1、第第6 6章章 窒息性毒剂窒息性毒剂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 member
2、s.Oct 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 chlorin
3、e,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 21,2007:A pi
4、ckup 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,killing 2 policemen an
5、d 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 bombs,one containing chlorine,a
6、imed 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 at a military checkpoint near Baghdad,k
7、illing 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 Diyala province,killing 32 people and injuring 50.M
8、ay 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 noxious cloud of chlorine gas that sickened at least 62 so
9、ldiers but caused no serious injuries.June 15,2004Fuzhou1.Introduction2.Representatives3.Physicochemical characteristics4.Toxicity5.Mechanism of toxicity6.Clinical effects7.Diagnosis&differential diagnosis8.medical managementContents1.Introduction2.Representatives3.Physicochemical characteristics4.T
10、oxicity5.Mechanism of toxicity6.Clinical effects7.Diagnosis&differential diagnosis8.medical managementContents窒息性毒剂亦称肺刺激剂(lung irritants)，是一类损伤呼吸道，引起急性中毒性肺水肿，导致急性缺氧和窒息的化学战剂。IntroductionConceptionu光气于1812年由John Davy首次合成u氯气在一战中交战双方都大量使用u光气首次战场使用：德国1915年12月于凡尔登(Verdun)；后来双方都使用(36600 吨,80%死于肺水肿)u二战中除日本针
11、对中国外，没有使用u美国在朝鲜战争中使用(1951,Nampo,1379 中毒,480 死亡).现已无库存History/Military Relevance1.Introduction2.Representatives3.Physicochemical characteristics4.Toxicity5.Mechanism of toxicity6.Clinical effects7.Diagnosis&differential diagnosis8.medical managementContentsPhosgeneu Chemical industry foam plastic(iso
12、cyanates)herbicides,pesticides dyes USA produces over billion pounds per year for industrial useu Burning of plastics carbon tetrachloride methylene chloride(paint stripers)degreasersOthers“dual use agent”Can you imagine?u虽是剧毒气体，但被广泛地应用于化工领域。以光气为基本原料制成的化学品不下上千种，有“工业金矿”之称;u由光气合成的聚碳酸酯是一种性能优良的无毒工程塑料，是五
13、大工程塑料中唯一具有良好透明性的产品，汽车的车窗、洗衣机的内缸、电脑的外壳，甚至超音速飞机的机头都由这种塑料制成的;u此外太阳镜、光盘、台灯、手机、香料、染料光气就是生产它们的最基本原料;u在医药和农药领域：青霉素、紫杉醇和杀虫剂等的生产.PFIB(Perfluoroisobutylene，全氟异丁烯)有机氟聚合物的高温毒性裂解产物u聚四氟乙烯(Polytetrafluoroethylene,“Teflon”)u有很多工业用途uUsed in armored vehicles,aircraft u导致肺水肿，同光气类似1.Introduction2.Representatives3.Physi
14、cochemical characteristics4.Toxicity5.Mechanism of toxicity6.Clinical effects7.Diagnosis&differential diagnosis8.medical managementContentsPhysical Characteristics 1206.9-57128无色或无色或微黄色微黄色液体液体双双光光气气难溶难溶于水，于水，易溶易溶于有于有机溶机溶剂剂63403.5-1268.2烂苹果烂苹果或烂干或烂干草味草味无色气无色气体体光光气气溶解溶解度度挥发度挥发度(mg/1，20)蒸气蒸气比重比重(20)凝固点
15、凝固点（）沸沸 点点（）气味气味状态状态毒毒剂剂名名称称uVery easy to hydrolyze:COCl2+2H2OCO2+2HClChemical Characteristics uStability:CG 150开始分解，800完全分解成CO和Cl2；DP 沸点开始分解，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)with ammonia COCl2+4NH3 O=C(NH2)2+2NH4C
16、l(4)with sodium sulfide COCl2+Na2S 2NaCl+COS(5)with urotropine(hexamine)-protection not antidote COCl2+2(CH2)6N4 COCl2.(CH2)6N42u Very easy to react with alkali:1.Introduction2.Representatives3.Physicochemical characteristics4.Toxicity5.Mechanism of toxicity6.Clinical effects7.Diagnosis&differential
17、 diagnosis8.medical managementContents2022-12-2422n毒 性(光气)u嗅觉阀值：1.5 mg/m3 u粘膜刺激阀值：4 mg/m3uLCt50:3,200 mgmin/m3 u氯气 LCt50:6,000 mgmin/m32022-12-2423光气对人的毒性 浓度（mg/m3）效 应24 可闻到气味 19刺激引起咳嗽 22暴露30min严重中毒 50暴露3060min危及生命 80 暴露12min严重肺损伤 100暴露3060min,50死亡5000暴露5min，23h内全部死亡*我国卫生标准规定：生产场所空气中光气最高允许浓度为0.5 mg/
18、m3 2022-12-2424双光气对人的毒性 浓度（mg/m3）效应 0.41 可闻到气味 40 暴露数秒钟引起明显刺激 160 暴露12min引起严重损伤 250 暴露30min引起死亡 500700 暴露15min引起死亡 1100 暴露5min引起死亡 1.Introduction2.Representatives3.Physicochemical characteristics4.Toxicity5.Mechanism of toxicity6.Clinical effects7.Diagnosis&differential diagnosis8.medical management
19、Contents2022-12-2426uPeripherally acting agents:Phosgene,NOx,and PFIB uCentral acting agents:HCl,NH3O1.Introduction2.Representatives3.Physicochemical characteristics4.Toxicity5.Mechanism of toxicity6.Clinical effects7.Diagnosis&differential diagnosis8.medical managementContentsMild exposure -mild co
20、ugh -dyspnea(呼吸困难)-chest tightness(胸闷)Moderate expoure -above symptoms plus -ocular irritation(眼部刺激)-smoke tobacco produces bad tasteSevere exposure -severe cough,dyspnea(呼吸困难)-onset of pulmonary edema within 4 hours -may produce laryngospasm(喉痉挛)Extreme severe exposure -death almost instantaneous恢复
21、期 中毒轻者经治疗，肺水肿可于发病后24天开始吸收，78天后罗音消失，23周内恢复健康。但仍可有头晕、乏力、食欲不振等后遗症状。刺激期症状（眼和上呼吸道刺激症状）：流泪、咳嗽、胸闷、气促，继之恶心呕吐、头晕、乏力、烦躁不安。体征：眼及咽喉充血，呼吸音粗糙。持续时间：离开毒区12h后可消失。潜伏期 自觉症状好转，但病理过程仍在发展，肺水肿正在逐渐形成，潜伏期越长，中毒越轻；反之则中毒越重。刺激期轻 度中 度重 度潜伏期(h)812h410h16h潜伏期肺水肿期恢复期u呼吸道症状：呼吸浅快，咳嗽，烦躁不安，头晕乏力，恶心呕吐等;u体征：呼吸音减弱，肺底部细湿罗音，或捻发音，X线检查已有肺水肿征象；
22、继之，典型肺水肿症状出现，气喘，呼吸困难，咳嗽频繁，咳出大量粉红色泡沫样痰(一昼夜可达12升)。叩诊肺部呈浊音、鼓音，肺下界降低，心浊音界消失，听诊为满肺干、湿罗音。根据循环系统机能可分为两个阶段：青紫型缺氧期(呼吸性血缺O2)：血O2，皮肤紫绀，但循环机能尚能代偿，血压、脉搏基本正常，神清，肺水肿使CO2排出障碍，血CO32-，导致呼吸性酸中毒；也可因过度换气使CO2排出过多而至呼吸性碱中毒。苍白型缺氧(或休克)期(呼吸+循环性血缺O2)：出现循环衰竭，血压、心率均，皮肤苍白、冷汗、昏迷，血O2及CO2，酮体、乳酸等氧化不全产物蓄积，pH导致代谢性酸中毒。Pulmonary edema(肺肺
23、水肿水肿)Ventilation disturbanceair exchange disorderEarly:(青紫型缺氧期青紫型缺氧期)Late:(苍白型缺氧期苍白型缺氧期)缺氧心肺缺氧组织缺氧酸中毒，水酸中毒，水电解质紊乱电解质紊乱中枢缺氧始兴奋后抑制始兴奋后抑制shock血液浓缩血栓栓塞心肺衰心肺衰竭竭右室负荷 左室负荷 1.Introduction2.Representatives3.Physicochemical characteristics4.Toxicity5.Mechanism of toxicity6.Clinical effects7.Diagnosis&differen
24、tial diagnosis8.medical managementContents2022-12-2437Diagnosis:u中毒史和毒剂侦检:sweet,newly-mown hay odoru临床表现:高浓度时粘膜刺激症状,呼吸困难(dyspnea),迟发的肺水肿(pulmonary edema of delayed onset)chest X-rayu 实验室检查X线检查是早期发现肺水肿和监测肺水肿发展的最好方法，是光气中毒最有意义的临床检验措施。连续X线检查：对中度以上中毒者应争取在中毒后8小时每2小时拍摄X线胸片一张。如果8小时内的胸片均正常，其病情可能较轻。2022-12-24
25、41预后不佳的指征:u中毒后很快出现进行性的缺氧和低血压；u 中毒后4小时内出现肺水肿（死亡的高危因素）l40,malel2h post exposurelmild dyspnealnormal physical examlCXR:normall7h post exposurelmod.dyspnea at restlfew crackleslCXR:mild interstitial edemalsurvivedl42,femalel2h post exposurelrapidly inc.dyspnealCXR:overt edemaldeath 6h post exp.刺激剂：强烈；全身
26、中毒性毒剂：迅速，无潜伏期；糜烂性毒剂：除此之外还有皮肤、全身损伤。1.Introduction2.Representatives3.Physicochemical characteristics4.Toxicity5.Mechanism of toxicity6.Clinical effects7.Diagnosis&differential diagnosis8.medical managementContentsuu Terminate exposure as a vital first measure:脱离毒区 佩戴合适的面具如果衣服及皮肤上有液体毒剂，即刻洗消综合治疗原则：综合治疗原
27、则：二防、二纠、一维持、一控制二防、二纠、一维持、一控制u二防：防治肺水肿，防治休克。u二纠：纠正缺氧，纠正酸中毒。u一维持：维持电解质平衡。u一控制：控制感染。肺水肿发生前：肺水肿发生前：u半卧位安静休息、保温、间歇吸氧u有咳嗽等刺激症状时对症处理：雾化吸入、可待因口服u尽早使用糖皮质激素u颈封u静注高渗糖液肺水肿发生后：肺水肿发生后：u加大给氧量或加压给氧u短程大剂量使用糖皮质激素?u保持呼吸道畅通u限制液体摄入量，适当使用利尿剂其它措施：其它措施：u预防和控制感染u防治呼吸循环衰竭u纠正酸中毒和电解质紊乱u维持心、脑能量供应，增加对缺氧耐受力治疗中注意的问题：1.不给祛痰剂，以免增加咳嗽
28、动作；2.在血液浓缩不明显，无休克征象时，避免输液；3.吗啡、杜冷丁、氯丙嗪和巴比妥类药物可抑制呼吸中枢，避免应用；4.禁做压胸式人工呼吸；5.禁止混合气体吸入，以免刺激呼吸频率和动度；6.乌洛托品对急性光气中毒无治疗作用，临床上不宜使用。2022-12-2451光气中毒救治重点：u严密观察预防肺水肿发生2448hu救治为“综合治疗”重点：氧疗法，特别是加压给O2，提高肺泡内压，对抗肺毛细血管渗透压，增加血O2，防止窒息。大剂量激素应用，降低毛细血管通透性，提高应激能力，提高cAMP酶活力 cAMP2022-12-2452光气中毒综合治疗（上海职防院）：u合理氧疗：不要长时间给高浓度氧（50%
29、）缺氧时可加压给氧（5cmH2O)u激素：早期、足量地塞米松 1080mg/天，重症加量短程35天肺水肿吸收后，改用呼吸道雾化吸入u改善微循环：6542、东莨菪碱、右旋糖酐u抗氧自由基：NAC雾化吸入、或布洛芬、茶碱类吸入u心理治疗2022-12-2453Chlorine浓度 (mg/m3)毒性效应36对眼鼻有一定刺激15刺激上呼吸道90剧咳120180接触3060 min，肺部严重损伤300致命损伤，短时间即可致死2022-12-2454中毒特点：u无潜伏期或潜伏期很短，中毒发展过程快u中毒后鼻、咽、喉及胸骨后有痛感，剧烈咳嗽(氯气样咳嗽）u主要损伤上呼吸道：反射期、肺损 伤期u眼刺激症状明显：结膜炎、角膜炎（瓷眼）u个别有皮肤炎症2022-12-2455全氟异丁烯（PFIB）：u不易被活性炭吸附，具有较好的穿透防毒面具的能力u毒性高，相当于HCN，比光气大约10倍u原料来源丰富u中毒后引起肺水肿，有明显潜伏期2022-12-2456思考题：1.窒息性毒剂在化学战中的地位？2.平时如何做好对光气接触人员的诊治？中毒后如何早期处理？
