急性有机磷农药中毒的护理查房

急性有机磷农药中毒的护理查房Acuteorganophosphatepesticidepoisoning（AOPP）carerounds2011/8/18病例介绍伍南臻患者，周桂云，女性，46岁入院时间：2011-08-07主诉：呕吐、口吐白沫、神志不清、大小便失禁4小时Patients,guiyunZhou,female,46yearsoldAdmissiontime：2011-08-07ChiefComplaint:vomiting,foamingatthemouth,confusion,incontinence4hours基本资料1病例介绍现病史：患者于4小时前因争吵后自服农药（半硫磷）约100ML，服用后出现神志改变。Historyofpresentillness,Forfourhoursafteranargumentwithhisfamilybefore,Shetakethepesticideabout100Milliliters,Pesticidesconsideredforthehalfsulphurphosphoric.Aftertakeappearmindchange.病例介绍家人行紧急救治后送入当地医院行洗胃治疗，于2011-08-0712:20急诊平车转入我院肾病内科Patientsaftermedicationwithvomiting,aftertheemergencysalvage,shewassendtothelocalhospitalforgastriclavageforherfamliy.Inaugust7,201112:20,Shewastransferredtoourhospitalnephropathyinternalmedicinewithemergencyflatcar.病例介绍转运途中出现呕吐，大小便失禁症状。门诊以“急性有机磷农药中毒”收治。起病以来，精神差，体重无明显变化。Intransit,PatientshadrepeatedvomitingandEliminationofurineandfecesarenotcontrolledbyherself,ClinicdiagnosisisAOPP,Afterthepatientisadmittedtohospital,herSpiritwassobadandweightdidnothavesignificantlychange.病例介绍既往有肺脓肿病史，已行部分肺叶切除术，术中有输血，有青霉素过敏史。shehadlungabscessbefore,andwasdoneapartiallobectomy,inthatoperation,Shehadabloodtransfusion.ThemostimportantisshehadthePenicillinallergy.病例介绍全凤春体格检查：T35.8℃P126次/分R20次/分BP109/69mmHgPhysicalexamination:Temperature：35.8℃,Pulse:126BeatPerMinute,respiration:20BeatPerMinute,BloodPress109/69mmHg病例介绍神志浅昏迷，双侧瞳孔等大等圆3mm,对光反射迟钝，口唇发绀，皮肤湿冷，双肺呼吸音粗，可闻及大量湿性啰音。Comaconsciousness,Pupilsareequalroundnessandsamesizewith3mm,reactiontolightshowsdelay,whilethelipsiscyanotic,BreathsoundshowsCoarsewhileitCanbeheardandalotofwetrales.病例介绍心率126次/分，肠鸣音活跃，四肢肌张力稍高，无自主活动，病理反射未引出。Heartrateis126BeatPerMinute,borhorygmusshowsincreased,Limbmuscletoneisslightlyhigher,thereisnoindependentactivity,Pathologicalreflexisnotelicited.病例介绍刘伟明入院诊断:1、急性重症农药中毒（半硫磷）2、中毒性心肌炎3、吸入性肺炎Admissiondiagnosis:1、severeacutepesticidepoisoning(halfsulphurphosphorous)2、toxicmyocarditis3、aspirationpneumonia主要病情变化马志群8-801:40T39.1摄氏度，予温水擦浴05：20患者开始出现躁动，予丙泊酚5毫升IV效果不明显，予地西泮镇静Onefortyonaugust8th,thepatient’sbodytemperaturerisestothirty-onepointonedegreescelsius,wegivehimawarmwaterbath.Fivetwenty,thepatientbegintoappearrestless,propofulfivemilliliterintravenensinjection,theeffectisnotobvious,tothediazepamsedation.病例介绍12:30患者躁动不安，血氧饱和度波动在70%-80%请麻醉科及ICU会诊后考虑气管插管脱出予重新插管14：50患者转入ICUTwelvethirty,thepatientisrestless,fluctuationsofoxygensatturationinseventypercenttoeightypercent.thenpleaseanesthesiaandintensivecareunitconsulation,consideringtheendotrachealtobeextrusion,toreintubationforhim.Fourteenfifty,thepatientistransforredtotheintensivecareunit病例介绍贺舒转入ICU时情况：体温37.3℃，脉搏140次/分，呼吸35次/分，血压116/87mmHg，血氧饱和度95%WhentransferredtoICUconditions:temperature37.3,pulse140beats/min,breathing35times/min,bloodpressure116/87mmHg,oxygensaturation95%.病例介绍神志镇静中，躁动不安，两侧瞳孔等大等圆4mm，对光反射迟钝，气管插管，呼吸机辅助呼吸，气道内少量痰液，皮肤干燥。conscioussedation,irritability,Pupilsareequalroundnessandsamesizewith4mm,reactiontolightshowsdelay,endotrachealintubation,mechanicalventilation,Withinafewairwaysputum,dryskin.病例介绍双肺可闻及中等量湿性啰音，腹部叩诊呈鼓音，诊断为：1.急性有机磷农药中毒；2.吸入性肺炎、1型呼吸衰竭；3.中毒性心肌炎。double-lungcanbeheardandmoderatemoistrales,ThedrumsoundabdominalsoundThediagnosisis:1:acuteorganophosphoruspesticidepoisoning;2:aspirationpneumonia,type1respiratoryfailure;3:toxicmyocarditis.病例介绍予以呼吸机辅助呼吸，留置胃管，胃肠减压，留置深静脉导管，遵医嘱予抗感染、护胃、护心、解毒、导泻等对症支持治疗。Tomechanicalventilation,indwellingstomachtube,decompression,indwellingvenouscatheters,prescribedtofightinfection,protectstomachmucosa,protectionofheartfunction,detoxification,catharsis,symptomaticandsupportivetreatment.病例介绍苏敏现患者的情况：神志模糊，躁动不安，双侧瞳孔等大瞪圆3mm,对光反射迟钝，皮肤干燥。Thecurrentsituationofpatients:mindfuzzy,restless,Pupilsareequalroundnessandsamesizewith4mm,reactiontolightshowsdelay,theskinisdry.病例介绍有发热，最高体温39℃，予物理降温。血压稳定，仍给予阿托品间断静推。withfever,themaximumtemperatureabout39℃,tothephysicalcooling.Bloodpressurestability,intermittentintravenousinjectionofatropine,病例介绍气道内有少量的黄色痰液，双肺未闻及湿啰音，四肢有自主活动。therewereafewoftheairwayyellowsputum,doublelungnotsmellandwetgosound,limbshaveindependentactivities.病例介绍主要的实验室检查8-7WBC27.3*109/L，CHE23KU/L,8-8尿常规RBC2-4/HP,K+3.38mmol/L,钙离子1.73mmol/L，CHE10KU/L，心肌酶、肝功能基本正常ThemainlaboratorytestsOn8-7Thepatient’sWBCis27.3*109/LandCHEis23KU/L.On8-8FormtheRoutineExaminationofUrineonhighpowerlenswecansee2to4redbloodcells,Thepatient’sPotassiumis3.38mmol/L,calciumis1.73mmol/LandCardiacenzymeandliverfunctionarenormal.CHE10.0KU/L病例介绍8-9CHE8.0KU/L,。胸片提示：肺部感染及双侧胸膜炎。8-12血常规正常，CHE32KU/LOn8-9,CHE8.0KU/L;ChestXraytip：lunginfectionandbilateralpleurisy.On8-12Bloodroutineisnormal，andCHEis32KU/L病因与发病机制谢妹娜病因生产及使用过程的不当：如生产设备密封不严导致化学毒物泄漏；喷洒杀虫药过程中经皮肤和呼吸道吸收EtiologyImproperproductionanduse:Forexample,productionequipmentsealedpoorlyresultinleakageofchemicaltoxicant;intheprocessofsprayingpesticide,absorbedthroughskinandairway.病因与发病机制生活性中毒：主要由于自服、误服或摄入被污染的水源和实物水果等。Livingpoisoning:Mainlyduetodrinkingoreatingcontaminatedwaterandfruitvoluntarilyorbymistakeetc.病因与发病机制有机磷农药中毒机制主要是抑制体内胆碱酯酶的活性。正常情况下，胆碱能神经兴奋所释放的递质——乙酰胆碱被胆碱酯酶水解为乙酸及胆碱而失去