GBZ 77-2002 Diagnostic criteria for multiple organ dysfunction syndrome caused by occupational acute chemical poisoning
Some standard content:
ICS 13.100
National Occupational Health Standard of the People's Republic of China GBZ77—2002
Occupational Acute Chemical Toxic
Diagnostic Criteria of Occupational Acute Chemical ToxicMultipleOrgansDysfunctionSyndromePublished on April 8, 2002
Implemented on June 1, 2002
Published by the Ministry of Health of the People's Republic of China
Article 5.1 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". In various occupational activities, people may be exposed to some high-concentration and highly toxic chemicals in a short period of time, causing acute poisoning. Some of these chemical poisons are known species, while others are still unclear pathogenic species after poisoning has occurred: some species have been included in the list of occupational diseases, while others have not yet been included: some have independent diagnostic standards, while others have not yet developed independent diagnostic standards. However, all acute poisoning diseases have common patterns of onset. It is possible and necessary to formulate common rules to be followed when diagnosing acute poisoning. The various rules specified in this series of standards involve the diagnosis of occupational acute chemical poisoning. These rules are used to ensure the unification of the diagnostic system of occupational acute chemical poisoning. Regardless of whether the cause is known or hidden, and regardless of which target organ is damaged after poisoning, the diagnosis can be made according to the rules specified in this standard. The "Diagnostic Standards for Occupational Acute Chemical Poisoning" includes the following ten parts. The scope defined in each part will be explained in the preface and introduction of each part:
Part 1
Diagnostic Standards for Occupational Acute Chemical Poisoning (General Principles): Diagnostic Rules for Occupational Acute Hidden Chemical Poisoning: Part 2
Part 3
Part 4
Part 5
Part 6
Part 7
Part 8
Occupational Acute Diagnostic criteria for multiple organ dysfunction syndrome caused by chemical poisoning; Diagnostic criteria for occupational acute chemical sudden death: Diagnostic criteria for occupational acute chemical poisoning nervous system diseases: Diagnostic criteria for occupational acute chemical poisoning respiratory system diseases; Diagnostic criteria for occupational acute toxic liver diseases: Diagnostic criteria for occupational acute toxic kidney diseases: Part 9
Diagnostic criteria for occupational acute chemical poisoning heart diseases: Part 10 Diagnostic criteria for occupational acute chemical poisoning blood system diseases: Appendix A of this standard is an informative appendix.
This standard is proposed and managed by the Ministry of Health of the People's Republic of China. This standard was drafted by the Second Hospital of Shanxi Medical University and Shanghai Chemical Occupational Disease Prevention and Control Institute, and Shanghai Sixth People's Hospital and Shanghai Occupational Disease Hospital participated in the drafting. The Ministry of Health of the People's Republic of China is responsible for interpreting this standard. Occupational acute chemical poisoning
Diagnostic criteria for multiple organ dysfunction syndrome GBZ77-2002
Occupational acute chemical poisoning multiple organ dysfunction syndrome (MODS) refers to a clinical syndrome caused by acute chemical poisoning, which causes simultaneous or sequential damage to the function of two or more organs and even failure. 1 Scope
This standard specifies the diagnostic criteria and treatment principles for occupational acute chemical poisoning multiple organ dysfunction syndrome. This standard applies to multiple organ dysfunction syndrome caused by acute chemical poisoning in occupational activities. The diagnosis of multiple organ dysfunction syndrome caused by non-occupational acute chemical poisoning can also refer to this standard. 2 Normative references
The clauses in the following documents become the clauses of this standard through reference in this standard. For all dated referenced documents, all subsequent amendments (excluding errata) or revisions are not applicable to this standard. However, parties to 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, its latest version shall apply to this standard.
GB/T16180
3 Diagnostic principles
Diagnostic criteria for occupational toxic liver disease
Diagnostic criteria for occupational acute chemical poisoning (general principles)Diagnostic rules for occupational acute latent chemical poisoningDiagnostic criteria for respiratory diseases of occupational acute chemical poisoningDiagnostic criteria for cardiac diseases of occupational acute chemical poisoningDiagnostic criteria for blood system of occupational acute chemical poisoningDiagnostic criteria for nervous system diseases of occupational acute chemical poisoningDiagnostic criteria for occupational sudden death from chemical sources
Diagnostic criteria for occupational acute toxic nephropathyIdentification of the degree of disability caused by work-related injuries and occupational diseases of workersBased on the occupational history of short-term exposure to a large amount of chemicals, the corresponding clinical manifestations of poisoning, and the indicators of simultaneous or sequential occurrence of two or more organ dysfunctions during the course of the disease, combined with the hygiene survey of the work site, a comprehensive analysis and differential diagnosis can be made before the diagnosis can be confirmed.
Diagnosis and classification standards
4.1 Cardiovascular dysfunction
4.1.1 Dysfunction Patients with any of the following
Mean arterial pressure (MAP) ≤ 8 kPa (60 mmHg), ≥ 6.65 kPa (50 mmHg), lasting for 4 hours: b)
Various common arrhythmias, such as frequent premature ventricular beats, transient ventricular tachycardia, atrial flutter or fibrillation; I° atrioventricular block;||tt ||Significant elevation of myocardial enzyme spectrum:
Myocardial damage, ischemic changes or myocardial infarction-like changes appear in the electrocardiogram 4.1.2 Functional failure
One of the following appears
MAP≤6.65kPa(50mmHg):
Congestive heart failure;
Torsades de pointes, ventricular fibrillation or ventricular flutter, or IⅢI\atrioventricular block; Myocardial infarction:
Sudden cardiac death.
Pulmonary dysfunction
Insufficiency: Patients with two of the following conditions:
When inhaling air, PaO2<9.31kPa (70mmHg) or PaCOz<4.65kPa (35mmHg): PaO2/FiO2≤39.9kPa (300mmHg)
P(Aa)DO2(FiO21.0)>13.3kPa (100mmHg); d) Chest X-ray shows consolidation200ml/24h, <400ml/24h; urine sodium (UNa) continuously >50mmol/L or filtered sodium excretion rate continuously >2%; blood urea nitrogen (BUN) >7.0mmol/L (20mg/dl) or daily increase >3.5mmol/L (10mg/dl);
blood creatinine (PCr) >177μmol/L (2mg/dl) or daily increase >89μumol/L (lmg/dl). Functional failure is characterized by two of the following: urine volume continuously <200ml/24h or <50ml/6h; blood urea nitrogen >21mmol/L (60mg/dl) or daily increase >7.0mmol/L (20mg/dl); blood creatinine continuously >430μmol/L (5mg/dl) or daily increase >177umol/L (2mg/dl); blood potassium continuously 6mmol/L (6meq/L):
Uremia.
4.4 Liver dysfunction
4.4.1 Insufficiency: Patients with two of the following:
Moderate jaundice, serum total bilirubin (STB)>34.2μumol/L (2mg/dl):a)
Blood alanine aminotransferase (ALT) or bile acid (CG) exceeds the normal value by more than 2 times, or multiple liver function tests are abnormal;
Prothrombin time>20 seconds;
c) Ascites.
Failure: Patients with one of the following:
Coma;www.bzxz.net
Obvious jaundice, serum total bilirubin ≥85.5μumol/L (5mg/dl);b)
Prothrombin time is prolonged to more than one times the normal value, accompanied by bleeding tendency. c)
4.5 Brain dysfunction
4.5.1 Functional insufficiency Patients with any of the following
a) Moderate consciousness disorder:
b) Grand mal seizure-like convulsions;
c) Obvious mental symptoms, such as hallucinations, delusions, psychomotor excitement and disorientation, 4.5.2
Function failure Patients with any of the following
Severe consciousness disorder;
b) Status epilepticus;
Brain death.
Gastrointestinal dysfunction
4.6.1 Functional insufficiency Patients with any of the following
Abdominal distension, decreased or almost disappeared bowel sounds: a
Positive fecal occult blood test +~+++.
Function failure with one of the following
Stress ulcer bleeding (vomiting coffee-like substance or black stool); a)
Necrotic or corrosive enteritis;
c) Paralytic ileus.
Blood dysfunction
Function failure with one of the following
a) Platelet count <50×10°/L, with bleeding tendency. Or white blood cell (WBC) <4.0×10°/L; b) Serum prothrombin time (PT) or thrombin time (TT) is prolonged compared with the normal reference value, fibrinogen 2~4g/L;
Mild hemolytic anemia;
d) Methemoglobin>30%.
Function failure with one of the following
Disseminated intravascular coagulation (DIC);
Blood WBC <2.0×10°/L or >30×10°/L: severe hemolytic anemia:
Acute aplastic anemia.
Treatment principles
5.1 Treatment principles
5.1.1 Etiological treatment: Treat acute poisoning according to the treatment principles in GBZ71 and the diagnostic standards for chemical poisoning. 5.1.2 Respiratory and circulatory support, effectively control and treat ARDS, and improve microcirculation. 5.1.3 Nutritional and metabolic support, reverse the body's high catabolism, and provide sufficient nutrients to tissues. 5.1.4 Actively control infection, correctly and timely use antibiotics, and use antifungal drugs when necessary. 5.1.5 Timely monitor patients with high-risk factors and severe conditions, and use advanced means to monitor in multiple aspects as much as possible, and strive to identify and stop the occurrence and development of MODS at an early stage. 5.1.6 Good nursing and psychological treatment
5.1.7 For patients with multiple organ dysfunction or failure, treat them according to the general principles of their organs and the standards of the corresponding systems and the treatment principles of various disciplines.
5.1.8 Treatment with traditional Chinese medicine
5.2 Other treatments
If labor capacity assessment is required, treat them according to GB/T16180. Instructions for the correct use of this standard
See Appendix A (Informative Appendix).
Appendix A
(Informative Appendix)
Instructions for the correct use of this standard
A.1 Any serious poisoning caused by various chemicals that can cause target organ damage or cause a major blow to the body may lead to the occurrence of multiple organ dysfunction (MODS). A list of common chemicals that cause toxic MODS and examples of vulnerable organs is attached for reference.
A.2 Multiple organ dysfunction caused by occupational acute chemical poisoning can be divided into primary (single-phase rapid-onset) and secondary (two-phase delayed-onset). Primary MODS is the result of the direct action of chemicals, so it appears early and the systemic inflammatory response (SIRS) may not be very significant; secondary MODS is a typical MODS, in which chemicals first cause SIRS, and then cause remote organ dysfunction on the basis of SIRS. There is a period of stable remission after the occurrence of chemical poisoning. A.3 This standard divides the severity of each organ dysfunction into two levels: dysfunction and failure. The standard of dysfunction is similar to the relevant indicators of moderate poisoning in the "Diagnosis of Occupational Chemical Poisoning" of each system, and the indicators of failure are similar to those of severe poisoning.
A.4 Explanation of the use of various organ diagnostic indicators A.4.1 Cardiovascular dysfunction Cardiovascular damage is not uncommon in multiple organ dysfunction caused by occupational acute chemical poisoning, and common myocardial damage, arrhythmia, circulatory disorders, heart failure, etc. Electrocardiogram is the main means of examination for arrhythmia and conduction block: myocardial damage, ischemia, myocardial infarction, heart failure, etc. should be comprehensively evaluated in combination with symptoms, signs, electrocardiogram and enzyme examination; mean arterial pressure (MAP) can be measured by arterial catheter insertion, or calculated as diastolic pressure + (systolic pressure + diastolic pressure) x 1/3. Units with conditions can actively carry out the application of catheter technology in the diagnosis and treatment of chemical poisoning. A.4.2 Pulmonary dysfunction Pulmonary function needs to be evaluated from the aspects of ventilation, perfusion, diffusion, transport and tissue oxygenation, so respiratory rate, PaO2, PaO2/FiO2, PaCO2 and chest X-ray manifestations are selected as the main observation indicators. P (A-a) DO2 can determine ventilation dysfunction and is one of the important indicators for diagnosing ARDS. Its determination requires corresponding equipment and needs to be calculated. Considering the continuous improvement of the conditions of various medical units, it is included in order to improve the level of diagnosis and treatment. The diagnosis of ARDS should meet 3 of the following 6 items:
Respiratory rate>28 times/min, respiratory distress; when inhaling air, PaOz<6.6kPa (50mmH); PaCO2>5.98kPa (45mmHg); PaO2/FiO2<26.6kPa (200mmHg); P(Aa)DO2(FiO21.0)>26.6kPa (200mmHg); positive end-expiratory pressure ventilation (PEEP) is required, PEEP>0.784kPa80mmH20): X-ray chest film shows consolidation>l/2 lung field. A.4.3 Renal dysfunction The kidney regulates water and electrolytes, acid-base balance and excretion of metabolites, and is also one of the organs most vulnerable to damage after poisoning. Urine volume, routine urine examination, urine sodium, filtered sodium excretion rate, blood urea nitrogen, and blood creatinine are selected as judgment indicators. Their significance can be found in the diagnostic criteria for occupational acute toxic nephropathy. In non-oliguric renal failure, the urine volume is not small but the blood urea nitrogen and creatinine are elevated, which should be noted during diagnosis. A.4.4 Liver dysfunction The liver has a strong compensatory capacity, and its damage is sometimes not easy to be discovered in time. Laboratory tests mainly select blood alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin, prothrombin time, etc. as diagnostic indicators. For details, please refer to GB163796. A.4.5 Brain dysfunction Brain damage is mainly judged by the degree of consciousness disorder, the type of mental disorder, the manifestation of increased intracranial pressure, and the condition of convulsions. For the classification and grading criteria of consciousness disorders, please refer to the Diagnostic Criteria for Occupational Acute Chemical Toxic Neurological Diseases. For patients with transient coma, their clinical manifestations should be combined to determine whether they belong to brain failure during grading.
A.4.6 Gastrointestinal dysfunction The gastrointestinal tract has multiple functions such as digestion and absorption of nutrients, separation of internal and external environments, and self-regulation. It is also a vulnerable organ and the starting point of MODS. The judgment of gastrointestinal dysfunction is mainly based on clinical manifestations, vomitus, fecal occult blood test, fiber endoscopy, etc. to observe the ulcer and bleeding of the digestive tract mucosa; intestinal obstruction, etc. can be judged by physical examination, ultrasound, X-ray and laboratory test indicators. A.4.7 Blood dysfunction The blood dysfunction of occupational acute chemical poisoning MODS is mainly manifested as coagulation dysfunction, toxic hemolytic anemia, toxic methemoglobinemia and toxic aplastic anemia. The coagulation disorder and fibrinolysis indicators mainly include platelets, prothrombin time, thrombin time, bleeding time and fibrinogen. The judgment indicators for other damage to the blood system are white blood cells, methemoglobin and bone marrow, etc., to judge the different degrees of damage to the blood system.
In the treatment of acute chemical poisoning MODS, the primary disease should be actively treated according to the detoxification and treatment methods of different chemical poisoning, and comprehensive treatment methods such as symptomatic and organ support should be adopted, with emphasis on prevention. Common chemicals that cause toxic MODS and their vulnerable organs Appendix Products
Gastrointestinal
Cardiovascular
Chemicals
Trichloromonofluoromethane
Dibromochloropropane
Arsenic trioxide
Dichromate
Phosphorus oxychloride
Carbon monoxide
Carbon tetrachloride
Ethylene dichloride
Lead acetate
Mercury sulfate
Mercury chloride
Organomercury
Nickel carbonyl
Nickel carbonate
Copper sulfate
Arsine
Hydrogen sulfide
Hydrofluoric acid
Nitrogen Olefins
Methyl mercaptan
Organic fluorine
Phosgene
Aniline nitro compounds
Ethylene oxide
Glacial acetic acid
Hydroxymethyl acrylamide
Dimethyl formamide
2,4-butyl ester
Dimethyl sulfate
Organophosphorus pesticides
Fluoroacetylamide
Sodium fluosilicate
Paraquat
Nitrobenzene
Hedazhuang
Capronitrile
2. "" indicates secondary organ damage
Note: 1. The MODS chemicals causing toxicity in the table are all derived from the clinical analysis data of 173 cases
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