Above Elbow Amputation For a Patient With Subcutaneously Injected Paraquate: Is It Possible to Halt the Doomed Mortality? -A Case Report and Literature Review

對於皮下注射巴拉乂的病人，手肘上截肢是否能阻止病人的死亡？－案例報告與文獻回顧

高瑞吟(Jui-Yin Kao) ； 李京軒(Jing-Syuan Lee) ； 張智皓(Chih-Hao Chang) ； 李經維(Jing-Wei Lee)

《臺灣整形外科醫學會雜誌》 26卷4期 (2017/12) Pp. 441-445

摘要

Background: Paraquat ingestion is a leading cause of fatal poisoning in many regions of Asia, the Pacific nations, and the Americas. Paraquat is reasonably safe to use in agriculture. Because of adequate protection, minimal dermal or spray exposure generally causes only limited and localized injury. However, accidental or deliberate ingestion has an extremely high fatality rate and there is limited information about the treatment in such cases. Aim and Objectives: The mortality rate is extremely high after paraquat ingestion; therefore, it is complicated to treat such a patient with subcutaneously injected paraquat. Hence, it is crucial for physicians to make an early decision with respect to treatment. Materials and Methods: A patient with subcutaneously injected paraquat immediately underwent amputation and debridement of the injection site. After the surgery, emergency hemoperfusion was performed, and anti-inflammatory drugs (such as cyclophosphamide and prednisolone) and anti-oxidant agents (such as vitamin E) were prescribed continuously. Results: The patient died on postoperative day 10 because of progressively deteriorating renal function and pulmonary fibrosis. Conclusion: All clinical information should be gathered completely before confirming the intramuscular use of paraquat. The decision to perform surgical intervention should be made at an early stage, and the procedure should be as radical as possible because it might be the only feasible way to cease the persistent absorption of the fatal substance.

關鍵字

paraquat (limitation : case report and human)

並列摘要

背　景：巴拉乂在亞洲、大洋洲、與南美洲的國家中是極為猛烈的致死毒藥。若是皮膚體表接觸，通常不致於產生太嚴重的傷害，但是食用或皮下肌肉注射巴拉乂，致死性是極高的，而且目前沒有效的治療。目的與目標：不論是口服或皮下肌肉注射，誤用巴拉乂都會造成嚴重的死亡，所以如何治療這群病人，方能挽救他們於死亡的陰影，對於臨床醫師而言是一大挑戰。材料與方法：本文描述一位於雙前臂皮下注射巴拉乂自殺的病人，到院後立即實行左上肢肘上截肢手術與右前臂注射部位清創手術，並於術後接受血液灌洗治療與抗發炎藥物 (cyclophosphamide, prednisolone)、抗氧化藥物 (Vitamin E)治療。結　果：病人於術後第十天，因持續惡化的腎功能與肺纖維化而導致死亡。結　論：在給予治療前，務必收集好各項臨床證據，以佐證病人是使用何種毒物與如何使用。當確認皮下注射或肌肉注射巴拉乂後，手術治療的決定務必及時，且須徹底執行，因為這不但能阻止毒物的持續吸收，也或許是挽救病人生命的最後一道防線。