常见的儿童中毒处置回顾


  March 11, 2009 — 3月1日的美国家庭医学会期刊回顾了常见儿童中毒的评估与治疗实务建议,此篇回顾强调12岁以下小孩意外食入毒物时的评估与治疗。
  
  德州大学西南家庭医学住院医师计画的Tamara McGregor医师等人写道,美国的毒物控制中心在2003年接获超过240万件的中毒报告,大多数是吃到毒物(76%),最常发生于家中(93%),多数为意外(超过80%);6岁以下小孩占了这些事件的51%,其中,38%发生在3岁以下小孩。
  
  开业的家庭医师中,医师经常会治疗一些吃入异物的小孩,大多数是没有毒性的;医师必须备有毒物控制中心的电话号码,且要熟悉疑似中毒时的适当初步评估。
  
  万一中毒了,初步处置必须包括迅速检伤分类,并且稳定呼吸道、维持呼吸与循环,接著采取适当的支持疗法或者特定解毒治疗。
  
  医师必须可以辨识与治疗乙醯胺酚(acetaminophen);抗胆碱剂,如抗组织胺与精神作用药物;抗凝血剂,如warfarin或杀鼠剂;钙离子阻断剂、乙型阻断剂、毛地黄等心脏药物;蕈毒胆碱剂,如氨基甲酸酯盐(carbamates)、某些有毒蘑菇、有机磷农药;菸碱性胆碱剂,如杀虫剂与尼古丁;氰化物;抗冻剂或外用酒精的乙二醇或者甲醇;含铁产品,如 deferoxamine;鸦片类,如吗啡、hydrocodone、美沙冬;水阳酸(含阿斯匹灵的产品);硫醯基尿素类(Sulfonylurea)降血糖药;拟交感神经药物(sympathomimetic agents),如安非他命、咖啡因、古柯碱或麻黄素等造成的明显中毒症候群。
  
  回顾作者写道,如果身体检查或者检验结果发现特定中毒症候群,医师应考虑进行特定解毒治疗,例如使用解毒剂。通常在病患稳定后给予解毒剂,最好是在中毒后几小时内,或许因为药效短而需要多次剂量。医师在给予特定解毒剂前,应向当地毒物控制中心进行咨询,除非已经有此类中毒的丰富治疗经验。
  
  初步检验可能包括「重碳酸盐」值、电解质、血清尿素氮、血清肌酸酐值,借以评估肾功能和电解质失衡状态;误食降血糖药时检查血糖值;心脏毒性时进行心电图检查;检查凝血酶原时间以判定凝血异常;脉动测氧器监测缺氧状态;检查血清乙醯胺酚值判断有无乙醯胺酚中毒;孕龄妇女检查尿液检查人类绒毛膜性腺激素值。
  
  根据临床与初步检查结果,动脉血气体分析或者脉动测氧器以评估低血氧症、肌酸酐激酶用于肾中毒或者横纹肌溶解,另外如血清渗透压、特定药物浓度(例如水阳酸、铁、毛地黄、抗痉挛药或酒精)、鸦片类或毒品者进行验尿、尿液分析判断肾毒性或者肾衰竭等其它检测也可能有用。
  
  除了最严重的案件,不再建议常规使用胃部除污(例如活性炭与洗胃);当认为需要除污时,应有毒物控制中心的协助。同样的,不再建议使用吐根(ipecac)。
  
  虽然症状轻微或者明显的毒性反应可以在家中监控,有些长效药物的毒性效果会延迟发生而需要额外监控。除了肠衣锭或者持续释放剂型,其它毒物也可能会延迟吸收,例如carbamazepine;铁剂、meprobamate、阿斯匹灵、茶碱等造成的凝集;以及diphenoxylate/atropine。
  
  其它延迟作用机转的毒物,包括抗凝血剂、单胺氧化酶抑制剂、硫醯基尿素类、甲状腺荷尔蒙、有毒的蘑菇。毒性代谢物也会延迟毒性反应,例如乙醯胺酚、acetonitrile、dapsone或者毒酒。锂盐毒性也可能延迟,这些在服用后都必须额外监控。
  
  证据等级C以上的特定关键临床建议如下:
  * 可能或已知服毒之后,出现呼吸、循环、神经症状的病患,须以救护车送到最近的急诊室。
  * 评估疑似服毒的病患时,医师必须纪录病患的年纪与性别、可疑药品的类型,以及服用时间、家中所有的药物名称。
  * 疑似服毒后第一时间无症状的小孩,可能服用了延迟作用的药物或其它物质,因此需监控较长时间。
  * 洗胃仅建议于服毒后1小时内进行,且须由有经验的医师放置口胃管。
  * 除了在服毒后1小时内,不鼓励使用活性碳。
  * 不再建议使用吐根糖浆进行疑似中毒治疗。
  
  回顾作者结论表示,儿童中毒需要支持治疗,包括监控与持续观察。轻微症状的低风险病患、非中毒、没有预期的后遗症者在观察一段时间之后可以出院。高风险病患(例如蓄意服毒者、持续有中毒症候群或者症状延迟者)应住院,以持续治疗和进一步观察。
  
  回顾作者宣告无相关财务关系。

Management of Common Childhood Poisonings Reviewed

By Laurie Barclay, MD
Medscape Medical News

March 11, 2009 — Practice recommendations to evaluate and treat common childhood poisonings are reviewed in the March 1 issue of American Family Physician. The review highlights the evaluation and treatment of children younger than 12 years who unintentionally ingest toxins.

"Poison control centers in the United States received more than 2.4 million reports of toxin exposures in 2003," write Tamara McGregor, MD, from the University of Texas Southwestern Family Medicine Residency Program in Dallas, and colleagues. "Most exposures involved oral ingestion (76 percent), occurred in the home (93 percent), and were unintentional (more than 80?percent). Children younger than six years accounted for 51 percent of the exposures. Of these, 38 percent involved children three years or younger."

In the family practice setting, clinicians often have to treat children who have ingested substances, most of which are nontoxic. Therefore, clinicians should have the telephone number of the poison control center available and be familiar with the appropriate initial evaluation of suspected toxin ingestion.

In case of poisoning, initial management must include rapid triage and stabilization of airway, respiration, and circulation, followed by appropriate supportive or toxin-specific treatment as indicated.

Clinicians should be able to recognize and treat significant toxidromes resulting from acetaminophen; anticholinergic agents including antihistamines and psychoactive drugs; anticoagulants such as warfarin or rat poison; cardiac medications including calcium channel blockers, beta-blockers, and digoxin; muscarinic cholinergic agents including carbamates, some mushrooms, and organophosphates; nicotinic cholinergic agents such as insecticides and nicotine; cyanide; ethylene glycol or methanol from antifreeze or rubbing alcohol; iron-containing products such as deferoxamine; opioids such as morphine, hydrocodone, or methadone; salicylate (aspirin-containing products); sulfonylurea; and sympathomimetic agents such as amphetamines, caffeine, cocaine, or ephedrine.

"If physical examination or laboratory findings suggest a specific toxidrome, the physician should consider toxin-specific treatments, such as an antidote," the review authors write. "Antidotes are usually given after the patient is stable, preferably within a few hours of ingestion, and may require multiple doses because of short durations of action. The physician should consult with the local poison control center before administering an antidote unless he or she has ample experience with specialized poison treatment."

Initial laboratory testing may include bicarbonate level, electrolytes, serum urea nitrogen, and serum creatinine levels to evaluate for renal failure and electrolyte imbalance; blood glucose levels for hypoglycemic ingestion; electrocardiography for cardiotoxicity; prothrombin time for coagulopathy; pulse oximetry for hypoxia; serum acetaminophen level for acetaminophen toxicity; and urine human chorionic gonadotropin levels in female patients of childbearing age.

Depending on clinical and initial laboratory findings, other tests that may be useful include arterial blood gas or pulse oximetry to evaluate for hypoxemia, creatine kinase for nephrotoxicity or rhabdomyolysis, serum osmolality, specific drug levels (eg, salicylates, iron, digoxin, anticonvulsants, or alcohol), urine drug screen for opioid or street drug ingestion, and urinalysis for nephrotoxicity or renal failure.

Except for the most severe cases, gastric decontamination (eg, activated charcoal and gastric lavage) is no longer routinely recommended. When decontamination is deemed necessary, it should be done with poison control center support. Similarly, the use of ipecac is no longer recommended.

Although a child with few symptoms or a witnessed toxin exposure may be monitored at home, some long-acting medications have delayed toxin effects and require additional surveillance. In addition to enteric-coated or sustained-release preparations, some other toxins have delayed absorption, such as carbamazepine; concretions from iron, meprobamate, aspirin, or theophylline; and diphenoxylate/atropine.

Other toxins have a delayed mechanism of action, including anticoagulants, monoamine oxidase inhibitors, sulfonylureas, thyroid hormones, or toxic mushrooms. Delayed toxin effects may also result from toxic metabolites, as is the case with acetaminophen, acetonitrile, dapsone, or toxic alcohols. The toxicity of lithium may also be delayed, requiring additional surveillance after ingestion.

Specific key clinical recommendations for practice, all with level of evidence rating C, are as follows:

· After possible or known toxin ingestion, patients with respiratory, circulatory, or neurologic symptoms should be transported by ambulance to the nearest emergency department.

· When evaluating patients with suspected toxin ingestions, the clinician should document the age and sex of the patient, time and type of probable exposure, and all medications present in the home.

· A child who is asymptomatic at first after suspected toxin ingestion may have ingested a delayed-action medication or other substance and should therefore be monitored for a longer period.

· Gastric lavage is only recommended when performed within 1 hour of the ingestion by a clinician experienced in placing orogastric tubes.

· Except when given within 1 hour of ingestion, the routine use of activated charcoal is discouraged.

· For the treatment of suspected toxin ingestions, syrup of ipecac is no longer recommended.

"Childhood poisonings require supportive treatment, including monitoring and continued observation," the review authors conclude. "Low-risk patients with minimal symptoms, nontoxic ingestions, and no expected sequelae may be discharged to caregivers after a short observation period. High-risk patients (e.g., intentional ingestions, patients who exhibit continued toxidromes or prolonged symptoms) should be admitted to the hospital for ongoing treatment and extended observation."

The review authors have disclosed no relevant financial relationships.

Am Fam Physician. 2009;79:397-403.

    
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