GBZ 65-2002 Diagnostic criteria for occupational acute chlorine poisoning
Some standard content:
ICS13.100
National Occupational Health Standard of the People's Republic of China GBZ65—2002
Diagnostic Criteria of Occupational Acute Chlorine Poisoning2002-04-08 Issued
2002-06-01 Implementation
Ministry of Health of the People's Republic of China
Article 6.1 of this standard is recommended, and the rest are mandatory. This standard is formulated in accordance with the "Law of the People's Republic of China on the Prevention and Control of Occupational Diseases". From the date of implementation of this standard, if the original standard GB4866-1996 is inconsistent with this standard, this standard shall prevail. Acute poisoning may occur after inhaling a large amount of chlorine in a short period of time during occupational activities. In order to protect the health of the contactors, the state promulgated GB4866-1996 in 1996. Appendix A of this standard is an informative appendix, and Appendix B and C are normative appendices. This standard is proposed and managed by the Ministry of Health of the People's Republic of China. This standard was drafted by Shanghai Sixth People's Hospital and Chongqing Tianyuan Chemical General Plant Staff Hospital. This standard is interpreted by the Ministry of Health of the People's Republic of China. ..comDiagnostic Standard for Occupational Acute Chlorine Poisoning
GBZ65-2002
Occupational acute chlorine poisoning is a systemic disease characterized by acute respiratory damage caused by inhaling a large amount of chlorine in a short period of time during work.
1 Scope
This standard specifies the diagnostic standard and treatment principles for occupational acute chlorine poisoning. This standard is applicable to acute poisoning caused by exposure to chlorine during work, and is also applicable to acute poisoning of similar inorganic chlorine compounds such as chlorine oxides, sulfides, phosphides, such as hydrogen chloride, chloric acid, chlorosulfonic acid, etc.: non-occupational poisoning can also be used as a reference.
2 Normative Reference Documents
The clauses in the following documents become the clauses of this standard through reference in this standard. For any dated referenced document, all subsequent amendments (excluding errata) or revisions are not applicable to this standard. However, parties reaching an agreement based on this standard are encouraged to study whether the latest versions of these documents can be used. For any undated referenced document, the latest version shall apply to this standard.
3 Diagnostic principles
Diagnostic criteria for pneumoconiosis
Based on the rapid onset of the disease after inhaling a large amount of chlorine gas in a short period of time, combined with clinical symptoms, signs, chest X-ray manifestations, and reference to the results of on-site labor hygiene surveys, comprehensive analysis, and exclusion of respiratory diseases caused by other reasons, a diagnosis can be made. 4 Irritation reaction
Transient eye and upper respiratory tract mucosal irritation symptoms occur, there are no positive signs in the lungs or occasional scattered dry rales, and no abnormal chest X-ray manifestations.
5 Diagnosis and grading criteria
5.1 Mild poisoning
Clinical manifestations are consistent with acute tracheobronchitis or peribronchitis. If there is choking cough, a small amount of sputum, chest tightness, scattered dry, wet rales or wheezing in both lungs, chest X-ray may show no abnormality or the lower lung field may show increased, thickened, extended, and blurred edges of lung texture.
5.2 Moderate poisoning
Any clinical manifestations that meet one of the following diagnoses: a) Acute chemical bronchopneumonia. If there is choking cough, sputum, shortness of breath, chest tightness, etc., it may be accompanied by mild purple; dry and wet rales in both lungs; chest X-ray manifestations are often irregular dots or small patches of blurred boundaries, partially dense or fused dense shadows distributed along the lung texture in the inner band of the lower part of the two lungs. b) Localized alveolar pulmonary edema. In addition to the above symptoms and signs, chest X-ray shows single or multiple localized clear outlines and high density flake shadows.
c) Interstitial pulmonary edema. Such as chest tightness and shortness of breath are more obvious; except for slightly reduced lung breath sounds, there may be no obvious rales: chest X-ray shows increased and blurred lung texture, widened hilar shadows with unclear boundaries, scattered dot-like shadows and reticular shadows in both lungs, reduced lung field brightness, often with thickened horizontal fissures, and sometimes with bronchial cuff signs and Kirschner B lines. d) Asthma-like attack. The symptoms are mainly asthma, especially difficult to exhale, with cyanosis and chest tightness: diffuse wheezing in both lungs: chest X-ray may not have abnormal findings.
5.3 Severe poisoning
Those who meet one of the following manifestations:
Diffuse alveolar pulmonary edema or central pulmonary edema: a)
Acute respiratory distress syndrome (ARDS): b)
Severe ventricular asphyxia;
d) Severe complications such as pneumothorax and mediastinal emphysema. Principles of treatment
Principles of treatment
6.1.1 On-site treatment
Immediately break away from contact, keep quiet and keep warm. Those who have irritation reactions should be closely observed for at least 12 hours and given symptomatic treatment. Those who have inhaled a large amount should rest in bed to avoid worsening of the condition after activity, and use sprays and oxygen inhalation; if necessary, intravenous injection of glucocorticoids will help control the progression of the disease. 6.1.2 Reasonable oxygen therapy
Appropriate methods can be selected to give oxygen, and the concentration of inhaled oxygen should not exceed 60%, so that the arterial oxygen partial pressure is maintained at 8-10kPa. If severe pulmonary edema or acute respiratory distress syndrome occurs, nasal mask continuous positive airway pressure (CPAP) or tracheotomy positive end-expiratory pressure (PEEP) therapy should be given, and the end-expiratory pressure should be around 0.5kPa (5cmH2O). 6.1.3 Use of glucocorticoids
It should be used early, in sufficient quantities, for a short period of time, and prevent side effects. 6.1.4 Maintain airway patency
Nebulizer inhalation therapy and bronchial decoction agents can be given, and dimethyl silicone oil (antifoaming agent) can be used for defoaming agents: tracheotomy should be performed promptly if indicated.
6.1.5 Prevent secondary infection
6.1.6 Maintain blood pressure stability, reasonably control infusion and use of diuretics, correct acid-base and electrolyte disorders, provide good nursing and nutritional support, etc.
6.2 Other treatments
6.2.1 Cure criteria
Symptoms, signs, chest X-ray abnormalities caused by acute poisoning are basically restored, and the patient's health status reaches the level before poisoning.
6.2.2 After the poisoning patient is cured, he can resume his original work. 6.2.3 If asthma-like attacks often occur after poisoning, he should be transferred away from irritating gas operations. 7 Instructions for the correct use of this standard
See Appendix A (Informative Appendix), see Appendix B, C (Normative Appendix)..com Appendix A
(Informative Appendix)
Instructions for the correct use of this standard
A.1 The hierarchical diagnosis in this standard is to make a comprehensive analysis of various clinical signs, in accordance with the corresponding disease diagnosis standards, so as to achieve a more comprehensive understanding of the condition, facilitate mastery and application. A.2 The irritation reaction is a transient reaction after contact with chlorine gas, which has not yet reached the level of poisoning, so it is not treated as poisoning. A.3 The classification of diffuse alveolar pulmonary edema and acute respiratory distress syndrome is helpful for estimating recovery and guiding treatment, and provides objective indicators for clinical case analysis, statistical data, and related scientific research work, so it has practical significance. If the clinical examination data is complete and the observation and follow-up are strict, it will help to make a correct clinical diagnosis. A.4 The diagnosis classification should be concluded after the treatment of acute poisoning is basically completed, and a comprehensive analysis should be made. A.5 If the patient has a chronic respiratory disease, inhaling chlorine can make the poisoning condition more serious or induce the original disease, so the situation is more complicated and difficult to treat. When judging the classification or treatment effect, a comprehensive analysis can be made based on the patient's past medical history combined with the clinical manifestations after poisoning, and a conclusion that conforms to the situation can be obtained as much as possible. A.6 Patients with no history of bronchial asthma may have asthma-like attacks during acute poisoning. After the acute phase, bronchial asthma may occur after exposure to chlorine or other substances again or in the absence of clear inducements. The pathogenesis of the above situation needs to be further studied, so there is currently no sufficient basis to define it as a sequela of acute chlorine poisoning, and it is necessary to transfer from irritating gas operations.
A.7 There are many ways to give oxygen, which can be selected according to the patient's condition and objective conditions. In order to prevent oxygen poisoning under high oxygen conditions, reasonable oxygen therapy is proposed, and blood gas analysis can be used as a monitoring indicator. High-frequency ventilation oxygen supply has a certain effect in the early stage, but when there is obvious carbon dioxide retention, it may do more harm than good. The use of artificial assisted respirators must be carried out under the guidance of experienced people in order to master and use them correctly.
A.8 The nebulizer inhalation therapy adopts the early administration of 5% sodium bicarbonate solution, which can be added with dexamethasone, Ventolin, etc.; or the bronchodilator albuterol or broliconide spray inhalation can be used. A.9 Since bedside chest X-rays are used for critically ill patients, the requirements and precautions for the radiographs are listed to meet the actual needs (see Appendix B (Normative Appendix).
A.10 After acute chlorine poisoning, due to hypoxia, pulmonary hypertension and neurological dysfunction, heart damage may occur, and electrocardiogram examination may have corresponding changes. Therefore, this examination should be taken seriously during rescue, which is helpful to grasp the overall condition and accumulate data. B.1 Technical requirements
Appendix B
(Normative Appendix)
Technical requirements for bedside chest X-ray film and notes on reading filmsB.1.1 Position: Take an anteroposterior chest film in a sitting or semi-recumbent position as much as possible. The chest film includes the entire thorax (the costophrenic angle must be included if there is difficulty); the sternoclavicular joints on both sides are symmetrical, the center line is aligned with the fifth thoracic vertebra and is perpendicular to the dark box; the target-film distance is more than 90cm. B.1.2 Exposure: There is no breathing movement during exposure (preferably using a fluorinated chlorinated lock high-speed intensifying screen), the lungs, bones and soft tissues have good contrast and layers, and the 1st to 4th thoracic vertebrae are visible. B.1.3 Darkroom: The tissue-free area above the shoulders should be dark black, and the area below the diaphragm should be transparent. B.2 Notes on reading the film
B.2.1 The blood distribution in the lungs is affected by gravity, which makes the lung texture of the upper lung field thin in the standing posterior-anterior position, and the lung texture of the upper and lower lung fields similar in thickness in the supine position.
B.2.2 The heart shadow enlarges and tends to be transverse
a. The diaphragm is elevated, causing the heart to move upward and rotate; b. In the standing posterior anterior position, the heart is supported by the diaphragm, while in the supine position, it is supported by the spine, posterior mediastinum and lungs on both sides. The heart wall is more likely to change its shape if it is relatively weak;
c. When standing, a large amount of blood is retained in the vascular bed of the abdominal organs and the sagging parts of the body. When lying, the amount of blood returning to the heart increases, and the heart shadow increases. The maximum difference between the positive area of the heart in the standing and supine positions can be about 25%. d. The target-film distance of the lying position changes from 180cm to 90-120cm, the cardiothoracic ratio increases significantly, the apex of the heart shifts to the upper left, the waist of the heart becomes shallower or disappears, and even bulges; e. The heart is located in front of the chest cavity. In the standing posterior anterior position, the heart is close to the film, and the magnification is small, while in the supine anteroposterior position, the heart is farther away from the film, the magnification is larger, and the heart shadow is also larger. B.2.3 The large blood vessels in the mediastinum are widened, and the shadow of the superior vena cava is more obvious. B.2.4 The position of the aortic bulb moves up, close to the level of the clavicle. B.2.5 A small amount of pleural effusion cannot be displayed in the supine position. The shoulder blades overlap with the lung field, which affects the observation of lesions. Therefore, the film should be read carefully to avoid making wrong conclusions.
..comAppendix C
(Normative Appendix)
Blood gas analysis and respiratory function of the lungs
C.1 The lungs are organs with respiratory function as the main function, including pulmonary ventilation and gas exchange function. The former can cause alveolar hypoventilation, hypoxia and carbon dioxide retention due to chest or neuromuscular lesions, respiratory muscle fatigue, and increased respiratory resistance; the latter can cause hypoxia due to pulmonary ventilation/blood flow imbalance, increased venous arterial shunt, and damage to diffusion function. C.2 Arterial blood gas analysis Paco2 and Pao2 can reflect the status of alveolar ventilation and gas exchange function, but due to the strong respiratory function reserve and compensatory ability of the lungs, although Paco2 is within the normal range, it does not mean that the patient's ventilation function is normal. When Paco2 is greater than 6kPa (45mmHg), it means that the ventilation is in a state of decompensation, and Pao2 has the same meaning. C.3 Purpose of blood gas analysis
a. To determine the nature of respiratory insufficiency, such as simple hypoxia or with carbon dioxide retention; b. To determine the severity of respiratory insufficiency, which can be used as one of the diagnostic bases for severe poisoning; c. To guide treatment and treatment evaluation.
C.4 Arterial blood gas analysis includes Pao2, SaO2, Paco2, pH, SB (standard bicarbonate), AB (actual bicarbonate), BB (buffered base), BE (base excess), SBE (extracellular base excess). Among them, SB, AB, BB, BE, and SBE all represent metabolic acid-base indicators, so the pH combined with Paco2, AB and K, Na, and CI can better evaluate the state of the patient's acid-base balance.
C.5 Venous-arterial shunt flow measurement allows patients to inhale pure oxygen through a one-way valve for 20 minutes, and then perform arterial blood gas analysis. Substituting the results into Fick's formula can be indirectly converted and calculated. Qs/Qr=[0.0031×(PA02-Pao2)]/[0.0031X(PA02-Pao2)-(Ca02-CV02)] Where:
Qs/Qr——the sum of anatomical and intrapulmonary venous arterial shunt: PAO2=atmospheric pressure-47 (water vapor partial pressure at 37℃) Pac02:(c1)
CaO2-CVO2——the difference in oxygen content between arterial blood and mixed venous blood, 5 is substituted for healthy people, and 3.5 is substituted for patients with cardiopulmonary diseases.
Alveolar collapse, atelectasis, pneumonia and pulmonary edema can all cause increased intrapulmonary shunt. Dynamic follow-up of patients' venous arterial shunt can reflect changes in the condition and assessment of efficacy. C.6 Evaluation of blood gas analysis should be closely combined with clinical practice. If it does not meet the requirements, the reliability of laboratory measurements must be understood. For quality control of pH, O2 and CO2 electrodes, calibration can be performed using standard pH solutions, standard O2 and CO2 concentrations and blood balance solutions or artificial blood.0031X(PA02-Pao2)-(Ca02-CV02)] Where: www.bzxz.net
Qs/Qr——The sum of anatomical and intrapulmonary venous arterial shunt: PAO2=atmospheric pressure-47 (water vapor partial pressure at 37℃) Pac02:(c1)
CaO2-CVO2——The difference in oxygen content between arterial blood and mixed venous blood. For healthy people, 5 is substituted, and for patients with cardiopulmonary diseases, 3.5 is substituted.
Alveolar collapse, atelectasis, pneumonia and pulmonary edema can all cause increased intrapulmonary shunt. Dynamic follow-up of the patient's venous arterial shunt can reflect the changes in the condition and the assessment of the efficacy. C.6 Evaluation of blood gas analysis should be closely combined with clinical practice. If it does not meet the requirements, the reliability of laboratory measurement must be understood. For quality control of pH, O2 and CO2 electrodes, standard pH solution, standard O2 and CO2 concentrations and blood balance solution or artificial blood can be used for calibration.0031X(PA02-Pao2)-(Ca02-CV02)] Where:
Qs/Qr——The sum of anatomical and intrapulmonary venous arterial shunt: PAO2=atmospheric pressure-47 (water vapor partial pressure at 37℃) Pac02:(c1)
CaO2-CVO2——The difference in oxygen content between arterial blood and mixed venous blood. For healthy people, 5 is substituted, and for patients with cardiopulmonary diseases, 3.5 is substituted.
Alveolar collapse, atelectasis, pneumonia and pulmonary edema can all cause increased intrapulmonary shunt. Dynamic follow-up of the patient's venous arterial shunt can reflect the changes in the condition and the assessment of the efficacy. C.6 Evaluation of blood gas analysis should be closely combined with clinical practice. If it does not meet the requirements, the reliability of laboratory measurement must be understood. For quality control of pH, O2 and CO2 electrodes, standard pH solution, standard O2 and CO2 concentrations and blood balance solution or artificial blood can be used for calibration.
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