窒息性毒劑課件

1、第6章 窒息性毒劑The large-scale chlorine attack in WWIMarch 16, 2007 Three separate suicide attacks on this day used chlorine. Bombers detonated three chlorine-filled trucks in Anbar province. The attacks at least killed two police officers and sickened about 350 Iraqis and six coalition force members.Oct

2、21, 2006: A car bomb carrying 12 120 mm mortar shells and two 100-pound chlorine tanks detonated, wounding 3 Iraqi policemen and a civilian in Ramadi. Jan 28, 2007: A a dump truck with explosives and a one-ton chlorine tank into an emergency response unit compound in Ramadi. No one injured by chlori

3、ne, but 16 people were killed in the blast.Feb 19, 2007: A suicide bombing in Ramadi involving chlorine killed two Iraqi security forces and wounded 16 other people. Feb 20, 2007: A bomb blew up a tanker carrying chlorine north of Baghdad, killing 9 and 148 others ill (incl. 42 women, 52 kids). Feb

4、21, 2007: A pickup truck carrying chlorine cylinders exploded in Baghdad, killing at least 5 and hospitalising over 50. Mar 16, 2007: Three separate suicide attacks used chlorine. The first at a checkpoint northeast of Ramadi, wounded 1 US service member and 1 Iraqi civilian. The second in Falluja,

5、killing 2 policemen and leaving chlorine exposed 100 Iraqis. Forty minutes later, the third at the entrance to a housing estate south of Falluja, injuring 250 and according to some reports killing 6. Chlorine Attacks in Iraq During 2006-2007Mar 28, 2007: Suicide bombers detonated a pair of truck bom

6、bs, one containing chlorine, aimed at the Fallujah Government Center. left 14 American forces and 57 Iraqi forces wounded.Apr 6, 2007: A chlorine-laden suicide truck bomb detonated at a police checkpoint in Ramadi, leaving 27 dead. Thirty hospitalized. Apr 25, 2007: A chlorine truck bomb detonated a

7、t a military checkpoint near Baghdad, killing one Iraqi and wounding two others. Apr 30, 2007: A tanker laden with chlorine exploded near a restaurant west of Ramadi, killing six people and wounding 10. May 15, 2007: A chlorine bomb exploded in an open-air market in the village of Abu Sayda in Diyal

8、a province, killing 32 people and injuring 50.May 20, 2007: A suicide truck bomber exploded his vehicle Sunday near an Iraqi police checkpoint outside Ramadi, killing two police officers and wounding 11 others. Jun 3, 2007: A car bomb exploded outside a U.S. military base in Diyala, unleashing a nox

9、ious cloud of chlorine gas that sickened at least 62 soldiers but caused no serious injuries. June 15, 2004FuzhouIntroductionRepresentativesPhysicochemical characteristicsToxicityMechanism of toxicityClinical effectsDiagnosis & differential diagnosismedical managementContentsIntroductionRepresentati

10、vesPhysicochemical characteristicsToxicityMechanism of toxicityClinical effectsDiagnosis & differential diagnosismedical managementContents窒息性毒劑亦稱肺刺激劑(lung irritants)， 是一類損傷呼吸道，引起急性中毒性肺水腫，導致急性缺氧和窒息的化學戰(zhàn)劑。IntroductionConception光氣于1812年由John Davy首次合成氯氣在一戰(zhàn)中交戰(zhàn)雙方都大量使用光氣首次戰(zhàn)場使用：德國1915年12月于凡爾登 (Verdun)；后來雙方都

11、使用 (36600 噸, 80% 死于肺水腫)二戰(zhàn)中除日本針對中國外，沒有使用美國在朝鮮戰(zhàn)爭中使用 (1951, Nampo, 1379 中毒, 480 死亡). 現(xiàn)已無庫存History/Military RelevanceIntroductionRepresentativesPhysicochemical characteristicsToxicityMechanism of toxicityClinical effectsDiagnosis & differential diagnosismedical managementContentsRepresentative氯甲酸三氯甲酯DP雙

12、光氣(diphosgene)二氯化碳酰CG光 氣(phosgene)化學名稱結構式美軍代號毒劑名稱ClCOCCl3OClCClOPhosgene Chemical industry foam plastic (isocyanates)herbicides, pesticidesdyesUSA produces over billion pounds per year for industrial use Burning ofplasticscarbon tetrachloridemethylene chloride (paint stripers)degreasersOthers“dual u

13、se agent” Can you imagine?雖是劇毒氣體，但被廣泛地應用于化工領域。以光氣為基本原料制成的化學品不下上千種，有“工業(yè)金礦”之稱;由光氣合成的聚碳酸酯是一種性能優(yōu)良的無毒工程塑料，是五大工程塑料中唯一具有良好透明性的產(chǎn)品，汽車的車窗、洗衣機的內缸、電腦的外殼，甚至超音速飛機的機頭都由這種塑料制成的;此外太陽鏡、光盤、臺燈、手機、香料、染料光氣就是生產(chǎn)它們的最基本原料;在醫(yī)藥和農(nóng)藥領域：青霉素、紫杉醇和殺蟲劑等的生產(chǎn).PFIB (Perfluoroisobutylene，全氟異丁烯)有機氟聚合物的高溫毒性裂解產(chǎn)物聚四氟乙烯(Polytetrafluoroethylene,

14、“Teflon”) 有很多工業(yè)用途Used in armored vehicles, aircraft 導致肺水腫，同光氣類似IntroductionRepresentativesPhysicochemical characteristicsToxicityMechanism of toxicityClinical effectsDiagnosis & differential diagnosismedical managementContentsPhysical Characteristics 1206.9-57128無色或微黃色液體雙光氣難溶于水，易溶于有機溶劑63403.5-1268.2

15、爛蘋果或爛干草味無色氣體光氣溶解度揮發(fā)度(mg/1，20)蒸氣比重(20)凝固點（）沸 點（）氣味狀態(tài)毒劑名稱Very easy to hydrolyze:COCl2+2H2OCO2+2HClChemical Characteristics Stability:CG 150開始分解，800完全分解成CO和Cl2；DP 沸點開始分解，300-350 完全分解成CG。(1) with sodium hydrate COCl2 + 4NaOH 2NaCl + Na2CO3 + 2H2O(2) with sodium carbonate COCl2 + Na2CO3 2NaCl + 2CO2(3) w

16、ith ammonia COCl2 + 4NH3 O=C(NH2)2 + 2NH4Cl(4) with sodium sulfide COCl2 + Na2S 2NaCl + COS(5) with urotropine (hexamine) -protection not antidote COCl2 + 2(CH2)6N4 COCl2.(CH2)6N42 Very easy to react with alkali:IntroductionRepresentativesPhysicochemical characteristicsToxicityMechanism of toxicityC

17、linical effectsDiagnosis & differential diagnosismedical managementContents2022/8/122毒 性(光氣)嗅覺閥值 ：1.5 mg/m3 粘膜刺激閥值：4 mg/m3LCt50: 3,200 mgmin/m3 氯氣 LCt50: 6,000 mgmin/m32022/8/123光氣對人的毒性 濃度（mg/m3） 效 應24 可聞到氣味 19刺激引起咳嗽 22暴露30min嚴重中毒 50暴露3060min危及生命 80 暴露12min嚴重肺損傷 100暴露3060min, 50死亡5000暴露5min，23h內全部死亡

18、 *我國衛(wèi)生標準規(guī)定：生產(chǎn)場所空氣中光氣最高允許濃度為0.5 mg/m3 2022/8/124雙光氣對人的毒性 濃度（mg/m3） 效應 0.41 可聞到氣味 40 暴露數(shù)秒鐘引起明顯刺激 160 暴露12min引起嚴重損傷 250 暴露30min引起死亡 500700 暴露15min引起死亡 1100 暴露5min引起死亡 IntroductionRepresentativesPhysicochemical characteristicsToxicityMechanism of toxicityClinical effectsDiagnosis & differential diagnosi

19、smedical managementContents2022/8/126Peripherally acting agents: Phosgene, NOx, and PFIB Central acting agents: HCl, NH3光 氣肺毛細血管壁、肺泡壁損傷(直接損傷學說)肺泡表面活性物質受損(?；瘜W說)細胞內環(huán)腺苷酸(cAMP)含量下降(cAMP下降學說)神經(jīng)反射(神經(jīng)反射學說)毛細血管通透性增強毛細血管壓力增加肺泡通透性增強中毒性肺水腫Mechanism of ToxicityIntroductionRepresentativesPhysicochemical characte

20、risticsToxicityMechanism of toxicityClinical effectsDiagnosis & differential diagnosismedical managementContentsMild exposure - mild cough - dyspnea (呼吸困難) - chest tightness (胸悶)Moderate expoure - above symptoms plus - ocular irritation (眼部刺激) - smoke tobacco produces bad tasteClinical effectsSevere

21、 exposure - severe cough, dyspnea (呼吸困難) - onset of pulmonary edema within 4 hours - may produce laryngospasm (喉痙攣)Extreme severe exposure - death almost instantaneous恢復期 中毒輕者經(jīng)治療，肺水腫可于發(fā)病后24天開始吸收，78天后羅音消失，23周內恢復健康。但仍可有頭暈、乏力、食欲不振等后遺癥狀。刺激期癥狀（眼和上呼吸道刺激癥狀） ：流淚、咳嗽、胸悶、氣促，繼之惡心嘔吐、頭暈、乏力、煩躁不安。體征：眼及咽喉充血，呼吸音粗糙。持續(xù)

22、時間：離開毒區(qū)12h后可消失。潛伏期 自覺癥狀好轉，但病理過程仍在發(fā)展，肺水腫正在逐漸形成，潛伏期越長，中毒越輕；反之則中毒越重。 Clinical Effects刺激期輕 度中 度重 度潛伏期(h)812h410h16h潛伏期肺水腫期恢復期Pulmonary Edema呼吸道癥狀：呼吸淺快，咳嗽，煩躁不安，頭暈乏力，惡心嘔吐等;體征：呼吸音減弱，肺底部細濕羅音，或捻發(fā)音，X線檢查已有肺水腫征象；繼之，典型肺水腫癥狀出現(xiàn)，氣喘，呼吸困難，咳嗽頻繁，咳出大量粉紅色泡沫樣痰 (一晝夜可達12升)。叩診肺部呈濁音、鼓音，肺下界降低，心濁音界消失，聽診為滿肺干、濕羅音。根據(jù)循環(huán)系統(tǒng)機能可分為兩個階段：

23、 青紫型缺氧期(呼吸性血缺O(jiān)2 )：血O2 ，皮膚紫紺，但循環(huán)機能尚能代償，血壓、脈搏基本正常，神清，肺水腫使CO2排出障礙，血CO32- ，導致呼吸性酸中毒；也可因過度換氣使CO2排出過多而至呼吸性堿中毒。 蒼白型缺氧(或休克)期(呼吸+循環(huán)性血缺O(jiān)2 )：出現(xiàn)循環(huán)衰竭，血壓、心率均，皮膚蒼白、冷汗、昏迷，血O2及CO2 ，酮體、乳酸等氧化不全產(chǎn)物蓄積，pH導致代謝性酸中毒。Pulmonary EdemaPulmonary edema (肺水腫)Ventilation disturbanceair exchange disorderEarly: (青紫型缺氧期)Late: (蒼白型缺氧期)缺

24、氧心肺缺氧組織缺氧酸中毒，水電解質紊亂中樞缺氧始興奮后抑制shock血液濃縮血栓栓塞心肺衰竭右室負荷 左室負荷 IntroductionRepresentativesPhysicochemical characteristicsToxicityMechanism of toxicityClinical effectsDiagnosis & differential diagnosismedical managementContents2022/8/137Diagnosis:中毒史和毒劑偵檢: sweet, newly-mown hay odor臨床表現(xiàn): 高濃度時粘膜刺激癥狀, 呼吸困難(dy

25、spnea), 遲發(fā)的肺水腫 (pulmonary edema of delayed onset)chest X-ray 實驗室檢查X線檢查是早期發(fā)現(xiàn)肺水腫和監(jiān)測肺水腫發(fā)展的最好方法，是光氣中毒最有意義的臨床檢驗措施。Diagnosis連續(xù)X線檢查：對中度以上中毒者應爭取在中毒后8小時每2小時拍攝X線胸片一張。如果8小時內的胸片均正常，其病情可能較輕。2022/8/141預后不佳的指征:中毒后很快出現(xiàn)進行性的缺氧和低血壓； 中毒后4小時內出現(xiàn)肺水腫（死亡的高危因素） 40, male2h post exposuremild dyspneanormal physical examCXR: nor

26、mal7h post exposuremod. dyspnea at restfew cracklesCXR: mild interstitial edemasurvived42, female2h post exposurerapidly inc. dyspneaCXR: overt edemadeath 6h post exp. 刺激劑：強烈；全身中毒性毒劑：迅速，無潛伏期；糜爛性毒劑：除此之外還有皮膚、全身損傷。Differential DiagnosisIntroductionRepresentativesPhysicochemical characteristicsToxicityMechanism of toxicityClinical effectsDiagnosis & differential diagnosismedical managementContents Terminate exposure as a vital first measure: 脫離毒區(qū) 佩戴合適的面具如果衣服及皮膚上有液體毒劑，即刻洗消綜合治療原則：二防、二糾、一維持、一控制二防：防治肺水腫，防治休克。二糾：糾正缺氧，糾正酸中毒。一維持：維持電解質平衡。一控制：控制感染。肺水腫發(fā)生前：半臥位安靜休息、保溫、間歇吸氧有咳嗽等刺激癥狀時對癥處理：霧化吸入、可待因口服盡早使用