Method for predicting the result of acute peroral intoxication with cauterizing liquids

FIELD: medicine, clinical toxicology.

SUBSTANCE: at patient's hospitalization one should gather the data of clinical and laboratory values: on the type of chemical substance, patient's age, data of clinical survey and laboratory values: body temperature, the presence or absence of dysphonia, oliguria being below 30 ml/h, hemoglobinuria, erythrocytic hemolysis, exotoxic shock, glucose level in blood, fibrinogen and creatinine concentration in blood serum, general bilirubin, prothrombin index (PTI), Ph-plasma, the state of blood clotting system. The state of every sign should be evaluated in points to be then summed up and at exceeding the sum of points being above "+20" one should predict unfavorable result. At the sum of "-13" prediction should be stated upon as favorable and at "-13" up to "+20" - prediction is considered to be doubtful.

EFFECT: higher accuracy of prediction.

2 ex, 3 tbl

 

The invention relates to medicine, namely to clinical toxicology, allows us to predict the outcome of acute oral poisoning chemical cauterizing action (HVPD).

In Russia poisoning HVPD occupy a significant place in the structure of acute poisoning [4]. On chemical structure there are the following main groups HVPD: acids (organic and inorganic), bases (alkalis) and oxidants (KMnO4N2O2, iodine, lO2and others).

There is a method of prediction of the outcome of poisoning one HVPD, namely acetic acid, using the method of clinical precedent [2]. Developed in 1980 EE garinim the model is simple, but to predict poor prognosis in it is only possible when combined stenosis of the larynx and esophageal-gastric bleeding. That is, in the absence of stenosis of the larynx, which is fairly often, to predict adverse outcome is not possible.

Developed in 1973 Linganamakki, Nvivanova [1] predictive model of outcome poisoning acetic acid on the basis of heterogeneous sequential procedure uses one of the most optimal methods of forecasting. But, unfortunately, this model is not used to score some important in the pathogenesis of poisoning acetic acid moments, such is AK the development of hemolysis, disorders of hemostasis up to disseminated intravascular coagulation (DIC) blood, and the main importance of the clinical manifestations of intoxication that does not meet the current theoretical knowledge. Consequently, in our opinion, erroneous (excluding doubtful) forecast was 5%.

SchemaName and Iaiaanaeo [4, 5] has been developed a method for predicting the outcome of acute oral poisoning acetic acid by assessing the patient's condition upon admission (based on history, clinical and laboratory characteristics), characterized in that to increase the accuracy of prediction is measured dose data received substance, time from poisoning to help, the patient's age, clinical examination (the amount of urine, blood pressure, temperature and the presence of disponee) and laboratory parameters (prothrombin index, then PETIT, fibrinogen concentration, creatinine, pH, potassium, bilirubin, leukocytosis and the level of free hemoglobin).

Methods of prediction of outcome poisoning HVPD in the prior art are not described (for all kinds of HVPD: acids, alkalis and oxidizers).

Us using heterogeneous sequential detection Gen and Ewhole [3], based on a study of a group of 728 patient is acute oral poisoning HVPD developed a way of forecasting the outcome of poisoning HITD.

The objective of the invention is to develop a forecast of the outcome of poisoning all HITD.

The technical result is to obtain an objective assessment of the forecast outcome.

Heterogeneous sequential procedure involves the selection of attributes by using informative measure Kullback (J) according to the formula {1}, where Akclass of diseases (conditions), P(xij/Ak- the probability of detection of the symptom in this disease.

Impact of selected characteristics on the outcome is determined by using diagnostic ratios {2} - scores (logarithm of the odds ratios detection of the symptom in groups with different prognosis).

When using the method the points are summed to achieve the thresholds, which are set depending on the allowable error (set by the researcher). Set two diagnostic threshold: positive (excess of his means of adverse outcome) and negative (excess it means a favorable outcome). If the evaluation of the condition of the patient diagnostic thresholds have not been reached, the Outlook remains uncertain.

In the study of informative measure Kullback and diagnostic factors we have investigated the one-dimensional distribution of priznakov groups of patients with poisoning by various types of corrosion. For calculating the probability P(x1) of the occurrence of each symptom of poisoning HVPD (regardless of the type of agent) was used the formula of full probability {3}

where P(A)P(B) ... - the probability of poisoning separate species HVPD (acetic acid, inorganic acids, alkalis, oxidizing agents and unknown corrosive); P(x1/A) ... - the probability of the presence of this symptom in some form of poisoning.

Given the known characteristics of the etiopathogenesis of poisoning cauterizing substances: chemical burns of the gastrointestinal tract (often upper respiratory tract), it is possible resorption agents with the development of metabolic acidosis, hemolysis of red blood cells, the development of complications [3]have investigated the prognostic significance of the following characteristics: 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-si the drôme. From the results of laboratory and instrumental examination methods was investigated the information content of the following: the level of free hemoglobin in the blood plasma, prothrombin index, fibrinogen level, potassium, creatinine, glucose, bilirubin, blood pH, total erythrocyte counts, hemoglobin content. These informative signs were 15 (table 1).

The method is as follows.

Admission will collect information about the age of the patient, as agent. Measure the body temperature, hourly diuresis, ascertain the presence or absence of disponee, hemoglobinuria and ekzoticheskogo shock.

The level of free hemoglobin determine hemiglobincyanide method according to the standard technique. The fibrinogen concentration in the blood was determined by gravimetric method and Raumberg (1961). Prothrombin index was determined by A.J.Quick modification V.I. Tugolukov (1974). The concentration of creatinine and total bilirubin spectrophotometric method according to the standard technique, the pH micromethods of Astrup. The level of glycemia determine glucose oxydase or orthotoluidine methods. 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 (bleeding).

Everyone at the NAC scored in accordance with the attached table 1. When exceeding the total score more than 20 points say a poor outcome, with a score of less than “-13” forecast regarded as favorable, if the sum of the scores from “-13” to “+20” - forecast doubtful.

Example 1. Patient K., 33 years delivered brigade ambulance complaining of pain in the mouth, in the course of the esophagus, stomach, shortness of breath. 6 hours ago drank 100 ml of vinegar with suicidal intent. Objectively: a serious condition. The passive position. Acrocyanosis, on the lips, burns, language with areas of desquamation, the scab dark color. In the lungs - hard breathing, respiratory rate of 28 per minute. Muffled heart sounds, rhythmic. HELL 110/70 mm RT. Art., pulse 78 per minute, satisfactory properties. In the car “emergency” was arterial pressure 60/20 mm Hg, a pulse of 140 per minute. The abdomen is painful in the epigastric region. Oliguria, urine dark cherry color. The body temperature of 36.7°C.

Data from laboratory studies on admission. Complete blood count: leukocytes 13,5·109. Acid-base balance: pH 7,34. Content To+- 5 mmol/l blood Biochemistry: creatinine 104 µmol/l, bilirubin is not defined due to the presence of hemolysis, blood glucose 6.42 per mmol/l Triglycerides: PETIT 68%, fibrinogen is not defined.

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

After 3 hours from the receipt diagnosed metrorragiya. The forecast evaluation of the outcome of the poisoning of acetic acid, the patient K. shown in table 2. Received mark “+54”. This exceeds the diagnostic threshold+20 points, which means an adverse outcome for a patient with a high probability, which was confirmed at day 2.

Example 2. Patient E., 31 delivered brigade “ambulance” 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. The passive position. 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 RT. Art., pulse 90 / minute, satisfactory properties. The abdomen is painful in the epigastric region. Urine in sufficient quantity of light. Body temperature 36,6°C.

Data from laboratory studies on admission. Acid-base balance: pH 7,28. Blood biochemistry: creatinine 75 µmol/l, bilirubin 23 µmol/l, blood glucose 2.8 mmol/l Triglycerides: PTI 100%, fibre ogen 2.5 g/l, ethanol test is negative.

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

The forecast evaluation of the outcome of the poisoning of acetic acid in a patient that is given in table 3. The score was “-40”, which means favorable for life outcome. The patient was discharged on the 26th day of the disease.

Bibliography

1. Goncharova, L.N., Ivanova NV Mathematical prediction of course and outcome of poisoning acetic acid //Ter. archive. - 1973. No. 7. - P.100-109.

2. Gorin EE Critical state when poisoning acetic acid (diagnosis, prognosis and resuscitation): author. Diss. ... candles. the honey. Sciences. - Moscow, 1980. - 15 S.

3. Gubler E.V. Computational methods of analysis and recognition of pathological processes. -L.: Medicine, 1978. - 296 S.

4. The Luzhniki E.A., G. Kostomarov Acute poisoning: Guidance for doctors. 2nd ed., revised and enlarged extra - M.: Medicine, 2000. - 434 S.

5. Shamanaev AGRICULTURAL, Jamanaeva I.E. a predictor of outcome in acute poisoning acetic acid //Materials of Ross. the scientific. - practical. proc. “About measures on improvement of medical care to patients with acute poisoning” -Ekaterinburg, 2002. - S-186.

6. Shamanaev AGRICULTURAL, Jamanaeva I.E. the Application of probabilistic methods rozpoznawanie is in clinical toxicology //Toxicol. Herald. - 2002. - №3-4. - P.17-29.

Table 1
Values score
No.A characteristic, observed in a patientScore
1Ecotoxicity shock+12
No-4
2Oliguria, less than 30 ml per hour+9
no-4
3the pH of the plasma<7,16+12
7,24+10
7,25-7,49-2
>7,49-6
4The state of the coagulation systemNorma 
coagulopathy without clinical manifestations-2
coagulopathy with clinical manifestations+12
5Fibrinogen, g/l<2,10
2,1-6,0 
>6,0+4
the impossibility of determination (hemolysis)+2
6PTI, %<61+1
61-80-1
81-100-3
>100+2
the impossibility of determination (hemolysis)+12
7Chemical substance (agent)acetic acid+2
inorganic acid0
lye-10
the oxidizing agent-11
unidentified corrosiv+5

Continuation of table. 1
No.A characteristic, observed in a patientScore
8Hemolysis of red blood cells+5
no-5
9Temperature, °<36,6+6
36,6-36,9+3
37,0 to 37.9-4
>to 37.9-9
10Creatinine, µmol/l<101-2
101-150 -2
151-2000
201-250+8
>250+10
11Bilirubin, µmol/l<31-4
31-50-1
>50+5
the impossibility of determination (hemolysis)+5
12Glucose, mmol/l<3,34-7
3,34-5,55-2
5,56-7,8+2
7,9-11,0+4
>11,0+13
13The hemoglobinuria+5
no-3
14Age, years<41-5
41-70+1
>70+5
15Dysphonia+4
no-3

Table 2
The forecast evaluation of the outcome of the poisoning of acetic acid, the patient K.
No.PA is Amer A characteristic, observed in a patientScore
1Ecotoxicity shock+12
2Oliguria, less than 30 ml per hour+9
3pH7,25-7,49-2
4The state of the coagulation systemcoagulopathies with clinical manifestations+12
5Fibrinogen, g/lthe inability assessment (hemolysis)+12
6PTI, %61-80-1
7Agentacetic acid+2
8Hemolysis+5
9Temperature, °36,6-36,9+3
10Creatinine, µmol/l101-150-2
11Bilirubin, µmol/lthe inability assessment (hemolysis)+5
12Glucose, mmol/l5,56-7,8+2
13The hemoglobinuria+5
14Age, years-5
15Dysphoniano-3
 AMOUNT54

Table 3
The forecast evaluation of the outcome of the poisoning HVPD patient E
No.A characteristic, observed in a patientScore
1Ecotoxicity shockno-4
2Oliguria, less than 30 ml per hourno-4
3pH7,25-7,49-2
4The state of the coagulation systemNorma-3
5Fibrinogen, g/l2,1-6,0-3
6PTI, %81-100-3
7Agentunidentified HVPD+5
8Hemolysisno-5
9Temperature, °36,6-36,9+3
10Creatinine, µmol/l<100-2
11Bilirubin, µmol/l<30-4
12Glucose, mmol/l<3,33-7
13The hemoglobinuriano-3
14Age, years<40-5
15Dysphoniano-3
 AMOUNT-40

A method for predicting the outcome of acute oral poisoning chemical cauterizing action (HVPD), characterized by the fact that evaluate data on chemical substances, the age of the patient, clinical examination and laboratory parameters: body temperature, the presence or absence of disponee, oligouria less than 30 ml/h, hemoglobinuria, hemolysis of erythrocytes, ekzoticheskogo shock, blood glucose, fibrinogen concentration and creatinine serum total bilirubin, prothrombin index (PTI), the pH of the plasma, the state of the blood coagulation system, the status of each symptom scored: chemical substances: acetic acid the“+2” points, inorganic acid - 0 points, alkali - “-10” points oxidant “-11” points that are not installed HVPD - “+5” scores; patient age: <41 year is - “-5” points, from 41 to 70 years “+1” score, >70 years - “+5” points, body temperature <36,6° - “+6” points, 36,6-36,9° - “+3” points, 37,0-37,9° - “-4” grade > 37,9° - “-9” points; the lack of disponee “-3” grade, the presence of “+4” points, oliguria of less than 30 ml/h: “+9” points, no “-4” score; hemoglobinuria: the “+5” points, no “-3” points; hemolysis of erythrocytes is “+5” points, no “-5” points; Ecotoxicity shock: defined “+12” points, no “-4” points; glucose: <to 3.34 mmol/l “-7” points, 3,34-5,55 mmol/l “-2” points to 5.56-7.8 mmol/l “+2” points, to 7.9-11.0 mmol/l “+4” grade >11.0 mmol/l -“+13” points; fibrinogen concentration in the blood serum: <2.1 g/l - 0 points, 2.1 to 6.0 g/l “-3” grade >6.0 g/l “+4” points, the impossibility of assessing fibrinogen due to intense hemolysis - “+12” points; PETIT < 61% -“+1” score 61-80% - “-1” score 81-100% - “-3” grade, >100% - “+2” points, impossibility to assess the PETIT view expressed hemolysis - “+12” points; the concentration of serum creatinine, blood <101 µmol/l “-2” points, 101-150 µmol/l “-2”, 151-200 µmol/l “0” points, 201-250 µmol/l -“+8” points >250 µmol/l “+10” points; total bilirubin <31 µmol/l “-4” grade 31-50 µmol/l “-1” point, >50 µmol/l “+5” points, the impossibility of estimating bilirubin due to intense hemolysis -“+5 points, a plasma pH <7,16 - “+12” points, 7,24 -“+10” points, to 7.25-7,49 - the -2” grade >7,49 - “-6” points; the condition of the blood coagulation system is determined by the variance of indices of coagulation and the development of clinical manifestations of DIC blood - norm “-3” grade coagulopathy without clinical manifestations - “-2” points, coagulopathy with clinical manifestations - “+12” points; the points are added up and in excess of the total score more than 20 points predict a poor outcome, with a score of less than “-13” forecast regarded as favorable, from “-13” to “+20” - forecast doubtful.



 

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