A 42-year-old male farmer from Punjab presents to the emergency department with a 3-day history of severe vomiting, profuse watery diarrhea, and abdominal pain. His wife reports that he consumed water from an old well on their farm. On examination, he is hypotensive (BP 80/50), tachycardic (HR 118/min), and has signs of severe dehydration. His skin shows hyperpigmentation over the palms and soles with hyperkeratosis. Laboratory investigations reveal elevated serum creatinine (2.8 mg/dL) and elevated liver enzymes. A 24-hour urine collection shows elevated arsenic levels (150 µg/L; normal <50 µg/L). What is the most appropriate immediate management?

Explanation

## Clinical Context This patient presents with acute arsenic poisoning manifesting as severe gastrointestinal symptoms, cardiovascular collapse, and acute kidney injury (AKI). The clinical triad of vomiting, diarrhea, and hypotension with evidence of systemic toxicity (hyperpigmentation, hyperkeratosis on chronic exposure, elevated urinary arsenic) confirms arsenic toxicity. ## Management Principles in Acute Arsenic Poisoning **Key Point:** Acute arsenic poisoning is primarily a medical emergency requiring immediate supportive care and correction of life-threatening complications. The mainstay of treatment is aggressive fluid resuscitation and electrolyte management. ### Why Supportive Care is Primary 1. **Fluid and electrolyte losses** from profuse diarrhea and vomiting lead to hypovolemic shock 2. **Acute kidney injury** develops from hypoperfusion and direct tubular toxicity 3. **Cardiovascular instability** requires hemodynamic support ### Chelation Therapy Considerations | Agent | Indication | Timing | Efficacy | |-------|-----------|--------|----------| | **Dimercaprol (BAL)** | Acute arsenic poisoning | Within 24 hrs of ingestion | Most effective in acute phase | | **DMSA (Succimer)** | Chronic arsenic exposure | Less effective acutely | Better for chronic/subacute | | **Penicillamine** | Not first-line for arsenic | Slower onset | Reserved for chronic lead exposure | **High-Yield:** In acute arsenic poisoning with systemic manifestations (shock, AKI), immediate priorities are: 1. **Aggressive IV fluid resuscitation** (normal saline or Ringer's lactate) 2. **Electrolyte monitoring and correction** (especially K^+^, Na^+^, Mg^2+^) 3. **Renal function monitoring** — hemodialysis if creatinine >3 mg/dL or oliguria develops 4. **Chelation therapy** (BAL) is considered *adjunctive* and is most effective if given within 24 hours of ingestion **Clinical Pearl:** While BAL is the chelating agent of choice for acute arsenic poisoning, it does NOT replace aggressive fluid resuscitation. In this case, the patient is in hypovolemic shock with AKI — fluid resuscitation and renal support are the immediate life-saving interventions. Chelation therapy would be initiated concurrently, not instead of supportive care. ### Why Activated Charcoal is Ineffective Arsenic compounds (especially inorganic arsenites and arsenates) have poor binding to activated charcoal and are rapidly absorbed from the GI tract. By 3 days post-ingestion, absorption is complete. ## Correct Answer Rationale Option 3 (aggressive IV fluid resuscitation, electrolyte correction, and consideration of hemodialysis) addresses the immediate life-threatening complications of acute arsenic poisoning. The patient's shock state and AKI require urgent hemodynamic stabilization and renal support before or concurrent with chelation therapy.