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Case of the Week: CO中毒性脑病

时间:2021-07-25 09:53:07

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CaseoftheWeek

患者女性,43岁,意识不清一天余入院。患者独居(末次与家人联系为发病前一天),一天前中午被发现倒地,意识不清,有口吐白沫及胃内容物、大小便失禁,发病后3小时至我院急诊。急诊查体:T:36.6℃;血压118/70mmHg;心率112次/分,律齐,SpO2:99%(吸氧3L/min),浅昏迷,双侧瞳孔2mm,对光反射迟钝,双上肢肌张力减低,双下肢肌张力增高,双侧病理征(-)。

辅助检查:血碳氧血红蛋白百分含量(FCOHb)15.9(正常值<1.0%),头颅CT(见图一),考虑一氧化碳中毒。

图一:发病当日急诊头颅CT:双侧基底节区低密度影

追问病史患者有抑郁症病史8年,近日有买炭史。予高压氧治疗、抗感染、减轻脑水肿等治疗后患者可自行睁眼,但无有意识反应。发病后十天辅助检查:脑电图示全导中高幅慢波弥漫性发放;头颅MRI(见图二)。

Case of the Week: CO中毒性脑病

图二:发病后十天头颅MRI:双侧基底节区异常信号,T1WI中央等、边缘低信号,T2WI呈中央等、边缘高信号,DWI信号稍高;双侧脑室旁及半卵圆白质异常信号,DWI呈稍高信号。影像学诊断:符合一氧化碳中毒性脑改变。

治疗期间患者神志无明显变化,呈缄默状态,去大脑皮层强直,双侧病理征(+),轻微刺激可引起发作性肌痉挛、呼吸急促、心率增快(最高可至210次/分左右)。发病一月后复查头颅MRI(见图三)

图三:发病一月后头颅MRI:双侧基底节区可见对称性异常信号灶,T1WI呈中央等、边缘低信号,T2WI呈中央等、边缘高信号,T2-Flair呈中央等、边缘稍高信号;DWI呈稍高信号;两侧侧脑室前后角周围皮层下白质可见对称性异常信号:T1WI低信号,T2WI、T2-Flair及DWI呈高信号。影现学诊断:一氧化碳中毒性脑改变。

CO中毒性脑病

标准状态下一氧化碳纯品为无色、无臭、无味的气体,空气中浓度超过30mg/m3时即能引起中毒,一氧化碳进入人体之后会和血液中的血红蛋白(hemoglobin, Hb)结合,产生碳氧血红蛋白(COHb),进而使血红蛋白不能与氧气结合,从而引起机体组织出现缺氧,导致人体窒息死亡。

一氧化碳中毒症状轻重取决于一氧化碳暴露的持续时间和吸入一氧化碳气体的浓度,症状多变,可仅仅表现为轻度的流感样症状,也可以出现昏迷甚至死亡。大多数的一氧化碳中毒的患者会出现头痛或头晕,严重的会出现意识混乱、晕厥、癫痫、卒中样症状或昏迷。血液FCOHb的测定是有价值的诊断指标,但采血标本要早,因为脱离现场数小时后COHb即逐渐消失。脑电图检测可见弥漫性低波幅改变,与缺血缺氧性脑病(Anoxic-Ischemic Encephalopathy)进展相平行。头MRI示单侧或双侧苍白球、豆状核、尾状核、丘脑、脑室周围、皮层下白质、双侧半卵圆中心受累,尤其是额叶及颞叶更易受累,海马及小脑的病灶也相对多。

一氧化碳中毒的诊断主要根据吸入高浓度一氧化碳接触史,急性发生的中枢神经损害的症状和体征,结合血液FCOHb即时测定的结果。治疗原则首先早期快速识别并迅速脱离一氧化碳暴露,立即给予常压高浓度、高流量吸氧。年龄大于36岁,即时血FCOHb达25%或以上是高压氧治疗的指征。需要强调的是患者从昏迷中苏醒后应尽可能休息观察2周,存在迟发性脑病和心脏后发症的可能。最新的研究报道正丁基苯酞(N-Butylphthalide)联合高压氧治疗可改善急性一氧化碳中毒后迟发型脑病患者的认知和运动功能。

参考文献:

1. Xu Y , Li W . Is Carbon Monoxide Poisoning a Risk Factor or a Bystander of Deep Venous Thrombosis?[J]. Annals of Emergency Medicine, 2020, 75(6):781-782.

2. Hormova R , Polat G . Efficiency of Hyperbaric Oxygen Therapy in the Treatment of Carbon Monoxide Toxicity[J]. Eurasian Journal of Medicine, 2017, 49(3):226-227.

3. Gozubuyuk, Atilla Alp, Dag, Huseyin, Kacar, Alper. Epidemiology, pathophysiology, clinical evaluation, and treatment of carbon monoxide poisoning in child, infant, and fetus[J]. North Clin Istanb, 2017, 4(1):100-107.

编辑王张阳

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