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Age features of acute poisoning treatment
Medical expert of the article
Features of intensive therapy of acute poisoning in children
Features of resuscitation and intensive care in children are associated with quantitative and qualitative differences in the adult and children's organism. These differences are most evident in early childhood (up to 5 years) and are due to the essential features of metabolic processes (in particular, water salt metabolism), increased permeability of membranes (BBB and blood vessel endothelium), nervous and humoral regulation of cardiovascular functions and excretory organs (liver, kidneys).
The often encountered opinion about the "imperfection" of the child's organism and its low tolerance to poisons as a cause of a more severe clinical course of poisoning in childhood is fundamentally wrong. The influence of the age factor on the resistance and adaptive capacity of the organism in acute poisoning has not been adequately studied at present. Nevertheless, based on the data of clinical toxicometry, when comparing the basic parameters of hemodynamics (stroke, minute volumes, OPSS) in children aged 1-3 years and adults with the same concentration of barbiturates in the blood, children showed greater resistance of the cardiovascular system to the action of toxic substance , than in adults. The study of the autonomic nervous system in these same groups of patients showed that in adults and children there are unidirectional changes in vegetative homeostasis in the form of pronounced hypersympathicotonia due to increased activity of the sympathetic part of the autonomic nervous system and parasympathetic depression. However, in children the degree of tension of the compensatory adaptive mechanisms was less pronounced than in adults. This phenomenon can be explained by the anatomical and physiological features of the cardiovascular and autonomic nervous system of young children.
It is well known about the increased tolerance of the organism in the early neonatal period of development to the action of many poisons that have an exciting effect on the CNS (strychnine) or acquire toxicity as a result of "lethal synthesis" due to the inadequacy of development in children of certain enzyme systems (organophosphorus substances, methyl alcohol, ethylene glycol and other). It is known about the higher renal clearance in children of most water-soluble poisons.
Opinion about the more severe course of poisoning in children is born of a number of circumstances. Firstly, 60-73% of all poisonings in children are caused by drugs, more than half of which are psychotropic substances with a depressing effect on the autonomic functions of the central nervous system, tolerance to which in young children is markedly reduced. Children are usually deprived of specific and non-specific tolerance to substances of narcotic action acquired by adults (alcohol, drugs, etc.), so the clinical picture of poisoning develops much faster with a predominance of stupor and coma.
Secondly, it is necessary to take into account the more intensive character of somatogenic reactions to the "chemical trauma", depending on the increased reactivity of the child's organism and the more rapid development of some complications, for example, toxic brain edema.
The nature of therapeutic measures for acute poisoning in children does not differ in principle from the complex method of combating poisoning in adults. The main attention of the doctor, as a rule, is directed to the fastest and most effective removal of the toxicant from the body with the help of methods of enhancing natural detoxification, artificial detoxification, as well as specific therapy with the help of antidote agents and therapy of violations of the function of vital organs and systems.
In the foreign literature there are discussions about the preferability of using ipecacuan or apomorphine for the artificial inducing of vomiting in children. In our country these substances are not used in connection with the obvious danger of aspiration complications. In addition, apomorphine depresses the respiratory center in young children. Therefore, among the methods for purifying the gastrointestinal tract, the most popular is gastric lavage. Gastric lavage is considered appropriate if the child has clinical manifestations of poisoning characteristic of the toxicogenic phase.
Young children before washing should be fixed (swaddled). In children with oppression of pharyngeal reflexes and in a coma, the procedure is carried out after a preliminary intubation of the trachea.
To wash the stomach use drinking water at room temperature.
When poisoning with cauterizing liquids, gastric lavage through the probe is mandatory in the first hours after taking the poison. The presence of blood in the wash water does not serve as a contraindication for this procedure. In these cases, the probe before the introduction into the stomach is abundantly lubricated (for the entire length) with vaseline oil, 0.1 ml for each year of life of 1% solution of trimeperidine or omnopone is injected subcutaneously. Neutralization of the acid in the stomach with an alkali solution is not effective, and the use of sodium hydrogencarbonate for this purpose significantly worsens the child's condition due to a significant expansion of the stomach formed by carbon dioxide. Laxatives for poisoning with cauterizing poisons are not injected, inside 4-5 times a day they give vegetable oil (children under 3 years old - 1 teaspoon, from 3 to 7 years - a dessert spoon, over 7 years - a tablespoon).
When the crystals of KMnO4 are poisoned, 1% solution of ascorbic acid is used to purify the mucous lips, oral cavity, and tongue from the brown-black coating.
When poisoning with gasoline, kerosene and other petroleum products, before washing in the stomach, you must enter 20-50 ml of vaseline oil (or 3 ml per 1 kg of the child's body weight), and then rinse according to the usual scheme.
For adsorption of substances in the gastrointestinal tract before and after washing the stomach, activated charcoal (or other adsorbents) is used at a rate of 1 g / kg body weight of children under 5 years and 0.5 g / kg - over 5 years.
Great importance in the treatment of poisoning in children has an intestinal cleansing. To this end, use laxatives - saline in a dose of 0.5 g / kg or poisoning with fat soluble substances vaseline oil (3 ml / kg). In addition, cleansing enemas are used to relieve the bowel.
To remove toxic substances from the bloodstream in children, the method of forced diuresis is common. As in adult patients, this method is shown for most poisonings with water-soluble poisons, when their excretion is performed mainly by the kidneys
Depending on the severity of the condition, forced diuresis is presented as an oral aqueous load or intravenous administration of solutions.
At a poisoning of an easy degree an oral water loading at children spend from calculation of 5-6 ml / (kghh). With medium poisoning, the amount of fluid is increased to 7.5 ml / (kghh). The water load is carried out during the toxicogenic stage of poisoning. To do this, use solutions of glucose 5-10%, electrolytes, as well as drinking water, juice, mineral water, etc. If the child refuses to take fluids, reacts negatively to personnel, etc., the water load is carried through the probe. To do this, a thin probe is inserted into the stomach, fixed with adhesive plaster and in small portions (30-50 ml), the necessary amount of liquid is introduced. If the patient arrives in a serious condition, the forced diuresis is carried out in the form of intravenous infusions with a speed of 8-10 (up to 12) ml / (kghh). Short-acting hemodilutants (0.9% isotonic sodium chloride solution, Ringer's solution, glucose solutions 5-10%) are used. The ratio of injected non-electrolytes and electrolytes in children under 1 year is 3 1, from 1 to 5 years is 2 1 and over 5 years is 11. If the hemodilution used does not provide sufficient diuresis, then diuretics - furosemide 1-3 mg / kg , mannitol - 1-2 g of dry matter per 1 kg of body weight. It is necessary to monitor the content of electrolytes and the continuous introduction of a solution of electrolytes intravenously, in an amount equal to the hourly diuresis.
In the treatment of acute poisoning with barbiturates, salicylates and other chemicals, whose solutions have acid reaction, as well as when poisoning with hemolytic poisons, shows the alkalization of plasma in combination with forced diuresis.
Acceptance of a large amount of the drug, a rapid increase in the symptoms of poisoning, as well as the lack of a positive effect on the methods of enhancing the natural processes of detoxification serve as an indication for the application of methods of artificial detoxification in children.
Blood substitution surgery (OCT) is one of the most simple, but not very effective methods of detoxification, used in pediatric practice.
Indications for the use of OC in children, it is mainly poisoning with substances that cause toxic damage to the blood - the formation of methaemoglobin and massive hemolysis, as well as severe poisoning with medicines in the absence of the possibility of using more intensive methods of detoxification - hemosorption and HD.
To replace the blood, one-group Rhesus-compatible, individually selected donor blood is used. A positive effect is observed after substitution of 25% BCC (bcc = 70-75 mlhkilograms of body weight).
Optimum substitution 1 BCC The speed of the operation should be 25-30% BCC per hour. When using donor blood containing sodium citrate, 10 ml of 4% sodium hydrogen carbonate solution and 1-2 ml of 10% calcium gluconate solution are injected intravenously for every 100 ml of transfused blood. According to the indications prescribed antihistamines, hormones, inhalation of oxygen. Among the methods of artificial detoxification, the hemosorption operation, widely used in the treatment of many types of poisoning in children, is recognized as the most effective. The main contraindications for carrying out HS in children - a decrease in blood pressure, especially with a decrease in the total peripheral resistance.
In recent years, for the treatment of poisoning with dialyzers, children have more often used DG with the use of the "artificial kidney" apparatus. Indications for its use do not differ from those for adults. In addition, an anuric phase of arthrosis, which arose as a result of poisoning, serves as an absolute indication for HD.
To increase the overall detoxification effect, the combined use of the above methods is possible.
In the treatment of acute drug poisoning in children, specific antidotal pharmacotherapy is performed according to the same rules as in adults, namely, differentially depending on the stage and severity of the disease. In the toxicogenic stage of poisoning, antidote therapy is based on conventional indications with strict adherence to the age-related dosage of medications.
Infusion therapy and other symptomatic measures also have no specific features, except for obvious corrections to the patient's age and body weight. Treatment of children with acute poisoning should be carried out in the intensive care units of the pediatric profile.
Features of intensive therapy of acute poisoning in old age
In the elderly and senile age, due to a decrease in the adaptive capabilities of the body, the clinical course of poisoning acquires certain features that have a significant effect on the outcome of the disease and the nature of the intensive therapy.
For patients of the elderly and senile age is characterized by a slow and sluggish development of the main pathological syndromes of acute poisoning, frequent adherence of intercurrent diseases and exacerbation of chronic. For example, pneumonia in these patients is observed in 2 times more often than in young patients, and acute cardiovascular insufficiency in the somatogenic stage of poisoning ("secondary somatogenic collapse") is more than 3-fold. Accordingly, the recovery period is slower, the transition to the chronic course of the disease (with chemical burns of the esophagus and stomach, toxic dystrophy of the liver and nephropathy) is more often noted.
At the same time, in elderly and elderly people, acute stress conditions in response to chemical trauma occur less frequently at a later date. For example, development of exotoxic shock in case of poisoning with cauterizing fluids is noted only in 10.2% of older patients (compared with 17.6% in young).
Particular attention should be paid to reducing the tolerance of elderly patients to various toxic substances, as evidenced by a sharp decrease in the critical and irreversible levels of toxic substances in the blood, to the extent that they are 10 or more times over the age of 70, and the thresholds the concentrations in the blood of many poisons are no longer very different from the critical ones.
Therefore, the choice of treatment methods for these patients requires a strictly individual approach. First of all, it concerns the volume of the infusion therapy. Overloading of the cardiovascular system in elderly patients is very dangerous due to the rapid development of hyperhydration, OL, cavitary and peripheral edema and other signs of circulatory insufficiency. This is due to a decrease in the contractility of the myocardium, a decrease in the filtration function of the kidneys, etc. As a consequence, they need to carry out a more thorough control of the main indices of central and peripheral hemodynamics, acid-base and osmotic state, the content of basic electrolytes in plasma, hourly urine output and body weight .
Infusion therapy in the first 2-3 hours after the poisoning is carried out at a rate of 5-6 ml / min, then with increasing diuresis and decreasing CVP, it can be increased to 15-20 ml / min, so that the CVP remains within 80-90 mm. Water. Art.
When choosing diuretics preference is given to furosemide, which is administered in divided doses of 50-80 mg 3-4 times with an interval of 1 hour, which allows you to keep a stable hourly (300-500 ml / h) and diuresis daily (4-5 l). In the composition of the electrolyte solution used, it is necessary to introduce a glucosoccal mixture and potassium and magnesium asparaginate.
Of the methods of extrarenal purification of the body in elderly people the most acceptable intestinal lavage, veno-venous GF, as well as PD, which does not cause noticeable violations of hemodynamics with proper technical performance. The volume of the dialysate solution administered simultaneously into the abdominal cavity should not exceed 1.0-1.5 liters, and in comatose patients it is necessary to perform artificial respiration during the entire period of the operation. To prevent fluid retention in the abdominal cavity, increase the glucose content (by 20-30%) in the dialysate fluid.
All other types of artificial detoxification are used as methods of choice with a significantly lower (about 10 times) concentration of poisons in the blood.
Carrying out drug therapy in elderly patients requires special care and consideration of individual drug tolerance.