poisoning (T037)
MSH D007855
ICD9 984.9, 984
ICD10 T56.0, T56.0X, T56.0X1
SnomedCT 38342005, 157695008, 212842003, 212519002
LNC LA10482-0
English Lead Poisoning, Lead Poisonings, Poisoning, Lead, Poisonings, Lead, Toxic effect of unspecified lead compound, Toxic effect of lead and its compounds (including fumes), LEAD POISONING, SATURNISM, Saturnism, Lead compound causing toxic effect NOS, Lead compound-toxic effect NOS, Lead and its compounds, Lead and lead compounds causing toxic effect, Lead+Pb comp causng tox effect, Toxic effect of lead and its compounds, LEAD POIS, POIS LEAD, Lead compound poisoning, poisoning by lead, poisoning by lead (diagnosis), Tox eff lead compnd NOS, Toxic effects of lead and its compounds, Lead Poisoning [Disease/Finding], lead poison, Poisoning;lead, lead poisoning, Toxic effects of lead and its compounds NOS, Lead and lead compounds causing toxic effect (disorder), Lead compound causing toxic effect NOS (disorder), Lead compound poisoning (disorder), Lead intoxication, Plumbism, Lead poisoning, Saturnine poisoning, Lead - toxic effect, Toxic effect of lead compound (disorder), Toxic effect of lead compound, painter's colic, plumbism, saturnism, Toxic effect of lead compound, NOS, Toxic effect of lead and its compounds, including fumes, Poisoning by compounds of lead
French SATURNISME, Effet toxique du plomb et ses composés (incl les fumées), Effet toxique d'un composé du plomb non précisé, INTOXICATION AU PLOMB, Saturnisme, Intoxication par le plomb, Intoxication au plomb, Intoxication saturnine
Dutch loodvergiftiging, toxisch gevolg van niet-gespecificeerde loodverbinding, toxisch gevolg van lood en zijn verbindingen (inclusief gassen), Lood en loodverbindingen, Loodvergiftiging, Vergiftiging, lood-
German toxischer Effekt von Blei und seinen Verbindungen (einschliesslich Daempfe), toxischer Effekt unspezifischer Bleiverbindungen, Toxische Wirkung: Blei und dessen Verbindungen, Bleivergiftung
Italian Saturnismo, Effetti tossici del piombo e dei suoi composti (compresi i vapori), Effetti tossici dei composti del piombo non specificati, Avvelenamento da piombo
Portuguese Intoxicação pelo chumbo, Saturnismo, Efeito tóxico de composto de chumbo NE, INTOXICACAO PELO CHUMBO, SATURNISMO, Efeito tóxico de chumbo e seus compostos (incluindo vapores), Intoxicação por Chumbo
Spanish Intoxicación por plomo, Efecto tóxico de compuestos del plomo no especificados, Efecto tóxico del plomo y de sus compuestos (incluido el humo), Saturnismo, efecto tóxico de compuesto con plomo (trastorno), efecto tóxico de compuesto con plomo, efecto tóxico del plomo (trastorno), efecto tóxico del plomo, intoxicación por compuesto de plomo, compuesto de plomo que produce efecto tóxico, SAI, compuesto de plomo que produce efecto tóxico, SAI (trastorno), intoxicación por compuesto de plomo (trastorno), Envenenamiento por Plomo, intoxicación plúmbica, intoxicación por plomo, intoxicación saturnina, plumbismo, Intoxicación por Plomo
Japanese 詳細不明の鉛化合物の毒作用, ショウサイフメイノエンカゴウブツノドクサヨウ, ナマリチュウドク, 中毒-鉛, 鉛中毒, なまり中毒
Swedish Blyförgiftning
Czech olovo - otrava, Toxický účinek olova a jeho sloučenin (včetně výparů), Saturnismus, Toxický účinek blíže neurčených sloučenin olova, Otrava olovem
Finnish Lyijymyrkytys
Russian SVINTSOVYE OTRAVLENIIA, СВИНЦОВЫЕ ОТРАВЛЕНИЯ
Korean 납 및 그 화합물의 중독작용
Croatian OTROVANJE OLOVOM
Polish Ołowica, Zatrucie ołowiem
Hungarian Ólommérgezés, Ólom és vegyületeinek toxikus hatása (beleértve füstök), Nem meghatározott ólomvegyület toxikus hatása
Norwegian Plumbisme, Blyforgiftning
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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