内科学教学课件：急性有机磷杀虫药中毒

Acuteorganicphosphorusinsecticidespoisoning急性有机磷杀虫药中毒OverviewOPIbelongto

organophosphate/有机磷酸酯ordithiophosphateester/硫代磷酸酯类compounds,mostisoilyorcrystal.Colorfromlightyellowtobrown.Slightlyvolatile,andthesmellofgarlic.OPIonhumanandanimaltoxicityismainlyofacetylcholineenzyme/乙酰胆碱酯酶inhibition,causetheaccumulationofacetylcholine/乙酰胆碱.rankpoison

/剧毒类：LD50＜10mg/kgphorate,phosphorusabsorptionandparathion/甲拌磷、内吸磷、对硫磷

highpoison

/高毒类：LD5010~100mg/kgmethylparathion,methamidophos,dichlorvos/甲基对硫磷、甲胺磷、敌敌畏

moderatepoison

/中毒类：LD50100~1000mg/kgdimethoate,trichlorfon/乐果、敌百虫

lowpoison

/低毒类：LD501000~5000mg/kgmarasulphurphosphorous/马拉硫磷CategoryEtiology

OccupationalpoisoningProduction,using

LivingpoisoningEtiology&MechanismToxicabsorption,metabolismanddischarge毒物的吸收、代谢与排出OPIBodyLiverOxidationDeductionHydrolysisConjugationDischargeviakidneyGItract,RespiratorytractSkin,etc.BloodRespiratorytractGItractSkinMucosaBiotransformationMechanism/发病机制Truecholinesterase/真性胆碱酯酶：CNSGraymatter、RBC、sympatheticganglionendplatemovement/CNS灰质、RBC、交感神经节、运动终板Pseudocholinesterase/假性胆碱酯酶（丁酰胆碱酯酶）：CNSwhitematter,serum,liverandintestinalsubmucosa/CNS白质、血清、肝、肠黏膜下层

水解正常生理状态下：乙酰胆碱

乙酸+胆碱

胆碱酯酶

Organophosphorus+cholinesterase/有机磷＋胆碱酯酶Phosphorusacylationcholinesterase/磷酰化胆碱酯酶Inhibitcholinesterase/抑制胆碱酯酶Acetylcholinedecomposition↓/乙酰胆碱分解↓Acetylcholineaccumulation/乙酰胆碱堆积Cholinergicnervedisorder/胆碱能神经紊乱

1.Muscarinicsigns/毒蕈碱（M)样症状：Glandssecretionincrease,smoothmusclecontraction,sphincterrelaxation,performance:/腺体分泌增加,平滑肌收缩,括约肌松弛（1）Sweating,salivate,tears,runnynose,lungbubble,shortnessofbreath,difficultybreathing/多汗,流涎,流泪,流涕,肺部湿罗音,气促,呼吸困难（2）Miosis,nausea,vomiting,abdominalpain,diarrhea/瞳孔缩小,恶心,呕吐,腹痛,腹泻（3）Urinaryandfecalincontinence/尿、便失禁

Clinicalmanifestation(一)Acutecholinergiccrisis/急性胆碱能危象

2.Nicotinicsigns/烟碱（N）样症状：Thesympatheticnervousexcitement,adrenalmedullasecretion/交感神经兴奋，肾上腺髓质分泌。

▲Highbloodpressure,cardiacarrhythmia/血压高，心律失常

▲

Skeletalmusclenerve----Musclejointblock,characterizedbymuscletremorsandmuscleweakness,respiratorymyoparalysis,leadtorespiratoryfailure/骨骼肌神经----肌肉接头阻断，表现为肌颤,肌无力，呼吸肌麻痹，导致呼吸衰竭。Clinicalmanifestation

3.CNSsymptoms

dizziness,headaches,moodswings;severepersonconvulsionsorcoma.Seriousbreathing,circulationcentralinhibitionanddeath/轻者头晕，头痛，情绪不稳；重者抽搐昏迷，严重者呼吸、循环中枢抑制而死亡。Clinicalmanifestation

4.Locallesion

sensitizationdermatitis/过敏性皮炎，exfoliativedermatitis/剥脱性皮炎（二）Delayedpolyneuropathy/迟发性多发神经病：Poisoningsymptomsdisappearedin2~3weeksafterfeeling,sportsmultipleneuropathy,mainlyinvolvingtheextremities,Canhavelowerlimbparalysis,limbmuscleatrophy,etc.中毒症状消失后2～3周出现的感觉、运动型多发性神经病变，主要累及肢体末端、可有下肢瘫痪、四肢肌肉萎缩等。mechanism:organophosphoruspesticideinhibitnervetargetesteraseandaging/有机磷杀虫剂抑制神经靶酯酶并使其老化。Clinicalmanifestation（三）Intermediatesyndrome/中间型综合征Occurwithin24-96hafterpoisoning,betweenthecholinergiccrisisandlate-onsetneuropathy/发生于中毒后24-96h，在胆碱能危象和迟发性神经病之间。ClinicalmanifestationMainshowismuscleweakness,involvingthecervicalmuscle,proximallimbmuscles,cranialnerveⅢ，Ⅶ，ⅨandⅩmuscleweakness,mayinvolverespiratorymuscle.Performancefor：lookuphard,droopingeyelids,opendifficult,yanfacialmasticatorymuscleweakness,voicehoarse,difficultyswallowingandbreathingmyoparalysis/屈颈肌，肢体近端肌，颅神经Ⅲ、Ⅶ、Ⅸ、Ⅹ支配的肌肉无力，重者累及呼吸肌。表现：抬头困难，眼睑下垂，睁眼困难，咀嚼肌无力，声音嘶哑，吞咽困难，呼吸肌麻痹

Mechanism:cholinesteraseaffectedbylong-termsuppression,impactthenerve-musclepostsynapticjointfunction./胆碱酯酶受到长期抑制，影响神经－肌肉接头处突触后功能Determinationofbloodcholinesteraseactivity/胆碱酯酶活力测定Normalcholineenzymeactivityvalueof100%Mild70-50%Moderate50-30%

Severe<30%

UrinarymetabolitedeterminationoforganicphosphorusLaboratory

examination

Historyofexposuretoorganophosphoruspesticides●Typicalclinicalmanifestations

Laboratorytest：ChE,urinarymetaboliteDiagnosis

Mildpoisoning,

muscarinicsigns,ChEfellto70-50%ofnormal/毒蕈碱样症状Moderatepoisoning,

muscarinicsigns+nicotinesigns,ChEdowntoabout50-30%ofnormal./毒蕈碱＋烟碱样症状

Severepoisoning,inadditiontotheabovesigns,havecoma,pulmonaryedemaandcerebraledema,ChEdroppedtobelow30%ofnormal./昏迷、肺水肿、脑水肿

DegreeclassificationTreatmentCleaningthepoisoning★Takeawayfromthescene★Cleaningtheskin，hairandnails★Gastriclavage：Trichlorfonavoidalkalinedrugs/敌百虫忌碱性药，Parathionavoidpotassiumpermanganate/对硫磷忌高锰酸钾★CatharsisEmergencyrecovery/紧急复苏Pneumonedema,respiratorymuscleparalysis,respiratoryfailure，cardiacarrest/肺水肿，呼吸肌麻痹，呼吸衰竭，心脏骤停

Antidote/解毒药●Principles：useantidotesassoonaspossible,insufficientquantities,coadunationandrepeat.●Cholinesterasereactivator/胆碱酯酶复活剂：Oximecompounds,removenicotinetoxiceffects/肟类化合物，解除烟碱样毒性作用.pralidoximechloride,pralidoximeiodide

obidoximeChloride/氯解磷定、碘解磷定、双复磷Cholinoceptorblockingdrugs/胆碱受体拮抗药（1）Mcholinergicantagonists－atropine，anisodamine/山莨菪碱

Alleviatemuscarinic

symptomsandagainstrespiratorycentralinhibition/缓解毒蕈碱样症状和对抗呼吸中枢抑制Principles:Atropine，graduallyreduced，tomaintainthedosage阿托品化、逐渐减量、维持用量differencebetween"atropine"andatropinepoisoning★Atropine:pupildilation,drymouth,dryskin,fastheartrateincreases,lungwetraledisappearing./阿托品化：瞳孔扩大、口干、皮肤干燥、心率增快、肺部湿罗音消失。★

Atropinepoisoni