RU2766405C1 - Method for assessing severity of condition in acute poisoning with topical decongestants in children - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to toxicology, paediatrics and resuscitation. Objective examination of the doctor is carried out and patient's complaints are taken into account. Complaints and indicators of objective examination are evaluated in points, where P1 - patient’s and/or parent’s complaints: child excited - 1 point, prolonged daytime sleep, refuses to play - 2 points, child cannot be awakened, but reaction to external stimuli - 3 points, P2 - CNS depression: moderate sleepiness - 1 point, severe sleepiness - 2 points, coma - 3 points, P3 - systolic and diastolic blood pressure: not changed or increased by no more than 10 % of the age norm - 1 point, reduced to 30 % of the age norm - 2 points, decreased by more than 30 % of the age norm - 3 points; P4 - bradycardia: not more than 20 % of the age norm - 1 point, 20–50 % of the age norm - 2 points, more than 50 % of the age norm - 3 points, P5 - hyperhidrosis: moderate - palms, feet, axillary cavities - 1 point, pronounced - palms, feet, axillary cavities, groin, perineum - 2 points, generalized - 3 points, P6 - intensity of hypothermia: more than 36 °C - 1 point, 36–35 °C - 2 points, less than 35 °C - 3 points, P7 - skin colour: pale - 1 point, grayish - 2 points, acrocyanosis - 3 points, P8 - time of the beginning of the provision of qualified assistance from the moment of poisoning: less than 6 hours - 1 point, from 6 to 12 hours - 2 points, more than 12 - 3 points. Then individual coefficient (Cts) is calculated by formula. If the Cts is less than 9 points, the severity of the patient’s condition is considered to be mild. If the Cts value makes 9 to 16 points, the severity of the patient’s condition is considered to be moderate. If the Cts value is more than 16 points, the severity of the patient’s condition is assessed as a severe degree.

EFFECT: method enables reducing the length of the examination, justifying the selection of the scope of emergency diagnostic measures prescribed in accordance with the severity of the patient's condition to improve the quality of medical care and to reduce financial costs for diagnostic examinations of the patient.

1 cl, 1 tbl, 2 ex

Description

The invention relates to medicine, namely to methods for assessing the severity of the condition of patients with acute poisoning with topical decongestants in children, and can be used in toxicology, pediatrics and resuscitation.

EFFECT: method allows to assess the severity of the condition and the patient's need for therapeutic measures in the conditions of the intensive care unit or intensive care unit or dynamic observation in the pediatric department in case of acute poisoning with topical decongestants in children.

Currently, the problem of improving the treatment of acute poisoning with naphazoline in childhood and the search for ways to solve it is relevant.

The widespread use of topical decongestants in the treatment of acute respiratory viral infections in modern practical medicine creates conditions for the occurrence of acute poisoning as a result of their improper dosing and accidental use. The influence of alpha2-agonists was studied, taking into account the characteristics of childhood, the main clinical signs of acute poisoning and treatment regimens for patients were considered [Pshenichnaya E.V. Decongestants and their side effects in the treatment of acute rhinitis in children (clinical example) / E.V. Wheat, A.P. Dudchak, N.A. Usenko // Mother and child in Kuzbass. - 2018. - T. 74. - No. 3 - C. 50-53 .; Shilov V.V. Modern ideas about acute naphazoline poisoning in children / V.V. Shilov, E.S. Derevianko, A.I. Al-Madhun // Preventive Medicine - 2019. Sat. scientific tr. All-Russian scientific and practical conference with international participation. - 2019. - S. 208-215 .; Euwema M.S. Deadly Single Dose Agents. [Updated 2020 Apr 13] / M.S. Euwema, T.J. Swanson // In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441849/; Norman K. Alpha Receptor Agonist Toxicity / K. Norman, T.M. Nappe // In: 2019 Aug 15. StatPearls[Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan. Available from http://www.ncbi.nlm.nih.gov/books/NBK500023/PubMed PMID: 29763199]. But these studies did not distinguish between separate groups of patients for a differentiated choice of treatment tactics.

It is known that clinical manifestations depend on the severity of the condition in children [Zhamlikhanov N.Kh. Clinical features of acute toxicosis caused by nasal vasoconstrictor drugs in children and adolescents / N.Kh. Zhamlikhanov, A.G. Fedorov // Health care of Chuvashia. - 2019. - No. 1 - S. 16-21]. But the study of the characteristics of drug therapy, diagnostic examination of the patient, depending on the severity of the child's condition, was not carried out.

The quality of emergency medical care for children at the prehospital stage is crucial for the prognosis and outcome of the patient's condition. In case of acute poisoning with nafazalin, prehospital treatment includes infusion therapy with 0.9% sodium chloride solution at a dose of 10 ml / kg per hour and correction of existing violations of vital functions (if necessary, resuscitation measures) [Russian Society for Emergency Medicine, Union of Pediatricians of Russia Clinical recommendations for emergency medical care for acute poisoning in children / A.A. Baranov, S.F. Bagnenko, L.S. Namazova-Baranova [et al.] // Pediatric pharmacology. - 2015. - T.12. No. 6. - S. 657-667]. At the hospital stage, laboratory tests are added, such as clinical and biochemical blood tests, coagulogram, clinical urinalysis, toxicological examination of urine and blood. In this case, the treatment regimen is based on the same principles as at the prehospital stage.

Clinical recommendations do not contain criteria for assessing the severity of the patient. Unfortunately, in severe and extremely severe conditions, detoxification measures may be ineffective and insufficient. As a rule, the doctor in such cases does not have a clear algorithm for assessing the severity of the patient's condition, prescribing laboratory and instrumental examinations and individual choice of drugs [Karpushkina E.S. Computer modeling of drug interactions in acute poisoning in children / E.S. Karpushkin, O.A. Zhdanova, G.A. Batishcheva // Bulletin of VGTU Information technologies in building, social and economic systems. - 2020. - T. 20, No. 2 - C. 148-152].

Thus, given the high incidence of acute poisoning with topical decongestants and the low adaptability of traditional diagnostic examination schemes to specific clinical situations, the development of a method for assessing the severity of the condition of patients with poisoning by alpha-agonists is relevant.

The purpose of the invention is to reduce the time of the examination, reasonable appointment of the volume of emergency medical care and reduce financial costs during the period of the child's stay in the hospital.

The goal was achieved by conducting a retrospective analysis of 183 case histories of patients with acute poisoning treated at the clinical base of the V.I. N.N. Burdenko of the Ministry of Health of Russia in the Voronezh Regional Children's Clinical Hospital No. 1 (VODKB No. 1) in 2016-2019. Drug poisoning was diagnosed in 122 children (66.7%), including topical decongestants (naphazoline) in 24 people (19.7%), children aged 1 to 3 years predominated (91.7%) [ Karpushkina E.S. Features of exogenous poisoning in children of different ages / E.S. Karpushkin, O.A. Zhdanova, G.A. Batishcheva // Russian Bulletin of Perinatology and Pediatrics. - 2019. - T. 64, No. 4. - S. 315; Certificate of state registration of the Database "Etiology, course and outcomes of acute poisoning in children" No. 2020620717 / E.S. Karpushkina E.S., O.A. Zhdanova, G.A. Batishchev - 25.04.2020].

To develop a method for assessing the severity, patients were selected who were admitted with poisoning by topical decongestants and did not have concomitant pathology. The clinical and laboratory parameters and complaints of the patient were retrospectively evaluated in case of acute poisoning with alpha-agonists.

For each patient, an individual coefficient of severity of the condition (K _ts ) was determined according to the formula:

K _ts \u003d P ₁ + P ₂ + P ₃ + P ₄ + P ₅ + P ₆ + P ₇ + P ₈ ,

where P ₁ - complaints of the patient and / or his parents; P ₂ - depression of the nervous system; P ₃ - deviation of blood pressure from the age norm; P ₄ - the magnitude of bradycardia from the age norm of heart rate; P ₅ - severity of hyperhidrosis; P ₆ - severity of hyperthermia; P ₇ - skin color; P ₈ - the time from the absorption of the poisonous substance to the start of the provision of qualified medical care.

The value of points is selected from the table below in accordance with the severity of the symptom in the patient.

Criteria for assessing the severity of the condition of patients with acute poisoning with topical decongestants in childhood 1 point 2 points 3 points Complaints of the patient and / or parents (P ₁ ) The child is excited Prolonged daytime sleep, refuses to play Impossible to wake up, but there is a defensive reaction to external stimuli Objective examination CNS depression (P ₂ ) Moderate sleepiness Severe drowsiness Coma Systolic and diastolic blood pressure (from the age norm) (P ₃ ) Not changed or increased by no more than 10% Up to 30% reduction Over 30% reduction Bradycardia (from age norm) (P ₄ ) no more than 20% 20-50% over 50% Hyperhidrosis (P ₅ ) Moderate
(palms, feet, armpits,) Expressed (palms, feet, armpits, groin, perineum) Profuse (generalized) Severity of hypothermia (P ₆ ) over 36°C 36-35°С less than 35°C Skin color (P ₇ ) pale grayish acrocyanosis The beginning of the provision of qualified assistance from the moment of poisoning (P ₈ ) less than 6 hours from 6 to 12 hours over 12

As a result of the analysis of clinical observations and the evaluation of objective laboratory studies of 183 pediatric patients with poisoning with topical decongestants, it was found that the value of _Kts in a patient with a mild condition is less than 9 points. If the value of _KTC was in the range from 9 to 18 points, then this corresponded to the state of moderate severity of the patient. With a _KTC value of more than 18 points, the patient was in a state of severe severity. The calculation of the value of _KTC allows the doctor to objectively approach the appointment of a therapy regimen.

Clinical examples.

Example 1. Patient A., age 2 years and 6 months. Diagnosis: acute poisoning with naphazoline (T50.9).

Disease history:

At about 13.00, 1 drop of Naphthyzin (international non-proprietary name - nafazolin) was dropped into the child's nose, after which the child became drowsy, refused to play and entertain. The temperature dropped to 36.2°C. Three hours later, an ambulance was called, the boy was taken to VODKB No. 1, where he was examined by a resuscitator, pediatrician and otolaryngologist. The child was hospitalized in the pediatric department for further examination and treatment.

Objective examination:

Based on clinical experience, the doctor on duty assessed the severity of the patient's condition as moderate. The child is sleepy. The skin is pale. The palms, feet and armpits are moist to the touch. The mucous membranes of the mouth are clean and moist. Zev is not hyperemic. Breathing is puerile, no wheezing. Heart sounds are sonorous, rhythmic, there are no noises. The abdomen is soft, painless on palpation, the liver, spleen are not palpable. Urination is not disturbed, there was no stool during examination. Respiratory rate - 28 per minute, heart rate - 115 beats per minute, blood pressure - 90/55 mm Hg. Art., body temperature - 36 °, 5C.

The following laboratory tests have been scheduled:

clinical analysis of blood and urine, biochemical blood test, blood test for electrolytes and acid-base status (CBS).

Upon admission, the following treatment regimen for the patient was determined:

Within 3 days, infusion therapy - a solution of sodium chloride 0.9% 300 ml and a solution of dextrose (glucose) 5% 300 ml intravenously at a rate of 50 ml / hour, alternating 100 ml; atropine 0.1% solution 0.1 ml intravenously.

Results of the laboratory examination:

Blood chemistry:

total protein - 64.8 g/l; urea - 3.1 mmol/l; glucose - 4.2 mmol/l; creatinine - 0.24 mg / dl; alanine aminotransferase - 11.2 U/l; aspartate aminotransferase - 33.9 U/l; total bilirubin - 5.5 µmol/l; serum iron - 20.7 µmol/l; C-reactive protein - 0.5 mg/l, amylase - 30.5 U/l, alkaline phosphatase - 231.5 U/l.

Clinical blood test:

Hemoglobin 140 g/l; Erythrocytes 5.36*10 ¹² /l; Leukocytes 11.4*10 ⁹ /l; neutrophils 41.5%; lymphocytes 45.8%; monocytes 9.3%; basophils 1.4%; eosinophils 2.0%; platelets 381*10 ⁹ /l; ESR 3mm/hour.

Acid-base state:

pH 7.436, pCO ₂ - 31.7 mm Hg. Art., pO ₂ - 81 mm Hg. Art., BE - -2.1 mmol / l, HCO ₃ - 21.3 mmol / l

Electrolytes:

sodium - 137 mmol/l; potassium - 4.9 mmol / l; calcium - 2.45 mmol / l; ionized calcium - 1.14 mmol / l; chlorides - 108 mmol / l.

Clinical analysis of urine:

density 1013; neutral reaction; protein - 0 g/l; leukocytes 0-1 in the field of view; erythrocytes were not found.

Analyzes for electrolytes and CBS were ready on the 2nd day from the moment of hospitalization. According to the results of the tests, the doctor changed the patient's treatment regimen, infusion therapy was canceled.

Dynamics of the patient's condition: the child was discharged on the 4th day from the date of hospitalization. Further outpatient supervision by a pediatrician is necessary.

Retrospectively, using the formula we proposed, the coefficient of severity of the patient's condition was calculated.

P ₁ \u003d 1 - according to parents, refuses to play, lethargic

P ₂ \u003d 1 - during an objective examination, moderate drowsiness was noted

P ₃ \u003d 1 - blood pressure - 90/55 mm Hg. Art. (systolic 100-115, diastolic 60-75) - decrease by no more than 30%

P ₄ \u003d 1 - heart rate - 115 beats per minute (normal for the age of 2-3 years: 110-140), bradycardia is absent

P ₅ \u003d 1 - palms, feet and armpits are wet to the touch

P ₆ \u003d 1 - body temperature 36 °, 5С

P ₇ \u003d 1 - pale skin

P ₈ \u003d 1 - delivered to the hospital three hours after poisoning

K _mc = 8 points, which corresponds to mild severity, which corresponds to overdiagnosis in the subjective assessment of the severity of the patient during examination by a doctor.

Example 2. Patient B., age 2 years and 1 month. Diagnosis: acute poisoning with naphazoline (T50.9).

Disease history:

Around 18.30 - 19.00, the mother noticed the child's drowsiness. At 19.30 the child became lethargic, the skin was pale. Mom found an empty vial of Naphthyzin. Parents called an ambulance, the child was taken to VODKB No. 1 at 20:30, examined together with the resuscitator, does not need resuscitation. Hospitalized in the pediatric department of young children.

Objective examination:

The child is lethargic and sleepy. The skin is clean, pale, palms and feet are moist, cold to the touch. Mucous membranes are clean and moist. Zev is not hyperemic. Breathing is puerile, no wheezing. Heart sounds are sonorous, rhythmic, there are no noises. The abdomen is soft, painless on palpation, the liver, spleen are not palpable. Stool and urination are not disturbed. Respiration rate - 30 per minute; heart rate - 110 beats per minute; blood pressure - 95/55 mm Hg. Art., body temperature - 36.5 ° C.

The severity of the condition was assessed by the patients based on objective criteria using the attached method, based on the criteria set out in the scoring table.

Parents' complaints: the child is naughty, but is involved in the proposed game (P ₁ = 1). Objective examination: depression of the central nervous system - the child is lethargic, moderately drowsy on examination (P ₂ \u003d 1); systolic and diastolic blood pressure changed from the age norm by no more than 10% (P ₃ =1). There is no bradycardia - 110 beats per minute at a rate of 110-140 (P ₄ = 0). Wet palms and feet, moderate hyperhidrosis (P ₅ =1). Body temperature - 36°, 5C, hypothermia is absent (P ₆ =0). The color of the skin is pale (P ₇ \u003d 1). From the moment of poisoning to admission to the hospital took 2 hours (P ₈ =1).

In total, _KTC was 8 points, which makes it possible to attribute the child's condition to a mild degree of severity.

In accordance with the mild severity of the condition, the patient must be assigned a clinical analysis of blood and urine, a biochemical blood test, an electrocardiogram. Treatment includes control of vital functions and dynamic observation.

A retrospective study of the case histories confirmed the absence of changes in the analyzes for electrolytes and acid-base status in mild severity. The exclusion of the appointment of these unnecessary studies with a mild severity of the condition will reduce the financial costs of diagnosing a patient while maintaining the proper level of medical care.

Dynamics:

the patient was discharged on the 2nd day after hospitalization in a satisfactory condition, under the supervision of a pediatrician.

The use of the proposed method for assessing the severity of the patient's condition in acute poisoning with topical decongestants, by highlighting the exact criteria, provides the following advantages:

- reduces the time of examination by increasing the objectivity of assessing the severity of the patient's condition;

- allows you to improve the quality of medical care through individually selected medical measures;

- reduces the financial costs of diagnostic studies of the patient and allows you to reasonably assign the amount of emergency care.

Thus, the proposed assessment method allows us to reduce the time of examination, justify the choice of the volume of emergency diagnostic measures prescribed in accordance with the severity of the patient's condition in order to improve the quality of medical care and reduce the financial costs of the patient's diagnostic studies.

Claims (1)

A method for assessing the severity of the condition in acute poisoning with topical decongestants in children, including performing an objective examination of a doctor and taking into account the patient's complaints, characterized in that the complaints and indicators of an objective examination are evaluated in points, where P1 is the patient's and / or parents' complaints: the child is excited - 1 score, prolonged daytime sleep, refuses to play - 2 points, the child cannot be woken up, but there is a protective reaction to external stimuli - 3 points, P2 - CNS depression: moderate drowsiness - 1 point, severe drowsiness - 2 points, coma - 3 points, P3 - systolic and diastolic blood pressure: unchanged or increased by no more than 10% of the age norm - 1 point, reduced to 30% of the age norm - 2 points, reduced by more than 30% of the age norm - 3 points; P4 - bradycardia: not more than 20% of the age norm - 1 point, 20-50% of the age norm - 2 points, more than 50% of the age norm - 3 points, P5 - hyperhidrosis: moderate - palms, feet, armpits - 1 score, pronounced - palms, feet, armpits, groin, perineum - 2 points, generalized - 3 points, P6 - severity of hypothermia: more than 36°C - 1 point, 36-35°C - 2 points, less than 35°C - 3 points, P7 - skin color: pale - 1 point, grayish - 2 points, acrocyanosis - 3 points, P8 - time to start providing qualified assistance from the moment of poisoning: less than 6 hours - 1 point, from 6 to 12 hours - 2 points , more than 12 - 3 points, then calculate the individual coefficient (Kts) according to the formula: Kts \u003d P 1 + P 2 + P 3 + P 4 + P 5 + P 6 + P 7 + P 8; if CTS is less than 9 points, the severity of the patient's condition is assessed as mild; if the value of CTS is from 9 to 16 points, assess the severity of the patient's condition as an average degree; if the value of CTS is more than 16 points, the severity of the patient's condition is assessed as severe.