1例早期严重脑水肿热射病病例报道

A case report of heat stroke with early severe brain edema

热射病分为劳力型和经典型,主要表现为有明确的高温高热环境暴露史或高温环境中的活动史,核心温度超过40℃,伴有中枢神经系统改变(包括意识改变、癫痫、精神症状等)和多器官损伤,包括呼吸衰竭、肝肾功能受损、横纹肌溶解、凝血障碍、腹胀腹泻等。其病理学可表现为器官内皮细胞损伤、炎症反应、广泛的血栓形成和出血倾向等。主要治疗措施为降温治疗,合并其他器官损伤时应及时早期行器官支持或替代治疗,包括输血改善凝血功能,血液净化治疗等,缺血缺氧性脑病可联合高压氧治疗,改善患者预后。本文报道一例消防员在森林救火过程中突发意识障碍、高热,至当地医院行头颅计算机断层扫描(CT)检查可见脑沟脑回显示不清,提示严重的脑水肿,最后诊断为热射病的病例。转入柳州市工人医院后,病情继续恶化,出现多器官功能衰竭表现。通过早期降温、镇静抗癫痫、气管插管呼吸机辅助呼吸、抗感染、液体复苏、输注新鲜冰冻血浆及血小板改善凝血功能、免疫调节治疗、肾脏替代治疗、及时人工肝治疗等一系列措施后,成功阻止了病情的进一步发展,逆转了脑水肿。康复阶段辅助以高压氧治疗,患者出院时恢复良好,未遗留明显神经系统后遗症。其预后情况明显优于入院时的预估。

Heat stroke can be divided into two types:exertional and classic,mainly manifested as a clear history of exposure to hot temperature/high heat environment or intense physical activity in hot environment,core temperature exceeding 40℃,accompanied by central nervous system changes(altered consciousness,epilepsy,psychiatric symptoms,etc.)and multiple organ damage,including respiratory failure,impaired liver and kidney function,rhabdomyolysis,coagulation disorders,abdominal distension,and diarrhea.Its pathology may be manifested as organ endothelial cell damage,inflammatory response,extensive thrombosis,and bleeding tendency.The main treatment measures are cooling therapy,and when combined with other organ damage,organ support or replacement therapy should be carried out in time,including blood transfusion to improve coagulation function and blood purification therapy.Hyperbaric oxygen therapy may improve the prognosis of patients with ischemic hypoxic encephalopathy.We reported a case of a firefighter with sudden impaired consciousness and high fever during forest fire fighting.The patient was sent to a local hospital and his head computed tomography(CT)results showed unclear cerebral gyrus,suggesting severe cerebral edema,and finally diagnosed as heat stroke.After being transferred to Liuzhou Workers'Hospital,his condition continued to deteriorate and signs of multiple organ failure appeared.The patient's cerebral edema was reversed and further development of heat stroke was prevented through early cooling,sedation and anti-epilepsy,endotracheal intubation ventilator-assisted breathing,anti-infection,fluid resuscitation,infusion of fresh frozen plasma and platelets to improve coagulation function,immunomodulatory therapy,renal replacement therapy,and timely artificial liver therapy.Hyperbaric oxygen therapy was ordered during the rehabilitation phase,and the patient recovered well at discharge,leaving no obvious neurological sequelae.Its prognosis is much better than that predicted at admission.