儿童抗凝血灭鼠药中毒临床分析

Clinical analysis of children with anticoagulant rodenticide poisoning

目的探讨抗凝血灭鼠药中毒患儿的临床表现、诊断和治疗方法。方法采用回顾性分析方法,选择2013年1月至2015年12月,在贵州省人民医院儿科住院并确诊为抗凝血灭鼠药中毒的50例患儿为研究对象,其年龄为2个月至12岁。观察50例患儿的以下临床项目。(1)一般临床资料:患儿的发病时间、性别、年龄、来源地、发病季节、抗凝血灭鼠药接触史及其临床表现;(2)实验室检查项目:血常规、凝血功能、凝血因子全套、血清毒物检测、肝功能、肾功能、心肌酶谱等检查;(3)患儿诊治经过、病程及预后等相关资料。对患儿接受维生素K1治疗前、后凝血酶原时间(PT)和部分活化凝血酶原时间(APTT)进行统计学分析。本研究遵循的程序符合贵州省人民医院伦理审查委员会制定的伦理学标准,得到该委员会批准。结果 (1)本研究50例患儿中,6例(12.0%)来自城市,44例(88.0%)来自农村。44例农村患儿中,18例(40.9%,18/44)为留守儿童。(2)抗凝血灭鼠药中毒以春、秋季发病为主,分别占30.0%(15/50)和28.0%(14/50)。(3)本研究50例患儿中,有明确抗凝血灭鼠药接触史者为17例(34.0%,17/50),有可疑抗凝血灭鼠药接物触史者为6例(12.0%,6/50),否认诱因及抗凝血灭鼠药接触史者为27例(54.0%,27/50)。(4)本研究50例患儿的主要临床表现为皮肤黏膜出血(50.0%,25/50),其他临床表现包括关节、肌肉疼痛,皮下血肿,以及消化道出血等。(5)本研究50例患儿中,37例患儿进行血清毒物检测的结果显示,26例(70.3%,26/37)患儿检出溴鼠灵,5例(13.5%,5/37)检出溴敌隆,6例(16.2%,6/37)同时检出溴鼠灵与溴敌隆。32例检出溴鼠灵患儿的检查结果显示,溴鼠灵水平为42~3 096ng/mL;11例检出溴敌隆患儿的检查结果显示,溴敌隆水平为5~767ng/mL。(6)本研究中,50例患儿接受维生素K1治疗前及治疗后PT、APTT分别比较,差异有统计学意义(Z=-6.093、-6.093,P<0.001)。结论维生素K1治疗儿童抗凝血灭鼠药中毒有效。临床应根据抗凝血灭鼠药中毒患儿体内血清毒物检测及凝血功能检查结果,对患儿进行个体化治疗,并且维生素K1用药疗程应不短于2~3个月。

Objective To investigate clinical characteristics ,diagnosis and treatment of children with anticoagulant rodenticide poisoning .Methods From January 2013 to December 2015 ,a total of 50 children with anticoagulant rodenticide poisoning who were admitted to Guizhou Provincial People′s Hospital were enrolled into this study by retrospective method .Their ages ranged from 2-month-old to 12-year old . The following items were observed . ① Basic information , including the onset of anticoagulant rodenticide poisoning , gender , age , origin , occurrence season , toxic exposure of anticoagulant rodenticide poisoning and clinical manifestations were analyzed . ② Laboratory examinations ,including routine blood test , blood coagulation , coagulation factor activity , serum toxicology examination , liver and renal function , myocardial enzymes were detected . ③ The diagnosis ,course of disease and prognosis were analyzed .Furthermore ,the prothrombin time （PT ）and activated partial thromboplastin time （APTT ） before and after the vitamin K1 treatment were statistically analyzed .The procedures followed in this study were in line with the ethical standards set by Ethical Review Board of Investigation in Human Beings of Guizhou Provincial People′s Hospital and were approved by the committee .Results ① Among those 50 cases ,6 cases （12 .0% ,6/50） came from city and 44 cases （88 .0% , 44/50 ） came from countryside . Among the 44 cases from countryside ,18 cases （40.9% ,18/44） were left-behind children .② The high-occurrence seasons of anticoagulant rodenticide poisoning were spring and autumn , accounted for 30 .0% （15/50 ） and 28.0% （14/50） ,respectively . ③ Among those 50 cases ,17 cases （34 .0% ,17/50） had toxic exposure of anticoagulant rodenticide poisoning ,6 cases （12 .0% ,6/50） had suspicious toxic exposure of anticoagulant rodenticide poisoning , and 27 cases （54 .0% , 27/50 ） denied toxic exposure of anticoagulant rodenticide poisoning . ④ The main clinical manifestations were mucocutaneous hemorrhage （50 .0% , 25/50 ） , as well as arthrodynia , myalgia , ecchymosis , alimentary tract hemorrhage ,and so on .⑤ A total of 37 cases received serum toxicology examination .The results revealed that 26 cases （70 .3% , 26/37 ） were detected simple brodifacoum poisoning , 5 cases （13.5% ,5/37） were detected simple bromadiolone poisoning ,and 6 cases （16 .2% ,6/37 ） were detected both brodifacoum and bromadiolone poisoning .And brodifacoum concentration ranged from 42 ng/mL to 3096 ng/mL among 32 cases with brodifacoum poisoning ,bromadiolone concentration ranged from 5 ng/mL to 767 ng/mL among 11 cases with bromadiolone poisoning .⑥ There were statistically significant differences in the aspects of PT , APTT before and after the vitamin K1 treatment among those 50 cases （Z= -6 .093 ,-6 .093 ;P〈0 .001） .Conclusions The vitamin K1 is an effective treatment for anticoagulant rodenticide poisoning . Clinicians should make the individualized treatment of vitamin K 1 for the children with anticoagulant rodenticide poisoning based on the results of serum toxicology examination and blood coagulation detection ,and the period of vitamin K1 treatment should more than 2-3 months .