Treatment of Ventricular Fibrillation Due to Ammonium Bifluoride Poisoning With Hemodialysis. Pediatrics 2018 Sep;142(3)
Date
08/17/2018Pubmed ID
30111553DOI
10.1542/peds.2018-0136Scopus ID
2-s2.0-85052740421 (requires institutional sign-in at Scopus site) 2 CitationsAbstract
Ammonium bifluoride is an inorganic, fluoride-containing compound found in glass and metal etching products, as well as wheel cleaners. Fluoride toxicity is a common cause of preventable poisoning and has been reported to cause life-threatening ventricular dysrhythmias. Here, we report a case of recurrent ventricular fibrillation secondary to ingestion of ammonium bifluoride. The patient presented with vomiting and coma. She was intubated for altered mental status and respiratory failure and subsequently had 5 episodes of ventricular fibrillation, each resolving with a single defibrillation. She developed metabolic acidosis and hypocalcemia, which were treated with sodium bicarbonate and calcium gluconate, respectively. During transfer to a tertiary care children's hospital, ventricular fibrillation recurred despite electrolyte correction. Hemodialysis (HD) was initiated emergently. No further dysrhythmia occurred after initiation of HD. The result of a basic urine drug screen was negative, and a comprehensive drug screen (gas chromatography and mass spectroscopy) revealed only a nonsignificant peak for diphenhydramine. Subsequent laboratory evaluation revealed an elevated serum fluoride level. Diagnostic laryngoscopy and upper endoscopy did not reveal evidence of caustic injury. She was successfully extubated on hospital day 2 and discharged from the hospital on day 4 with no neurologic sequelae. With this example, we demonstrate a potential therapeutic approach to this potentially lethal poisoning. Fluoride toxicity is typically treated with calcium. However, dysrhythmia may result from calcium-independent direct myocardial toxicity. The kinetics of fluoride are amenable to HD, and renal clearance is slow. The potential use of HD in cases of fluoride poisoning refractory to other therapies warrants further study.
Author List
Farkas AN, Wolf MS, Landzberg E, Lynch MJ, Woods KSAuthor
Andrew N. Farkas MD Assistant Professor in the Emergency Medicine department at Medical College of WisconsinMESH terms used to index this publication - Major topics in bold
Ammonium CompoundsChild, Preschool
Electric Countershock
Female
Fluorides
Humans
Hypocalcemia
Quaternary Ammonium Compounds
Renal Dialysis
Ventricular Fibrillation
