5年精神科急诊抢救的急重症患者情况分析

目的:分析5年来精神科抢救的急重症患者情况。方法:回顾性分析2011年1月至2016年6月本院精神科急诊抢救的患者情况。结果:5年来精神科急诊抢救的急重症患者463例(男314例,女149例);急诊抢救的主要原因依次为酒精戒断(240例,男231例,女9例)、过量服药(198例,男67例,女131例)及伴发躯体严重情况(25例);急诊抢救时65.9%(3095例)患者有不同程度的意识障碍;仅10.1%过量服药患者出现谵妄或昏迷;因各种原因在精神科急诊抢救的患者均以春季为多;病情转归为稳定或好转424例(91.6%),加重或恶化39例(8.4%)。结论:精神科急诊抢救的急重症患者中酒精戒断者多于过量服药患者;过量服药患者较少出现重度意识障碍;春季抢救的病例数多,伴有躯体严重情况患者的躯体问题更加复杂多样。     

急诊抢救精神药物过量者的总结

对精神药物自杀中毒者的抢救常见于精神科门、急诊或住院部.我们汇集了近十年本院因精神药物中毒抢救的临床资料54例,现报道如下.     

抢救安眠药中毒的体会

在医院急诊急救的疾病谱中,药物中毒的急诊病例并不少见,据我院2000～2004年的统计资料分析,因药物中毒而进行救治的患者有290例,其中安眠药物中毒113例,经洗胃导泻、特异性解毒剂的合理应用及对症处理后,治愈111例,2例因服药量过多,服药时间长经抢救无效死亡.现将抢救治疗中的几点体会报告如下.     

精神科急诊抢救中的自杀32例分析

精神科急诊是精神科临床工作的一个重要部分,其所处理的问题往往较内、外科急诊更为复杂,也更为严重。除需处理病人的内、外科问题外,更需处理病人的精神科问题,即思维、情感或行为方面的异常,而危重病人的抢救则又是急诊工作的重中之重。文献对精神科急诊规律性的研究较多,但对急诊抢救的特点研究则较少。作者对1996年6月～1999年6月来我院精神科抢救的危重病人共38例进行回顾性分析,发现因各种原因、各种方式企图自杀的病人占大多数(32例)。现将临床分析结果总结如下。     

精神科疑难重危症讲习班招生

国家级继续医学教育项目:“第三届全国精神科疑难重危症讲习班”将于2002年10月11-20日举办,本期讲习班内容涉及精神科症状学、疾病学以及治疗学的疑难重危问题的诊断与处理,如:急性药物中毒的抢救;难诊性人格障碍的鉴别诊断;CCMD-3简介与ICD-10的比较;性心理障碍与其他精神疾病;神经症诊     

自杀急入院精神病人100例分析

过去,国内外住院精神病人自杀的报导较多,而对自杀急入院的精神病人却缺少报导。实际上,每年都有相当数量的病人因自杀而急入院抢救。统计他们的发生率,分析自杀的诱因、原因、方式及抢救疗效等,对减少精神病人的自杀发生率、提高精神科急诊抢救水平、建立联络精神病学等皆颇有帮助。为此,我们分析了100例因自杀而急入院的精神病人,结果如下:     

开颅术后急性肾功能衰竭血液透析治疗1例

我科于2004年12月收治1例重症颅脑损伤术后并发急性肾功能衰竭患者,给予护肾、排毒、利尿等治疗无效,后急诊行血液透析治疗,肾功能恢复,患者临床治愈出院。患者男性,30岁,因骑摩托车摔伤致重症颅脑损伤,在外院行开颅术后3d,伴昏迷、发热于2004年12月9日转入我院。查体:体温38.5     

误诊为脑炎的药物中毒2例报告及文献复习

<正>药物中毒是临床常见疾病,如有明确的药物中毒史,容易诊断;反之,由于药物中毒的种类多,症状与体征往往没有特异性,患者常不能提供详细的用药史,临床诊断困难且容易导致误诊和误治。我院收治了2例因过量服用感冒药导致的药物中毒,均以精神行为异常为主要表现,同时具有发热、上呼吸道感染等症状,临床均初步诊断为病毒性脑炎,但追问及发病前确切的用药史、结合其发展经过及随访与病毒性脑炎不符,确诊为过量服用感冒药导致的药物中毒。本文     

精神科常见抢救程序的探讨

根据精神病房易发生的意外事件和抗精神病药物中毒的抢救,拟定了5种抢救流程图程序:①急性抗精神病药物中毒抢救程序;②重症颅脑损伤抢救程序;③自缢抢救程序;④药源性直立性虚脱抢救程序;⑤触电抢救程序。按流程图程序进行抢救,能使护士在抢救时做到心中有数,工作有序,争分夺秒,准确无误;从而提高抢救效率。     

血糖变异性对重症急性卒中患者预后的影响

目的探讨血糖变异性对重症急性卒中患者预后的影响。方法对重症急性卒中患者进行回顾性分析,依据出院3 m的改良Rankin量表将患者分为预后不良组及预后良好组。对患者入院血糖、平均血糖、血糖标准差、血糖变异系数以及其他临床资料应用多变量Logistic回归分析,确定重症急性卒中患者预后不良的独立预测因素。结果共纳入420例重症急性卒中患者,其中预后良好组207例(49. 3%),预后不良组213例(50. 7%)。多变量Logistic回归分析显示,年龄、NIHSS、GCS、APACHEⅡ、血糖标准差、血糖变异系数及其分类是影响其预后的独立危险因素。结论血糖变异性是重症急性卒中患者出院3 m预后不良的独立预测因素,血糖波动范围大提示预后不良。     

Neuropsychiatric aspects of psychogenic status epilepticus

We studied 20 patients with continuous repetitive psychogenic seizures simulating status epilepticus. Most patients received intravenous doses of multiple anticonvulsants. Our definition used for status epilepticus was that of Delgado-Escueta et al, at least 30 minutes of repetitive seizures without regaining consciousness. Nineteen of 20 patients were young women, all but one under 40 years of age. Sixteen of these patients had a history of childhood seizures. In over 50% of patients, seizures continued until respiratory arrest and intubation occurred. Thorough neuropsychological testing and psychiatric interview were done after cessation of the acute episode. Long-term outcome and prognosis depended on definitive psychiatric diagnosis. Repetitive psychogenic seizures simulating status epilepticus are not uncommon, and such patients may incur serious iatrogenic complications from treatment for status epilepticus. Appropriate management and long-term prognosis may be determined by the type and severity of the underlying psychiatric disorder.     

伴意识障碍的缺血性脑卒中急诊血管不同再通方案的疗效比较

目的研究伴意识障碍的急性缺血性脑卒中(AIS)患者急诊血管不同再通方案的疗效比较。方法采用回顾性调查研究。选取112例进行早期血管再通治疗的伴意识障碍的AIS患者为研究对象,按治疗方法分为静脉溶栓组、直接介入组和桥接治疗组,分析相关病理因素,观察90 d mRS评分和不良事件。结果伴意识障碍的AIS患者约80%存在颅脑大血管闭塞。静脉溶栓组和桥接治疗组总体预后良好率(20.8%,15/72)低于直接介入组(32.5%,13/40)(P<0.05)。三组患者脑梗死后出血转化率和死亡率的差异无统计学意义。结论AIS合并意识障碍的主要病理因素是颅脑大血管闭塞,早期血管再通方案适宜选择直接血管内介入治疗。     

First-year follow-up of the Psychiatric Emergency Response Team (PAM) in Stockholm County,Sweden: A descriptive study

In the spring of 2015 a project named PAM (Psykiatrisk akut mobilitet, i.e., Psychiatric Emergency Response Team) started in Stockholm, Sweden. The main purpose of PAM is to respond to emergency calls regarding persons in severe mental health or behavioral distress, with focus towards patients with acute risk of suicidal behavior. In Sweden these emergency cases are traditionally handled by the police, though suggestions have been made to involve trained health professionals, thus improving the quality of care provided, as well as minimizing stigmatization of patients with psychiatric problems. The PAM vehicle is staffed with two specialized psychiatry nurses and a paramedic, who often collaborate with police, ambulance and rescue services. This article is an evaluation of the first year of the project. Our objective was to quantify certain parameters regarding patients, response time and cooperation with other departments. Data were collected from medical records, the police department, the emergency call center and from a logbook kept by the PAM personnel. During the first year, PAM was requested 1,580 times, and had 1,254 cases attended to which is an average of 4.3 requests and 3.4 cases per day. 1,036 individuals of all ages were attended to, and 96 of them had contact more than once. One third of all attended cases resulted in no further action after a psychiatric assessment and sometimes crisis intervention had been made on site.     

Clinical characteristics of status epilepticus in an emergency hospital: importance of nonconvulsive status epilepticus]

Although nonconvulsive status epilepticus (NCSE) is a major neurological emergency, its frequency and clinical course are not well clarified. We investigated the clinical characteristics of status epilepticus focusing on the significance of NCSE. One thousand seven hundred twenty-three patients were admitted as neurological emergency cases in our hospital between October 2003 and September 2006. Of these cases, 94 (5.5%) were diagnosed as status epilepticus of which, 24 (25.5%) were diagnosed with NCSE on admission. Moreover, 8 patients who presented with convulsive status epilepticus on admission had episodes of NCSE during hospitalization. Thus, 32 patients (34.0%) suffered from NCSE during their clinical course. We analyzed the prognostic factors of status epilepticus using the Glasgow Outcome Scale. Poor outcome was significantly correlated with NCSE (p = 0.003) and acute cerebrovascular disease (p = 0.010), independent of age, sex, history of epilepsy, and other etiologies. Our study revealed that NCSE is not a rare condition and results in a poor outcome. Careful EEG evaluation of patients with consciousness disturbance might increase the diagnostic accuracy of NCSE, and aggressive treatment of patients with NCSE should be necessary to improve the prognosis of NCSE.     

A clinical trial for developing PICU management scale, a tool reviewing the frequency and use of seclusion and restraint in psychiatric acute care]

OBJECTIVE AND METHODS: Medical management in psychiatric acute care involving seclusion and restraint is an intervention of which reasonable use is often required. Regarding such measures, guidelines for seclusion and restraint are important, and also, psychiatric treatment facilities should engage in a continuous quality improvement process that seeks to minimize the use of seclusion and restraint. To review and monitor the existing use of seclusion and restraint, the authors developed a tool, the "PICU management scale", and investigated its usefulness in two functionally different psychiatric wards, a psychiatric emergency care unit (emergency ward) and a psychiatric acute care unit (acute ward) in the Japanese payment system. The PICU management scale is a tool which classifies the status of psychiatric intensive care into six categories by four factors; "S: seclusion", "R: restraint", "N: forced nutrition" and "Ph: physical care", and we evaluated its usefulness by occurrence of variance. In terms of minimizing or optimizing the use of seclusion and restraint, we also analyzed characteristics and risk factors of 1) recurrent application of seclusion and restraint, 2) high PICU management ranking, and 3) prolongation. RESULTS: During the five months of investigation, medical management involving seclusion and restraint was applied in 98 cases at the emergency ward and 50 at the acute ward. The total number of management days was 894 and 950, respectively. The mean management duration per case was 9.1 and 19.0 days, respectively. The variance was 2.5 % and 4.5 %, respectively, and our tool covered most of the statuses and conditions observed in psychiatric emergency and acute care. Analysis of the variance suggested the existence of a trend which is considered to be typical of the status of medical management. Most cases that required recurrent application of seclusion and restraint were diagnosed as F0 or F2 in ICD -10, and hebephrenic cases with a high grade of disability, refractory-paranoid schizophrenic, or drug-resistant cases in F2 were remarkable in this category. In the high PICU management ranking, most cases were related to consciousness disturbance, and the mean duration of intervention was short. Reversal of the therapeutic stage was considered to be a risk factor of prolongation. CONCLUSION: The "PICU management scale" is considered to be a useful tool for minimizing the use of seclusion and restraint, in addition to the guidelines for the use of seclusion and restraint. Contributions to team strategy and consensus by the addition of objectivity or symbolizing are also expected. To verify these findings and make further progress, more clinical trials using this tool in various institutions are required.     

Psychiatric disorders among patients admitted to a French medical emergency service

OBJECTIVE: The authors assessed the prevalence of psychiatric disorders among a population of patients examined in the emergency service of a French general hospital. They compared patients with and without psychiatric disorders. They also compared patients where the primary motive of emergency was psychiatric to those whose psychiatric disorders were secondarily diagnosed by a systematic assessment. METHOD: Five hundred consecutive patients admitted to the emergency service of Bichat Claude Bernard Hospital (Paris, France) were interviewed with standardized questionnaires. Demographic details were collected along with information on current and past contacts with emergencies and psychiatric services. Psychiatric disorders were identified using a structured psychiatric interview, the Mini International Neuropsychiatric Interview (MINI). Domestic violence was identified with a specific checklist validated for this purpose. RESULTS: Prevalence of psychiatric disorders was 38% (189 patients). Forty (8%) patients were primary psychiatric cases referred to the emergency department for psychiatric reasons, while 149 (30%) were secondary psychiatric cases, as revealed by a systematic assessment of their mental state. Psychiatric patients, primary or secondary, were more often homeless (13.6% vs.1.95%). They had been more often referred to the emergency department after an aggressive (7.4% vs.3.5%) or violent behavior (5.8% vs.0.9%) and less often after an accident (8.4% vs.14.3%). Psychiatric patients were more often examined after an episode of domestic violence (21.7% vs. 6.8%). Psychiatric diagnoses, according to the DSM-IV criteria, were depression (80 cases), generalized anxiety disorder (34 cases) acute alcohol intoxication (21 cases), alcohol dependence (20 cases), schizophrenia (16 cases), posttraumatic stress disorder (14 cases), drug abuse (4 cases), agoraphobia (4 cases), alcohol abuse (3 cases), anorexia nervosa (3 cases), mania (2 cases) and obsessive compulsive disorder (2 cases). The proportion of psychiatric diagnoses was equivalent in primary and secondary psychiatric cases except for schizophrenia (more often a primary demand for psychiatric help) and acute alcohol intoxication (more often revealed by a systematic assessment of the mental state). CONCLUSION: Thirty-eight percent of the patients examined in a French emergency service presented with psychiatric disorders. The majority of the patients (78%) were not referred to the emergency service for psychiatric reasons. Patients seen in an emergency service should thus be identified as a population at risk for psychiatric disorders whatever their reason for utilizing this service.     

Predicting hospitalization versus discharge of suicidal patients presenting to a psychiatric emergency service

OBJECTIVE: Suicidal ideation frequently prompts visits to psychiatric emergency departments, and more information is needed about factors that mediate clinicians' decisions to hospitalize or discharge patients with suicidal ideation. METHODS: The authors reviewed records for 257 patients presenting with suicidal ideation to a psychiatric emergency service. Demographic and clinical correlates of hospitalization were examined by backward stepwise binary logistic regression. RESULTS: Hospitalization occurred for 70% of suicidal persons and was significantly associated with psychosis, a history of attempted suicide, and a suicidal plan. With potential confounding factors controlled, these variables correctly classified 80% of hospitalization decisions. CONCLUSIONS: Psychosis, past suicide attempts, and the presence of a suicide plan robustly predicted the decision to hospitalize suicidal persons seen in psychiatric emergency services. Diagnosis, pharmacotherapy, having a psychiatrist, and insurance subtype were unrelated to hospitalization decisions, suggesting that psychiatric emergency department staff perceive few alternatives to hospitalization when psychosis and suicide plans accompany suicidal ideation.     

综合医院内精神科会诊的回顾性分析

目的探讨联络精神病学在综合医院中的作用。方法回顾性分析３年内综合医院精神科向非精神科３１０例患者提供的４１１次会诊。结果总会诊率０．６％，其中５９．０３％的患者来自内科；会诊后的诊断主要为器质性疾病所致精神障碍（３６．５％）、神经症（３２．９％）、精神分裂症和情感性精神障碍（共１０６％）；会诊医嘱执行率达９８．１％；精神科问题经会诊处理后的总有效率达８９．２％。结论综合医院内精神科会诊可及时发现和治疗精神障碍，并拓展精神病学业务     

交通事故性重型颅脑损伤院前急救与预后关联分析(附1107例报告)

目的 探讨院前急救在时间环节上对交通事故性重型颅脑损伤预后的重要性,为我国相关部门制定预防和控制措施提供参考依据.方法 根据珠江医院神经外科制定的<交通事故性重型颅脑损伤统计表>严格筛选出合格病例,对其相关资料进行统计学分析,主要分析急救接报时间与到达现场时间差的不同时间段以及现场抢救中不同时间段与患者预后的相关性.结果 急救接报到到达现场时间段以及现场抢救时间段与患者预后均存在负相关关系(rs=-0.10,P=0.002;rs=-0.06,P=0.034),即随着接报到到达现场时间的增加及随着现场抢救时间的增加,患者死亡率及致残率逐渐增高,预后越差.结论 通过建立和完善急性颅脑损伤预防和控制中心,科学制定院前急救、转运等各项救治制度,尽量缩短路途耽搁时间及现场抢救时间,提高急救反应速度,可提高救护质量,减少死亡率和致残率.

Abstract：

Objective To analyze the importance of pre-hospital emergency treatment in patients with severe head injury in traffic accidents in terms of time and explore the general rule of severe head injury in traffic accidents to provide some evidence for relevant authority making the prevention and control measures of acute traumatic brain injury. Methods The patients were selected according to "statistical table of severe head injury in a traffic accident" established by our department; their correlated data were statistically analyzed. Based on the time intervals between receiving telephone time asking for first-aid and arriving to location of incidence, and time intervals between time of giving first-aid and injured time, the regularity of prognosis was analyzed.Results With the prolonged time intervals between time of giving first-aid and injured time, the mortality and disability rates gradually increased,followed by poor prognosis, which indicated that the prognosis was negatively correlated to the delayed time on the way and the on-site rescue time (rs=-0.10,P=0.002; rs=-0.06,P=0.034). Conclusion Prevention and control center for acute brain injury should be built and the roles for pre-hospital emergency treatment and transportation should be established to decrease the injured time (the delayed time on the way and the on-site rescue time) to improve the quality of care, and to reduce the death and disability in patients with severe head injury in traffic accidents.