Management Protocol of Paraphenylene Diamine (PPD, Diamond Paraffin, Kala Pathar) Poisoning

Paraphenylene Diamine (PPD, Diamond Paraffin, Kala pathar), a component of various hair dyes, is an emerging suicidal/homicidal poisoning in developing countries like Pakistan and India. It is called as “Kala pathar” in local language. It is one of the most lethal poisons having allergic, mutagenic and highly toxic properties with high morbidity and mortality.
Cervicofacial edema, acute renal and respiratory failures are the major contributors to poor prognosis. Instant and proper management in an intensive care unit is required to deal with the patients who ingest kala pathar. Management protocol of Kala Pathar Poisoning is given below: 

1. Airway Maintenance: Perform tracheostomy and assessment of atrial blood gases (ABGs)
2. Secure Breathing: Assure oxygen supply and assisted ventilation (if required).
3. Circulation: Save intravenous access with wide bore IV line. Assess fluid status by pulse rate, jugular venous pressure (JVP), blood pressure (in both supine and sitting conditions) and urine output (by catheterizing the patient).
4. Gastric Lavage: Perform gastric lavage with 2 grams of activated charcoal every 6 hours.
5. If develops Laryngeal edema and ARDS: Give injection hydrocortisone sodium succinate (Solucortef), 500mg five times a day + injection pheniramine maleate (Avil), 4mg every 8 hours.
6. Forced Diuresis: Give 5-6 liters of IV fluids + injection sodium bicarbonate (Soda Bicarb) 75 mmol + injection furosemide (Lasix) 20mg every 8 hours. Give Injection Mannitol 250 cc (If the patient is still oligouric).
7. If develops Hyperkalemia: Give injection calcium gluconate 8 hourly and salbutamol (Ventoline) nebulization every 3 hours.
8. Cardiac Support: If hypotension persists despite adequate fluid resuscitation, give Injection Dopamine infusion at the rate of 6-8 micrograms per kilogram body weight per minute in order to maintain systolic blood pressure above 90 mmHg.
9. Consult Nephrologist if the patient develops acute renal failure (ARF).
10. Daily Investigations: Send samples for hemoglobin level, renal parameters (RPMs), serum electrolytes (S/E), prothrombin time and activated partial thromboplastin time (PT/APTT), liver function tests (LFTs), creatinine phosphokinase (CPK), electrocardiogram (ECG), random blood sugar (RBS), atrial blood gases (ABGs), Ph, bicarbonate (HCO3) on daily basis.
11. Counseling of the patient’s attendants.
12. Information to administration and toxicology department.

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Keywords: Paraphenylene Diamine poisoning, PPD Poisoning, Diamond Paraffin, Management protocol of Kala pathar poisoning, Treatment of Kala Pathar Poisoning