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中华卫生应急电子杂志 ›› 2016, Vol. 02 ›› Issue (06) : 333 -347. doi: 10.3877/cma.j.issn.2095-9133.2016.06.002

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急性中毒的诊断与治疗专家共识
中国医师协会急诊医师分会, 中国毒理学会中毒与救治专业委员会   
  • 收稿日期:2016-11-24 出版日期:2016-12-18

Expert consensus on diagnosis and treatment of acute poisoning

Emergency physician branch of Chinese Medical Doctor Association, Chinese society of toxicology and Specialized Committee   

  • Received:2016-11-24 Published:2016-12-18
引用本文:

中国医师协会急诊医师分会, 中国毒理学会中毒与救治专业委员会. 急性中毒的诊断与治疗专家共识[J]. 中华卫生应急电子杂志, 2016, 02(06): 333-347.

Emergency physician branch of Chinese Medical Doctor Association, Chinese society of toxicology and Specialized Committee. Expert consensus on diagnosis and treatment of acute poisoning[J]. Chinese Journal of Hygiene Rescue(Electronic Edition), 2016, 02(06): 333-347.

表1 中毒严重度评分
器官与系统 无症状 轻度 中度 重度 死亡
评分 0 1 2 3 4
? 轻度,一过性,自限性症状或体征 明显、持续性症状或体征;器官功能障碍 严重威胁生命的症状或体征;器官功能严重障碍 ?
消化系统 ? ?呕吐、腹泻、腹痛
?激惹、口腔小溃疡、一度烧伤
?内镜下可见红斑或水肿
?明显或持续性的呕吐、腹泻、梗阻、腹痛
?重要部位的一度烧伤或局限部位的二度或三度烧伤
?吞咽困难,呃逆
?内镜下可见黏膜溃疡
?大出血、穿孔
?大范围的Ⅱ度或Ⅲ度烧伤
?严重的吞咽困难,呃逆
?内镜下可见透壁性溃疡,伴周围黏膜病变
?
呼吸系统 ? ?咳嗽,轻度支气管痉挛
?胸部X线片轻度异常或无异常
?持续性咳嗽,支气管痉挛,
?胸部X线片出现异常伴有中度症状
?明显呼吸功能障碍,低氧需要持续供氧(如严重支气管痉挛、呼吸道阻塞、声门水肿、肺水肿、急性呼吸窘迫综合征、肺炎、气胸)
?胸部X线片出现异常,伴有严重度症状
?
神经系统 ? ?头昏,头痛,眩晕,耳鸣 ?嗜睡,对疼痛反应正常 ?意识丧失 ?
?烦乱不安 ?兴奋,幻觉,谵妄 ?呼吸抑制或功能障碍
?轻度锥体束外系症状 ?中度锥体束外系症状 ?极度兴奋
?轻度胆碱能或抗胆碱能症状 ?中度胆碱能或抗胆碱能症状 ?癫痫持续状态
?感觉异常 ?局部麻痹但不影响重要功能 ?瘫痪
?轻度的视觉和听力障碍 ?明显视觉和听力障碍 ?失明、耳聋
心血管系统 ? ?偶发早搏 ?窦性心动过缓 ?窦性心动过缓 ?
?轻度或一过性血压过高或过低 心率: 心率:
?窦性心动过缓 成人40~50次/min; 成人<40次/min
心率: 儿童60~80次/min; 儿童<60次/min
成人50~60次/min; 婴儿80~90次/min; 婴儿<80次/min?心动过速心率:成人>180次/min?致命性室性心率失常,Ⅲ度房室传导阻滞,心肌梗死,急性心功不全,休克,高血压危象
儿童70~90次/min; ?窦性心动过速 ?窦性心动过速
婴儿90~100次/min; 心率:成人140~150次/min; 心率:成人140~150次/min;
?窦性心动过速心率: ?持续性早搏,房颤房扑,Ⅰ度、Ⅱ度房室传导阻滞,QRS和QT间期延长,心肌缺血,明显高或低血压 ?持续性早搏,房颤房扑,Ⅰ度、Ⅱ度房室传导阻滞,QRS和QT间期延长,心肌缺血,明显高或低血压
成人100~140次/min;
代谢系统 ? ?轻度酸碱平衡紊乱 ?酸碱平衡紊乱明显 ?严重酸碱平衡紊乱 ?
碳酸氢根15~20或30~40 mmol/L,pH值7.25~7.32或7.5~7.59 碳酸氢根10~14或>40 mmol/L,pH值7.15~7.2或7.6~7.69 碳酸氢根<10 mmol/L,pH值<7.15或>7.7
?轻度水电解质紊乱 ?水电解质紊乱明显 ?严重水电解质紊乱
钾3.0~3.4或5.2~5.9 mmol/L 钾2.5~2.9或6.0~6.9 mmol/L 钾<2.5或>7 mmol/L
?轻度低血糖 ?低血糖明显 ?严重低血糖
成人50~70 mg/dL或2.8~3.9 mmol/L 成人30~50 mg/dL或1.7~2.8 mmol/L 成人<30 mg/dL或<1.7 mmol/L
?一过性高热 ?持续性高热 ?致命性高热或低热
肝脏 ? ?轻度血清酶升高 ?中度血清酶升高(AST、ALT 5~50倍正常值),无其他生化异常(如血氨,凝血异常)或严重肝功能障碍的临床证据 ?重度血清酶升高(AST、ALT >50倍正常值),其他生化异常(如血氨,凝血异常)或肝衰竭的临床证据 ?
AST、ALT 2~5倍正常值
肾脏 ? ?轻度蛋白尿/血尿 ?大量的蛋白尿/血尿 ?肾衰竭 ?
?肾功能障碍 无尿 血清肌酐>500 μmol/L
少尿多尿血清肌酐200~500 μmol/L
血液系统 ? ?轻度溶血 ?溶血 ?重度溶血 ?
?轻度高铁血红蛋白血症(10%~30%) ?明显高铁血红蛋白血症(30%~50%) ?重度高铁血红蛋白血症(>50%)
?凝血异常,但无活动性出血 ?凝血异常并伴活动性出血
?中度贫血,白细胞减少,血小板减少症 ?重度贫血,白细胞减少,血小板减少症
肌肉系统 ? ?肌肉疼,压痛 ?僵硬,痉挛肌束震颤 ?严重肌疼、僵硬、痉挛、肌束震颤 ?
?肌酸磷酸激酶250~1 500 U/L ?横纹肌溶解肌酸磷酸激酶1 500~10 000 U/L ?横纹肌溶解症
?肌酸磷酸激酶>10 000 U/L
?骨筋膜间隔综合征
局部皮肤 ? ?不适,Ⅰ度烧伤(发红)或小于体表面积10%的Ⅱ度烧伤 ?占体表面积10%~50%的Ⅱ度烧伤(儿童10%~30%)或Ⅲ度烧伤小于体表面积2% ?占体表面积>50%的Ⅱ度烧伤(儿童>30%)或Ⅲ度烧伤大于体表面积2% ?
眼部 ? ?不适,发红,流泪,轻度眼睑水肿 ?剧烈不适、角膜擦伤 ?角膜溃疡或穿孔,永久性的损伤 ?
?轻度角膜溃疡
叮咬处局部反应 ? ?局部瘙痒,肿胀 ?明显的水肿,局部坏死,疼痛明显 ?明显水肿,接连部位水肿,广泛坏死 ?
?轻微疼痛
? ?重要部位的水肿阻碍气道
?剧烈疼痛
表2 特殊中毒特征
特殊中毒表现 常见毒物
阵挛性惊厥、癫痫发作 农药:毒鼠强、有机氯杀虫剂、有机氟农药、拟除虫菊酯、二甲四氯、烟碱医用药物:异烟肼、中枢兴奋剂、氨茶碱、阿托品和乙胺嘧啶植物毒物:马钱子、白果、马桑和莽草子
呕吐物或洗胃液颜色异常 ?
? 紫红色 高锰酸钾
? 蓝绿色 铜盐、镍盐
? 粉红色 钴盐
? 黄色 硝酸盐、苦味酸
? 亮红色 红汞、硝酸
? 咖啡色 硝酸、硫酸及草酸
? 棕褐色 盐酸
? 暗处发光 黄磷
? 无色或白色 碱类
尿色异常 ?
? 蓝色 亚甲蓝
? 棕褐-黑色 苯胺染料、萘、苯酚、亚硝酸盐
? 樱桃红-棕红色 安替匹林、锌可芬、可以引起血尿及溶血的毒物
? 橘黄色 氟乐灵
? 绿色 麝香草酚
? 黄色 引起黄疸的毒物、呋喃类
皮肤颜色异常 ?
? 化学性发绀 高铁血红蛋白血症、胺碘酮
? 樱红色 一氧化碳
? 黄染 米帕林(阿地平)、损肝毒物及溶血毒物引起的黄疸(磷、四氯化碳、蛇毒、毒蕈、苯的氨基或硝基衍生物、蚕豆病及氯丙嗪引起的黄疸)
? 红色 硼酸、双硫仑反应、万古霉素
? 紫癜 抗凝血灭鼠剂(敌鼠钠盐和溴敌隆)、氯吡格雷、糖皮质激素、肝素、华法林、水杨酸制剂
特殊气味 ?
? 水果味 乙醇、盐酸碳氢化合物、氯仿、丙酮、酮酸中毒
? 乙烯基 乙氯维诺
? 枯草味 光气
? 苦杏仁味 氰化物、苦杏仁苷
? 大蒜味 砷、二甲基亚砜、铊、硒酸、有机磷
? 臭鸡蛋味 硫化氢、硫醇
? 冬青油味 甲基水杨酸盐
? 芳香味 苯类芳香烃、有机氯农药毒杀芬
? 鞋油味 硝基苯
? 樟脑丸 樟脑萘、二氯苯
? 皮肤黏膜出血 敌鼠钠盐杀鼠剂、肝素、水杨酸、华法林等
表3 毒(药)物中毒血液净化及模式选择
表4 医院储备解毒药目录
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