POISONINGS — the pathological processes developing owing to impact on the person or an animal it is exogenous the chemicals which got to an organism capable to cause disturbances of various physiological functions and to create danger to life. The lake should distinguish from endogenous (at insufficiency of function of kidneys, a liver) and infectious intoxications (see).
Lakes are a constant problem a wedge, medicine as in the Wednesday surrounding the person there are always chemical substances having toxic properties (see. Pesticides , Poisons , Poisons industrial ), noxious plants (see) and poisonous animals (see). However this problem acquired special relevance with development of chemistry, especially in civilized countries of the world where production of the new chemical substances which are widely applied to industrial, agricultural, household, medical and other purposes considerably increased. Many of them at misuse and storage become the reason acute and hron. O. Tak, from O. pesticides annually in the world loses working capacity or more than 500 thousand people perish. Besides, annually suffers from stings of venomous snakes apprx. 1 million people, at the same time deaths make from 30 to 40 thousand.
Acute O. have preferential household, and chronic — professional character.
acute O.' Frequency increases in proportion to an urbanization of the population and growth of consumption of chemical means in a household. In total quantity acute and hron. Lakes prevail the acute household O. making more than 90%. With a tendency to increase household suicide O. have big distribution, to-rye annually in the world make apprx. 120 cases on 100 000 population, and 13 of them are deadly.
In the 60th concerning acute O. in the European countries it was hospitalized on average 1 people for 1000 zhit., from them more than 1% perished. Since then in many countries of the world the number of patients with O. considerably increased and continues to increase. In the USA in 1975 the St. 6,2 million cases of O. V of Great Britain concerning O. is registered also 20% of number of injured accidents are hospitalized apprx. 11% of total number which are urgently arriving on hospitalization according to urgent indications. In the USSR negotiability concerning acute O. at the station of emergency medical service of the large cities (with the population apprx. 500 thousand people) fluctuates within 1,0 — 2,6 for 1000 of the population. The number of patients with O. surpasses number hospitalized concerning an acute myocardial infarction, and the quantity of lethal outcomes are twice more, than at the road accidents. According to the centers for treatment of poisonings in RSFSR for 1977, among hospitalized the greatest number of cases is made by patients with acute O. with drugs of household chemicals — to-tami and alkalis (14 — 38%), various medicines, generally somnolent action (27 — 35%), alcohol and its substitutes (6 — 20%), organophosphorous insecticides (10 — 30%). The considerable share of victims of O. is made by children (in the USA — apprx. 50% of all cases of O., in the USSR — 8%).
Mortality from O., despite improvement of methods of their treatment, remains high. On everyone 100 000 zhit. in Canada is registered apprx. 6 lethal cases of O., in the USA — 8, in England — 10, in Sweden-13. Only among children in the USA 1500 people annually perish that exceeds number of victims of poliomyelitis, measles, scarlet fever and diphtheria combined. A large number of patients with acute O. perishes at a pre-hospital stage before rendering medical aid to them. E.g., in England from 1000 people with deadly O. apprx. 160 dies on the spot directly incidents. Therefore the absolute number of deadly O. surpasses number registered in hospitals. In the USSR among deadly O.' reasons the main role belongs to alcohol and its substitutes, then carbon monoxide, acetic essence, medicines and pesticides. O.'s number drugs and pesticides tends to increase, and O. acetic to - that and carbon monoxide gas — to decrease.
is not present Uniform classification of O. in connection with them etiol, variety, a large number of toxic agents, a variety of ways of their receipt to an organism, conditions and ways of interaction of poisons with an organism. O.'s classification by the name of the chemical substance which caused it (O. hlorofosy, is most extended by arsenic, a dichloroethane and so forth), according to the name of group, to a cut the toxic agent (O. barbiturates, to-tami, alkalis and so forth), according to the name of the whole class combining various chemical substances on a community of their use (O. toxic chemicals, drugs) or origins belongs (O. vegetable, animal, synthetic poisons).
Depending on a way of intake of poisons to an organism distinguish inhalation (through respiratory tracts), peroral (through a mouth), percutaneous (through skin), injection (at parenteral administration) poisonings and so forth.
At O.'s characteristic widely use also the existing classifications of poisons by the principle of their action (irritating cauterizing, hemolitic and so forth) and «selective toxicity» (nephrotoxic, Hepatotoxic, cardiotoxic, etc.).
The wedge, classification provides allocation acute and hron. The lake, and also concerns assessment of weight of a condition of the patient (easy, moderately severe, heavy and extremely heavy) that taking into account conditions of emergence of O. (household, production, medical) and its reasons is of great importance in court. - the medical relation.
the Toxicants which are etiol O.'s factors, are various on the chemical structure and sources of education. In the most habit view they can be classified on the following groups. 1. Toxic chemical agents of not biological nature; treat them strong mineral to - you, alkalis, oxides, compounds of heavy metals and arsenic, organic to - you, chlorinated hydrocarbons, organophosphorous and fluorides, a number of synthetic pharmaceuticals, etc. 2. Toxic waste products of nek-ry bacteria, napr, botulotoxin (see. Botulism ), and fungi, including nek-ry antibiotics. 3. Poisons of a plant origin; most often alkaloids (see) and glycosides (see), and also saponins (see). Existence of these connections causes toxicity of many medicines received from plants. Virulence of nek-ry plants is connected with contents in them toxic proteins, and also other organic compounds and pitches. 4. Poisons of animal origin; the greatest a wedge, poisons of nek-ry snakes matter (see. Snake poison ) and fishes, and also arthropods (karakurt, scorpion, tarantula).
At sots. - a gigabyte. the analysis of an etiology of O. their division according to a source of poison in an organism on production (O. industrial poisons) and household is reasonable.
In the USSR the leading place among O. is taken by the household O. connected with uncontrolled reception of pharmaceuticals, and also misapplication of drugs of household chemicals, the use of substitutes of alcohol. Poisonings on production meet rather seldom. Have special value food poisonings (see).
The reasons of hit of poisons in an organism can be divided into two main categories: subjective, directly depending on behavior of the victim, and objective, connected with specifically created «toxic situation». In each case of O. it is usually possible to find influence of the reasons of both categories. The subjective reasons of O. are connected generally with self-poisoning as a result of accidental (wrong) or deliberate (suicide) reception of various chemical means. The criminal cases of O. connected with use of poisons for the purpose of murder or development in the injured helpless state were widespread in the past, especially in the Middle Ages; in modern conditions they became a rarity what is promoted, in particular, improvement of methods court. - chemical examinations and strict supervision of storage of highly toxic drugs.
Among the objective reasons determining growth of acute poisonings influence of broad use of the calming pharmaceuticals, their uncontrollable sale and impetuous advertizing in the capitalist countries is undoubted. The special place is allocated hron, to alcoholism and toxicomanias, to-rye it is necessary to consider «risk factors» for widespread O.' development by substitutes of alcohol and medicines. Self-treatment, and also the use of toxic doses of drugs or chemical drugs for extra hospital) abortion, especially in the countries where abortions are prohibited is among the important reasons of O.
O. in pathogenetic aspect it is reasonable to consider a pathogeny as the chemical injury developing owing to implementation in an organism of a toxic dose of alien chemical substance. All effects connected only with specific impact on an organism of toxicant refer to toxicogenic effect of a chemical injury. According to it the earliest a wedge, O.'s stage which is shown symptoms of specific effect of the poison (connected with dysfunction of certain membranes, proteins and other receptors of toxicity) call toxicogenic. At the same time join and then develop patofiziol. the reactions of adaptation value directed to elimination or compensation of disturbances of a homeostasis. Those are lysosomic reaction, pituitary and adrenal reaction (stress reaction), vascular reactions of centralization of blood circulation, a coagulopathy, etc., to-rye treat somatogenic effect of a chemical injury. Compensatory reactions and recovery processes along with signs of disturbance of structure and function of various bodies or systems of an organism create the main symptoms the second wedge, O.'s stages — somatogenic, coming after removal or destruction of the toxic agent and proceeding to a complete recovery of functions or death.
In the course of a chemical injury of reaction pato-and a sanogeneza are always combined, but at various stages of a disease they can change the role and value considerably. Such compensatory reactions as centralization of blood circulation or hypocoagulation and a fibrinolysis at their hyperproduction, often become the reason of the new disturbances of life activity demanding performing urgent corrective treatment. These disturbances can sometimes play a large role during a chemical injury, than specific influence of poison.
The analysis of a pathogeny of O. separate poisons is based on studying of interaction of this poison with an organism, a cut is defined toksi-kodinamiky and toksikokinetiky this poison. Toksikodinamika characterizes effects of impact of poison on various structures and functions of an organism, mechanisms of its specific action and «selective toxicity», i.e. abilities to damage certain cells or to break certain functions, without influencing at the same time other cells, including directly contacting to poison. Toksikokine-tika characterizes ways of intake of poison to an organism, its distribution in fabrics and bodies, metabolism and removal from an organism. Knowledge of a toksikokinetika in many respects helps to explain character patol, process. Distribution of toxicants in an organism depends on three major factors: space, temporary and concentration.
The steric factor defines ways of introduction and distribution of poison. The last is in many respects connected with blood supply of bodies and fabrics as the amount of poison arriving to this body depends on its volume blood-groove carried to a mass unit of fabrics. According to it it is possible to allocate the following bodies, the greatest number of poison in unit of time usually comes to fabrics to-rykh: lungs, kidneys, liver, heart, brain. At inhalation poisonings the main part of poison comes with blood to no4Pvii, and at peroral — to a liver since the ratio of a specific blood-groove of a liver/kidney makes about 1: 20. However toxic process is defined not only concentration of poison in fabrics, but also degree of order to it, i.e. «selective toxicity». The toxicants causing irreversible damages of cellular structures (e.g. are especially dangerous in this respect, at chemical burns of fabrics to-tami or alkalis) and the reversible damages (e.g., at an anesthesia) causing only funkts, frustration are less dangerous.
The temporary factor is meant as the speed of intake of poison in an organism, its destruction and removal, i.e. it reflects communication between time of effect of poison and its toxic effect.
The concentration factor, i.e. concentration of poison in biol, Wednesdays, in particular in blood, is considered the basic in a wedge, toxicology. Definition of this factor allows to distinguish toxicogenic and somatogenic stages of O. and to estimate efficiency of disintoxication therapy.
Expressiveness of a toxicogenic stage of O. depends on toxicity of chemical drug, i.e. its damaging effect, to-ry in experimental toxicology is quite precisely estimated quantitatively by definition of threshold (Limac) and a srednesmertelny (DL60) dose. In a wedge, toxicology the concept «conditional lethal dose» is traditionally used, edges corresponds to the minimum dose causing the death of the person at single influence of this toxicant. Objective data on deadly concentration of toxicants in the blood received by chemical analysis researches in clinic are more informative.
The pathogeny of the disorders of life activity creating a wedge, O.'s manifestations is defined in a toxicogenic stage by generally specific properties of poison, and these disturbances reflect degree and the nature of damage in a somatogenic stage various funkts, systems depending on intensity of a chemical injury, duration of a toxicogenic stage and «selective toxicity» of poison.
In an origin psikhonevrol, frustration the leading role is played by the disturbances developing owing to a combination of direct impact of poison on various structures of the central and peripheral nervous system in a toxicogenic stage of O. (exogenous toxicosis) and under the influence of endogenous toxins in a somatogenic stage of defeats of secretory systems of an organism, preferential a liver and kidneys (endogenous toxicosis). Poisoning with the substances breaking normal mediation of nervous processes on the terminations of peripheral nerves leads to heavy disturbances of vegetative functions (action of the heart, secretion of glands, a tone of unstriated muscles), as a result of oppression or stimulation adreno-and holinoretseptor. The convulsive syndrome which is observed at O. different poisons can be result of direct toxic impact of nek-ry poisons (strychnine, derivatives of an isoniazid, etc.) on function of c. N of page, and also display of the accompanying hypoxia or wet brain. At acute O. vascular defeats and degenerative changes of brain fabric (the disseminated sites of a necrosis in bark and subcrustal educations), testimonial of the combined toxic and hypoxemic damage with the phenomena attract attention haemo-and liquorodynamic disturbances,
Disturbances of breath can develop owing to disorders of gas exchange and transport of oxygen on any of three main levels: in lungs, in blood and in fabrics. It leads to development of different types hypoxias (see). The wedge, signs of disturbances of external respiration with the phenomena of a hypoxemic hypoxia make about 86%, in other cases the phenomena of a gemichesky, circulator and fabric hypoxia prevail. The heaviest respiratory frustration are observed at a combination of the listed forms that is noted in 45% of cases (the mixed form of a hypoxia). Mechanical asphyxia at the expense of obturation of bronchial tubes from an oral cavity is a secret and aspirirovanny masses the frequent reason of respiratory disturbances at disturbance of drainage function of bronchial tubes. At nek-ry acute O. the bronchorrhea — the increased allocation of a bronchial secret in connection with patol is its cornerstone, that sharply limits ventilation of the lungs, prevents excitement of a parasympathetic part of century of N of page diffusion of gases and leads to «self-drowning» of patients. In a pathogeny of pneumonia, edge is one of frequent causes of death of patients in a somatogenic stage of O., two major factors — the long coma complicated aspira-tsionno-obturatsionnymi by frustration, and the substances cauterizing burns of upper respiratory tracts or gastric contents with low pH attract attention. Besides, the great value is attached to disturbance perfused ventilyatsion-nykh the relations in lungs owing to regional frustration of a hemodynamics and toxic coagulopathy («shock lung»).
Circulator disturbances — cardiac arrhythmias, an asystolia, a collapse, toxic shock — are caused by toxic defeat of both links of regulation of blood circulation, and the most cardiovascular system (e.g., at O. cardiac glycosides, kardiotropny poisons). In a toxicogenic stage of O. the so-called primary toxicogenic collapse observed in 1 — 5% of cases of deadly O. V its development develops the acute anoxia of a brain and disturbance of conductivity and a heart rhythm as an atrioventricular block and fibrillation of ventricles (cardiotoxic poisons) matter. If in response to a chemical injury compensatory mechanisms of increase in peripheric vascular resistance and centralization of blood circulation manage to turn on, then other wedge develops. a syndrome — ekzotoksichesky shock. At shock the hypovolemia — relative (owing to redistribution of blood and expansion of capacity of a vascular bed of venous system) or absolute is characteristic of a pathogeny of hemodynamic disturbances (as a result of the plazmopotera coming because of increase in permeability of membranes of an endothelium). In a pathogeny of the collapse developing in a somatogenic stage approximately in 1/3 cases of deadly acute O. the hypokinetic condition of a hemodynamics and the expressed toxic dystrophy of a myocardium ranks high. Morfol, substrate of this pathology are melkoochagovy necrobiotic changes in a myocardium.
In a pathogeny of disturbances of functions of a liver and kidneys allocate two main ways of their development: specific, connected with the secretory and neutralizing functions, and nonspecific, depending on participation of these bodies in maintenance of a homeostasis. In the first case the direct influence of hepatotoxic and nephrotoxic poisons damaging a parenchyma with development of fatty infiltration (dystrophy) or focal gepato-or a nefronek-rose is observed. In the second case the regional disturbance of blood circulation (e.g., priekzotok-sichesky shock) leading to ischemic damage of these bodies is primary. These pathogenetic mechanisms are not mutually exclusive. On the contrary, in cases of the heavy O. complicated by shock, many chemical drugs (e.g., barbiturates) uncharacteristic for them gepato-also nephrotoxic properties as if get. Similar «situational» gepato-and nephrotoxicity of drugs is found also in the patients suffering hron, diseases of these bodies when their disintoxication and compensatory opportunities are sharply limited. Besides, there is a big group of the toxicants causing an intravascular hemolysis with emergence in blood of free hemoglobin. It is followed< by dysfunctions of secretory bodies for type expressed pigmental gepato for and a hemoglobinuric nephrosis. The toksiko-allergic processes causing dysfunctions of these bodies owing to individually hypersensitivity to therapeutic doses of drugs can have essential value.
O.'s pathogeny considerably is defined toksikodinamiky poison, the main data about a cut at separate O. are presented in the table «The most widespread acute poisonings and acute management at them» .
The main clinical manifestations
Depending on a look and amount of the poison which got to an organism the wedge, acute O.' picture can develop very quickly with rough progressing funkts, frustration, leading to death, or slowly — with fading in of separate symptoms and development of a characteristic symptom complex for this O. within several hours or days. Due to the relative or preferential selectivity of toxic effect of many poisons (psychotropic, kardio-tropny, hepatotropic, etc.) in a wedge, a picture symptoms of defeat of separate life support systems — nervous, cardiovascular, respiratory etc. can prevail. Therefore in a wedge, the toxicology can allocate the leading syndromes corresponding to disturbances of functions of these major systems.
Psychoneurological frustration consist of set of symptoms of mental, neurologic and somatovegetativny disturbances. The heaviest manifestations of these frustration are toxic coma (see) and intoksikatsionny psychoses (see). Along with a toxic coma of narcotic character various forms of disturbance of consciousness and mental activity with the expressed hyperreflexia, hyperkinesias of myoclonic or choreic type, a convulsive syndrome can be observed. Even easy degree of any exogenous O. can cause the heavy psychosis proceeding as alcoholic hallucinosis or delirium tremens in the persons suffering hron, alcoholism.
The most noticeable in nevrol, a picture acute and hron. Lakes often are somatovegetativny frustration: symmetric changes of size of pupils (miosis, mydriasis), disturbances of secretion of sweat, salivary and bronchial glands, thermal controls and so forth. At O. the substances causing m-holinomimetiche-skiye effects (organophosphorous insecticides, a fly agaric, etc.), the syndrome expressed muskarinopodobny — a miosis, perspiration, a bronchorrhea, a hypothermia develops; at O. of m - cholinolytic substances (a belladonna, Asthmatolum and so forth) the atropinopodobny syndrome — a mydriasis, dryness of mucous membranes, tachycardia, a hyperthermia is observed. Big danger at heavy O. nek-ry neurotoxic poisons is constituted by the disturbances of neuromuscular conductivity proceeding in the form of paresis and paralyzes (a toxic myasthenia). From the diagnostic point of view it is important to know about a possibility of an acute disorder of sight (a toxic amaurosis) and disorders of hearing as a result of toxic neuritis visual and a cochlear part preddverno-cochlear nerves. At the patients who transferred acute O. in the period of reconvalescence the asthenic state with the phenomena of irritable weakness, emotional lability, increased fatigue, etc. is observed. It is long and hard proceeding psikhonevrol, frustration designate the term «toxic encephalopathy», edges O. neurotoxic poisons is inherent. However accurate compliance between expressiveness a wedge, and patomorfol. data usually are not found.
Defeat of a respiratory organs, in particular acute respiratory insufficiency (see), is frequent manifestation of the Lake. At acute O. usually allocate three most frequent types of the reasons of ventilating disturbances: the central (neurogenic) disorders of regulation of the act of breath and function of respiratory muscles that is peculiar to O. poisons of neurotoxic action at development in patients of coma; aspiration obtura-tsionnye the frustration leading to mechanical asphyxia; patol, processes in lungs — atelectases and pneumonia.
Toxic pneumonia and a toxic fluid lungs are diagnosed only when there are signs of direct toxic damage of the pulmonariest membrane and increase in its permeability that it is characteristic at O. nek-ry chemical substances of generally irritating and cauterizing action.
Dysfunctions of cardiovascular system at acute O. consider as result of a chemical injury. In an early toxicogenic stage of a row O. increase in the ABP as manifestation a stress reaction on a chemical injury, asphyxia or specific exciting effect of poison is sometimes noted. Primary toxicogenic is more often observed collapse (see), to-ry it is characterized by sudden and bystry development of a circulatory unefficiency owing to reduction of cordial emission and paralysis of vessels. At toxic shock the acute circulatory unefficiency is only one of numerous a wedge, the manifestations concerning also disturbances of functions of c. N of page, metabolism, etc. Shock (see) causes apprx. 65 — 70% of an over-all mortality at acute O. V to clinic of toxic shock distinguish two phases: compensated (erectile) and dekompensirovanny (torpid), followed by considerable decrease in the ABP.
The so-called secondary somatogenic collapse developing as a result of exhaustion of compensatory reserves of cardiovascular system in the conditions of insufficiency of function of a liver, kidneys or a respiratory organs is characteristic of a somatogenic stage of O. Many O., especially kardio-tropny poisons, are followed by disturbances of conductivity and a heart rhythm; in other cases decrease in sokratitelny function of a myocardium is leading, and on an ECG characteristic «metabolic» changes of a final part of a ventricular complex are found (decrease in a segment S — T, smoothing and a negativation of a tooth of T).
The gastrointestinal tract disease is usually shown in the form of dispeptic frustration (nausea, vomiting), esophageal and gastrointestinal bleedings (see) and specific gastroenterocolitis (see). However at a toxic fermentopatiya (e.g., at decrease of the activity of cholinesterase) and a muska-rinopodobny syndrome vomiting and epiphenomena of a gastroenteritis can carry neurogenic funkts, character. Esophageal and gastric bleedings are most often observed at O. by the cauterizing poisons (acids and alkalis), and it is possible their early (the first days) and later (2 — 3 weeks) emergence. Early bleedings develop owing to a direct injury of vessels of a mucous membrane of a stomach and intestines and the expressed hypocoagulation of blood (a toxic coagulopathy), and late — result from rejection of sites of a nekrotizirovanny mucous membrane and formation of deep erosion and ulcers. A toxic gastroenteritis is dangerous first of all by development of dehydration and disturbance of electrolytic balance.
An abnormal liver function and kidneys are found more than to 30% of acute Lakes. Due to the lack of the expressed inflammatory reaction at toxic damages of a liver and kidneys and features their wedge, manifestations in a wedge, the toxicology can call these disturbances the terms «toxic nephropathy» and «toxic hepatopathy». Distinguish three degrees of manifestation of these syndromes.
The easy hepatopathy and a nephropathy are characterized by absence any a wedge, signs funkts, insufficiency of these bodies. At a hepatopathy and a moderately severe nephropathy there are a certain wedge, signs of damage of a liver (its increase and morbidity at a palpation, hepatic colic, jaundice, the phenomena of hemorrhagic diathesis) and kidneys (back pains, hypostases, an oliguria). At a heavy hepatopathy, besides, disturbances of consciousness — hepatic encephalopathy are observed (see. Hepatargy ) and coma (see). The heavy nephropathy is characterized by development of a syndrome of acute renal failure (see) with an anury and an azotemia.
In diagnosis of a toxic hepatopathy and nephropathy laboratory and tool methods of researches have great value. At toxic damage of hepatocytes in a vascular bed, first of all, there are well soluble cytoplasmatic enzymes (aminotransferases and dehydrogenases), and at heavier disturbances with the phenomena of a gepatonekroz activity of the enzymes which are directly connected with intracellular structures, napr, mitochondrions amplifies (malate dehydrogenases 3 — 4 fractions, glutamatdegidrogenaza), activity of pseudo-cholinesterase decreases. According to weight of defeat protein and lipidic metabolism suffers that finds the reflection in decrease in content in blood of ^-lipoproteids, cholesterol, phospholipids and albumine. Informative indicators receive at a radio isotope research, with the help to-rogo it is possible to define severity of a toxic hepatopathy.
At a toxic nephropathy, except changes of composition of urine (a proteinuria, a cylindruria, etc.), decrease in glomerular filtering (to 60,7 ml/min. — is noted at average and to 22,8 ml/min. — at a severe form of O.), a canalicular reabsorption (respectively to 98 and 89%) and a renal plazmotok (respectively to 468,7 and 131,6 ml/min.).
At seriously ill patients with a toxic hepatopathy and a nephropathy the syndrome of hepatonephric insufficiency as a result of the combined defeat of function of a liver and kidneys is usually noted (in 82% of cases) that causes the high lethality reaching 50%. Nephrotoxic influence of a heavy toxic hepatopathy (see. Hepato-renal syndrome ), leads often to development of an aminoatsiduriyny nephrosis.
A wedge, separate O.' manifestations — see in the table «The most widespread acute poisonings and acute management at them» .
The general principles of rendering acute management
Feature of acute management at acute exogenous O. consists in need of the combined carrying out the following to lay down. actions: the accelerated removal of toxicants from an organism (methods of an active detoxication), urgent use of the specific (antidotal) therapy which is favorably changing metabolism of toxicant in an organism or reducing its toxicity, the symptomatic therapy directed to protection and maintenance of that function of an organism, edge preferential is surprised this toxicant in connection with its «selective toxicity».
Methods of an active detoxication of an organism. The gastric lavage via the probe is an obligatory and emergency action at O. the substances accepted inside. The patient in coma, in the absence of tussive and laryngeal reflexes, for the purpose of prevention of aspiration gastric lavage (see) make after a preliminary intubation of a trachea a tube with a razduvny cuff.
The artificial diuresis as a method of a detoxication is based on use of osmotic diuretics (urea, Mannitolum) or saluretics (lasixum, furosemide) promoting sharp increase of a diuresis (see. Disintoxication therapy ). The method is shown at the majority of intoxications when removal of toxicants is carried out preferential by kidneys. It includes three consecutive stages: water loading,
intravenous administration of diuretic and replaceable infusion of electrolytes. Prepost compensation of the hypovolemia developing at a serious poisoning by intravenous administration of plasma substituting solutions (Polyglucinum, Haemodesum and 5% of solution of glucose) of 1 — 1,5 l. It is at the same time recommended to make definition of concentration of toxicant in blood and urine and to measure an hourly diuresis by means of a constant uric catheter. Urea in the form of 30% of solution or 15% solution of Mannitolum is entered intravenously struyno within 10 — 15 min. in number of 1 — 2 g on 1 kg of weight of the patient; lasixum, furosemide — in a dose of 80 — 200 mg. Upon termination of administration of diuretic begin infusion of solution of electrolytes (4,5 g of potassium chloride, 6 g of sodium chloride and 10 g of glucose on 1 l of solution). Speed of intravenous administration of solutions shall correspond to the speed of the diuresis reaching 800 — 1200 ml! hour. This cycle is repeated if necessary in 4 — 5 hours up to full removal of toxic agent from a circulatory bed. In process and after the end of treatment by method of an artificial diuresis control of content of electrolytes (potassium, sodium, calcium) in blood with the subsequent compensation of the found disturbances of water and electrolytic balance is necessary.
At treatment of acute poisonings with barbiturates, salicylates and other chemical drugs, solutions to-rykh have acid reaction (pH lower than 7,0), and also at poisonings with hemolitic poisons is shown in combination with water loading to carry out alkalization of blood. For this purpose intravenously kapelno enter from 500 to 1500 ml of 4% of solution of hydrosodium carbonate a day with simultaneous control acid-base equilibrium (see) for maintenance of constant alkali reaction of urine (pH more than 8,0).
Use of an artificial diuresis allows to accelerate removal of toxicants from an organism by 5 — 10 times. However the method is contraindicated at intoxications complicated by acute cardiovascular insufficiency (a persistent collapse), hron, disturbance of blood circulation of the II—III degree and also at a renal failure (an oliguria, an azotemia, increase in content of creatinine of blood more than 0,05 g/l). At patients 50 years are more senior efficiency of a method of an artificial diuresis considerably is reduced.
The hemodialysis with use of the device «artificial kidney» is an effective method of treatment of poisonings with the «dialyzed» toxicants, to-rye are capable to get through a semipermeable membrane of the dialyzer (see. Hemodialysis ). It is applied as an action of acute management in an early toxicogenic stage of intoxication in the special centers of treatment of poisonings or departments «artificial kidney». In the speed of clarification (clearance) of blood from poisons a hemodialysis in 5 — time would surpass a method of an artificial diuresis.
A contraindication to use of a hemodialysis is acute cardiovascular insufficiency, dekompensirovanny toxic shock.
Peritoneal dialysis is used for the accelerated removal of the toxicants having ability to be deposited in fatty tissues or to contact strongly proteins of plasma. Performance of operation peritoneal dialysis (see) perhaps in the conditions of any surgical hospital. Feature of this method is the possibility of its use without decrease in efficiency on clearance even at the phenomena of acute cardiovascular insufficiency, than it favourably differs from other ways of the accelerated removal of toxicants from an organism.
A contraindication to use of peritoneal dialysis — the expressed commissural process in an abdominal cavity and big durations of gestation.
Hemosorption by means of perfusion of blood of the patient through a special column (detoksikator) with active coal or other type of a sorbent — a new and perspective method of removal of a number of toxicants, to-ry is applied in the conditions of a specialized hospital. It is effective at O. not - the dialyzed poisons. Clearance of toxicants at hemosorptions (see) 5 — 6 times above, than at a hemodialysis.
Substitution of blood of the recipient blood the donor and (see. Hemotransfusion ) it is shown at acute poisonings with some chemicals causing toxic damage to blood — formation of a methemoglobin, long decrease of the activity of cholinesterases, massive hemolysis and so forth. After substitution of blood of 2 — 3 l control and correction of electrolytic and acid-base composition of plasma is necessary. Efficiency of substitution of blood on clearance of toxicants considerably concedes to all to the methods of an active detoxication stated above.
Substitution of blood is contraindicated at acute cardiovascular insufficiency.
Specific (antidotal) therapy (see. Antidotes of OV , Antidotes ) it is effective in an early toxicogenic phase of acute O. and it can be used only on condition of the authentic klinikolaboratorny diagnosis of the corresponding type of intoxication. Otherwise the antidote can exert toxic impact on an organism.
Symptomatic therapy. Treatment psikhonevrol, frustration at acute O. demands holding strictly differentiated detoksikatsionny actions from the patients who are in a condition of a toxic coma. Stopping of intoksikatsionny psychosis is reached by use of tranquilizers, neuroleptics, means for anesthesia (aminazine, a haloperidol, viadril, GOMK and so forth).
At a convulsive syndrome first of all it is necessary to recover passability of respiratory tracts and to enter intravenously on 2 — 4 ml 0,5% of solution of diazepam (Seduxenum). In hard cases the radio and oxygen anesthesia with muscle relaxants is shown.
At development of a syndrome of a hyperthermia of the central origin (to differentiate with feverish states or pneumonia!) the kraniotserebralny hypothermia, repeated spinal punctures are necessary. Intramusculary enter lytic mix: 1 ml of 2,5% of solution of aminazine, 2 ml of 2,5% of solution of isopromethazine (Pipolphenum) and 10 ml of 4% of solution of pyramidon.
Treatment of disorders of breath at acute O. is carried out depending on a type of ventilating disturbances.
At an aspiration obturatsionnoy to a form with sharply expressed sialosis and a bronchorrhea subcutaneously enter 1 ml of 0,1% of solution of atropine. If asphyxia is caused by a burn of upper respiratory tracts and hypostasis of a throat as a result of poisoning with the cauterizing poisons, urgent operation — lower is necessary tracheostomy (see). At the central (neurogenic) form of disturbance of breath it is necessary artificial respiration (see), whenever possible hardware, a cut carry out after a preliminary intubation. At the pulmonary form of disturbances of breath connected with development patol, processes in lungs the lechebnodiagnostichesky trakheobronkhoskopiya is recommended (see. Bronkhoskopiya ).
In all cases of heavy O. with disturbance of external respiration an early antibioticotherapia is required (enter daily intramusculary not less than 10 000 000 PIECES of penicillin and 1 g of streptomycin). At indications increase a dose of antibiotics, make their change, sometimes apply glucocorticoids.
A special form of disturbances of breath at acute poisonings the gemichesky hypoxia owing to hemolysis makes, methemoglobinemias, a carboxyhaemoglobinaemia, and also a fabric hypoxia owing to blockade of respiratory enzymes of fabrics. In such cases apply hyperbaric oxygenation (see) also carry out specific antidotal therapy.
Treatment of dysfunctions of cardiovascular system in a toxicogenic phase of poisoning consists in fight against ekzotoksichesky shock. In these cases performing active infusional therapy is necessary: intravenous drop administration of plasma substituting liquids (Polyglucinum, Haemodesum) and 10 — 15% solutions of glucose with insulin before recovery of volume of the circulating blood and normalization of the ABP and the central venous pressure (sometimes to 10 — 15 i a day). Apply Prednisolonum to 500 — 800 mg a day intravenously. For fight against a metabolic acidosis intravenously kapelno enter 300 — 400 ml of 4% of solution of hydrosodium carbonate. In the presence of a pain syndrome (at poisoning with the cauterizing poisons — to-tami, alkalis) it is stopped intravenous administration of glyukozonovokainovy mix (500 ml of 5% of solution of glucose together with 50 ml of 2% of solution of novocaine), an injection of drugs or way neyroleptanalgeziya (see).
For treatment of arrhythmias at O. the cardiotoxic poisons which are initially operating on heart intravenously enter 1 — 2 ml of 0,1% of solution of atropine, 5 — 10 ml of 10% of solution of potassium chloride.
At a toxic fluid lungs enter 60 — 80 mg of Prednisolonum intravenously from 20 ml of 40% of solution of glucose (if necessary repeatedly), 100 — 150 ml of 30% of solution of urea intravenously or 80 — 100 zhg lasixum, apply oxygen therapy (see).
In complex therapy of acute toxic dystrophy of a myocardium the medicines improving exchange processes (Nerobolum, cocarboxylase) shall be used.
At a toxic nephropathy special attention is paid to prevention of possible development of an acute renal failure. Use of operation of a hemodialysis in the early period of acute poisonings with nephrotoxic poisons allows to bring these substances out of an organism and to prevent development of damage of kidneys. At poisonings with hemolitic poisons and a myoglobinuria the good effect renders alkalization of plasma and urine with simultaneous carrying out an artificial diuresis. In a complex to lay down. actions intravenous drop administration of glyukozonovokainovy mix (300 ml of 10% of solution of glucose and 30 ml of 2% of solution of novocaine), and also alkalization of blood is recommended by intravenous administration of 300 ml of 4% of solution of hydrosodium carbonate. Indications to carrying out operation of a hemodialysis are the clear hyperpotassemia, high figures of urea in blood (St. 200 l*g/100 ml), a considerable delay of liquid in an organism.
At a toxic hepatopathy as emergency treatment apply vitamin therapy: intramusculary — 2 ml of 5% of Solution of a pyridoxine (rat anti-acrodynia factor), 1 ml of 1% of solution of a nikotiiamid, 500 mkg of cyanocobalamine (B12 vitamin). Reasonablly intravenous administration of 20 — 40 ml of 1% of solution glutaminic to - you, 0,5% of solution lipoic to - you (200 mg) intramusculary, 200 mg of cocarboxylase and to 40 ml in days of 5% of solution of Unithiolum. Intravenously kapelno twice a day enter on 750 ml 10% of solution of glucose and intramusculary insulin on 16 — 20 PIECES. An effective method of treatment is catheterization of an umbilical vein (see. Catheterization of umbilical vessels ) with direct introduction to a liver of above-mentioned medicines, drainage of a chest channel, hemosorption and a limfosorbtion. In hard cases of hepatonephric insufficiency apply also operation of a hemodialysis and hyperbaric oxygenation.
O.'s Forecast in many respects depends on severity of toxic internal injuries. At easy and medium-weight O. the forecast usually favorable (during 10 — 25 days the broken functions completely are recovered). At heavy O. with dystrophic and necrotic changes of fabrics (a toxic hepatopathy and a nephropathy) recovery of the broken functions continues from 6 months to 2 years if O. does not come to the end with a lethal outcome.
At chemical burns of a digestive tract to-tami and alkalis with development of a fibrinous and ulcer inflammation of a mucous membrane in 10% of cases in 5 — 6 months after O. it is necessary to resort to surgical interventions for recovery of passability deformed by cicatricial process of a gullet or stomach.
O.'s Prevention consists in strict observance a dignity. - a gigabyte. rules of use and storage of chemical means on production and especially in life, in failure from self-treatment by drugs and reception of alcoholic substitutes and so forth
Chemicalixation of all industries of the national economy of the country leads Professional poisonings to increase in number of the persons contacting in the course of production activity to chemical substances to-rye have toxic properties and under certain conditions (disturbance a gigabyte. standards and rules, the accident prevention, measures of personal hygiene, emergencies) can get into an organism and cause professional O. and diseases (see. Occupational diseases , Professional harm ).
According to a dignity. all chemical substances implemented in the national economy are subject to the legislation obligatory toksikol, assessment. For the connections synthesized in vitro on semi-plants approximate safe levels of influence are approved; for the substances produced commercially are approved maximum allowable concentrations (see). The main documents regulating the content of chemical substances in air of a working zone are GOST 12.1. 007 — 76 and 12.1.005 — 76. Control of the content of toxicants in air of a working zone is exercised by bodies of the State sanitary inspection.
In conditions of production the main way of penetration of chemical substances to an organism is a respiratory organs. Penetration of nek-ry substances through the unimpaired skin is possible. Through went. - kish. a path of chemical connection can get during the swallowing them from mucous membranes of a nose and a throat, and also from the contaminated hands at meal and smoking in a workplace.
Distinguish acute and hron. O. Pervye, as a rule, arise at single impact of chemical connections in rather high concentration, the second — at long contact with their trace amounts. Professional O.' character depends on concentration and duration of influence of chemical substances, their physical properties (temperature of boiling, a volatility, dispersion, solubility in liquids of an organism, fats), on ability to collect in an organism, the speed of their neutralization, from sensitivity of an organism to poison (at children, men and women, elderly people and had various diseases sensitivity different). Toxic effect of chemical substances on an organism can amplify at influence of high temperature of air, an exercise stress, consumption of alcohol, smoking, reception of nek-ry medicinal substances, defective food etc.
Toxicity and the mechanism of effect of poisons are defined substantially by their chemical structure. E.g., monochlorination in a molecule of aromatic hydrocarbons, as a rule, increases their toxicity, and polyfluorination (more than one) both education fluorine - and fluorine-chlorhydrocarbons reduces their toxic properties; existence nitro-and amino groups reports to connections of property of a metgemoglobinoobra-zovatelea; organic compounds of metals are, as a rule, more toxic, than inorganic, etc. Knowledge of the listed dependences allows to predict toxic properties of again synthesized substances from these classes.
Getting into an organism, chemical substances have polytropic effect (on most bodies and systems). However a number of substances selectively influences nervous or cardiovascular systems, a liver, kidneys, blood, sexual function.
Due to the improvement of working conditions in the USSR O.'s danger with carbon monoxide, lead, mercury, zinc, manganese, aromatic nitro - both the amidoconnections and other substances which were in the past of great importance in professional incidence is almost completely eliminated. The organism in conditions of production, as a rule, is influenced by substances in concentration at the level of the established maximum allowable concentrations or below. Therefore the wedge, a current hron gradually change the, intoxications, to-rye are characterized by a stertost of a picture, lack of specific symptomatology now. The increasing value gets identification of the remote effects of influence of chemical substances in small concentration. The remote effects can be shown by disturbances from gonads, an embryo, increase in oncological and cardiovascular incidence, emergence of allergic reactions, etc. It is shown, e.g., that such substances as chloroprene, 4,4 dimethyldioxanes, cresol, phosphorus oxychloride, at influence in concentration, not defiant disturbances of functions of an organism, have effect on gonads, dimethyl formamide, hloroprenvinilkhlorid — on an embryo, carbamates (ziram, zineb), arsenic, lead, ethylene imine, ethylene oxide induce aberation chromosomes, carbon sulfur exerts impact on vessels. In this regard maximum allowable concentrations establish also taking into account the remote effects of influence.
The destiny of poisons in an organism is defined by hl. obr. their physical. - chemical properties. Transformation of separate connections can happen to education more toxics (so-called lethal synthesis at a detoxication of monoftoratsetat, education ant to - you or formaldehyde at decomposition of methyl alcohol, etc.).
Determination of content of poisons or products of their metabolism in blood, urine, in secrets of glands or in body tissues is important diagnostic reception.
First aid at O. which developed in conditions of production consists in the following: the victim needs to be taken out to the warm, well aired room, to exempt from the constraining clothes; at hit of substance on skin carefully to remove it with warm water with soap; at an apnoea to make an artificial respiration. At indications urgent delivery in specialized institution.
Professional O.' treatment is performed according to the above general principles of treatment of the Lake.
Professional O.' prevention — one of the major tasks at the industrial enterprises. During the development of technology preference shall be given to the continuous, closed circuits, wasteless productions automated and the mechanized processes with distance steering and lack of manual operations. Constant search of less toxic and hazardous substances and replacement of poisonous products with them, introduction of strict standardization of raw materials for the purpose of restriction of contents in it of the impurity capable in the course of synthesis to form more toxic intermediate products are necessary. O.'s prevention is promoted the device of rational ventilation with a preferential suction of the formed vapors, gases, aerosols in the place of their education and the rational device of all-exchange ventilation (see); systematic control (constant automatic recording is desirable) of the content of toxicants in air; carrying out preliminary at revenues to work and periodic medical examinations (see. Medical examination , Professional selection ), investigation and the accounting of cases of professional O., and also strict observance of measures of personal hygiene, use of individual means of protection (see. Footwear , Clothes , Pastes protective , Gas masks , Respirators ), balanced diet, observance of work-rest schedules.
Poisonings in the medicolegal relation
In court. - the medical practician O. represent a subject of examination at investigation by bodies of inquiry or the investigation of conditions and circumstances of emergence of accidental and deliberate Lakes. At nonlethal O. court. - medical examination establishes severity of disorder of health according to standards of the criminal code, and at deadly — a specific cause of death according to requirements of the code of criminal procedure and to «The instruction about production of forensic medical examination in the USSR» (1978).
Main objective court. - medical examinations of O. objective establishment of the toxicant which came from the outside to a human body and caused disorder of health or approach of death is; at the same time, if the pathogeny is combined with existence of the accompanying or previous disease, then the leading value in a thanatogenesis of toxicant shall be proved.
A wedge, reactions of an organism in initial stages of O. can be similar to sharply developing diseases that sometimes is a source of defects of diagnosis and the appointed treatment. For providing the correct differentiated O.'s diagnosis, except anamnestic data, careful identification of symptomatology, the analysis of dynamics and sequence a wedge, the phenomena and use a wedge, laboratory researches, essential value is represented by the organization of a timely judicial and chemical research of emetic masses, rinsing waters of a stomach, urine and a calla. These material evidences shall be collected, packed (with taking a step against accidental hit into them chemical substances), are sealed and through bodies of investigation are taken to court. - medical laboratory. If in to lay down. establishment together with the victim the remains of estimated toxicant, the ware used for its reception or packaging are delivered, all such objects are subject to sealing up and transfer of investigation to bodies, to-rye in turn take them to court. - medical laboratory.
For court. - medical establishments of the occurred O. the expert shall, considering sources of an origin of O., to apply system of proofs. In court. - the medical relation as sources of an origin of O. distinguish: household, occurring accidentally or purposely; medicamentous — from toxic effect of medicines at their misapplication or unusual reaction of an organism to them; professional — at disturbance a gigabyte. conditions on productions where harmful substances are applied; toxicomanias — as a result of the long use of the increasing doses of toxicant; food, being in a causal relationship with the use of substandard food. Shall join in system of expert proofs of O.: results of inspection of the scene and the place of detection of a corpse, at the same time identification and withdrawal of the objects promoting diagnosis of specific toxicant is obligatory; the careful analysis of testimonies of the witnesses and medics who were present on site incidents and giving first aid; studying of medical documents; at nonlethal O. — court. - medical survey of the victim in out-patient clinic or a hospital; at deadly — court. - a medical research of a corpse with full compliance with features of this research; laboratory examination of the material evidences collected on site incidents, received from medical institutions and withdrawn at a research of a corpse.
At inspection of the scene and a corpse court. - the medical specialist shall pay special attention to detection of the remains of toxicants. The opening of a mouth can have them on hands, on a neck and other parts of a corpse, on clothes and in its pockets, on linen and footwear, in food and drink, in ware, packing materials (bubbles, ampoules and their splinters etc.), in the syringes and other devices used for introduction to an organism of different chemical substances. The orienting value recipes on receiving such substances can have, records about them. On site incidents (near a corpse, in a wash basin, a toilet bowl, a bathtub, etc.) there can be emetic masses and other allocations containing the toxicant which caused the Lake. Detection of the above-named objects obliges to their withdrawal and the direction on a laboratory research.
Investigative documents (protocols of interrogations) may contain the data important for O.'s examination: about a profession of the dead, his family, relatives and their occupations; about conditions and circumstances, at to-rykh there was O.; about the nature of the applied pre-medical help (artificial vomiting, antidotes, etc.).
For expert diagnosis of O. essential value is represented by the medical data relating to assistance on site incidents (symptomatology, to lay down. influence) and to the characteristic a wedge, currents reflected in documents to lay down. institutions. At the same time the expert pays attention to dynamics of symptoms of O. and to methods of treatment (a gastric lavage, enemas, introduction to an organism with to lay down. the purpose of various substances, including belonging to group poisonous and strong).
In the analysis a wedge, O.'s currents in the expert and diagnostic relation it must be kept in mind: physical and chemical properties of toxicant, a way of introduction to an organism (orally, rektalno, through respiratory organs, urinogenital system, the surface of skin, subcutaneously, intramusculary, intravenously); amount of the toxicant which came to an organism, its ability to metabolism; character of the accompanying substances; ratio of rate of absorption and allocation; condition of an organism (age, weight, existence of diseases, etc.); influence of external conditions (temperature, humidity etc.); influence of the applied methods and remedies.
At court. - medical survey of the victim the expert shall determine the fact of the occurred O., using if it is necessary, consultations of the therapist, the pediatrician, the neuropathologist, the surgeon, etc.; at O.'s examination in a hospital participation of the attending physician is obligatory. For a conclusion about O.'s presence evidences, documents, laboratory analyses and results of expert survey can serve. After establishment of the fact O. define severity of disorder of health on the basis of all-union «Rules of medicolegal definition of severity of injuries».
Court. - the medical research of a corpse at suspicion on O. shall be made with observance of the existing rules, instructive and methodical instructions. Prior to the research of a corpse the expert is obliged to analyze investigative and medical data (the preliminary data) and to exclude all conditions, to-rye can lead to accidental hit of chemical substances in a corpse or its separate bodies, napr, use in the section hall of the disinfecting and preserving substances, pollution of ware, tools, tables from the previous researches of corpses, use metal and pottery for packaging of the bodies directed to laboratory researches. As the expert shall expect a possibility of a repeated or additional research of bodies and fabrics of a corpse, it is necessary to watch that chemical substances or the objects contaminated by them were not entered into the period and upon termination of necropsy in it (cotton wool, a gauze, etc.). If suspicion on O. arises after burial of a corpse, then investigating or judicial authorities is appointed it exhumation (see), at a cut the expert is obliged to withdraw a number of the objects able for a laboratory research to be sources of hit of chemical substances in a corpse after his burial (the soil, metal jewelry, artificial flowers Etc.).
At survey of clothes on a corpse and the things delivered together with it the expert can find: damages of clothes from effect of «aggressive» chemical substances, the remains of poisons on it or in pockets (tablets, packagings from powders, etc.), pharmaceutical recipes and other documents with records about chemical substances.
At an outside research of a corpse it is necessary to pay attention to singularity of coloring of integuments, livors mortis, mucous membranes; acceleration and considerable expressiveness or delay of process of a cadaveric spasm; the traces indicating a way of administration of toxicant (chemical burns, places of injections); sharp expansion of pupils or their narrowing.
At an internal research of a corpse, depending on chemical properties of substance, changes can be observed: in ways of its introduction or allocation (guts, kidneys, lungs, etc.), in the fabrics and bodies which underwent the greatest toxic influence (inflammatory reactions and necroses in a digestive tract, destructive processes in parenchymatous bodies, specific coloring of fabrics and bodies), and also characteristic smells (ethanol, acetic to - you, phenol, bitter almonds, etc.). At the same time consider that morfol, changes, to-rye would allow to concretize toxicants, can be not expressed macroscopically or atypical (e.g., at Oh, functional poisons).
Specific toxicant apply laboratory methods of examination to justification of diagnosis of O.: chemical, physical, physical and chemical, microscopic, botanical, pharmako-Gnostic, microbiological and biological. Their choice and a necessary combination defines court. - the medical expert, proceeding from preliminary investigative and medical data, a wedge, yielded, results of a research of a corpse, character of the estimated toxicant which caused O.; according to «Rules of a medicolegal research of corpses» and special instructive-methodological instructions. The objects found on site incidents, received from are exposed to such researches to lay down. institutions, withdrawn at examination of a corpse. At O.'s establishment most often apply court. - a chemical research of fabrics and bodies of a corpse. At court. - medical assessment of results of this analysis needs to mean that detection of substances of toxic character is possible owing to their introduction to an organism as medicines or with food in harmless quantities; at professional intoxications; because of hit of poisons in a corpse at its conservation or non-compliance with rules of a research of a corpse at suspicion on O.; at errors of the chemical analysis. Nondetection at a chemical research of the toxicant which caused O. is possible because of its chemical transformations during O. or in bodies of a corpse, its allocation in a wedge, O.'s stage; at the wrong choice by the expert of bodies and fabrics for a research; because of incompleteness of the chemical analysis; at O. of a bacterial etiology. Therefore, the positive take of the chemical analysis of fabrics and bodies of a corpse in itself does not serve as the authentic proof of O., and negative — does not exclude it.
Thus, to a final valid conclusion about existence or O.'s absence specific toxicant court. - the medical expert shall come on the basis of comparison and assessment of the evidentiary importance of all data established at stages of examination of O. and at its investigation.
Features of poisonings at children
According to WHO statistics, in the developed industrial countries mortality from accidents among children up to 15 years makes 20% of the general mortality of children, and mortality from accidental acute O. — 45% of mortality of accidents. As well as at adults, growth of number O. at children is connected with increase in production of new drugs and means household and page - x. chemistry. Accidental O. of children is promoted by negligent storage of these means, their beautiful, bright packaging drawing attention of children. Besides, O. the wild-growing berries, in flowers or plants containing toxic agents meet in the summer. 75% of O. at children are the share of age from 1 to 3 years since children at this age show big inquisitiveness, all pull in a mouth the objects which interested them.
O.'s cases of newborns through skin are known for the aniline paints used for marking of diapers during the use of pharmaceuticals on an ointment basis, and also the pharmaceuticals received by the child with milk of mother.
Islands are to the suicide purpose generally at girls in the pubertal period, at emotionally unstable teenagers, as a rule, after a conflict situation at school or at home. Couple-suntsidalnaya the purpose O., i.e. desire to summon sympathy, to show the disagreement, a protest meets more often. The reasons of a parasuicide of l of ny O. — the most unexpected and various: a quarrel at school, with friends, at home, undeserved offense, dissatisfaction etc. In all these cases children behave defiantly: having drunk medicine or chemical substance, report to parents about the act, sometimes call the ambulance, leave notes with an explanation of the reason O.
Patogenez, clinic and diagnosis of poisonings at children generally same, as at adults. At the same time in manifestations and acute O.' current at children the originality caused fiziol, features of the child — lability of metabolic processes and a water salt metabolism is possible; reduced activity of the enzymatic systems responsible for metabolism of pharmaceuticals (especially at children of early age); hyperpermeability of a blood-brain barrier and vascular wall. At children of early age immaturity of hepatic mechanisms of a detoxication of poisons, in particular their oxidations, acetylation and a konjyugirovaniye with glucuronic to - that is noted. Bystry penetration of poison into an organism of the child, big weight of intoxication and tendency of children to development of an eksikoz at many Lakes is explained by these features.
The clinical picture of acute O. at children consists of a complex patol, syndromes, to-rye it is conditionally possible to divide on specific to this poison or group of chemical substances, nonspecific, meeting at any O., and the atypical manifestations connected with features of individual reactivity or with the combined influence of several poisons. Identification of a specific syndrome or group of syndromes allows to establish a type of poison or to define accessory it to a certain group of chemical substances.
Recognition of a type of toxicant is promoted by the following signs: a characteristic smell from the patient and his allocations (at O. kerosene, gasoline, alcohol, acetone, a dichloroethane); visible burns of skin and mucous membranes of a mouth (at O. to-tami, alkalis, quicklime, potassium permanganate, iodine); cyanosis (at O. aniline, nitrobenzene, saltpeter, sodium nitrite); petekhialny hemorrhages (at O. heparin, Phenilinum, benzene, a xylol, salicylates); a hamaturia (at O. acetic to - that, potassium chloride, iodine, salicylates); spasms (at O. of an adrenomimetikama, analginum, Butadionum, cardiac glycosides, strychnine, etc.); mydriatic pupils (at O. atropine, a henbane, a belladonna, Trioxazinum); narrow pupils (at O. aminazine, barbiturates, Pilocarpinum, codeine); perspiration (at O. salicylates, Pilocarpinum); fervescence (at O. antibiotics, salicylates, streptocides, atropine, a haloperidol, etc.); bronchorrheas, hypersalivation (at O. organophosphorous connections, salts of heavy metals, the cauterizing poisons); discoloration of excrements (at O. salts of heavy metals, organophosphorous connections, Haemitonum); a muscular wryneck (at O. a haloperidol); a catatonic stupor (at O. Frenolonum, Triphtazinum); hallucinations (at O. atropine, Pipolphenum).
Treat nonspecific signs of O.: the psychoneurological syndrome, a syndrome of hemodynamic frustration, a syndrome of disturbance of breath, a syndrome of dysfunction went. - kish. path, syndrome of disturbance of acid-base equilibrium. The toxic encephalopathy which is characterized in the beginning by excitement, a lack of coordination, concern, aggression, negativity, euphoria, hallucinations, spasms, and then slackness, an adynamia, drowsiness, oppression and disappearance of reflexes, disturbance of consciousness, a coma is typical for many O. The second for frequency is the cardiac disturbance which is shown arrhythmia, change of heart rate, dullness of tones, metabolic and hypoxemic changes in a cardiac muscle. At the vast majority of O. are noted nausea, vomiting, abdominal pains, paresis went. - kish. path, frequent liquid chair, increase or decrease in body temperature. Frustration of acid-base equilibrium at children in an acute stage of O. are almost always characterized by a metabolic acidosis. At heavy O. at children syndromes of a renal and liver failure, water and electrolytic disturbances quite often develop.
Atypical manifestation of O. is observed at the weakened children with acute infectious or hron, diseases when there are no specific symptoms, and nonspecific develop quickly and proceed hard. So, at O. the muscular wryneck is not expressed by a haloperidol at the weakened children or is absent, but there are Meningeal syndromes and a severe form of a hyperthermia. At the children inclined to allergic reactions, O. can begin an acute anaphylaxis, and at having an infectious disease — a collapse. In such cases specific manifestations of O. do not manage to develop or they are hidden by the general serious condition of the patient.
Lakes can proceed with the complications caused as a current of the basic patol, process, and carrying out an intensive care. The most frequent complications are: secondary endogenous intoxication products of the broken exchange; metabolic disturbances in a cardiac muscle; phlebitis; bronchial pneumonia; tsistouretrit; gastritis, coloenteritis; renal failure and liver; anemia, thrombocytopenia, leykotsitopeniya; defeat of c. N of page and peripheral nerves of functional and organic character.
Diagnosis of exogenous intoxications at children of a mnogoetapn also depends on weight patol, process and a spetsia-lizirovannost of the department giving help to the injured child. The receptions used for O.'s diagnosis divide into 5 groups on tests of significance: 4) studying of a so-called toxicological triad — a toxicological situation, the toxicological anamnesis and features of clinic of O. at this patient; 2) laboratory and tool diagnostic methods of exogenous intoxication; 3) biol, the proof of hit of poison in an organism of the child (a priming of animals to contents of a stomach of the child, etc.); 4) chemical research of structure of poison and its concentration; 5) court. - medical examination. The first group of tests of significance is obligatory reception of diagnosis of any O. and is used in the conditions of a pre-hospital stage, the others — in the conditions of a hospital.
To recognition and assessment of weight of O. apply the special chemical and toxicological researches defining purposeful detoksikatsionny therapy and use the general, elektrofiziol, and biochemical, express methods, to-rye allow to determine the volume of resuscitation and intensive corrective care at disturbances of the vital functions.
At assessment of weight of a condition of the patient called by acute O. it is necessary to specify and, whenever possible, to define approximately amount of the poison which got to an organism of the child, force of his impact on an organism and time, a past from the moment O. Boley a difficult task assessment of individual reactivity of an organism of the victim important for the forecast of the Lake is.
Treatment, the forecast and prevention of poisonings at children generally match those at adults; features are connected by hl. obr. with age struck.
Detoksikatsionny therapy is carried out taking into account ways of receipt, a toksikodinamika and a toksikokineti-ka of poison. At O. the child through skin it is deleted from the infected atmosphere, exempted from clothes, skin of all body surface is carefully washed out warm solution of soap water, and processing is made since the contaminated sites. At O. through a conjunctiva mucous membranes of eyes wash out a stream of warm water, using a rubber pear or the 20-gram syringe. Upon termination of the procedure in a conjunctival sac dig in 1% solution of novocaine or 0,5% solution of Dicainum from 0,1% solution of adrenaline.
At hit of toxic agent on mucous membranes of a nasopharynx and an oral cavity of the children of advanced age who are in consciousness and capable to come into contact, force to rinse repeatedly a mouth, and then wash out Nov warm water. At unconscious children repeatedly rub off mucous membranes a gauze tampon. At damage of mucous membranes flying poisons make intranasal novocainic blockade of 0,25% solution of novocaine. Apply alkaline inhalations, to-rye alternate to inhalation of mix from 10 ml 0,5% of solution of novocaine, i of ml of 2% of solution of Suprastinum and 25 mg of a hydrocortisone; at hypostasis of subcopular space add 1 ml of 5% of solution of ephedrine to mix.
At intoxication the drugs entered subcutaneously or intramusculary make infiltration of the place of an injection of 0,25% solution of novocaine in a dose of 10 mg/kg, and then isotonic salt solutions of 7 — 10 ml! kg. At intravenous administration of a toxic dose of medicine begin intravenous administration of plasma (10 ml/kg), Haemodesum (10 ml/kg) at once, further carry out hemodilutions) of 3 — 4 ml/kg an hour with maintenance of the corresponding diuresis.
At hit of poison in a stomach an obligatory and emergency action in all cases is the gastric lavage, a cut carry out at once after O. or to the earliest terms. At a stage of pre-medical and first medical assistance at children of advanced age with easy degree of intoxication it is possible to resort to removal of poison by calling of vomiting, however it does not exclude further a careful gastric lavage. Before washing it is necessary to be convinced that the probe is in a stomach. Reliable sign of it is allocation of gastric contents; it can be received, massing a stomach through an abdominal wall. If massage did not give the expected result, it is necessary to be convinced that via the probe there is no movement of air according to a respiration rate. It is necessary to begin a gastric lavage with solution of sodium chloride (1 table. l. on 1 l of water). It causes a pylorospasm, interfering thereby with further intake of poison went to lower parts. - kish. path. Solution of sodium chloride is contraindicated at O. the poisons possessing the cauterizing action. Further washing is made water t ° 35 — 37 °. The number of single administration of water or various liquids in a stomach shall be strictly dosed according to age of the child (see the corresponding table).
Table. The volume of liquid which is in one step entered into a stomach at its washing at children depending on age
If O. occurred after reception by the child of food, the first portion of the liquid entered into a stomach shall not exceed a half of all dose. At a delay of water in a stomach the next portion decreases by the same quantity. Washing is made repeatedly to pure rinsing waters. During washing vomiting as a result of overflow of a stomach or excessive concern of the child can sometimes develop. In this case the head of the child should be inclined, and to reduce introduction of the next portion of water half. Children of younger age before washing need to be swaddled. At children with oppression of gag reflexes and being in coma washing it is made after a preliminary intubation of a trachea, and with oppression or disturbance of breath — against the background of auxiliary or artificial ventilation of the lungs. The first portion of rinsing waters is collected for a toxicological research. Availability of blood in gastric contents is not a contraindication for a gastric lavage, but the amount of liquid entered in one step shall be reduced to 2/3 doses. At the end of washing via the probe enter antidotes and after exposure within 5 — 10 min. repeatedly wash out a stomach. Finish a gastric lavage with introduction of purgatives to it.
In need of repeated gastric lavages (at O. the large number of berries, plants, mushrooms tableted, the almost insoluble or emitted in a gleam of a stomach poison) washing is made with an interval of 20 — 30 min. the probe of smaller diameter entered into a stomach in Nov. At O. the concentrated solutions to - t or alkalis the patient before washing make anesthesia by intravenous administration of 2% of solution of Promedolum and 0,1% of solution of atropine on 0,1 ml for a year of life of the child.
Use of salt laxatives and cleansing enema are necessary in all cases of reception of poison inside and at O. through a rectum, except for O. the prizhi-thawing poisons and at patients with the phenomena of a gastroenteritis when they are preferable as laxatives liquid or sweet-almond oil in a dose of 3 g! kg. These oils are recommended also at O. by products of distillation of oil. A contraindication for use of oil is O. fat-soluble substances (phosphorus, naphthalene, etc.).
Removal of the poison which came to blood is reached by the same methods, as at adults.
For carrying out an artificial diuresis solutions enter as through a stomach, and intravenously. At easy degree of intoxication to children of advanced age appoint nice to the taste drinks, to children of younger age water loading is carried out through a gastric tube (for this purpose after a gastric lavage the probe of smaller diameter or a catheter enter in Nov into a stomach and fix an adhesive plaster to face skin). At medium-weight and heavy degree of O. at children of advanced age make a puncture of a peripheral or main vein on Seldingera, at children of younger age — a venosektion or a puncture of the main vein on Seldingera. Bystry completion of the increasing fluid losses is possible administration of solutions in two veins and through a gastric tube in a stomach. Water loading is carried out of 3 — 5 ml/kg an hour at easy degree of intoxication, and at medium-weight degree infusion is begun with 5 ml/kg an hour within the first hour and increase during the subsequent 1,5 — 2 hours up to 12 — 15 ml/kg an hour. At heavy degree of intoxication the amount of the entered liquid from 5 ml/kg in the first hour of infusion is led up in 3 — 4 hours prior to 20 — 25 ml/kg an hour. The composition of the entered liquid in each case needs to be selected individually taking into account a condition of the central and peripheral hemodynamics, secretory function of kidneys, the phenomenon hyper - or hypovolemia, dehydrations or overhydratations. However anyway potassium, sodium, glucose shall be a part of solutions. It is possible to use ready solutions of a difficult copy-book or one-component solutions in the following ratios: 5% solution of glucose — 50% of total quantity of the entered liquid, 25% of solution of Ringer, 25% of physiological solution. In need of alkalization of plasma add 4% solution of hydrosodium carbonate — 10% of total quantity due to reduction of physiological solution and Ringer's solution. For the purpose of strengthening of an intravascular detoxication apply Haemodesum (a single dose of 10 ml/kg, a daily dose of 20 — 40 ml/kg) at glyukozonovokainovy mix (a single dose of 8 mg/kg, daily — 16 — 32 mg/kg). For maintenance of constancy of oncotic pressure and improvement of rheological properties of blood appoint proteinaceous drugs (a single dose of 5 — 10 ml/kg, daily — 10 — 20 ml/kg), reopoliglyukin (a single dose of 10 ml/kg, daily — 20 — 40 ml/kg). All solutions used infusional for one-time introduction shall not exceed 10 ml/kg. Control of an artificial diuresis shall be constant with obligatory hourly registration in the sisterly card. Control of infusional therapy and a diuresis from special methods requires constant comparison of amount of intravenously entered solutions and size of a diuresis; definition in erythrocytes of sodium and potassium and in plasma — sodium, potassium, chlorine, magnesium, phosphorus, pH and an alkaline reserve. If use of water loading gives insufficient increase in a diuresis, appoint diuretics: lasixum of 1 — 3 mg/kg, Mannitolum of 1 — 2 g of nonvolatile solid or urea of 1 g of nonvolatile solid on 1 kg of body weight.
Antidotal therapy consists in use of the chemical substances possessing detoksikatsionny action as a result of direct interaction with poison and formation of nontoxic connections or reducing intoxication by influence on various biochemical, systems.
Partial substitution of blood is recommended at the heavy contingent of patients. This manipulation demands observance of the following conditions: continuous inhalation of oxygen through a narcotic mask or a nasal catheter; the desensibilizing therapy (antihistaminic drugs, glucocorticoid hormones, calcium chloride); carrying out an artificial diuresis of 5 — 8 ml/kg an hour.
Peritoneal dialysis is applied at O. salts of heavy metals, derivatives barbituric and salicylic to - t, tranquilizers and hypnotic drugs of not barbituric row, etc. As well as at adults, at O.'s treatment at children use a method of a hemodialysis (at O. derivatives of pyrazyl ketone, tranquilizers, hypnotic drugs, antibiotics, salicylates, streptocides, antidepressants, aniline, brake fluid, salts of metals, a dichloroethane, perchloromethane, acetic essence), hemosorption, hyperbaric oxygenation (especially at O. toxic gases and as an auxiliary method at O. nitrates, cyanides).
Important part of treatment of O. at children is the correct maintaining patients during the post-toxic period.
During the next post-toxic period patients depending on available a stalemate. changes need throughout treatment in the conditions of policlinic or a hospital.
Patients with O. with the cauterizing poisons are transferred to a surgical hospital for esophagoscopic control and bougieurage, patients with suicide or parasuitsi-dalny attempt — in a psychiatric clinic (after preliminary consultation of the psychiatrist), patients with functional or organic lesion of the central or peripheral nervous system — in a neurology unit. The main contingent of patients with changes from the internals and systems which are not needing an intensive care in the post-toxic period is transferred to pediatric department.
The important final stage in the general structure of treatment of patients with O. is medical examination. Carry out by the patient specialized treatment in the conditions of policlinic and if special inspection and treatment is required, rehospitalize. Carry out a complex of the recreational actions including optimization of the mode of wakefulness at children of younger age, the mode of work at school students, sufficient time of rest, a balanced diet, physiotherapeutic procedures to lay down. physical culture, vitamin therapy, fortifying means, timely providing dignity. - hens. treatment, necessary dietary food etc. The dignity is carried out. - a gleam, work with parents, tutors, teachers.
At the children who had acute exogenous intoxication it is necessary to observe optimum terms of failure from preventive inoculations. The issue of carrying out inoculations needs to be resolved taking into account epidemiol, situations. One week prior to an inoculation and within one week after an inoculation perform the desensibilizing therapy.
Optimum terms of dynamic observation (for the purpose of identification and the prevention of effects of O.): the first survey — in 10 — 15 days after an extract from a hospital; further within the first 3 months — every other month; the subsequent observations and inspections within the first year — each 3 months; within the next year — in 6 months. Children, at to-rykh during medical examination pathology is revealed, are subject to longer observation.
Acute O.' prevention at children begins even during pregnancy. In clinic for women with the woman lead a discussion about harmful effects of various pharmaceuticals and chemical substances on the developing fruit.
At an extract of mother and child from a maternity home and carrying out patronage the doctor or the nurse lead with mother a discussion about rules of storage of pharmaceuticals and chemical substances in life and about O.'s possibility them the newborn and the baby at their allocation with maternal milk. With growth of the child, at achievement of age of 8 — 10 months by it (the beginning of independent movement), parents shall be warned about danger of maintenance of the home first-aid kit and drugs of household chemicals in places, available to the child.
Doctors of preschool institutions and schools shall carry out permanent job with tutors, teachers, to-rye shall be informed on possible group O. of children during childish sports, during the gathering wild-growing berries, mushrooms.
For O.'s prevention at children of the advanced school age use the most various means of sanitary and explanatory work: seminars, lectures, press, radio, television. Pay special attention to O. narcotic poisons, and also on O.'s possibility during the passing of a work practice and performance of page - x. works.
Within city and regional managements of health care in volume of modern requirements of toxicology shall be carried out systematically work with medical staff of policlinics, child care preschool and school facilities, summer camps, children's sanatoria on training in methods of the prevention of O. and pre-hospital treatment of children with O.
Sud. - medical examination at O. at children is carried out according to the above principles.
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E. A. Luzhnikov; A. I. Korbakova (prof.), Ya. M. Lutsky, V. A. Tabolin (ped.), B. M. Smolyaninov (court.); author of tab. E. A. Luzhnikov.