中暑急诊科医师熟悉而又陌生的疾病.ppt

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1、中暑-急诊医师熟悉而陌生的疾病,东南大学附属中大医院 急诊科徐昌盛,主要内容,南京地区中暑天气条件指数研究预报气象科学，2001,21（2）：246-252,1995 Chicago heat wave,No official death toll.Figures show that 739 additional people died in that particular week above the usual weekly averageMost of the victims were elderly poor residents of the inner city,who could

2、not afford air conditioning and did not open windows or sleep outside for fear of crime.11%more hospital admissions than average for comparison weeks,July 11:2332 CJuly 12:2437 CJuly 13:2741 CJuly 14:2939 CJuly 15:2537 CJuly 16:2434 CJuly 17:2332 C,The 2003 European heat waveIntensive Care Med,2004

3、Jan;30(1):1-3.,During the 9 days of extreme temperatures,the summer heat wave was exceptional for the extensive loss of life,which culminated in 14,800 deaths in France.300 by August 4th,3,900 by August 8th,10,600 by August 12th and 14,800 by August 20th.The excess deaths occurred in hospital(42%),h

4、ome(35%)and“maisons de retraite”(19%).Heavy casualties occurred in other European countries,namely Italy,Spain,Portugal and the United Kingdom,where the as yet unconfirmed figures for fatalities are between 1,000 and 5,000 people,The 2006 California Heat Wave:Impacts on Hospitalizations and Emergenc

5、yDepartment Visits.Environ Health Perspect.2009 Jan;117(1):61-7.,During the heat wave,16,166 excess ED visits and 1,182 excess hospitalizations occurred statewide.ED visits for heat-related causes increased across the state,especially in the Central Coast region,which includes San Francisco.Children

6、(04 years of age)and the elderly(65 years of age)were at greatest risk.ED visits also showed significant increases for acute renal failure,cardiovascular diseases,diabetes,electrolyte imbalance,and nephritis.,Heat-Related Deaths After an Extreme Heat Event Four States,2012,and United States,19992009

7、.MMWR Morb Mortal Wkly Rep,2013 Jun 7;62(22):433-6.,During June 30July 13,2012,32 deaths from excessive heat exposureMedian age:65 years,72%were male75%were unmarried or living alone69%died at home,with lack of air conditioning5 who died,a air conditioner was present but not turned on.3 deaths Heat

8、exposure occurred outdoorsDuring 19992009,an annual average of 658 heat-related deaths occurred in USA,火炉上的中国,20130808高温中暑报告-浙江CDC,6月1日8月7日，浙江省各级各类医疗机构共报告高温中暑病例2082例，死亡15人重症中暑288例，热射病112例重症中暑比去年同期上升247%死亡人数是去年同期的近3倍各类病例均比2012年大幅增多,20130809高温中暑报告-武汉,从今年月日至月日，累计报告中暑病例例（去年同期为例），其中重症为例(是去年同期两倍多)中暑患者中，以岁

9、以上人群居多，占例例重度中暑患者中，多数为露天作业工人，其次为空巢独居老人中暑死亡例，其中例因“热射病”死亡，其余例是因“重症中暑”死亡的高龄老人,无锡实行中暑病例日报告,无锡市医管中心2013-07-31启动中暑病例日报告制度。当日8家市属医院昨日共诊治中暑病例25例，有7人病情危重正在抢救。7月份市人民医院收治中暑病人23位，死亡1人；市二院收治中暑病人20位，死亡2人；市三院收治中暑病人37人，死亡3人；四院收治中暑病人9位，无死亡病例。,依法治国，任重道远,重庆：截止8月6日全市累计报告中暑病例145例，死亡3例上海：数据未公开南京：未监测 行政不作为,主要内容,高温中暑事件卫生应急预

10、案卫应急发号,每年6月1日，各地卫生部门启动高温中暑事件的监测、报告工作，每年9月30日终止事件的监测、报告工作医疗卫生机构发现高温中暑病例后填写高温中暑病例报告卡，于当日通过中国CDC网络直报系统报告当地CDC每日12:00时汇总辖区内前24h报告的高温中暑病例总数，网络直报，同时通知同级气象业务单位，并报同级卫生行政部门。卫生行政部门收到报告后要立即对高温中暑事件进行确认，并通报同级气象行政主管机构。,高温中暑事件卫生应急预案卫应急发号,高温中暑病例报告卡 初次报告 订正报告 省 地（市）区（县）姓名：性别：男 女 年龄：居住住址：中暑诊断：轻症中暑 重症中暑：热射病 热痉挛 热衰竭 混合

11、型 患者情况：治疗中 治愈 死亡 中暑日期：年 月 日 诊疗单位：报告日期：年 月 日 报告人：,中暑事件分级,特别重大事件（级）24h内，1个县（市）区域内报告中暑患者300人以上（含300人）,或有10例以上（含10例）死亡病例发生；国务院卫生行政部门和气象行政主管机构共同认定的其他情形。重大事件（级）24h内，1个县（市）区域内报告中暑患者150人至299人,或有4至9例死亡病例发生；省级及以上人民政府卫生行政部门和气象行政主管机构共同认定的其他情形。较大事件（级）24h内，1个县（市）区域内报告中暑患者100人至149人,或有1至3例死亡病例发生；地市级及以上人民政府卫生行政部门和气象

12、行政主管机构共同认定的其他情形。一般事件（级）24h内，1个县（市）区域内报告中暑患者30人至99人。,高温中暑事件卫生应急预案卫应急发号,一级预警（红色预警）高温中暑事件级别达到级，且高温中暑气象预报级别达“极易发生中暑”，高温天气还有持续或加重趋势的二级预警（橙色预警）高温中暑事件级别达到级，且高温中暑气象预报级别达“易发生中暑”以上，高温天气还有持续或加重趋势的三级预警（黄色预警）高温中暑事件级别达到级，且高温中暑气象预报级别达“较易发生中暑”以上，高温天气还有持续或加重趋势的四级预警（蓝色预警）高温中暑事件级别达到级，且高温中暑气象预报级别达“可能发生中暑”以上，高温天气还有持续或加重

13、趋势的,高温中暑气象预报,主要内容,产热过程,安静状态：内脏 劳动或运动：肌肉产热的调节反应提高基础代谢率：TSH分泌增加寒战：骨骼肌不随意的节律性收缩,剧烈运动,600-900 kcal/hm2气温28静息状态下，50-60 kcal/hm2,剧烈运动,600-900 kcal/hm2气温28静息状态下，50-60 kcal/hm2,剧烈运动,600-900 kcal/hm2气温28静息状态下，50-60 kcal/hm2,散热过程,辐射散热：体热以热射线的形式传给外界较冷物体 60%对流：通过气体或液体来交换热量，受风速、衣服影响 12%传导：机体热量直接传给同他接触的较冷物体，受导热度影

14、响 3%蒸发 高温环境下唯一的散热途径 受湿度影响，90%蒸发完全停止不感蒸发：体液的水分直接透出皮肤和黏膜表面，在未聚成明显水滴前就蒸发掉。可感蒸发：发汗 1000ml水分蒸发可带走580 Kcal的热量,散热过程的调节,发汗 发汗中枢：下自脊髓上至大脑皮层均存在发汗中枢，下丘脑的发汗中枢起主要作用汗腺：交感神经支配（节后纤维为胆碱能纤维）汗液：汗腺细胞主动分泌，最大分泌量1.5L/h，乳酸浓度高于血浆，氯化钠浓度低于血浆（受醛固酮调节），糖和蛋白质=0，大量出汗致高渗性脱水循环系统的调节皮肤血流量：最大可达CO的12%，决定皮肤温度，影响散热量交感神经：影响皮肤血管的口径，决定皮肤血流量,

15、体温调节,自主性体温调节：在下丘脑体温调节中枢的控制下，通过增减皮肤的血流量、发汗、寒战等生理调节反应，维持恒温动物体温在一个稳定的水平行为性体温调节：机体为了维持体温恒定采取的一切行为炎热环境：交感神经紧张度降低，皮肤小动脉舒张，动-静脉吻合支开放，增加皮肤血流量、发汗寒冷环境：交感神经紧张度增强，皮肤血流量剧减,主要内容,中暑相关理论,教科书定义：常发生在高温和湿度较大环境中，是以体温调节中枢障碍、汗腺功能衰竭和水电解质丢失过多为特征的疾病徐昌盛定义：在高温环境中，机体丢失大量水分和电解质导致的低血容量状态和电解质紊乱，伴或不伴体温升高以及多器官功能失常的临床综合征分型：热痉挛 heat

16、cramp热衰竭 heat exhaustion热（日）射病 heat stroke 或 sun stroke,职业性中暑诊断标准 GBZ 412002,中暑先兆：指在高温作业场所劳动一定时间后，出现头昏、头痛、口渴、多汗、全身疲乏、心悸、注意力不集中、动作不协调等症状，体温正常或略有升高。轻症中暑：除中暑先兆的症状加重外，出现面色潮红、大量出汗、脉搏快速等表现，体温升高至38.5以上。重症中暑 热射病（包括日射病）：在高温环境中突然发病，体温高达40以上，疾病早期大量出汗，继之“无汗”，可伴有皮肤干热及不同程度的意识障碍等。热痉挛：主要表现为阵发性肌痉挛，好发于四肢肌肉及腹肌等，尤以腓肠肌为

17、著。常呈对称性。患者意识清，体温一般正常。热衰竭：起病迅速，主要表现为头昏、头痛、多汗、口渴、恶心、呕吐，继而皮肤湿冷、血压下降、心律紊乱、轻度脱水，体温稍高或正常。,发病机制,获取过多环境热量：环境温度过高：反向辐射、传导、对流；日光照射：100-150Kcal/h产热增加：剧烈运动：600-900 kcal/hm2重体力劳动癫痫持续状态甲亢感染性发热,散热障碍：湿度过高肥胖衣服透气不良硬皮病大面积烧伤后疤痕形成、先天性汗腺缺乏药物：抗胆碱能药物、吩噻嗪,发病机制-热环境适应,CO和出汗量增加（每小时1-3L)醛固酮分泌增加使汗液钠含量减少（20-50mmol/L)有氧代谢增加、能量利用最多

18、产热减少正常人生理性适应需7-14天,病理,体温过高42对细胞的直接毒性：酶变性、线粒体功能障碍、细胞膜稳定性丧失、有氧代谢中断小脑和大脑皮质神经细胞坏死，purkinjie细胞病变较突出。灶性心肌细胞溶解、出血、坏死，心外膜、心内膜和瓣膜组织出血不同程度肝细胞坏死和胆汁淤积劳力性热射病 肌肉组织变性和坏死,临床表现-热痉挛,高温环境中剧烈运动，大量出汗后出现痛性肌肉痉挛，常在活动停止后发生，常见于下肢腓肠肌或腹部肌群，持续数分钟后缓解无明显体温升高可能与严重体钠缺失（大量出汗和饮用低张液体）和过度通气有关 问题不那么简单 局部酸中毒？肌细胞破坏？,Sodium balance during

19、U.S.football training in the heat:cramp-prone vs.reference players.Int J Sports Med.2009 Nov;30(11):789-94.,U.S.football players The reference group(R,n=8 without a cramping history)cramp-prone group(C,n=6,history of whole-body cramps)were measured for body mass and Bna（血钠）before and after training

20、of 2.2 h in hot conditions(29-32).Intake and loss of fluid and sodium Bna（mmol/L）pre-to post-training In R 138.9+/-1.8 to 139.0+/-2.0in C 137.8+/-2.3 to 135.7+/-4.9 and 3 subjects below 135C consumed a greater percentage of total fluid as water(p0.05).In R 38.3+/-18.3 in C 52.6+/-29.2,热衰竭 heat exhau

21、stion,主要原因：脱水和血容量不足症状：疲乏、无力、眩晕、恶心、呕吐、头痛、多汗、晕厥、肌痉挛特征：体温轻度升高、低血压、心动过速、呼吸增快实验室检查：HCT升高、高血钠、氮质血症、肝功能异常、高危人群：常见于老年人、慢性疾病患者,热射病-heatstroke,劳力性热射病：多见于健康青壮年，在环境温度25以上、湿度较大和无风天气进行重体力劳动、剧烈运动或新兵军训时发生。约50%病人持续出汗，心率可达160-180次/分，常有急性肝坏死和横纹肌溶解，30%以上发生急性肾衰竭和高钾血症，常因MOF死亡非劳力性热射病：常发生在环境温度超过32或室温在27以上、湿度较大时。早期出现疲乏、无力、头

22、痛、头晕、恶心和多汗，继而高热（直肠温度41-46.5）、谵妄、抽搐、昏迷、各种行为异常，84-100%无汗，可出现低血压、心律失常、心力衰竭、肺水肿，约5%发生急性肾衰竭，有轻、中度DIC，多在发病后24小时左右死亡。80%病例年龄在65岁以上，城市居民多见，其他高危人群包括精神分裂症、帕金森病、慢性酒精中毒及偏瘫或截瘫患者。,主要内容,劳力性热射病的临床特点济南军区总医院，生物医学工程研究，2010,29（4）：263-267,2010年野外演练，气温为32，相对湿度80，负重徒步28 km，18名男学员（年龄18-22岁）相继倒下,体温均39，无汗神经系统：深昏迷1例，浅昏迷6例，神志恍

23、惚11例循环系统：血压 89/50 16例，心率120bpm 16例 呼吸系统：气管插管1例（呼衰）血液系统：Plt在24h内降低幅度 50109L 17例，Hb99L 14例，PT延长11例，Fib降低7例泌尿系统:5例少尿，SCr为342 113umolL消化系统：恶心、呕吐18例，上消化道出血7例。15例ALT为(26424)uL、总胆(4211)umolL骨骼肌：CK为(153421)UL、LDH为(142125)UL、Mb为(35227)UL预后：全部治愈，无后遗症。住院时间16-20 d,军事训练所致劳力性热射病的临床特点及治疗湛江解放军第四二二医院 海军医学杂志，2011,32（

24、5）：315-318.,2004年6月-2010年8月 17例，男性官兵，18-31岁。16例为战士，1例为干部。新战士8例，下连队锻炼老兵3例，6例训练前感冒或者腹泻不适越野训练进行1 h左右发病，2-3 h左右为发病高峰，就诊时间在发病后26 h(平均4 h)体温：39-40 4例，40-41 10例，41 以上3例神经：深昏迷6例，浅昏迷1O例，躁动不安1例，全身抽搐9例消化道：消化道出血4例循环：低血压12例，室速10例合并呼吸衰竭2例其他：少尿7例，无尿4例，DIC 3例实验室检查：低氧血症17例，高碳酸血症的10例，低碳酸血症2例；电解质紊乱15例，血糖升高5例，低钾低钠11例，高

25、钾6例。血肌肝、尿素氮均超过正常10例死亡3例，存活14例，遗留严重神经功能障碍1例，遗留单纯舌咽神经损伤1例,剧烈运动,600-900 kcal/hm2,剧烈运动,600-900 kcal/hm2,非劳力性热射病的临床特点Near-Fatal Heat Stroke during the 1995 Heat Wave in Chicago,To describe the clinical features of patients admitted to an ICU with near-fatal classic heat stroke.58 patients admitted to the

26、 hospital from 12 July to 20 July 1995 who met the case definition of classic heat stroke.Patients experienced MODS with neurologic impairment(100%),moderate to severe renal insufficiency(53%),DIC(45%),and the ARDS(10%).57%of patients had evidence of infection on admission.In-hospital mortality was

27、21%.resulting in moderate to severe functional impairment in 33%of patients at hospital discharge.At 1 year,no patient had improved functional status,and an additional 28%of patients had died.Ann Intern Med.1998;129(3):173-181.,热射病的机制,热射病的机制,中暑检查清单,血常规尿常规生化纤溶功能血气分析脏器损害标志物：肌红蛋白、肌钙蛋白、淀粉酶、NSE、PCT心电图、头颅

28、CT,热射病的治疗,南京军区福州总医院血液净化科，世界临床药物，2010,31（5）：283-287,1小时内使直肠温度降至39以下,物理降温,体表降温,降低环境温度：空调电风扇降低体表温度：降温毯冰帽冰袋酒精擦浴,体表降温-冰毯,通过主机工作使冰毯内的水进行循环更换，促使冷却的冰毯接触皮肤进行散热降温通电源，打开主机开关46 min，待装置循环稳定普通高热降温时将毯温设置在8.O 12.O，预期肛温下降至37.O 37.7亚低温治疗时将毯温设置在6.O 10.0，预期肛温下降至32.0 35.0,体腔降温,用冷却的无菌生理盐水灌入胃、结肠或腹腔进行灌洗降温,结肠途径治疗系统,全电脑自动控制主

29、机，腔内压力自动监测，灌注量、排出量数据监测，蠕动计量泵控装置、出水口无压设计，任意定温、恒温装置，PID技术，专利探头设计，真正无压灌洗，舒适、安全、有效，床边数码监控台车，自动化水处理装置，提供纯水，智能化治疗程序和完工乐曲报知。,结肠途径治疗对高温中暑犬恢复的影响白求恩国际和平医院消化科.军医进修学院学报，2007,28（4）：316,静脉麻醉后，将犬置于恒温恒湿箱中，同时监测深部鼻腔温度，达43 后，维持10 min两组犬均置于温度23，湿度65%下降温，对照组给予冰袋置于大动脉处，肠疗组应用结肠途径治疗机结肠途径治疗液组成：甘露醇200 g，葡萄糖100 g，加去离子水至20 000

30、 mi，液体温度经结肠治疗系统控制在37-38 C 之间将探头插入直肠10 cm，进水管缓慢插入60 cm 至升结肠，调节注水速度为200 ml/min。待犬体温下降至38时降温结束,Iced gastric lavage for treatment of heatstroke:Efficacy in a canine.Departments of Emergency Medicine,University of Cincinnati Medical Center,Cincinnati,Ohio,USA.Annals of Emergency Medicine,1985,14(5):424-4

31、32,11 mongrel dogs were anesthetized,and externally heated until core temperature reached 43.0.Control animals(n=6)were cooled passively in room air.Treatment animals(n=5)were cooled with the addition of gastric lavage with iced tap water through a large-bore orogastric tube.Temperatures were monito

32、red using thermocouples in the brain,pulmonary artery,rectum,and subcutaneous tissue of the chest wall.Serial enzymatic and hematologic laboratory studies and hemodynamic parameters were measured prior to heating,at the end of heating,and at 0,0.5,1,2,and 12 hours after heating.Central cooling rates

33、 of achieved in the lavage group were five to six times faster than in the control group,(P.01).Rapid cooling in the lavage group resulted in a statistically significant improvement in serum creatinine and LDH after heatstroke induction(P.05).,Evaporation versus iced gastric lavage treatment of heat

34、stroke:comparative efficacy in a canine model.Crit Care Med,1987 Aug;15(8):748-50.,9 random-source,mongrel dogs were anesthetized,and internally heated until the core temperature reached 43.0.The animals were then randomly assigned to be cooled to 37 either by iced tap water gastric lavage(n=5，200 m

35、l/min)through a large orogastric tube,or by spraying with tap water(n=4,15,12 L/min)before a large fan blowing room temperature air(23)across the dog at 0.5 m/sec from a height of 50 cm.Temperatures were monitored by thermocouples in both tympanic membranes and the pulmonary artery.BP,pulse,and card

36、iac output were measured every 5 min.Evaporative cooling was twice as fast as iced gastric lavage(0.16+/-.05 degree vs.0.08+/-.01 degree C/min X m2,p less than.01).Animals in the evaporatively cooled group also experienced a quicker and more complete return to baseline cardiac indices than the lavag

37、e-treated group.Moreover,all animals treated with evaporation survived and were neurologically intact 48 h later,while only one lavage-treated dog was neurologically intact over the same period.The others in the lavage group died one hour after cooling(n=1),were grossly ataxic(n=1),or were persisten

38、tly comatose(n=2).,Peritoneal lavage cooling in an anesthetized dog heatstroke model.Aviat Space Environ Med.1978 Jun;49(6):779-84.,compare cooling in room air(27,20%RH),ice slush surface cooling,and peritoneal lavage cooling(6-10)as methods for lowering body temperature in an anesthetized dog heats

39、troke model.19 animals with sodium pentobarbital(25 mg/kg)intravenously,and maintained them in an ambient temperature of 42-46 C with a water heating blanket approximately 2.0 h until rectal temperatures rose to 43.2+/-0.2.At the maximum rectal temperature,the heating blankets were removed,and anima

40、ls were cooled,observed until death occurred or 18 h elapsed,and then sacrificed.The data demonstrate that maximum cooling rates of rectal temperature were:peritoneal lavage,0.56/min;ice slush,0.11;and 27 air cooling,0.06 degrees C/min.,Evaporation versus iced peritoneal lavage treatment of heatstro

41、ke:comparative efficacy in a canine model.Department of Emergency Medicine,Georgetown University Medical Center,Washington.Am J Emerg Med.1993 Jan;11(1):1-3.,9 mongrel dogs were anesthetized,shaved,and internally heated until the core temperature reached 43.0.The animals were then randomly assigned

42、to be cooled to 37 either by sterile normal saline(6)continuous peritoneal lavage at 250 mL/min(n=4),or by spraying with tap water(15,12 L/min)before a large fan blowing room temperature air(23)across the dog at 0.5 m/sec from a height of 50 cm(n=5).Temperatures were monitored by thermocouples in bo

43、th tympanic membranes.Evaporative cooling was as rapid as iced peritoneal lavage(0.18+/-.03 versus 0.17+/-.07/min/m2,P=NS).All animals survived,although one animal in each treatment group demonstrated a moderate neurologic deficit when measured 48 hours following resuscitation.,Survival in a heat st

44、roke victim with a core temperature in excess of 46.5 C Department of Medicine,Grady Memorial Hospital,Atlanta,USA.Ann Emerg Med.1982,11(5):269-71.,a 52-year-old male heat stroke victim.deep coma with a temperature 46.5 C.Following rapid assessment,the patient was intubated,rehydration was begun.Mul

45、tiple organ system failure developed over the ensuing days.He was externally cooled with ice bags and internally cooled with ice water gastric lavageWith aggressive care,the patient improved dramatically and was discharged at prior baseline status on the 24th day of hospitalization without permanent

46、 residua.,血液降温,静脉输液法：30分钟静脉输注4 的晶体30ml/kg 体外循环法：CVVH、HD、ECMO血管内热交换法：将闭合的冷盐水循环管道插入静脉系统,血液降温,Effects of continuous haemofiltration on serum enzyme concentrations,endotoxemia,homeostasis and survival in dogs with severe heat stroke.Fuzhou General Hospital,Nanjing Military Command,Fuzhou 350025,China.Re

47、suscitation 83(2012)657 662,Methods:Dogs were randomly allocated to a control or continuous haemofiltration group(both n=8).Heat stroke was induced by placing anaesthetised dogs in a high temperature cabin simulator.Upon confirmation of heat stroke(rectal temperature 42 C,mean arterial pressure(MAP)

48、decrease 25 mmHg),dogs were removed from the chamber and continuous haemofiltration was initiated and continued for 3 h for dogs in the continuous haemofiltration group.Dogs in the control group were observed at room temperature.Results:After 3 h,rectal temperature was 36.680.51 C in the continuous

49、haemofiltration group and 39.831.10 C in the control group(P 0.05).After 3 h,endotoxin concentrations were 0.140.02 EU ml1 in the continuous haemofiltration group and 0.230.05 EU ml1in the control group(P=0.003),while malondialdehyde concentrations were 4.860.61 mmol l1 in the continuous haemofiltra

50、tion group and 8.630.66 mmol l1 in the control group(P 0.001).Five dogs died in the control group within 3 h,whereas no dogs died in the continuous haemofiltration group.,连续性血液净化在热射病并发高热及多脏器功能障碍综合征中的应用济南军区总医院血液净化科 国际移植与血液净化杂志，2012,10（2）：20-22,血液降温,Core cooling by central venous infusion of ice-cold(