《急危重症护理学》英文版-第十二章 急性中毒课件

1、Chapter TwelveAcute ToxicationSevere Food PoisoningIn the evening of August 11th, 2010, the Ruichang City in Jiangxi Province held the first Lobster Festival, opening the “Ten Thousand People Lobster Feast”. About 4000 local people joined this activity. More than 110 people suffered the food poisoni

2、ng.The Lead ingot smelter in Wei County of Gansu has made about 300 children suffering lead poisoningThe little patient is only 14 months old, his level of Lead in blood exceed standard for several times.The villagers seeing the doctors are showing their laboratory test reports, the level of Lead in

3、 blood of most people exceeds standard. The leaked liquid nitrogen happened in Yinchuan resulted in intoxication of more than 160 people. Yangxin in Hubei一the leaked ammonia gas in the medical corporation caused the intoxication of more than 200 people.Summary Foreign substances being able to causin

4、g poisoning are called poison. -Industrial poison, drug, pesticide, toxic flora and faunaDefinition：Acute poisoning refers to that toxic chemicals enter humans body in a short time or with excess amount at a time, causing organic or functional injury of tissues and organs.The conception of poison is

5、 relative, the dosage of them is critical factor.Poisoning includes the acute ones and the chronic onesAcute poisoningAbsorbing too much poison in a short time, its urgent, the symptom is severe, the state of illness changes rapidly. It can threaten lives without timely treatment.Chronic poisoningRe

6、sults of absorbing small amounts of poison for a long time, beginning slowly, the course of disease is long, lacking specific diagnostic indexes, not belonging to the category of emergency.The pathway of poisoningMechanism of poison transport1.Respiratory tract The fastest way of poison functioning2

7、 .Digestive tract Taking the poison through mouth3.Skin and mucosa Liposoluble and corrosive poison, permeating through skin, having local skin injury4.othersBeing bitten by insects or snakes. injectionMetabolism and excretion of poisonAbsorption of poisonrespiratory tract: smoke, fog, steam, gas, c

8、arbon monoxideDigestive tract： Taking varieties of poison through mouthSkin and mucosa ：aniline, nitrobenzene, tetraethyl lead, organophosphorus pesticide Detoxication through metabolismReducing the toxicity through oxidation, deoxidization, hydrolyzation, combination in the liver.The toxicity of a

9、few substances increase after metabolism instead.( parathion is oxidized to mintacol.)Excretion of poisonMost poison is excreted from the kidney.Being excreted form digestive tract in the way of excrement.Some is excreted from respiratory tract.Being excreted form the skinBeing excreted from milk.Ab

10、sorption, metabolism and excretion of poisonPoisonRespiratory tractDigestive tractSkin and mucosaHuman bodyfunctioning on target organ and tissue, causing poisoning.Liver：After oxidation, deoxidation, hydrolyzation or combination and the like, toxicity of most poison decreases, but a few may increas

11、e their toxicity or maintain their prototypeIntestinal tractSweat glandkidney saliva milkGas and volatile poison is excreted from respiratory tract in prototypeIdea to diagnosePreliminary evaluationpoisoned or not？Ask for case historyto know what type of poisoning it is？Evaluating again-Judging clin

12、ical manifestation relating to this poisoning Laboratory testif there is some evidence relating to some poison Ask for medical historySuspecting of carbon monoxide poisoning：Getting to know if there is stove or chimney, condition of people staying together.Suspecting professional poisoning：Ask about

13、 profession, type of work, working age, type of poison and time they contact with, environmental conditions, protective measures and if they have suffered poisoning before. For those having unsure contacting history, we should consider poisoning if they have tic with unknown reasons, coma, shock, dy

14、spnea and the like.Suspecting of taking excess drugsAsk about disease history, kind of drugs taken and the dosage.Suspecting of food poisoningAsk about kind of food taken in, the source and the condition of people eating togetherSuspecting taking drugs for suicideAsk about the mental state before il

15、lness. If there is empty medicine bottle, bag or remained drugs and lable at the scene.Attention Evaluating againChecking poisoned patients from following aspectsIf there is drug(poison) blot, color and special smell.If there is dermatitis lesions, would and bleeding, sweating. If there are changes

16、of the color of lips.(cyanosis, cerise, pale or hoary)Pay attention to the size of pupil, reaction to light.Pay attention to the rate of respiration, rhythm, if there is dyspnea, rale in lung, special odor when breathing.Pay attention to the color and smell of vomitus and excreta(excrement, urine).

17、If there is abdominal pain.Pay attention to see if there is muscle twitch and spasm,Laboratory tests as accessory diagnosisQualitative and quantitative examinations of poisontests of metabolite of poison in the bodyTests of poisoning mechanism of poisonTests of the injury caused by poison to organsP

18、rinciples of first-aidStop contacting poison timelyClear the poison unabsorbedPromote the absorbed poison to be excreted.Use special antidoteSymptomatic treatmentStop contacting poison instantly&Clear unabsorbed poisonInfection through respiratory tract：Leave the contaminative environment, take in f

19、resh air or oxygen.Infection through skin：Take off clothes, drain off the poisonous fluid using cotton or paper. Wash the body using large amount of water. Cant use hot water or alcohol.Infection through eyes：Wash off using normal saline or large amount of water. Clear off unabsorbed poisonPrecondit

20、ion of use：noncrrosive poisonMethods: promoting emesis gastric lavage catharsis clyster gastric lavageAdaptation disease ：most effective within 6h after taking in poison.Position：head lowing left lying position or horizontal position with head tilting to on side.Washing liquor infused each time Volu

21、me：300400ml，Temperature：2538Principle：first in and later out，fast-in and fast-out，in primary balance between in and out. Leave some specimen for identification of poison when first suction.Fluid of gastric lavage ：rinsing or normal saline.Promote absorbed poison to be eliminated Strengthen diuresis：

22、 1）fluid infusion，supplement fluid in a large dosage quickly. 2）use diuretic，furosemide or mannitol. 3）alkalize urine, change PH value of urine to promote the poisoned enzyme to be excreted. 4） Pay attention to the water, electrolyte, acid-base balance while conducting diuresis.Provide oxygen：carbon

23、 monoxide poisoningBlood purification： 1）Hematodialysis：Using when the poisoning is severe, level of poison in the blood is high, normal therapy is ineffective, companied with renal failure and respiratory depression. 2）Blood perfusion：This way can absorb fat-soluble or chemicals combined with prote

24、ins, clearing out the poison. Symptomatic treatmentConduct protective and symptomatic treatment to the injured organs and tissues.Circulatory failure: pressor agentHeart failure: digitalis preparations洋地黄制剂Convulsions: phenobarbital sodiumencephaledema: mannitolcentral inhibition made by poisoning w

25、ith hypnotic:bemegrideCase one female，28, found in coma by families half an hour ago, then sent to hospital. Healthy in the past. Physical examination：drowsiness，clammy skin, garlic odor can be smelled. BP120/70mmHg，P 54 bpm，R20 bpm， T36.8.Being isocoria, diameter 0.1cm，cardiac physical examination(

26、一).Moist rales can be heard in lungs. Abdominal physical examination(-), limbs twitching occasionally，pathologic characters(-) laboratory examinations：blood glucose 6.0mmol/L，blood ammonia 20 mmol/L，cholinesterase activity 50%，COHb1%。 Acute organophosphorus poisoning Diagnosis? Chapter two organopho

27、sphorus pesticides poisoningDiagnostic basis Sudden onset，coma，exclude the coma caused by liver disease, diabetes, CO poisoning, central nervous system disease.Ask for medical history(the contact history of organophosphorus pesticide.garlic odorclammy skin, contracted pupil, moist rales in the lung.

28、(M symptom)activity of cholinesterase decreases.measure the poison being in vomitus and gastric content.Summaryorganophosphorus pesticide belongs to the organophosphorus ester or thiophosphoricesters compounds, mostly presenting the character of oilness or crystal. Its color is like faint yellow or

29、brown. Its slightly volatile and smelled like garlic odor.Etiological factorProductive poisoningUsability poisoningLiving poisoningPathway of poisoning Skin, mucosa, respiratory tract, digestive tractMechanism of poisoningPhosphorus acylation cholinesteraseACHOrganophosphorus pesticidecholinesterase

30、胆碱能神经兴奋Choline acetateHydroxycholine, nicotine and cetral nervous system symptoms.Phosphorus acylation cholinesterase will age within 72h, without recovery.Inhibit the activity of cholinesterase in nervous system, making the ACH accumulatingMain clinical manifestationM symptoms:occurring earliest,Ma

31、inly manifest as increased glandular secretion, smooth muscle contracting, sphincter relaxing, feeling sick, vomiting, stomachache, diarrhea, salivation, hidrosis, blurred vision, contracted pupil, increased respiratory secreta, bronchospasm, dyspnea, pulmonary edema, gatism and so on. Atropine can

32、be used to fight.N symptoms:Striated muscles in the whole body suffer muscle fibrillation. Usually beginning with small muscles, like eyelid and facial muscles, lingualis and the like, and gradually developing muscular fasciculation, trismus, generalizedconvulsions, and then developing decreased myo

33、dynamia, respiratory muscle paralysis, causing respiration failure.Central symptoms: Head pain, swirl, weak, ataxia, dysphoria,clouding of consciousness, delirium, spasm, coma, inhibited respiratory and circulatory central and die in severe patients. Principle of first-aidStop contacting poison inst

34、antly -take off clothes, rinse skin, have haircut or wash hair. Clear off unabsorbed poison -gastric lavage, catharsisPromote excreting the absorbed poison.dialysis, blood perfusion.Use special antidote-provide drugs in early time, in full dose, quickly, repeatedly.Symptomatic therapySpecific antido

35、te Atropine：can counteract the M symptoms. cholinesterase revivifier（pyraloxime iodide, Obidoxime Chloride, pralidoxime chloride): recover the activity of cholinesterase.Medication principle: as soon as possible, as much as possible, combination, repeated drug taking.Sign of atropinizationpupil beco

36、mes dilated face become flushingskin and mouth becomes dry, moist rales becomes decreasing or disappearing markedly in lung.heart rate accelerates （100120bpm） anticholinergic agent（ Penehyclidine hydrochloride ）Penehyclidine hydrochloride: Its convenient, safe, long-acting and effective.Strong speci

37、ficity, long action time, little side-effect.The distinction of atropine and Penehyclidine hydrochloride:When using Penehyclidine hydrochloride, the heart rate wont increase, pupil wont become larger. Activity of CHE will recover faster, being able to reaching more than 50% of the normal value.When

38、using atropine, the heart rate becomes fast, face is red, the body doesnt have sweat, pupil becomes larger, urinary retention, the activity of CHE recovers slowly.Symptomatic treatmentAtropine can be used to treat pulmonary edema. Using pressor agent for shock. Dehydrating agent and glucocorticold i

39、s used to treat encephaledema. And antiarrhythmic agent for arrhythmia. Blood transfusion can supply cholinesterase in severe cases. Perform CPR when cardiac arrest occurs. The point of observation The state of illness of acute organic phosphorus pesticide poisoning is severe. Patients usually die f

40、or pulmonary edema, encephaledema, respiration failure If the patient shows cough, sense of suppression in the chest, pink frothy sputum. Acute pulmonary edemaIf the patient shows disturbance of consciousness with head pain, vomit, convulsions, hyperspasmia. Acute encephaledema. Change of the rate,

41、rhythm and depth of respiration. respiration failureOrdinary nursing1、Observe the state of illness.2、Keep the airway open, clear out the excretion in respiratory tract timely, provide oxygen, set up artificial airway if necessary, use artificial breathing machine as assisted ventilation.3、Observe ch

42、anges of consciousness and pupil. Change of the pupil is one feature of organophosphorus poisoning.4、Notice the differences of atropinization and atropinismus.5. Frequent observation in case of “bounce” and occurrence of sudden death: bounce and sudden death usually occur 2-7 days after poisoning. P

43、ay attention to premonitory symptom of bounce like: sense of suppression in the chest, salivation, sweat, alalia, dysphagia and so on. Inform doctors timely, supply atropine instantly, reaching the state of atropinization quickly.6. Retention catheterization, intravenous drip of atropine, sphincter

44、vesicae becomes loose, dysuresia, retention catheterization, strengthen the nursing of perineum, providing bladder irrigation everyday, clip the urine tube at regular intervals.7. Conduct gastric lavage earlier, thoroughly and repeatedly until the washing gastric juice doesnt have pesticidal smell.8

45、.mental nursing. Chapter 3 paraquat poisoning paraquat poisoningParaquat is a kind of touch type herbicide quickly effecting. It can quickly function after being sprayed and lost its activity when contacting the soil.20% of the paraquat is green.The paraquat can be absorbed through gastrointestinal

46、tract, skin and respiratory tract. Poisoning through mouth is the most common reported in our country.Patients suffering paraquat poisoning usually show the injuries in the lung.Types of the severity of paraquat poisoning.Light type Medium to heavy type Rampant type dose of paraquat taken in50%. Seq

47、uelae: acroparalysis, shaking palsy,peripheral neuritis, stupid, dysgnosia, and even cerebral cortex syndrome.Principles of first-aidStop contacting unabsorbed poison timely-Break away from the poisonous environmentClear off unabsorbed poison-Take in fresh air, correct anoxiaPromote absorbed poison

48、being excreted-Take in oxygen, high pressure oxygenUse of special antidoteSymptomatic treatment-Protect important viscera, prevent the encephaledema.Principles of treatment Principles of treatment: break away from the poisonous environment, correct anoxia, prevent encephaledema, improve brain tissue

49、 metabolism, prevent complication and viscera.Break away from the poisonous environment:Leave the scene instantly, keep the windows open, unfasten the neckline, keep warm. Give CPR when cardiopulmonary arrest occurs.Correct anoxia:Taking in oxygen can make COHb dissolved. When taking in fresh oxygen

50、, Half CO releasing from COHb takes about 4 hours. The time contracts to 30-40min when taking in pure oxygen, to 20min when taking in pure oxygen of 3 pressure of atmosphere. Give hyperbaric oxygen therapy as far as possible. Giving oxygen from vitro, exchange of blood, ultraviolet irradiation and o

51、xygenation, red blood cell exchange therapy is also OK. Prevent encephaledema:It reaches the peak in 24-48 hours. Use mannitol, hypertonic glucose, furosemide, hexadecadrol for diuresis dehydration. Energy mixture, like CoA, ATP, cytochrome can promote the metabolism of brain cells.hyperbaric oxygen

52、 chamber Chapter 6 Acute sedative hypnotics poisoningsedative hypnotics poisoningBarbiturates first come out in 1903.Sedative hypnotics poisoning ranks in the first position of drug poisoning.Small dose of sedative hypnotics has sedative-hypnotic effects. Large dose has narcotism. Taking in too much

53、 drugs in one time will cause acute poisoning, mainly showing the inhibition of central nervous system.Dividing into three types:benzodiazepinesbarbituratesneurolepticsbarbiturates poisoning is divided into three degreesMild poisoning:Taking in 2-5 times of hypnotic dose, the patients will go to sle

54、ep, being able to been waked, with slow response and slurred speech, disturbance of consciousness in ability of judgment and orientation after waking up. Moderate poisoning:When taking in 5-10 times of hypnotic dose, the patients will sunk in sleep or go to state of coma, being able to be waked with

55、 strong stimulation, yet without speech, being in lethargy again when the stimulation disappears. The eyeball may show tremble.Severe poisoning:When taking in 10-20 times of hypnotic dose, patients will show coma, areflexia, contracted or loose pupil, shallow and slow respiration, sometimes Cheyne-s

56、toke respiration, weak and fast pulse, decreased blood pressure. Patients will die of respiratory and circulatory failure if without timely rescue.Symptoms of benzodiazepines poisoning Central inhibition: Drowsiness, dizziness, allophasis, unconsciousness, dystaxia, dysgnosia and hypomnesis.Critical factors and