烧伤并发严重阵发性交感神经过度兴奋综合征的早期诊断与处理

Early diagnosis and treatment for burn complicated with severe paroxysmal sympathetic hyperactivity

目的探讨烧伤并发严重阵发性交感神经过度兴奋综合征(PSH)的早期诊断与处理措施。方法回顾性分析笔者科室2016年4月—2019年3月收治的符合入选标准的5例烧伤并发严重PSH患者的病历资料。患者中男4例、女1例;年龄17个月~39岁,平均(21±16)岁。PSH发生时,常规监护患者生命体征并吸氧,中心静脉置管输注电解质溶液,视情况输注血浆,应用阿片类镇痛药和苯二氮卓类镇静药,行物理降温和药物降温,并针对性建立或维持人工气道及使用呼吸机。采用镇痛镇静为主的综合治疗将成人心率控制在120次/min以下,儿童心率控制在140次/min以下。应用单一或多种血管活性药物,甚至较大剂量药物维持患者正常血压。统计PSH发生特点、发生时期及治疗结局。结果PSH发生迅速,数分钟至数十分钟内急剧加重。5例患者均存在高体温、呼吸急促、心率超快、发作初期收缩压正常或升高、大汗、肌张力障碍等症候群,这些症候群同时或相继出现。以上6项指标中按临床特征量表评分,除收缩压外均获得最高分值3分。4例患者出现瞳孔散大和意识障碍。患者中PSH发生于急性渗出期3例、液体回吸收期1例、修复后期1例,发作持续3h^12d。4例患者病情得到有效控制,1例患者病情恶化死亡。随访3~14个月治愈患者未再发生PSH。结论烧伤并发严重PSH可发生于烧伤不同伤情和创面愈合前的任一时期。诱发原因包括突发烧伤、持续疼痛、惊吓恐惧、陌生环境、低血容量等不良刺激,脑功能发育不完善的儿童可能更易发生PSH。静脉镇痛镇静,物理和药物降低体温,稳定血压和呼吸频率是治疗PSH的有效措施。PSH需与烧伤常见并发症如脓毒症、脑水肿、高热惊厥、输液输血反应、应激障碍等相鉴别。

Objective To investigate the early diagnosis and treatment for burn complicated with severe paroxysmal sympathetic hyperactivity (PSH). Methods Medical records of patients with burn complicated with severe PSH, admitted to our department from April 2016 to March 2019 and meeting the inclusion criteria were analyzed retrospectively. There were 4 males and 1 female, aged 17 months to 39 years, with an average of (21±16) years. During occurrence of PSH, the vital signs of patients were routinely monitored and oxygen were given. Other treatment included central venous catheterization and infusion of electrolyte solution, infusion of plasma according to patients′ condition, use of opioid analgesics and benzodiazepine sedatives, physical cooling and drug cooling, and establishment or maintenance of artificial airway and use of ventilator. Heart rate was controlled below 120 beats per minute in adults and 140 beats per minute in children with comprehensive treatment dominated by analgesia and sedation. Besides, single or multiple vasoactive agents, even in large doses were used to maintain normal blood pressure of patients. The occurrence characteristics, time, and treatment outcome of PSH were analyzed. Results PSH happened rapidly, with a sharp increase in several minutes to dozens of minutes. Five patients were with symptoms such as high body temperature, shortness of breath, very fast heart rate, normal or elevated systolic blood pressure, hyperhidrosis, and dystonia at the onset. The symptoms occurred simultaneously or successively. According to the Clinical Feature Scale, the above-mentioned 6 indexes achieved the highest score of 3 points except of systolic blood pressure. Four patients showed dilated pupils and impaired consciousness. Among the patients, PSH occurred in the acute exudation stage in 3 patients, in the fluid reabsorption stage in 1 patient, and in the late repair stage in 1 patient. PSH of patients lasted for 3 hours to 12 days. The symptoms of 4 patients were effectively controlled, and 1 patient died of deterioration. No PSH occurred in the cured patients during follow-up of 3 to 14 months. Conclusions Burn complicated with PSH can occur at any time before wound repair and in patients with different injury conditions. The causes of PSH include sudden burn, persistent pain, fright and fear, strange environment, low blood volume, and other adverse stimuli, and PSH is more likely to occur in children with underdeveloped brain function. Intravenous infusion of analgesics sedatives, physical therapy and medication to lower body temperature, stabilizing blood pressure and respiration are effective measures to treat PSH. PSH should be distinguished from the common complications of burns, such as sepsis, cerebral edema, hyperpyretic convulsion, transfusion response, stress disorder, etc.