急救网络建设在危重氢氟酸烧伤患者早期救治中的作用

张元海; 田鹏飞; 张惟; 叶春江; 毛书雷; 韩春茂; 张建芬; 王新刚

doi:10.3760/cma.j.cn501120-20210707-00237

急救网络建设在危重氢氟酸烧伤患者早期救治中的作用

doi: 10.3760/cma.j.cn501120-20210707-00237

1.
浙江衢化医院烧伤整形科，衢州　　324004
2.
浙江大学医学院附属第二医院烧伤与创面修复科，杭州　　310009

基金项目:

国家重点研发计划 2018YFC0808600

浙江省基础公益研究计划 LGF18H150001

详细信息

通讯作者:
王新刚，Email：wangxingang8157@zju.edu.cn

计量
- 文章访问数: 74
- HTML全文浏览量: 87
- PDF下载量: 19
- 被引次数: 0
出版历程
- 收稿日期: 2021-07-07

The role of first-aid network construction in the early treatment of patients with critically severe hydrofluoric acid burns

1.
Department of Burns and Plastic Surgery, Zhejiang Quhua Hospital, Quzhou 324004, China
2.
Department of Burn and Wound Repair, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China

Funds:

National Key Research and Development Program of China 2018YFC0808600

Zhejiang Research Project of Commonweal Technology of China LGF18H150001

More Information

Corresponding author: Wang Xingang, Email: wangxingang8157@zju.edu.cn

摘要

摘要: 目的探讨急救网络建设在危重氢氟酸烧伤患者早期救治中的作用。方法以浙江省、江西省、福建省、内蒙古自治区的27家氟化工企业，浙江省内有烧伤/整形科或烧伤专业组的包括浙江衢化医院在内的22家医院及省外5家医院为成员单位，进行氢氟酸烧伤急救网络建设，其中浙江衢化医院是急救网络的主体单位，负责急救网络的日常维护和技术指导。20家氟化工企业的定点急救医院是浙江衢化医院，7家氟化工企业就近指定1家定点急救医院。收集2006年1月—2021年6月5家急救网络医院收治的符合入选标准的56例（均为男性）危重氢氟酸烧伤患者的病历资料，进行回顾性队列研究。按照患者所在企业是否纳入急救网络建设，将患者分为急救网络组［27例，年龄（41±9）岁］和非急救网络组［29例，年龄（42±10）岁］。急救网络组的患者伤后所在企业立即与医院联动，接诊医院利用急救网络，提前调集救治力量、设备和物资药品，做到院前急救与院内治疗无缝对接。非急救网络组患者到达医院急诊科后启动急救流程，临时调集救治力量、设备和物资药品。统计2组患者的院前时间、血钙首次检出时间、急诊科停留时间、低钙血症与低镁血症持续时间，以及治疗转归情况。对数据行χ²检验、Fisher确切概率法检验、独立样本t检验、Wilcoxon秩和检验。结果急救网络组患者的院前时间、血钙首次检出时间、急诊科停留时间分别为40.0（30.0，55.0）、23.0（17.5，37.5）、42.0（37.0，53.0）min，明显短于非急救网络组的180.0（120.0，240.0）、31.0（22.5，47.5）、61.0（52.0，65.5）min（Z=-6.17、-1.98、-4.15，P<0.05或P<0.01）。急救网络组患者伤后低钙血症、低镁血症持续时间为1.2（1.1，1.6）、1.9（1.7，2.1）h，明显短于非急救网络组的4.6（3.1，6.2）、3.2（2.5，4.6）h（Z=-5.80、-4.81，P<0.01）。急救网络组患者死亡3例（11.1%），其中2例患者于伤后40 min死亡，另1例患者于伤后9.0 h死亡；非急救网络组患者死亡4例（13.8%），分别于伤后3.0、3.0、4.5、7.0 h死亡。2组患者病死率相近（P>0.05）。结论危重氢氟酸烧伤是临床上遇到的非常紧急的状况，急救网络建设为患者就地救治创造了条件，提高了急救效率，从而为挽救生命赢得时间。
- 烧伤，化学 /
- 氢氟酸 /
- 氟中毒 /
- 急救网络
Abstract: Objective To explore the role of first-aid network construction in the early treatment of patients with critically severe hydrofluoric acid burns. Methods Twenty-seven fluorine chemical enterprises distributed in Zhejiang province, Jiangxi Province, Fujian Province, and Inner Mongolia Autonomous Region and 22 hospitals with burn/plastic department or professional burn treatment group in Zhejiang province, including Zhejiang Quhua Hospital, and 5 hospitals outside Zhejiang province were involved in the first-aid network construction as member units. As the main unit, Zhejiang Quhua Hospital was responsible for the daily maintenance and technical guidance of the first-aid network. Zhejiang Quhua Hospital was assigned as the designated emergency hospital for 20 fluorine chemical enterprises, a near emergency hospital to the other 7 fluorine chemical enterprises was assigned as the designated hospital for them. Medical records of 56 patients (all males) with critically severe hydrofluoric acid burns who admitted to 5 first-aid network hospitals from January 2006 to June 2021, meeting the inclusion criteria, were involved in the retrospective cohort study. Based on whether the enterprise belonging to the first-aid network construction or not, the patients were divided into first-aid network group (27 cases, aged (41±9) years) and non first-aid network group (29 cases, aged (42±10) years). After the patients in the first-aid network group were injured, the enterprises and hospitals linked up immediately. The hospital where the patient was treated mobilize the treatment force, equipment, materials, and drugs in advance by the first-aid network, thereby realizing seamless joint between pre-hospital first-aid and in-hospital treatment. The hospital started the first-aid process and temporarily mobilized the rescue forces, equipment, materials, and drug after patients in non first-aid network group arrived at the department of emergency of the hospital. The time from injury to medical service, the first detection time of serum calcium, the time staying in department of emergency, the duration of hypocalcemia and hypomagnesemia, and the treatment outcome of patients in the two groups were recorded. Data were statistically analyzed with chi-square test, Fisher's exact probability test, independent-sample t test, and Wilcoxon rank-sum test. Results The time from injury to medical service, the first detection time of serum calcium, and the time staying in department of emergency of patients in first-aid network group were 40.0 (30.0, 55.0), 23.0 (17.5, 37.5), and 42.0 (37.0, 53.0) min, which were significantly shorter than 180.0 (120.0, 240.0), 31.0 (22.5, 47.5), 61.0 (52.0, 65.5) min in non first-aid network group (Z=-6.17, -1.98, -4.15, P<0.05 or P<0.01). The duration of hypocalcemia and hypo- magnesemia of patients in first-aid network group were 1.2 (1.1, 1.6) and 1.9 (1.7, 2.1) h, which were significantly shorter than 4.6 (3.1, 6.2) and 3.2 (2.5, 4.6) h in non first-aid network group (Z=-5.80, -4.81, P<0.01). Three patients (11.1%) in first-aid network group died, among whom 2 patients died at 40 min after injury and 1 patient died 9.0 h after injury. Four patients (13.8%) died in non first-aid network group at 3.0, 3.0, 4.5, and 7.0 h after injury, respectively. The mortality rates of patients in the two groups were similar (P>0.05). Conclusions Critically severe hydrofluoric acid burn is an extremely urgent situation encountered in clinical practice. The construction of a first-aid network creates condition for on-site treatment of patients and improves the first-aid efficiency, thereby gaining time to save lives.
- Burns, chemical /
- Hydrofluoric acid /
- Fluorosis /
- First-aid network
所有作者均声明不存在利益冲突

烧伤并发症的发生率和病死率均较高，长期被低估。近几十年，随着烧伤创面治疗、营养支持、液体复苏及抗感染等手段不断提高，毁损性烧伤患者的存活率也在不断升高，但死亡的风险仍旧较高。目前,脓毒症已成为严重烧伤患者死亡的首要原因，也是烧伤最常见的并发症。四川大学华西医院华西基础医学与法医学学院Canhua Huang教授团队近期在《Burns & Trauma》发文《The pathogenesis and diagnosis of sepsis post burn injury》，该文指出烧伤患者可因大面积皮肤缺损引起的创面感染、大量体液流失、高代谢状态等导致序贯性多系统功能紊乱,极易诱发全身性感染甚至脓毒症。因此，明确其诊断标准和辅助诊断的生物标志物对防治脓毒症和感染性休克至关重要。目前通过C反应蛋白、降钙素原及细胞因子等生物标志物来预测烧伤脓毒症仍有局限性，因此寻找更多新型诊断标准十分有必要，如可溶性白细胞分化抗原14-亚型、中性粒细胞功能、未成熟粒细胞计数等也可能与烧伤脓毒症的诊断相关。该文着重讨论了烧伤创面感染及烧伤后导致的脓毒症的发病机制，归纳了更多可指导临床治疗和辅助诊断脓毒症的生物标志物。

刘洋，编译自《Burns Trauma》，2021, 9:tkaa047；郇京宁，审校

HTML全文

1 危重氢氟酸烧伤急救网络示意图

下载: 全尺寸图片幻灯片

2 急救网络组危重氢氟酸烧伤患者的急救流程图

下载: 全尺寸图片幻灯片

3 非急救网络组例1患者面颈部、躯干、上肢被质量分数80%的氢氟酸烧伤，到达急诊科时，患者已死亡。3A.伤后3.0 h，面颈部、胸部创面表皮撕脱、基底红，右上臂约1%体表总面积（TBSA）创面基底呈灰白色，周边皮肤呈褐色；3B.伤后3.0 h，背部2%TBSA创面基底呈灰白色，周边皮肤呈褐色；3C.伤后3.0 h，左前臂1%TBSA创面基底呈灰白色

下载: 全尺寸图片幻灯片

4 急救网络组例2患者面颈部、胸腹部、双下肢被无水氢氟酸烧伤的治疗。4A.伤后6.0 h，胸腹部皮肤潮红；4B.伤后6.0 h，双小腿部分表皮撕脱，基底呈褐色，双踝创面呈灰白色；4C.伤后10.0 h，双小腿上段绑扎弹力绷带止血带，小腿表皮浮脱；4D.伤后29 d，创面大部分愈合，双踝部创面行中厚自体皮移植

下载: 全尺寸图片幻灯片

表1 2组危重氢氟酸烧伤患者一般资料比较

组别	例数	年龄（岁，x¯±s）	氢氟酸质量分数［%，M（P₂₅，P₇₅）］	烧伤面积［%TBSA，M（P₂₅，P₇₅）］		吸入性损伤（例）		眼烧伤（例）
组别	例数	年龄（岁，x¯±s）	氢氟酸质量分数［%，M（P₂₅，P₇₅）］	总面积（包括Ⅰ度）	浅Ⅱ度及以上烧伤面积	有	无	有	无
急救网络组	27	41±9	40.0（18.0，99.0）	10.0（6.0，22.0）	4.0（2.0，8.0）	16	11	13	14
非急救网络组	29	42±10	40.0（25.0，80.0）	12.0（8.5，19.5）	5.0（2.5，7.0）	9	20	10	19
统计量值		t=-0.33	Z=-0.11	Z=-0.60	Z=-0.17	χ²=4.51		χ²=1.08
P值		0.74	0.91	0.55	0.87	0.03		0.30
注：TBSA为体表总面积

下载: 导出CSV

表2 2组危重氢氟酸烧伤患者的急救效率比较[min，M（P₂₅，P₇₅）]

组别	院前时间	血钙首次检出时间	急诊科停留时间
急救网络组	40.0（30.0，55.0）	23.0（17.5，37.5）	42.0（37.0，53.0）
非急救网络组	180.0（120.0，240.0）	31.0（22.5，47.5）	61.0（52.0，65.5）
Z值	-6.17	-1.98	-4.15
P值	<0.01	<0.05	<0.01
注：急救网络组患者数为27例，非急救网络组29例中的1例院前死亡，未统计急诊科停留时间

下载: 导出CSV

参考文献(28)

[1]	LippertJ,DesaiB,FalgianiM,et al. Management of hydrofluoric acid burns in the emergency department[J]. Cureus,2020,12(3):7152.DOI: 10.7759/cureus.7152.
[2]	ZhangY, ZhangJ, JiangX, et al. Hydrofluoric acid burns in the western Zhejiang Province of China: a 10-year epidemiological study[J]. J Occup Med Toxicol, 2016,11:55. DOI: 10.1186/s12995-016-0144-3.
[3]	毛新兴, 王新刚, 张元海, 等. 重大氢氟酸泄漏事故中成批患者的救治[J]. 中华烧伤杂志, 2015, 31(5): 381-383.DOI: 10.3760/cma.j.issn.1009-2587.2015.05.015.
[4]	ZhangY,WangX,SharmaK,et al.Injuries following a serious hydrofluoric acid leak: first aid and lessons[J].Burns,2015,41(7):1593-1598.DOI: 10.1016/j.burns.2015.04.002.
[5]	YeC,WangX,ZhangY,et al.Ten-year epidemiology of chemical burns in western Zhejiang Province, China[J].Burns,2016,42(3):668-674.DOI: 10.1016/j.burns.2015.12.004.
[6]	ZhangYH,HanCM,ChenGX,et al.Factors associated with chemical burns in Zhejiang province, China: an epidemiological study[J].BMC Public Health,2011,11:746.DOI: 10.1186/1471-2458-11-746.
[7]	ZhangY, WangX, LiuY, et al. Management of a rare case with severe hydrofluoric acid burns: the important roles of neutralizers and continuous renal replacement therapy[J]. Int J Low Extrem Wounds, 2017, 16(4): 289-295. DOI: 10.1177/1534734617736198.
[8]	田鹏飞,张建芬,胡祖良,等.浙西地区316例职业性氢氟酸灼伤病例流行病学分析[J].环境与职业医学,2018,35(6):578-581.DOI: 10.13213/j.cnki.jeom.2018.17631.
[9]	WangX,ZhangY,NiL,et al.A review of treatment strategies for hydrofluoric acid burns: current status and future prospects[J].Burns,2014,40(8):1447-1457.DOI: 10.1016/j.burns.2014.04.009.
[10]	BurdA.Hydrofluoric acid-revisited[J].Burns,2004,30(7):720-722.DOI: 10.1016/j.burns.2004.07.001.
[11]	ZhangY, HanC, QiuX, et al. Response to "Chemical injuries caused by the hydrofluoric acid leak"[J]. Burns, 2016, 42(3): 706-708. DOI: 10.1016/j.burns.2016.01.016.
[12]	田鹏飞,王新刚,张元海,等.316例氢氟酸烧伤患者临床特征分析[J].中华烧伤杂志,2018,34(5):271-276.DOI: 10.3760/cma.j.issn.1009-2587.2018.05.004.
[13]	ZhangJ, NiL, JiangX, et al. Clinical significance of urinary fluoride levels in patients with hydrofluoric acid burns [J]. Burns, 2018, 44(8): 2074-2079. DOI: 10.1016/j.burns.2018.07.013.
[14]	WuML, DengJF, FanJS. Survival after hypocalcemia, hypomagnesemia, hypokalemia and cardiac arrest following mild hydrofluoric acid burn[J].Clin Toxicol (Phila), 2010,48(9): 953-955.DOI: 10.3109/15563650.2010.533676.
[15]	张元海,王新刚,田鹏飞,等.改良葡萄糖酸钙给药剂量对非手足部的氢氟酸烧伤患者的治疗效果分析[J].中华烧伤杂志,2018,34(5):277-282. DOI: 10.3760/cma.j.issn.1009-2587.2018.05.005.
[16]	ChoeM,LeeMJ,SeoKS,et al.Application of calcium nebulization for mass exposure to an accidental hydrofluoric acid spill[J].Burns,2020,46(6):1337-1346.DOI: 10.1016/j.burns.2020.02.015.
[17]	胡祖良,张元海,王新刚,等.静脉结合皮下注射葡萄糖酸钙治疗氢氟酸烧伤[J].环境与职业医学,2016,33(1):77-80.DOI: 10.13213/j.cnki.jeom.2016.15224.
[18]	马捷,邓津菊,吴健,等.氢氟酸烧伤的临床表现及治疗进展[J/CD].中华损伤与修复杂志:电子版,2019,14(6):466-470.DOI: 10.3877/cma.j.issn.1673-9450.2019.06.015.
[19]	仇旭光,韩春茂,毛新兴. 氢氟酸烧伤死亡一例[J]. 中华急诊医学杂志,2016,25(7):950-952.DOI: 10.3760/cma.j.issn.1671-0282.2016.07.022.
[20]	CoffeyJA, BrewerKL, CarrollR,et al. Limited efficacy of calcium and magnesium in a porcine model of hydrofluoric acid ingestion[J].J Med Toxicol,2007,3(2):45-51.DOI: 10.1007/BF03160907.
[21]	A S, G M. Inhibitory effect of fluoride on Na+,K+ ATPase activity in human erythrocyte membrane[J]. Biol Trace Elem Res,2015,168(2):340-348. DOI: 10.1007/s12011-015-0349-9.
[22]	Bajraktarova-ValjakovaE, Korunoska-StevkovskaV, GeorgievaS, et al. Hydrofluoric acid: burns and systemic toxicity, protective measures, immediate and hospital medical treatment[J]. Open Access Maced J Med Sci, 2018,6(11):2257-2269. DOI: 10.3889/oamjms.2018.429.
[23]	WuML, YangCC, GerJ, et al. Acute hydrofluoric acid exposure reported to Taiwan Poison Control Center, 1991-2010[J]. Hum Exp Toxicol, 2014,33(5): 449-454. DOI: 10.1177/0960327113499165.
[24]	张茂,韩春茂.重视重大突发公共事件创烧伤的应急救治[J].中华急诊医学杂志,2020,29(8):1011-1013.DOI: 10.3760/cma.j.issn.1671-0282.2020.08.001.
[25]	张文武,徐军,梁锦峰,等.加快社会急救体系建设,打造“5 min社会救援圈”[J].中华急诊医学杂志,2020,29(2):156-158.DOI: 10.3760/cma.j.issn.1671-0282.2020.02.004.
[26]	葛芳民, 李强, 林高兴, 等. 基于5G 技术院前-院内急诊医疗服务平台建设的研究[J]. 中华急诊医学杂志, 2019,28(10):1223-1227.DOI: 10.3760/cma.j.issn.1671-0282.2019.10.008.
[27]	王宁,万烨东,杜国森,等.互联网+智慧急救在重型颅脑创伤患者开颅术前应用效果的研究[J].中华急诊医学杂志,2020,29(12):1554-1558.DOI: 10.3760/cma.j.issn.1671-0282.2020.12.008.
[28]	张旻海,王慧,庾航,等.无人机在县域医共体急救体系中应用的初步研究[J].中华急诊医学杂志,2019,28(10):1237-1241.DOI: 10.3760/cma.j.issn.1671-0282.2019.10.011.