《急危重症护理学》英文版课件-第十二章急性中毒

SevereFoodPoisoningIntheeveningofAugust11th,2010,

theRuichangCityinJiangxiProvinceheldthefirstLobsterFestival,openingthe“TenThousandPeopleLobsterFeast”.About4000localpeoplejoinedthisactivity.Morethan110peoplesufferedthefoodpoisoning.第一页，共66页。TheLeadingotsmelterinWeiCountyofGansuhasmadeabout300childrensufferingleadpoisoningThelittlepatientisonly14monthsold,hislevelofLeadinbloodexceedstandardforseveraltimes.Thevillagersseeingthedoctorsareshowingtheirlaboratorytestreports,thelevelofLeadinbloodofmostpeopleexceedsstandard.

第二页，共66页。TheleakedliquidnitrogenhappenedinYinchuanresultedinintoxicationofmorethan160people.

第三页，共66页。YangxininHubei一theleakedammoniagasinthemedicalcorporationcausedtheintoxicationofmorethan200people.

第四页，共66页。Professionalchemicalcompoundspoisoning

Forbeingdiagnosedwithprofessionalchemicalcompoundspoisoning,tenemployeesthreatenedtojumpfrombuildingstogetthecompensation.

第五页，共66页。SummaryForeignsubstancesbeingabletocausingpoisoningarecalledpoison.--Industrialpoison,drug,pesticide,toxicfloraandfaunaDefinition：Acutepoisoningreferstothattoxicchemicalsenterhuman’sbodyinashorttimeorwithexcessamountatatime,causingorganicorfunctionalinjuryoftissuesandorgans.Theconceptionofpoisonisrelative,thedosageofthemiscriticalfactor.第六页，共66页。PoisoningincludestheacuteonesandthechroniconesAcutepoisoningAbsorbingtoomuchpoisoninashorttime,it’surgent,thesymptomissevere,thestateofillnesschangesrapidly.Itcanthreatenliveswithouttimelytreatment.ChronicpoisoningResultsofabsorbingsmallamountsofpoisonforalongtime,beginningslowly,thecourseofdiseaseislong,lackingspecificdiagnosticindexes,notbelongingtothecategoryofemergency.第七页，共66页。ThereasonofacutepoisoningProfessionalpoisoningtoxicmaterial,accessory,intermediateproducts,finishedproducts.Custody,use,transportLivingpoisoningTakingorcontactingaccidentallytoxicsubstancesTakingexcessdrugs,suicideormurder第八页，共66页。ThepathwayofpoisoningMechanismofpoisontransport1.Respiratorytract

Thefastestwayofpoisonfunctioning2.Digestivetract

Takingthepoisonthroughmouth3.Skinandmucosa

Liposolubleandcorrosivepoison,permeatingthroughskin,havinglocalskininjury4.othersBeingbittenbyinsectsorsnakes.injection第九页，共66页。MetabolismandexcretionofpoisonAbsorptionofpoisonrespiratorytract:smoke,fog,steam,gas,carbonmonoxideDigestivetract：TakingvarietiesofpoisonthroughmouthSkinandmucosa：aniline,nitrobenzene,tetraethyllead,organophosphoruspesticideDetoxicationthroughmetabolismReducingthetoxicitythroughoxidation,deoxidization,hydrolyzation,combinationintheliver.Thetoxicityofafewsubstancesincreaseaftermetabolisminstead.(parathionisoxidizedtomintacol.)ExcretionofpoisonMostpoisonisexcretedfromthekidney.Beingexcretedformdigestivetractinthewayofexcrement.Someisexcretedfromrespiratorytract.BeingexcretedformtheskinBeingexcretedfrommilk.第十页，共66页。Absorption,metabolismandexcretionofpoisonPoisonRespiratorytractDigestivetractSkinandmucosaHumanbodyfunctioningontargetorganandtissue,causingpoisoning.Liver：Afteroxidation,deoxidation,hydrolyzationorcombinationandthelike,toxicityofmostpoisondecreases,butafewmayincreasetheirtoxicityormaintaintheirprototypeIntestinaltractSweatglandkidney

salivamilkGasandvolatilepoisonisexcretedfromrespiratorytractinprototype第十一页，共66页。Mechanismofpoisoning1.Localirritantandcrrosivefunction

2.Anoxia

3.Narcotism

4.Activityofinhibitoryenzyme

5.Disturbingphysiologicalfunctionofcellmembraneororganelle

6.Competitivebindingwiththereceptor

第十二页，共66页。第十三页，共66页。IdeatodiagnosePreliminaryevaluation—poisonedornot？Askforcasehistory—toknowwhattypeofpoisoningitis？Evaluatingagain--JudgingclinicalmanifestationrelatingtothispoisoningLaboratorytest—ifthereissomeevidencerelatingtosomepoison第十四页，共66页。PreliminaryevaluationSuddendisturbanceofconsciousness—Dysphoria,delirium,confusionofconsciousness,coma

Liverdiseaseinacoma,diabeticcoma,intracraniallesions,severeelectrolytedisturbanceSuddendyspnea,cyanosiswithunknowncause.第十五页，共66页。AskformedicalhistorySuspectingofcarbonmonoxidepoisoning：Gettingtoknowifthereisstoveorchimney,conditionofpeoplestayingtogether.Suspectingprofessionalpoisoning：Askaboutprofession,typeofwork,workingage,typeofpoisonandtimetheycontactwith,environmentalconditions,protectivemeasuresandiftheyhavesufferedpoisoningbefore.Forthosehavingunsurecontactinghistory,weshouldconsiderpoisoningiftheyhaveticwithunknownreasons,coma,shock,dyspneaandthelike.SuspectingoftakingexcessdrugsAskaboutdiseasehistory,kindofdrugstakenandthedosage.SuspectingoffoodpoisoningAskaboutkindoffoodtakenin,thesourceandtheconditionofpeopleeatingtogetherSuspectingtakingdrugsforsuicideAskaboutthementalstatebeforeillness.Ifthereisemptymedicinebottle,bagorremaineddrugsandlableatthescene.Attention

第十六页，共66页。EvaluatingagainCheckingpoisonedpatientsfromfollowingaspectsIfthereisdrug(poison)blot,colorand

specialsmell.Ifthereisdermatitislesions,wouldandbleeding,sweating.Iftherearechangesofthecoloroflips.(cyanosis,cerise,paleorhoary)Payattentiontothesizeofpupil,reactiontolight.Payattentiontotherateofrespiration,rhythm,ifthereisdyspnea,raleinlung,specialodorwhenbreathing.Payattentiontothecolorandsmellofvomitusandexcreta(excrement,urine).Ifthereisabdominalpain.Payattentiontoseeifthereismuscletwitchandspasm,第十七页，共66页。LaboratorytestsasaccessorydiagnosisQualitativeandquantitativeexaminationsofpoisontestsofmetaboliteofpoisoninthebodyTestsofpoisoningmechanismofpoisonTestsoftheinjurycausedbypoisontoorgans第十八页，共66页。Principlesoffirst-aidStopcontactingpoisontimelyClearthepoisonunabsorbedPromotetheabsorbedpoisontobeexcreted.UsespecialantidoteSymptomatictreatment第十九页，共66页。Stopcontactingpoisoninstantly&Clearunabsorbedpoison

Infectionthroughrespiratorytract：Leavethecontaminativeenvironment,takeinfreshairoroxygen.Infectionthroughskin：Takeoffclothes,drainoffthepoisonousfluidusingcottonorpaper.Washthebodyusinglargeamountofwater.Can’tusehotwateroralcohol.Infectionthrougheyes：Washoffusingnormalsalineorlargeamountofwater.

第二十页，共66页。ClearoffunabsorbedpoisonPreconditionofuse：noncrrosivepoisonMethods:promotingemesis

gastriclavage

catharsis

clyster第二十一页，共66页。promoteemesisAdaptationdisease：earlystage（within2～3haftertakingpoison）inone’srightsence.Method：Mechanicalway：AfterDrinkingwaterabout300～500ml,stimulatetheretropharyngeal.RepeatforseveraltimesDrugway：DrinkAlkaliipecacsyrup15~20mlandwater200mltogether,emesiswilloccurafter15~30minutes.第二十二页，共66页。gastriclavageAdaptationdisease：mosteffectivewithin6haftertakinginpoison.Position：headlowingleftlyingpositionorhorizontalpositionwithheadtiltingtoonside.Washingliquorinfusedeachtime

Volume：300~400ml，Temperature：25~38℃Principle：firstinandlaterout，fast-inandfast-out，inprimarybalancebetweeninandout.Leavesomespecimenforidentificationofpoisonwhenfirstsuction.Fluidofgastriclavage：rinsingornormalsaline.第二十三页，共66页。第二十四页，共66页。

Catharsisandclyster

Weusuallyusesodiumsulfatefor15-30gormagnesiumsulfatefor15-20gmixturedwithwater200ml,makingup10%solutionforpatientstotakeorally.Ifthepoisonhascausedseverediarrhea,catharsisisnotnecessary.Weoftenusewarmwateror1%warmsudsforcontinuoushighclyster,promotingpoisontobeexcreted.Activatedcarboncanalsobeaddedtoabsorbpoison.第二十五页，共66页。PromoteabsorbedpoisontobeeliminatedStrengthendiuresis：

1）fluidinfusion，supplementfluidinalargedosagequickly.2）usediuretic，furosemideormannitol.3）alkalizeurine,changePHvalueofurinetopromotethepoisonedenzymetobeexcreted.4）Payattentiontothewater,electrolyte,acid-basebalancewhileconductingdiuresis.Provideoxygen：carbonmonoxidepoisoningBloodpurification：

1）Hematodialysis：Usingwhenthepoisoningissevere,levelofpoisoninthebloodishigh,normaltherapyisineffective,companiedwithrenalfailureandrespiratorydepression.2）Bloodperfusion：Thiswaycanabsorbfat-solubleorchemicalscombinedwithproteins,clearingoutthepoison.

第二十六页，共66页。SymptomatictreatmentConductprotectiveandsymptomatictreatmenttotheinjuredorgansandtissues.Circulatoryfailure:pressoragentHeartfailure:digitalispreparations洋地黄制剂Convulsions:phenobarbitalsodiumencephaledema:mannitolcentralinhibitionmadebypoisoningwithhypnotic:bemegride第二十七页，共66页。Caseonefemale，28,foundincomabyfamilieshalfanhourago,thensenttohospital.Healthyinthepast.Physicalexamination：drowsiness，clammyskin,garlicodorcanbesmelled.BP120/70mmHg，P54bpm，R20bpm，T36.8℃.Beingisocoria,diameter0.1cm，cardiacphysicalexamination(一).Moistralescanbeheardinlungs.Abdominalphysicalexamination(-),limbstwitchingoccasionally，pathologiccharacters(-)laboratoryexaminations：bloodglucose6.0mmol/L，bloodammonia20mmol/L，cholinesteraseactivity50%，COHb1%。第二十八页，共66页。

AcuteorganophosphoruspoisoningDiagnosis?第二十九页，共66页。

Chaptertwo

organophosphoruspesticidespoisoning第三十页，共66页。Diagnosticbasis

Suddenonset，coma，excludethecomacausedbyliverdisease,diabetes,COpoisoning,centralnervoussystemdisease.Askformedicalhistory(thecontacthistoryoforganophosphoruspesticide.garlicodorclammyskin,contractedpupil,moistralesinthelung.(Msymptom)activityofcholinesterasedecreases.measurethepoisonbeinginvomitusandgastriccontent.第三十一页，共66页。Summaryorganophosphoruspesticidebelongstotheorganophosphorusesterorthiophosphoric

esterscompounds,mostlypresentingthecharacterofoilnessorcrystal.Itscolorislikefaintyelloworbrown.It’sslightlyvolatileandsmelledlikegarlicodor.第三十二页，共66页。EtiologicalfactorProductivepoisoningUsabilitypoisoningLivingpoisoningPathwayofpoisoningSkin,mucosa,respiratorytract,digestivetract第三十三页，共66页。MechanismofpoisoningPhosphorusacylationcholinesteraseACHOrganophosphoruspesticidecholinesterase胆碱能神经兴奋↑CholineacetateHydroxycholine,nicotineandcetralnervoussystemsymptoms.Phosphorusacylationcholinesterasewillagewithin72h,withoutrecovery.Inhibittheactivityofcholinesteraseinnervoussystem,makingtheACHaccumulating

第三十四页，共66页。MainclinicalmanifestationMsymptoms:occurringearliest,Mainlymanifestasincreasedglandularsecretion,smoothmusclecontracting,sphincterrelaxing,feelingsick,vomiting,stomachache,diarrhea,salivation,hidrosis,blurredvision,contractedpupil,increasedrespiratorysecreta,bronchospasm,dyspnea,pulmonaryedema,gatismandsoon.Atropinecanbeusedtofight.Nsymptoms:Striatedmusclesinthewholebodysuffermusclefibrillation.Usuallybeginningwithsmallmuscles,likeeyelidandfacialmuscles,lingualisandthelike,andgraduallydevelopingmuscularfasciculation,trismus,

generalized

convulsions,andthendevelopingdecreasedmyodynamia,respiratorymuscleparalysis,causingrespirationfailure.Centralsymptoms:

Headpain,swirl,weak,ataxia,dysphoria,cloudingofconsciousness,delirium,spasm,coma,inhibitedrespiratoryandcirculatorycentralanddieinseverepatients.

第三十五页，共66页。Principleoffirst-aidStopcontactingpoisoninstantly--takeoffclothes,rinseskin,havehaircutorwashhair.Clearoffunabsorbedpoison--gastriclavage,catharsisPromoteexcretingtheabsorbedpoison.—dialysis,bloodperfusion.Usespecialantidote--providedrugsinearlytime,infulldose,quickly,repeatedly.Symptomatictherapy第三十六页，共66页。SpecificantidoteAtropine：cancounteracttheMsymptoms.cholinesteraserevivifier（pyraloximeiodide,ObidoximeChloride,pralidoximechloride):recovertheactivityofcholinesterase.Medicationprinciple:assoonaspossible,asmuchaspossible,combination,repeateddrugtaking.第三十七页，共66页。Signofatropinizationpupilbecomesdilatedfacebecomeflushingskinandmouthbecomesdry,moistralesbecomesdecreasingordisappearingmarkedlyinlung.heartrateaccelerates（100~120bpm）第三十八页，共66页。anticholinergicagent（Penehyclidinehydrochloride）Penehyclidinehydrochloride:It’sconvenient,safe,long-actingandeffective.Strongspecificity,longactiontime,littleside-effect.ThedistinctionofatropineandPenehyclidinehydrochloride:WhenusingPenehyclidinehydrochloride,theheartratewon’tincrease,pupilwon’tbecomelarger.ActivityofCHEwillrecoverfaster,beingabletoreachingmorethan50%ofthenormalvalue.Whenusingatropine,theheartratebecomesfast,faceisred,thebodydoesn’thavesweat,pupilbecomeslarger,urinaryretention,theactivityofCHErecoversslowly.第三十九页，共66页。SymptomatictreatmentAtropinecanbeusedtotreatpulmonaryedema.Usingpressoragentforshock.Dehydratingagentandglucocorticoldisusedtotreatencephaledema.Andantiarrhythmicagentforarrhythmia.Bloodtransfusioncansupplycholinesteraseinseverecases.PerformCPRwhencardiacarrestoccurs.第四十页，共66页。ThepointofobservationThestateofillnessofacuteorganicphosphoruspesticidepoisoningissevere.Patientsusuallydieforpulmonaryedema,encephaledema,respirationfailure①Ifthepatientshowscough,senseofsuppressioninthechest,pinkfrothysputum.Acutepulmonaryedema②Ifthepatientshowsdisturbanceofconsciousnesswithheadpain,vomit,convulsions,hyperspasmia.Acuteencephaledema.③Changeoftherate,rhythmanddepthofrespiration.respirationfailure第四十一页，共66页。Ordinarynursing1、Observethestateofillness.2、Keeptheairwayopen,clearouttheexcretioninrespiratorytracttimely,provideoxygen,setupartificialairwayifnecessary,useartificialbreathingmachineasassistedventilation.3、Observechangesofconsciousnessandpupil.Changeofthepupilisonefeatureoforganophosphoruspoisoning.4、Noticethedifferencesofatropinizationandatropinismus.5.Frequentobservationincaseof“bounce”andoccurrenceofsuddendeath:bounceandsuddendeathusuallyoccur2-7daysafterpoisoning.Payattentiontopremonitorysymptomofbouncelike:senseofsuppressioninthechest,salivation,sweat,alalia,dysphagiaandsoon.Informdoctorstimely,supplyatropineinstantly,reachingthestateofatropinizationquickly.6.Retentioncatheterization,intravenousdripofatropine,sphinctervesicaebecomesloose,dysuresia,retentioncatheterization,strengthenthenursingofperineum,providingbladderirrigationeveryday,cliptheurinetubeatregularintervals.7.Conductgastriclavageearlier,thoroughlyandrepeatedlyuntilthewashinggastricjuicedoesn’thavepesticidalsmell.8.mentalnursing.第四十二页，共66页。Chapter3paraquatpoisoning第四十三页，共66页。paraquatpoisoningParaquatisakindoftouchtypeherbicidequicklyeffecting.Itcanquicklyfunctionafterbeingsprayedandlostitsactivitywhencontactingthesoil.20%oftheparaquatisgreen.Theparaquatcanbeabsorbedthroughgastrointestinaltract,skinandrespiratorytract.Poisoningthroughmouthisthemostcommonreportedinourcountry.Patientssufferingparaquatpoisoningusuallyshowtheinjuriesinthelung.第四十四页，共66页。Typesoftheseverityofparaquatpoisoning.Lighttype

Mediumtoheavytype

Rampanttype

doseofparaquattakenin<20mg/kg,don’thaveclinicalsymptomsoronlyhaveerosionoforalmucosa,ulcer.Mayshowvomit,diarrhea.doseofparaquattaken＞20mg/kg，Partofpatientscansurvive,butmostpatientswilldieofpulmonaryfailurewithin2-3weeks.doseofparaquattaken＞40mg/kg。Dieofmultipleorganfailurein1-4days.第四十五页，共66页。TreatmenttotheparaquatpoisoningStopthecontinuousabsorptionofpoison

AcceleratetheexcretionofpoisonPreventthepulmonaryfibrosisSymptomaticandsupportivetreatment

Thereisn’tspecificantidoteforparaquat.Wemustcontroltheprogressionofdiseaseinearlystage,preventingtheoccurrenceofpulmonaryfibrosis.第四十六页，共66页。Case2female，20yearsold.foundincomabyfamilieshalfanhourago,thensenttohospital.Healthyinthepast.Physicalexamination：drowsiness,lipsshowscherry-red.BP110/60mmHg，P72bpm，R18bmp，T37℃。Samesizeofpupils，diameteris0.5cm，cardiacexamination(-)lungs(-).Abdominalexamination(-),activityoflimbsisbarrier-free,pathologicalsign(-).Laboratorytests：bloodglucose6.5mmol/L，bloodammonia20mmol/L，activityofcholinesterase100%，COHb30%。第四十七页，共66页。

AcutecarbonmonoxidepoisoningDiagnosis第四十八页，共66页。DiagnosticbasisSuddenonset,incoma,excludingthecomaresultedfromliverdisease,diabetes,drugpoisoning,centralnervoussystematicdiseases.Askforthemedicalhistory(COcontacthistory)COHb30%Coloroflips第四十九页，共66页。Chapter4carbonmonoxidepoisoning第五十页，共66页。SummaryCarbonmonoxideiscommonlyknownascoalovengas.TheinadequateburningofcarbonaceousmattercanproduceCO.COiscolorless,tasteless,nonirritatinggas,itsspecificgravityis0.967.WhenthecontentofCOabsorbedintohumanbodyexceeds0.01%,thereisriskofacutepoisoning.第五十一页，共66页。Causeofdisease1productivepoisoning：Coking,steelmaking,pudding,fluegasletoutfromthemine.Forexample,looseprotectionorimproperventilation,andleakageofcoalgaspipeline.

2Livingpoisoning：Theuseofgasstoveorfuelgaswaterheaterinlife.Improperventilation,blockingofthecoal-firedfurnacechimneyatnorth,theamountofCOescapingoutcanreach30%.第五十二页，共66页。第五十三页，共66页。MechanismofpoisoningCOCOHb240times1／3600ofthedissociationspeedofoxyhemoglobin(O2Hb)COHbpreventthedissociationofO2Hb,bloodoxygencan’treleaseintothetissueeasily.CO＋ferroushurtthefunctionofmitochondriamyosinreducedcytochromeoxydasehindertheuseofoxygen＋hemoglobin(Hb)Thebraintissue,heartisthemostsensitivetoanoxia,theinjuryofcentralnervoussystemisthemostprominent.

第五十四页，共66页。DiseaseassessmentClinicalmanifestationisdividedintothreedegrees:Mildpoisoning:Headache,swirl,weak,nausea,vomit,evenfaint.COHb10%~20%,breakawayfromthescene,takeinfreshair,symptomscandisappear.Moderatepoisoning：Besidesfortheaggravatingabove-mentionedsymptoms,theskinandmucosashowlikecherry-red,heartrateisquick,beingagitatedandhidrosis,mindwonders,instablegait,andevenbeingincoma.ThelevelofCOHbis30%~40%,patientscanrecoverwithoutcomplicationaftertreatment.Severepoisoning:Deepcoma,varietiesofreflexdisappear,showthestateofcerebralcortexfailure:gatism,coldlimbs,stillandsilent,havenotreactiontocall,motionless,bloodpressuredecreases,pupilcontracts,irregularrespiration.Complication:encephaledema,pulmonaryedema,fever,shock,respiratoryfailure,myocardialdamage,uppergastrointestinalhemorrhage,andacuterenalfailure.LevelofCOHb>50%.

Sequelae:acroparalysis,shakingpalsy,peripheralneuritis,stupid,dysgnosia,andevencerebralcortexsyndrome.第五十五页，共66页。Principlesoffirst-aidStopcontactingunabsorbedpoisontimely--BreakawayfromthepoisonousenvironmentClearoffunabsorbedpoison--Takeinfreshair,correctanoxiaPromoteabsorbedpoisonbeingexcreted--Takeinoxygen,highpressureoxygenUseofspecialantidoteSymptomatictreatment--Protectimportantviscera,preventtheencephaledema.第五十六页，共66页。Principlesoftreatment

Principlesoftreatment:breakawayfromthepoisonousenvironment,correctanoxia,preventencephaledema,improvebraintissuemetabolism,preventcomplicationandviscera.Breakawayfromthepoisonousenvironment:Leavethesceneinstantly,keepthewindowsopen,unfastentheneckline,keepwarm.GiveCPRwhencardiopulmonaryarrestoccurs.Correctanoxia:TakinginoxygencanmakeCOHbdissolved.Whentakinginfreshoxygen,HalfCOreleasingfromCOHbtakesabout4hours.Thetimecontractsto30-40minwhentakinginpureoxygen,to20minwhentakinginpureoxygenof3pressureofatmosphere.Givehyperbaricoxygentherapyasfaraspossible.Givingoxygenfromvitro,exchangeofblood,ultravioletirradiationandoxygenation,redbloodcellexchangetherapyisalsoOK.Preventencephaledema:Itreachesthepeakin24-48hours.Usemannitol,hypertonicglucose,furosemide,hexadecadrolfordiuresisdehydration.Energymixture,likeCoA,ATP,cytochromecanpromotethemetabolismofbraincells.第五十七页，共66页。hyperbaricoxygenchamber第五十八页，共66页。Chapter6

Acutesedativehypnoticspoisoning第五十九页，共66页。sedativehypnoticspoisoningBarbituratesfirstcomeoutin1903.Sedativehypnoticspoisoningranksinthefirstpositionofdrugpoisoning.Smalldoseofsedativehypnoticshassedative-hypnoticeffects.Largedosehasnarcotism.Takingintoomuchdrugsinonetimewillcauseacutepoisoning,mainlyshowingtheinhibitionofcentralnervoussystem.Dividingintothreetypes:benzodiazepinesbarbituratesneuroleptics第六十页，共66页。barbituratespoisoningisdividedintothreedegreesMildpoisoning:Takingin2-5timesofhypnoticdose,thepatientswillgotosleep,beingabletobeenwaked,withslowresponseandslurredspeech,disturbanceofconsciousnessinabilityofjudgmentandorientationafterwakingup.Moderatepoisoning:Whentakingin5-10timesofhypnoticdose,thepatientswillsunkinsleeporgotostateofcoma,beingabletobewakedwithstrongstimulation,yetwithoutspeech,bei