Method for estimating needs in resuscitation care to patients suffering from acute poisoning caused by chemical cauterization

FIELD: medicine.

SUBSTANCE: method involves checking consciousness, blood coagulation state, peripheral blood leukocytes number, K+ ions, bilirubin, fibrinogen, hemolysis and hemoglobinuria availability, prothrombin index and exotoxic shock development. Each value is calculated in points as follows. Lucidity is evaluated as -2 points; depression - +3 points; coma - +6 points; lack of changes in blood coagulation system - -2 points; coagulation availability without clinical injuries - +2 points; coagulopathy with clinical manifestation signs - +19 points; K+ ions concentration being less than 3.0 mmole/l - +3 points, from 3.1 to 3.5 mmole/l - -5 points, from 3.6 to 5.0 mmole/l - 0 points, greater than 5.0 points - +7 points, failure in determining K+ ions concentration - 0 points; hemolysis availability - +6 points, its lack - -3 points; hemoglobinuria availability - +8 points, its lack - -1 points; leukocytes number being less than 12.0x109/l - -2 points, from 12,1 to 18.0x109/l - 0 points, higher than 18.0x109/l - +8 points; hourly urine output being less than 30 ml/h - +6 points, greater than 30 ml/h - -2 points; bilirubin content being less than 31 mcmole/l - -2 points, from 30.1 to 50.0 mcmole/l - 0 points, greater than 50.0 mcmole/l - +2 points, failure in determining bilirubin content due to hemolysis being available -+6 points; prothrombin index being equal to or less than 60% - +3 points, greater than 60% - 0 points, failure in determining prothrombin index due to hemolysis being available - +12 points; fibrinogen concentration in blood plasma being less than 2.1 g/l - +4 points, from 2.1 to 4.0 g/l - -1 point, from 4.1 to 6.0 g/l - +1 point, failure in determining fibrinogen concentration due to erythrocyte hemolysis being available - +13 points; exotoxic shock development - +9 points, its lack - -1 point. The points are summed up. The value being greater than +13, admission for treatment in resuscitation department is indicated. The value being less than -13, admission for treatment in therapeutics department is indicated. The value being from -13 to +13, resuscitation expert consultation is advised.

EFFECT: high evaluation accuracy.

3 tbl

 

The invention relates to medicine, namely to clinical toxicology, allows to determine the patient's need intensive therapy in resuscitation and anesthesiology branch (RAO) for acute oral poisoning chemical cauterizing action (HVPD).

There is a method to forecast the development of critical conditions for poisoning acetic acid, developed in 1980 Age using methods of correlation analysis and clinical precedent [Gorin EE Critical state when poisoning acetic acid (diagnosis, prognosis and resuscitation): author. Diss....Kida. the honey. Sciences. - Moscow, 1980. - 15 S.]. In this model, developed treatment options for specific combinations of critical States, but is not the sort of patients on admission.

A known method of detecting lesions of severe poisoning with acetic acid, proposed in 1973 Linganamakki and Nvivanova [Goncharov, L.N., Ivanova NV Mathematical prediction of course and outcome of poisoning acetic acid //Ter. archive. - 1973. No. 7. - P.100-109]. But this method does not allow for the selection of patients in need of hospitalization in the intensive care unit.

The closest analogue is the way to determine the need for intensive therapy for poisoning acetic acid, proposed SchemaName and Iaiaanaeo in 2002 [shamanaev AGRICULTURAL, Jamanaeva I.E. the Application of probabilistic recognition methods in clinical toxicology //Toxicol. Herald. - 2002. No. 4. - P.17-29], but this method is also intended for use in poisoning only one kind of cauterizing agents.

The method of determining the need for intensive therapy for poisoning all kinds of chemical cauterizing action (acids, alkalis and oxidizing agents) are not described in literature.

The objective of the invention was to develop objective criteria to determine the needs of the patient in the emergency care of acute poisoning chemical cauterizing action.

The technical result in the use of the invention is to improve the accuracy of estimates.

Us using heterogeneous sequential detection Gen and Ewhole [Gubler E.V. Computational methods of analysis and recognition of pathological processes. - L.: Medicine, 1978. - 296 S.] on the basis of a study of a group of 728 patients with acute oral poisoning HVPD developed a method to determine the needs of the patient in therapy in RAO acute oral poisoning by chemicals cauterizing action.

In accordance with the requirements of heterogeneous consistent about what edure was the selection of informative features using informative measure Kullback. In the calculations took into account the prevalence of poisoning by various agents. For the selected traits were calculated diagnostic odds - points.

When using the method the points are summed to achieve the threshold: positive (excess of his means high demand in observation resuscitator) or negative (excess it refers to the ability of the patient management in terms of therapeutic Department). If the evaluation of the condition of the patient diagnostic thresholds have not been reached, shown consultation resuscitator.

Was investigated the diagnostic significance of the following parameters: age, gender, the intention of poisoning, alcohol intoxication, “dose - exposure, the time of receipt. According to the clinical examination included such features as character vomiting, depression of consciousness, body temperature, respiratory rate per minute, dysphonia, the level of mean arterial pressure, heart rate, coefficient of Allgower, hemoglobinuria, oliguria. Take into account the development of such complications, as Ecotoxicity shock, gastrointestinal bleeding, pneumonia, pulmonary edema, DIC. From the results of laboratory and instrumental examination methods was investigated the information content of the following: the level of free plasma hemoglobin is s, prothrombin index, fibrinogen level, potassium, creatinine, glucose, bilirubin, blood pH, total erythrocyte counts, hemoglobin content. These informative signs were 11 (PL. 1).

The method is as follows.

Upon admission of the patient to determine the degree of inhibition of consciousness, hourly diuresis, ascertain the presence of manifestations of hemoglobinuria and ekzoticheskogo shock.

The leukocyte count manually in the camera Goryaeva or with the use of an automatic device. The level of free hemoglobin determine hemiglobincyanide method according to the standard technique. The concentration of total bilirubin, spectrophotometry-metric method. The level of ions To+the blood was determined by the method of plasma photometry. The fibrinogen concentration in the blood was determined by gravimetric method and Raumberg (1961). Prothrombin index (PTI) is determined by A.J. Quick modification Vintagelove (1974). The state of the blood coagulation system is determined by the variance of indices of coagulation and the development of clinical manifestations of DIC blood (e.g. bleeding).

Each symptom scored in accordance with the attached table 1, namely: a clear consciousness estimated as -2 points, when depression of consciousness +3 points, coma as +6 points; the absence of which eneny of the blood coagulation system is estimated as -2 points coagulopathy without clinical lesions as +2 points, coagulopathy with clinical manifestations as +19 points; the concentration of K+up to 3 mmol/l is estimated as +3, from 3.1 to 3.5 mmol/l as -5 points from 3.6 to 5.0 mmol/l as 0 points, more than 5.0 mmol/l as +7 points, the impossibility of determining the level of ions To+evaluate as 0 points; the presence of hemolysis was evaluated as +6, its absence as -3; hemoglobinuria appreciate how +8 points, its absence as a -1 point; the number of cells up to 12·109/l is estimated as -2 points, ranging from 12.1 to 18.0·109/l as 0 points, more than 18,0·109/l as +8 points; hourly urine output less than 30 ml/hour estimated as +6 points, more than 30 ml/hour as -2 points; the concentration of bilirubin less than 31 µmol/l estimated as -2 points, from 31 to 50 µmol/l as 0 points, more than 50 µmol/l as +2 points, the inability to determine bilirubin due to the presence of hemolysis as +6 points; PETIT 60% or less was evaluated as +3 points, PETIT, more than 60% as 0 points, cannot be determined from PETIT-because of the presence of hemolysis as +12 points; the concentration of fibrinogen in the blood plasma of less than 2.1 g/l is estimated as +4 points, from 2.1 to 4.0 g/l as -1 point, from 4.1 to 6.0 g/l as -2 points, more than 6.0 g/l as +1, the impossibility of determination of fibrinogen due to the hemolysis of erythrocytes as +13 points; development ekzoticheskogo shock is estimated as +9 points, his absence as -1 point. Polucen the data summarize patient and a score of more than +13 recommended hospitalization in RAO, a score of less than -13 may be hospitalized in the internal medicine Department, if the sum of the scores from -13 to +13, shown consultation resuscitator.

Example 1. Patient K., 33 years delivered brigade ambulance complaining of pain in the mouth, in the course of the esophagus, stomach, difficulty in breathing, a single vomiting with blood. 6 hours ago drank 100 ml of vinegar. Objectively: a serious condition, consciousness is preserved. Acrocyanosis, a language with focal erosions. In the lungs - hard breathing, respiratory rate of 28 per minute. Muffled heart sounds, rhythmic. HELL 110/70 mm Hg, pulse 78 per minute, satisfactory properties. Car, emergency reduction of blood pressure to 60/20 mm Hg, a pulse of 140 per minute. The abdomen is painful in the epigastric region. Hourly less than 30 ml/hour, urine dark cherry color. Data from laboratory studies: the number of leukocytes 13,5·109;+- 5 mmol/l; bilirubin is not defined due to the presence of hemolysis; triglycerides: PETIT 68%, fibrinogen is not defined.

Diagnosis: acute poisoning acetic acid severe chemical burn of the esophagus, stomach. Complications: acute renal failure, oligoanalgesia stage, Ecotoxicity shock.

Received mark +65 (PL. 2). This exceeds the diagnostic threshold of +13 points, reflecting the needs is in the hospital this patient, in RAO.

Example 2. Patient E., 31 year delivered the car “emergency” with complaints of pain in the mouth, in the course of the esophagus and stomach. 5 hours ago accidentally drank 100 ml of an unknown liquid. Directly observed repeated vomiting with an admixture of red blood. Objectively: a serious condition, consciousness is preserved. On the lips, burns, language with areas of desquamation, the scab dark color. In the lungs - hard breathing, respiratory rate of 24 per minute. Muffled heart sounds, rhythmic. HELL 160/100 mm Hg, pulse 90 / minute, satisfactory properties. Urine in sufficient quantity of light. Data from laboratory studies: the number of leukocytes is 9.5·109/l; K+- 3.5 g/l, bilirubin - 23 µmol/l; triglycerides: PTI 100%, fibrinogen 2.5 g/l, ethanol test is negative.

Diagnosis: acute poisoning cauterizing liquid severe chemical burn of the esophagus, stomach. Complications: gastrointestinal bleeding.

The score was -22 (PL. 3), which shows the possibility of the admission of the patient to the medical Department.

Table 1

The severity of the valuation settings in points
No.A characteristic, observed in a patientScore
1The state of the coagulation systemNorma-2
coagulopathies+2
coagulopathies with clinical manifestations+19
2Potassium, mmol/l≤3,0+3
3,1-3,5-5
3,6-5,0+0
>5,0+7
3Hemolysis+6
no-3
4The hemoglobinuria+8
no-1
5Leukocytosis, ·109/l≤to 12.0-2
the 12.1-18, 0mm0
>18,0+8
6Hourly diuresisless than 30 ml/hour+6
more than 30 ml/hour-2
7Bilirubin, µmol/l≤30,0-2
30,1-50,00
>50,0+2
the impossibility of determination (hemolysis)+6
8Ecotoxicity shock+9
no-1
9PTI, %≤60+3
>600
the impossibility of determination (hemolysis)+12
continuation of table 1
No.A characteristic, observed in a patientScore
10Fibrinogen, g/l≤2,0+4
2,1-4,0-1
4,1-6,0-2
>6,0 +1
the impossibility of determination (hemolysis)+13
11Consciousnessclear-2
oppressed+3
coma+6
 AMOUNT 

Table 2

Assessment of needs in the intensive care patient monitoring K.
No.A characteristic, observed in a patientScore
1The state of the coagulation systemcoagulopathies with the wedge. manifestations+19
2Potassium, mmol/l3,6-5,0+0
3Hemolysis+6
4The hemoglobinuria+8
5Leukocytosis, 109/lthe 12.1-18, 0mm0
6Hourly urine output (ml/hour)Myung is e 30 ml/hour +6
7Bilirubin, µmol/lthe impossibility of determination (hemolysis)+6
8Ecotoxicity shock+9
9PTI, %>600
10Fibrinogen, g/lthe impossibility of determination (hemolysis)+13
11Consciousnessclear-2
 AMOUNT+65

Table 3

Determining the need for hospitalization in RAO patient E.
No.A characteristic, observed in a patientScore
1The state of the coagulation systemNorma-2
2Potassium, mmol/l3,1-3,5-5
3Hemolysisno-3
4The hemoglobinuriano-1
5Leukocytosis, 109/l≤to 12.0-2
6Pacaso the Oh diuresis, ml/hourmore than 30 ml/hour-2
7Bilirubin, µmol/l≤30,0-2
8Ecotoxicity shockno-1
9PTI, %>60-1
10Fibrinogen, g/l2,1-4,0-1
11Consciousnessclear-2
 AMOUNT-22

Method of assessment needs emergency care of the patient with acute poisoning chemical cauterizing action, characterized by the fact that when handling patient care take into account the state of consciousness of the blood coagulation system, the number of peripheral blood leukocytes, the concentration of potassium ions, the content of bilirubin and fibrinogen, the presence of hemolysis, hemoglobinuria, the amount of the hourly diuresis, prothrombin index (PTI), the development ekzoticheskogo shock, evaluate each indicator in points, namely: a clear consciousness estimated as -2 points, the consciousness of the oppressed as +3 points, coma as +6 points; no change of the blood coagulation system estimated as -2 points, coagulopathy without clinical lesions as a +2 point is, coagulopathy with clinical manifestations as +19 points; ion concentration To+to 3.0 mmol/l is estimated as +3 points, from 3.1 to 3.5 mmol/l as -5 points from 3.6 to 5.0 mmol/l as 0 points, more than 5.0 mmol/l as +7 points, the impossibility of determining the level of K+as 0 points; the presence of hemolysis was evaluated as +6 points, his lack of -3 points; hemoglobinuria appreciate how +8 points, its absence as a -1 point; the number of cells to 12.0·109/l is estimated as -2 points, ranging from 12.1 to 18.0·109/l as 0 points, more than 18,0·109/l as +8 points; hourly urine output less than 30 ml/hour estimated as +6 points, more than 30 ml/hour as -2 points; the content of bilirubin less 30,1 µmol/l estimated as -2 points, to 30.1 to 50.0 µmol/l as 0 points, more than 50.0 µmol/l as +2 points, the inability to determine bilirubin due to the presence of hemolysis as +6 points; PETIT 60% or less was evaluated as +3 points, more than 60% as 0 points, cannot be determined PETIT due the presence of hemolysis as +12 points; the concentration of fibrinogen in the blood plasma of less than 2.1 g/l is estimated as +4 points, from 2.1 to 4.0 g/l as -1 point, from 4.1 to 6.0 g/l as -2 points, more than 6.0 g/l as +1 point, the inability to determine fibrinogen due to the hemolysis of erythrocytes as +13 points; development ekzoticheskogo shock is estimated as +9 points, his absence as -1 point, summarize the obtained scores and the value of the sums of the scores of more than +13 believe shows hospitalization in the intensive care the Department, less than -13 points - admission to the medical Department, from -13 to +13 - consultation resuscitator.



 

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