常見的兒童中毒處置回顧


  March 11, 2009 — 3月1日的美國家庭醫學會期刊回顧了常見兒童中毒的評估與治療實務建議,此篇回顧強調12歲以下小孩意外食入毒物時的評估與治療。
  
  德州大學西南家庭醫學住院醫師計畫的Tamara McGregor醫師等人寫道,美國的毒物控制中心在2003年接獲超過240萬件的中毒報告,大多數是吃到毒物(76%),最常發生於家中(93%),多數為意外(超過80%);6歲以下小孩佔了這些事件的51%,其中,38%發生在3歲以下小孩。
  
  開業的家庭醫師中,醫師經常會治療一些吃入異物的小孩,大多數是沒有毒性的;醫師必須備有毒物控制中心的電話號碼,且要熟悉疑似中毒時的適當初步評估。
  
  萬一中毒了,初步處置必須包括迅速檢傷分類,並且穩定呼吸道、維持呼吸與循環,接著採取適當的支持療法或者特定解毒治療。
  
  醫師必須可以辨識與治療乙醯胺酚(acetaminophen);抗膽鹼劑,如抗組織胺與精神作用藥物;抗凝血劑,如warfarin或殺鼠劑;鈣離子阻斷劑、乙型阻斷劑、毛地黃等心臟藥物;蕈毒膽鹼劑,如氨基甲酸酯鹽(carbamates)、某些有毒蘑菇、有機磷農藥;菸鹼性膽鹼劑,如殺蟲劑與尼古丁;氰化物;抗凍劑或外用酒精的乙二醇或者甲醇;含鐵產品,如 deferoxamine;鴉片類,如嗎啡、hydrocodone、美沙冬;水陽酸(含阿斯匹靈的產品);硫醯基尿素類(Sulfonylurea)降血糖藥;擬交感神經藥物(sympathomimetic agents),如安非他命、咖啡因、古柯鹼或麻黃素等造成的明顯中毒症候群。
  
  回顧作者寫道,如果身體檢查或者檢驗結果發現特定中毒症候群,醫師應考慮進行特定解毒治療,例如使用解毒劑。通常在病患穩定後給予解毒劑,最好是在中毒後幾小時內,或許因為藥效短而需要多次劑量。醫師在給予特定解毒劑前,應向當地毒物控制中心進行諮詢,除非已經有此類中毒的豐富治療經驗。
  
  初步檢驗可能包括「重碳酸鹽」值、電解質、血清尿素氮、血清肌酸酐值,藉以評估腎功能和電解質失衡狀態;誤食降血糖藥時檢查血糖值;心臟毒性時進行心電圖檢查;檢查凝血酶原時間以判定凝血異常;脈動測氧器監測缺氧狀態;檢查血清乙醯胺酚值判斷有無乙醯胺酚中毒;孕齡婦女檢查尿液檢查人類絨毛膜性腺激素值。
  
  根據臨床與初步檢查結果,動脈血氣體分析或者脈動測氧器以評估低血氧症、肌酸酐激酶用於腎中毒或者橫紋肌溶解,另外如血清滲透壓、特定藥物濃度(例如水陽酸、鐵、毛地黃、抗痙攣藥或酒精)、鴉片類或毒品者進行驗尿、尿液分析判斷腎毒性或者腎衰竭等其他檢測也可能有用。
  
  除了最嚴重的案件,不再建議常規使用胃部除污(例如活性炭與洗胃);當認為需要除污時,應有毒物控制中心的協助。同樣的,不再建議使用吐根(ipecac)。
  
  雖然症狀輕微或者明顯的毒性反應可以在家中監控,有些長效藥物的毒性效果會延遲發生而需要額外監控。除了腸衣錠或者持續釋放劑型,其他毒物也可能會延遲吸收,例如carbamazepine;鐵劑、meprobamate、阿斯匹靈、茶鹼等造成的凝集;以及diphenoxylate/atropine。
  
  其他延遲作用機轉的毒物,包括抗凝血劑、單胺氧化酶抑制劑、硫醯基尿素類、甲狀腺荷爾蒙、有毒的蘑菇。毒性代謝物也會延遲毒性反應,例如乙醯胺酚、acetonitrile、dapsone或者毒酒。鋰鹽毒性也可能延遲,這些在服用後都必須額外監控。
  
  證據等級C以上的特定關鍵臨床建議如下:
  * 可能或已知服毒之後,出現呼吸、循環、神經症狀的病患,須以救護車送到最近的急診室。
  * 評估疑似服毒的病患時,醫師必須紀錄病患的年紀與性別、可疑藥品的類型,以及服用時間、家中所有的藥物名稱。
  * 疑似服毒後第一時間無症狀的小孩,可能服用了延遲作用的藥物或其他物質,因此需監控較長時間。
  * 洗胃僅建議於服毒後1小時內進行,且須由有經驗的醫師放置口胃管。
  * 除了在服毒後1小時內,不鼓勵使用活性碳。
  * 不再建議使用吐根糖漿進行疑似中毒治療。
  
  回顧作者結論表示,兒童中毒需要支持治療,包括監控與持續觀察。輕微症狀的低風險病患、非中毒、沒有預期的後遺症者在觀察一段時間之後可以出院。高風險病患(例如蓄意服毒者、持續有中毒症候群或者症狀延遲者)應住院,以持續治療和進一步觀察。
  
  回顧作者宣告無相關財務關係。

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.

    
相關報導
家庭治療可能對嚴重兒童肥胖患者有效
2009/10/22 上午 09:31:00
蔗糖可能對兒童止痛有幫助
2009/3/9 上午 09:47:00
兒童與青少年疫苗接種時程更新
2009/1/7 下午 02:48:00

上一頁
   1   2   3   4   5   6   7   8   9   10  




回上一頁