Acute poisoning patients account for 15% ~ 20% in emergency rescue, and as high as 25% ~ 50% in primary medical units. Acute organophosphorus poisoning (AOPP) still ranks first, and it is on the rise in recent years. For patients with oral poisoning, gastric lavage is the first choice and important link in the treatment of AOPP, and its correct implementation sometimes determines the success or failure of rescue. With the deepening of clinical research on AOPP, great changes have taken place in gastric lavage. This article reviews the implementation and nursing of AOPP gastric lavage in recent years.

1 implementation of gastric lavage

1. 1 gastric lavage

After long-term gastric lavage with plenty of warm water, it is found that hyponatremia is a common complication of gastric lavage, which can further cause hypotonic encephalopathy and endanger life. Its pathogenesis is: (1) gastric lavage with a large amount of water in a short time, and poisoning by absorbing a large amount of water; (2) Gastric lavage leads to sodium loss, and fasting leads to reduced intake; (3) Dehydration and diuresis promote sodium excretion; (4) With the increase of extracellular fluid volume, the renin-angiotensin-aldosterone system was inhibited and sodium excretion increased; (5) Due to the supplement of a large number of hypotonic fluids, blood sodium is scarce. Fan Huoqin and Chen used self-made physiological saline as gastric lavage fluid, and clear water as gastric lavage fluid. It was found that there was significant difference in the incidence of hyponatremia between the two groups 3 hours after gastric lavage. Gastric lavage with normal saline can reduce the incidence of hyponatremia, thus reducing hospitalization time and mortality. Chen Zongyuan and others used the same method for gastric lavage to compare the effects of two gastric lavage methods on blood pressure. It is found that gastric lavage with normal saline can also effectively reduce the decrease of arterial pressure before and after gastric lavage. Some scholars added 0.00 1% and 0.008% norepinephrine to normal saline gastric lavage. Compared with normal saline gastric lavage, it is found that adding norepinephrine can effectively reduce gastric mucosal bleeding and complications, and there is no significant difference in the concentration of norepinephrine and norepinephrine in reducing gastric mucosal bleeding. Zuo Xiaolan and Jiang Genshen also reported that washing gastric juice with 0.00 1% and 0.008% norepinephrine saline can effectively reduce the further absorption of toxic substances by the stomach, and has no adverse effects on the patient's blood pressure, heart rate and urine volume. At present, gastric lavage with normal saline instead of water has become a trend in clinic.

1.2 Insertion method of gastric tube

Gastric lavage is the key to the treatment of AOPP, and rapid and effective insertion of gastric tube is the key to gastric lavage. At present, there are two main methods to insert gastric tube: oral intubation and nasal intubation.

1.2. 1 oral intubation

Oral intubation is divided into conscious patients and coma patients.

1.2. 1 Most conscious patients can cooperate with intubation and insert a gastric tube while swallowing. When someone intubates, let the patient insert warm water into the mouth together with the stomach tube, which not only increases the disposable insertion rate, but also increases the comfort of the patient and reduces complications. Zhang Zhiying fed the patient warm water when inserting the gastric tube into the throat for 5 ~ 7 cm, and quickly inserted the gastric tube with the help of its normal swallowing action. It can reduce the chance of stomach tube mistakenly entering trachea and reduce the occurrence of asphyxia and aspiration pneumonia.

1.2. 1.2 There are many intubation methods for coma patients. Someone exposed the pharynx and esophagus with a laryngoscope, then put a guide wire in the trachea catheter, inserted it into the esophagus, pulled it out, coated the stomach tube with paraffin oil, and inserted it into the stomach through the trachea catheter. However, Zhang Xiaobin and others think that if the glottis can be seen clearly, the laryngoscope can be directly inserted into the trachea through the glottis, and then inserted into the gastric tube along the tracheal catheter, and it is difficult for the inserter to be guided by a hard guide wire; If it is difficult to see the glottis clearly, you should insert the glottis blindly. After inserting 20 ~ 25 cm, observe whether there is gas flowing out and judge whether it is inserted into the stomach. They believe that the advantage of using direct laryngoscope is the high success rate of intubation under direct vision. Even if it enters the trachea, it can keep the tracheal tube for artificial ventilation, and then insert the gastric tube, which will not interfere with each other and save the rescue time. In addition, the prone intubation method is designed by taking advantage of the characteristics of large tongue drop and oral obstruction when comatose patients are prone, which can improve the success rate of intubation once and alleviate the pain of patients.

1.2.2 nasal cannula In recent years, more and more scholars have reported the use of nasal cannula. For conscious patients, first insert through one nostril, and if there is resistance, insert through the other nostril. When reaching the throat, the patient who requires cooperation swallows and quickly inserts the gastric tube to the required length. For comatose or uncooperative patients, the head leans back. When the gastric tube is inserted into epiglottis (15cm), the patient's head is lifted to make the mandible close to the sternal stalk, and then it is slowly inserted to the required length. They think that gastric lavage via nasal cannula has the following advantages: (1) conscious patients rarely cause malignant vomiting; (2) The oral secretion is obviously reduced; (3) The gastric tube is relatively easy to fix; (4) Nurses don't need to fix the stomach tube and the tooth pad by hand, which reduces the labor intensity; (5) During gastric lavage, medical staff can communicate with patients by language; (6) Forced gastric lavage can be used; (7) You can leave the tube for a long time.

1.3 Insertion length of gastric tube

Generally, the insertion length of gastric tube is 45 ~ 45~55cm, but this length only reaches the cardia or the body of the stomach, not the lower part of the stomach, and the toxins in the stomach cannot be completely washed out. Jin Liping et al. adopted the method of inserting 40~70cm, and thought that the poison on the mucosa of the middle and lower esophagus could be sucked out at the above 40 ~ 70cm, and then moved down to the top of the gastric tube to reach the antrum at the 70cm, and the lateral holes of the gastric tube were all in the stomach, so that the gastric lavage fluid flowed out smoothly, the gastric lavage time was shortened, and the damage to the gastric mucosa was obviously alleviated.

During gastric lavage 1.4 posture

Most scholars lie on their left side, constantly changing their postures during gastric lavage and cooperating with abdominal massage, so that the poison attached to the stomach wall can be easily mixed with gastric lavage fluid and sucked out. Dong Shuhong and others adopt the left lateral position with head down and feet high, and think that the great curvature of the stomach is located on the left side and the direction of water flow is always the same, which can fully relieve the poison on the stomach wall and make gastric lavage more thorough.

1.5 times and methods of gastric lavage

Jia Xiaojun et al. found that after indwelling catheter, they used gastric lavage machine to rinse 65,438+0 times every 8 ~ 65,438+02h, with 65,438+0,000 ~ 65,438+0,500ml each time. The general extubation time is 24 ~ 48h. Compared with the group without indwelling catheter, the atropinization amount, atropinization time and hospitalization time of the former were significantly reduced. The former also has obvious advantages in the influence of rebound, intermediate syndrome and death number. After routine gastric lavage, Xiu et al. indwelling gastric tube, then injecting normal saline, connecting negative pressure device for drainage, using pesticide quick test card for qualitative analysis every 4 hours, and gastric lavage for positive patients until negative. Compared with routine gastric lavage, the difference is obvious. It is considered that intermittent repeated gastric lavage combined with gastrointestinal negative pressure drainage can effectively remove gastrointestinal toxins in time, improve the success rate of rescue, reduce mortality and shorten hospitalization time. Intermittent off-line gastric lavage in Jin Liping can not only reduce the amount and time of gastric lavage, but also prevent vomiting during gastric lavage, which is worth popularizing.

2 Nursing care of gastric lavage

2. 1 Nursing of body position during gastric lavage

For conscious patients, if they feel uncomfortable, they can change their posture. During gastric lavage, always press the stomach counterclockwise with moderate force to avoid impact pressing and squeezing when the machine "enters the stomach"; When blood pressure is stable, you can often change your position. For comatose patients, we should always observe the oral secretions of patients, change the body position in time to reduce or reduce the interference to the airway, and avoid excessive secretions blocking the airway. Be prepared for the rescue with foresight. If you have respiratory failure, you should use tracheal intubation for mechanical ventilation in time. If the patient is fidgeting, a restraint belt should be used to prevent him from falling out of bed.

2.2 Observation and nursing of ventilation and breathing during gastric lavage

During gastric lavage with mechanical ventilation, the tracheal catheter should be fixed well, and the balloon pressure is slightly higher than that when only tracheal intubation is done. After gastric lavage, the balloon pressure should be reduced to 15 ~ 25 cmH2O. In order to reduce the formation of sputum scab after long-term use of mechanical ventilation, Wang Wei and others used wetting solution: 20ml of physiological saline, 5mg of α -chymotrypsin and 80,000 U of gentamicin, humidified every 1min/time, 3 ~ 5 ml each time. All patients with AOPP are in danger, so we should pay attention to the changes of breathing. It has been observed that short-term and high-dose application of pralidoxime easily leads to respiratory inhibition and stop, so special attention should be paid to the changes of respiratory rhythm and frequency.

2.3 Nursing care of nervous system symptoms during gastric lavage

After gastric lavage, patients may have symptoms of central nervous system such as dizziness, headache, irritability, ataxia and mental disorder, which may lead to coma and death. Sedatives can be used to rule out atropine poisoning. If the patient has listlessness, lethargy, pallor, bad habits, vomiting, etc. It can't be simply thought that it is caused by poisoning itself. It should be considered that hyponatremia after gastric lavage with plenty of clear water will further lead to hypotonic encephalopathy. The solution is gastric lavage with normal saline.

2.4 Diet care after gastric lavage

The rebound of organophosphorus pesticide poisoning is related to the eating time, and it is reasonable to eat after 48 hours of poisoning. For poisons with a long half-life, such as dimethoate and parathion, the fasting time should be appropriately extended and eaten after 72 hours. In the early stage, you should eat foods with high calories and vitamins, but not foods with high protein, high fat and high sugar.

2.5 Observation and nursing care of rebound and intermediate syndrome after gastric lavage

The patient's poisoning symptoms were obviously improved and his consciousness was clear. Suddenly the condition deteriorates sharply, and those who have symptoms of poisoning again are called "rebound". Its occurrence is mainly related to the "intestinal-hepatic circulation" of organophosphorus pesticides. Tang Xiongxiu and others think that intermittent repeated gastric lavage combined with negative pressure drainage can reduce the occurrence of rebound and intermediate syndrome. The main reasons are: (1) prolonging the gastric lavage time to ensure the continuous elimination of poisons not sucked out of the original gastrointestinal tract; (2) Blocking enterohepatic circulation. Therefore, it is necessary to closely observe the patient's condition changes during the recovery period to prevent the premature or rapid use or withdrawal of atropine drugs. Ning and Cen Kong Lan believe that the key to the rescue of intermediate syndrome is to closely observe the condition, emphasizing the dynamic observation of pupil, heart rate and cholinesterase activity. At the same time, we should pay attention to the occurrence of respiratory failure, the main complication of intermediate syndrome. Once respiratory arrest occurs, tracheal intubation should be used to assist breathing.

Psychological care of patients with AOPP: Most scholars believe that patients with AOPP have hidden reasons, they don't cooperate with treatment, or they are afraid of gastric lavage. Therefore, correct psychological counseling is necessary. It is necessary to clearly introduce the necessity and importance of various treatments, so that patients can achieve psychological adaptation in a short time; Encourage patients to talk and keep patients' privacy; For penniless emergency patients, good doctor-patient communication should be realized. It is also an important part to save people first and then talk about economic problems and get the cooperation of family members.

2.6 The use of atropine is related to gastric lavage.

Intravenous injection of atropine is an important measure to rescue AOPP. The traditional administration of atropine is intravenous injection of atropine 5 ~ 10 mg for 5 ~ 10 min until atropine is transformed. Its disadvantages are heavy nursing workload and poor accuracy. At the same time, intravenous injection can lead to instantaneous high blood concentration, and patients are prone to excessive atropine performance, which interferes with the diagnosis of the disease. Therefore, in recent years, many domestic scholars use micropump to inject atropine, which is divided into two stages: intravenous injection and maintenance, and adjust the speed of infusion pump according to the doctor's advice. Compared with the control group, there was no atropine poisoning or excessive performance in the treatment group, and the success rate of rescue was significantly improved. Its advantages are saving medical resources, reducing work intensity, improving the accuracy of treatment, and avoiding mistreatment and overdose.