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Paraphenylene Diamine (PPD) Protocol

Paraphenylene Diamine (PPD) Protocol

PPD toxicity (Paraphenylene Diamine)

The commonest constituent of all hair dyes

Typical Clinical picture:

(toxicity can occurs through local contact or ingestion)
  1. First: upper airway edema and obstruction (the main cause of death).
    *Patient presents with angio-edema (rapid progressive edema of face, tongue, neck and larynx with respiratory distress, resistant to adrenaline.
  2. Later phase: renal manifestations: ranges from mild proteinuria up to acute kidney injury due to direct nephrotoxic effect or rhabdomyolysis.
    *patient presents with cola-colored urine, oliguria, hyperkalemia, hyperphosphatemia or hypocalcaemia.
  3. Other rare complications which may occur: Acute hepatitis/cardiac toxicity (arrhythmia or heart block) /hemolytic anemia.

ER pathway

Symptomatic
⬇

*ABCD (ETT or Tracheostomy) +

  • IM adrenaline (0.3-0.5 ml) Table below
  • IV hydrocortisone: Adult: 100 to 500 mg IV / Children: 0.5 mg/kg IV up to MAX 8 mg/dose
  • IV Avil (45.5mg/2ml): Adult: 1ampule/children: ½ ampule

Observation pathway

Asymptomatic
⬇
Inpatient admission for 24 hrs. (for close observation and labs follow up)
⬇
If patient becomes symptomatic
⬅ Return to ER box

ICU

  • Follow up (ABG, electrolytes, KFT, LFT, CBC, CPK, cardiac enzymes and ECG)
  • No specific antidote
  • Supportive symptomatic treatment to maintain hydration, oxygenation and good urine output for the patient:
  1. IV Hydrocortisone: Adult: 100 to 500 mg IV; may repeat at intervals of 2, 4, or 6 hours as indicated by response and clinical condition / Children: 0.56 to 8 mg/kg/day (20 to 240 mg/m (2)/day) IM/IV in 3 or 4 divided doses.
  2. Antihistamines: Adult: 1ampule Avil/12hrs--Children: 12amp/12h.
  3. Fluids for good hydration/ TPN if >3 days with no oral feeding.
  4. Alkalinization of urine: in non oliguric patients.
  5. Hemodialysis is required in AKI (Noting that toxin is not removed by dialysis).
  6. Correction of hypocalcaemia: Correct the cause + IV calcium correction: Bolus 2g calcium gluconate (20 mL or 2 ampules of 10% calcium gluconate; in 50–100 mL of 5% dextrose or saline IV over 10–15 min then begin continuous Ca2+ infusion: dilute 6 g of calcium gluconate in 500 mL of 5% dextrose or saline and infuse at 0.5–1.5 mg elemental Ca2+/kg/hr .

Adrenaline volume 1:1000 (by age/weight)

Age (years)Weight (kg)Adrenaline volume 1:1000
<15–100.05–0.1 mL
1–2100.1 mL
2–3150.15 mL
4–6200.2 mL
7–10300.3 mL
10–12400.4 mL
>12 and adult>500.5 mL

Alkalinization of urine:

Initial IV bolus of NAHCO3:
1-2 mEq/kg over 1-2 minutes.

Then
NaHCO3 infusions: 100-150 mEq in 1 liter of D5% at 150- 200 ml/h (or about twice the maintenance requirements in a child).

Goals of Urinary alkalization is to keep the urinary pH 7.5-8, and blood PH not > 7.55

Monitoring during alkalinization
-ABG / 4 h
-Electrolyte/ 4 h,
-Urinary PH/ 4 hrs
-UOP: 3-5 ml/Kg/hr