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中华卫生应急电子杂志

中华卫生应急电子杂志 ›› 2024, Vol. 10 ›› Issue (03) : 129 -139. doi: 10.3877/cma.j.issn.2095-9133.2024.03.001

专家共识

中毒患者急诊护理专家共识（2024版）
何雯1, 王颖2, 汪晓攀3,†(), 龚玉枝4, 冯毕龙5, 田丹6, 代凯利7, 凌传仁8, 唐杏9, 董然10, 黄清平11, 姜汉兰12, 肖洁13, 张军辉14, 郭庆15, 张小红16, 袁观惺17   
  1. 1. 430010　湖北武汉，湖北省中西医结合医院急诊科
    2. 430030　湖北武汉，华中科技大学同济医学院附属同济医院护理部
    3. 430010　湖北武汉，湖北省中西医结合医院护理部
    4. 430077　湖北武汉，华中科技大学同济医学院附属梨园医院护理部
    5. 430071　湖北武汉，武汉大学中南医院护理部
    6. 430060　湖北武汉，武汉大学人民医院急诊科
    7. 610041　四川成都，四川大学华西第四医院急诊科
    8. 510120　广东广州，广州中医药大学第二附属医院急诊科
    9. 310005　浙江杭州，浙江中医药大学附属中山医院急诊科
    10. 430064　湖北武汉，湖北省妇幼保健院急诊科
    11. 510260　广东广州，广州医科大学附属第二医院急诊科
    12. 430015　湖北武汉，武汉市儿童医院急诊科
    13. 430074　湖北武汉，湖北省中医院急诊科
    14. 430030　湖北武汉，华中科技大学同济医学院附属梨园医院急诊科
    15. 443008　湖北宜昌，宜昌市中心人民医院急诊科
    16. 441021　湖北襄阳，襄阳市中心医院护理部
    17. 430056　湖北武汉，武汉亚心总医院急诊科
  • 收稿日期:2024-04-15 出版日期:2024-06-18
  • 通信作者: 汪晓攀

Expert consensus on emergency nursing of poisoned patients(2024)

Wen He1, Ying Wang2, Xiaopan Wang3,†(), Yuzhi Gong4, Bilong Feng5, Dan Tian6, Kaili Dai7, Chuanren Ling8, Xing Tang9, Ran Dong10, Qingping Huang11, Hanlan Jiang12, Jie Xiao13, Junhui Zhang14, Qing Guo15, Xiaohong Zhang16, Guanxing Yuan17   

  1. 1. Emergency Department, Hubei Provincial Hospital of Integrated Chinese and Western Medicine, Wuhan 430010, China
    2. Nursing Department, Tongji Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
    3. Nursing Department, Hubei Provincial Hospital of Integrated Chinese and Western Medicine, Wuhan 430010, China
    4. Nursing Department, Liyuan Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430077, China
    5. Nursing Department, Zhongnan hospital of Wuhan University, Wuhan 430071, China
    6. Emergency Department, Wuhan University People's Hospital, Wuhan 430060, China
    7. Emergency Department, West China Fourth Hospital, Sichuan University, Chengdu 610041, China
    8. Emergency Department, the Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510120, China
    9. Emergency Department, the Third Affiliated Hospital of Zhejiang University of Traditional Chinese Medicine, Hangzhou 310005, China
    10. Emergency Department, Hubei Maternal and Child Health Hospital, Wuhan 430064, China
    11. Emergency Department, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou 510260, China
    12. Emergency Department, Wuhan Children's Hospital, Wuhan 430015, China
    13. Emergency Department, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan 430030, China
    14. Emergency Department, Liyuan Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430077, China
    15. Emergency Department, Yichang Central People's Hospital, Yichang 443008, China
    16. Emergency Department, Xiangyang Central Hospital, Xiangyang 441021, China
    17. Emergency Department, Wuhan Asian Heart General Hospital, Wuhan 430056, China
  • Received:2024-04-15 Published:2024-06-18
  • Corresponding author: Xiaopan Wang
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引用本文：

何雯, 王颖, 汪晓攀, 龚玉枝, 冯毕龙, 田丹, 代凯利, 凌传仁, 唐杏, 董然, 黄清平, 姜汉兰, 肖洁, 张军辉, 郭庆, 张小红, 袁观惺. 中毒患者急诊护理专家共识（2024版）[J]. 中华卫生应急电子杂志, 2024, 10(03): 129-139.

Wen He, Ying Wang, Xiaopan Wang, Yuzhi Gong, Bilong Feng, Dan Tian, Kaili Dai, Chuanren Ling, Xing Tang, Ran Dong, Qingping Huang, Hanlan Jiang, Jie Xiao, Junhui Zhang, Qing Guo, Xiaohong Zhang, Guanxing Yuan. Expert consensus on emergency nursing of poisoned patients(2024)[J]. Chinese Journal of Hygiene Rescue(Electronic Edition), 2024, 10(03): 129-139.

中毒会危及患者生命，因其整体发病率不高、不被广大医护熟悉，给急诊医护人员带来许多挑战。有必要对中毒患者采取有条理、深思熟虑的治疗方法。了解毒物学病史和体格检查的细微差别，规范接诊中毒患者的首次接触，有助于管理这些病人。为此，湖北省中毒与职业病联盟组织国内多家医疗机构，综合相关专家的学术和临床经验起草本专家共识，并和部分中毒救治经验丰富的护理专家实战运用，最后提交本共识专家委员会讨论通过，就中毒患者急诊护理达成共识。本文旨在帮助急诊护理人员对中毒患者做出实用可行的评估与管理。

关键词: 中毒, 急诊, 护理

Poisoning can endanger the lives of patients. Because its overall incidence is low and it is not familiar to the majority of medical staff, it brings many challenges to emergency medical staff. It is necessary to adopt a structured and thoughtful treatment approach to poisoned patients. Understanding the nuances of toxicological history and physical examination and standardizing the first contact of poisoned patients can help manage these patients. To this end, the Hubei Province Alliance on Poisoning and Occupational Diseases organized a number of domestic medical institutions to draft this expert consensus based on the academic and clinical experience of relevant experts, and applied it in practical terms with some nursing experts with rich experience in poisoning treatment. Finally, it was submitted to this consensus expert committee for discussion and approval to reach a consensus on emergency care for poisoned patients. This article aims to help emergency nursing staff make practical and feasible assessment and management of poisoned patients.

Key words: Poisoning, Emergency care, Nursing
表1 是否洗胃的指征
不洗胃指征 洗胃指征
几乎任何剂量的毒物毒性都有限；
虽然摄入的毒可能有毒，但摄入的剂量可能小于产生严重损害的预期剂量；
摄入的毒物能被活性炭很好地吸附，预计摄入量不会超过活性炭的吸附能力；
已出现大量自发性呕吐；
患者在服药后数小时出现轻微中毒症状或体征；
摄入的毒物有高效解毒剂（如APAP和N-乙酰半胱氨酸）；
无法正确或安全地完成操作（插管尺寸错误、医护人员技术欠缺、预计存在食管或胃损伤等）		 已知摄入的毒物会产生危及生命的毒性，或患者有明显的危及生命的毒性体征或症状；
鉴于摄入的时间，胃中仍存在大量摄入的毒物；
摄入的毒物未被活性炭吸附或无法获得活性炭；
虽然摄入的毒物被活性炭吸附，但即使使用的活性炭剂量是建议标准剂量的两倍，摄入量仍超过了10：1的活性炭毒物比率，并且患者没有自发性呕吐或没有高效的特效解毒剂，或替代疗法（如血液透析）对患者构成重大风险
表2 洗胃的适应证与禁忌证
适应证 禁忌证
患者符合洗胃的指征（表1）； 患者不符合洗胃的任何指征（表1）；
洗胃的益处大于风险 患者已经丧失或可能丧失气道保护反射，但未插管。（插管后，如有其他指征，可进行洗胃）；
  在未进行气管插管的情况下，摄入了误吸可能性较高的毒物；
  摄入碱性腐蚀剂；
  摄入异物（如药包）；
  患者因潜在病变、近期手术或其他疾病而有大出血或胃肠道穿孔的风险，使用洗胃可能会进一步加重病情；
  摄入的毒物形式过大，无法进入洗胃管腔内（如许多缓释制剂）
表3 使用活性炭的适应证和禁忌证
适应证 禁忌证
患者不符合洗胃标准或洗胃可能有害； 已知活性炭不能吸附的毒物；
摄入物可能有毒，但活性炭可以很好地吸附； 气道保护性反射消失或预期消失，患者没有插管；
摄入的毒物在可被活性炭吸附的时间范围内，或存在临床因素，表明并非所有毒物都已被全身吸收； 与摄入腐蚀性物质的情况一样，很可能发生胃肠道穿孔；
治疗很可能会增加吸入的风险和严重程度；
只要没有绝对禁忌证，无论摄入时间长短，有可能危及生命的中毒患者 确定将行内镜检查（腐蚀剂）
表4 使用多剂量活性碳的适应证和禁忌证
适应证 禁忌证
摄入致命剧毒鹅膏、胺碘酮、阿米替林、卡马西平、秋水仙碱、右旋丙氧芬、洋地黄毒甙、地高辛、丙吡胺、度硫平、度洛西汀、敌草快、赭黄裸伞、拉莫三嗪、纳多洛尔、苯巴比妥、保泰松、苯妥英、吡罗昔康、喹硫平、奎宁、索他洛尔、茶碱、丙戊酸、维拉帕米、长春瑞滨； 任何单剂量活性炭禁忌证；存在回肠或其他导致肠蠕动减弱的原因
摄入大量经过肠肝循环或肠道再循环并被活性炭吸附的、危及生命的毒物；
摄入大量缓慢释放的毒物或已知会形成凝块或结块的毒物
表5 全肠道灌洗的适应证和禁忌证
适应证 禁忌证
摄入缓释和控释药物可能中毒； 未插管患者的气道保护性反射消失或预期消失；
在无法采用其他消化道净化方法或这些方法无效的情况下，摄入一定量的活性炭无法吸附的毒物； 消化道受损，有回肠梗阻、消化道严重出血或血液动力学不稳定的迹象，可能会影响消化道蠕动；
从携带毒品的体内取出毒品包 持续呕吐；
  可卡因包有渗漏迹象（手术取出的指征）
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