2.2 Case Presentation
X J, male, 29 years old, a chemical plant worker in Nantong City, Jiangsu Province, China, ingested a mouthful triethylamine because of a bad mood and suffered occupational exposure from operation at 1.0 pm on Jan. 13, 2019. About 10 minutes later, a burning sensation was presented in his mouth, accompanied by chest tightness, chest pain, multiple nausea and his discomforts worsened with vomiting. His vomitus was dark brown or bright red-colored, about 600 ml. He had no digestive illness before and had not taken any other medicine recently.
X J was first sent to a local hospital for basic medical care and was initially diagnosed as triethylamine poisoning. He was administered pantoprazole, almagate suspension for 6 hours without significant improvement. Then he was transferred to the affiliated hospital of Nantong University at 7.0 pm. Physical examination showed that his blood pressure ( BP ) was 130/86 mmHg, heart rates ( HR ) 104 beats/minute, respiration ( R ) rates 20 breaths/minute. His laboratory dates were as follows: oxygen saturation ( SpO2 ), 100%; hemoglobin, 170 g/L; platelets, 182 × 109/L; alanine aminotransferase ( ALT ), 30 µ/L; aspartate aminotransferase ( AST ), 76 µ/L; blood urea nitrogen ( BUN ), 4.9 mmol/L; creatinine, 64 µmol/L. white blood cells ( WBC ) count, neutrophils ( N ) were significantly elevated at 20.2 × 109/L, 91.8% respectively, and his occult blood of vomit was positive. He had a swelling tongue and mouth ulcers, and no other abnormalities. Computed tomography ( CT ) scans revealed exudative lesions in the right lower lung, thickened edema of the esophagus wall, cholecystitis, left kidney stones, and decreased liver parenchymal density——possibly fatty liver, and he may suffer from chemical-induced liver injury. He was diagnosed as triethylamine poisoning.
For better medical treatment. at 0:30 am on Jan. 14, 2019, he was transferred to the emergency department ( ED ), Jinshan Hospital, Fudan University - the nuclearization treatment center of the Yangtze River Delta Area, China, which is famous for the treatment of nuclear and chemical injury. His physical examination revealed that axilla temperature was 37.7 degree Celsius ( °C ), BP 126/76 mmHg, HR 90 beats/minute, R 21 beats/minute, and SpO2 98%. He was conscious. He had coarse sounds on bilateral lung and no abnormalities in others. He was diagnosed as triethylamine poisoning and upper gastrointestinal bleeding. He received femoral vein catheterization, blood purification ( Technical parameters: continuous veno venous hemodiafiltration ( CVVHD ) and hemoperfusion ( HP ), blood flow 200 ml/min, dialyzer area 1.4 m2, low molecular heparin calcium injection 4100 AxaIU, combined with heparin sodium injection12500 units for anticoagulation, replacement fluid is hemodialysis replacement fluid, replacement rate of 0 ml/h, flow rate of 3000 ml/h ), omeprazole ( 80 mg, ivgtt, once a day ) and supplement with normal saline.
He was hospitalized in the intensive care unit ( ICU ) after multi-disciplinary consultation. He was conscious and cooperative with a physical examination, his abdomen was soft with scattered pain, no rebound pain, no skin yellowing and ecchymosis. His BP was 98/44 mmHg, and HR 73 beats/minute, R 20 breaths/minute, and axilla temperature 38.5 °C. Arterial blood gas analysis ( ABG ) values were as follows: pH 7.527; SpO2, 98.5% (under oxygen uptake by Nasal catheter of 3 L/min ); partial pressure of carbon dioxide ( PCO2 ), 3.42 Kpa; arterial partial pressure of oxygen ( PO2 ), 13.3 Kpa; potassium, 3.70 mmol/L; sodium, 135 mmol/L; chlorine, 109 mmol/L; lactic acid, 1.2 mmol/L; serum chemistries and coagulation values were: prothrombin time ( PT ), 13.70 seconds ( s ); activated partial thromboplastin time ( aPTT ), 25.1 s; thrombin time ( TT ), 15.5 s; international normalized ratio ( INR ), 1.21; D-dimer, 0.898 mg/L; amylase, 113 U/L; procalcitonin, 0.33 ng/ml; total bilirubin ( TB ), 32 µmol/L; combined bilirubin, 7 µmol/L; ALT, 64 U/L; AST, 26 U/L; urea, 5.0 mmol/L; uric acid, 290 µmol/L; creatinine, 61 µmol/L. His liver chemistries were mildly elevated with no other abnormalities. He had smoked for 10 years and drank occasionally. He took no medication before and had no other illness. His diagnosis was ① triethylamine poisoning, ② acute upper gastrointestinal bleeding, ③ chemical esophagitis ( triethylamine poisoning ). He was fasting at first. He received hemostasis, symptomatic treatment and adjuvant therapy ( as in Table 1 ). On Jan. 15, he was allowed to take food ( only cold fluid ) and received heparin-free blood purification treatment. The next day he had melena ( paste-like, without blood, about 300 ml ) and had abdominal pain, his blood purification was suspended. Lab data were showed in Table 2. The previous treatment was continued. On Jan. 18, he was unable to eat due to sore throat, and was diagnosed as a chemical injury in the throat and pharynx diagnosed by an ent doctor. One week later, he had no obvious abnormalities, no obvious gastrointestinal bleeding and discomfort, indicating that the treatment results were good. On Jan. 22, his PT was 15 s, aPTT 28.6 s, and TT 13.8 s. The clotting time was still prolonged.
On Jan. 23, a little blood was found in his sputum, he was suggested continuing his treatment. He requested to discharge home due to medical costs and other reasons and was discharged. The final diagnosis was: ①triethylamine poisoning, ②acute upper gastrointestinal bleeding, ③chemical esophagitis. His medical orders suggested having more rest, keeping warming, taking foods with rich vitamin k, taking tests of blood routine and fecal occult blood tests, and avoiding possible potential poisoning and gastrointestinal bleeding. His medications were omeprazole enteric-coated capsules ( 20 mg, bid, orally); Clostridium caseinate tablets ( 40 mg, tid, orally ). He had a good recovery by telephone query on Jan.12, 2020, and left that plant.