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病例报告:因不当使用某类中成药导致的意外乌头碱中毒。

Case report: Accidental aconitine poisoning caused by the inappropriate use of a type of Chinese patent medicine.

作者信息

Shang Ruikai, Liu Hongyu, Tian Qiaoxin, Liu Yuru, Jian Xiangdong, Li Qilu

机构信息

Department of Occupational and Environmental Health, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.

Department of Poisoning and Occupational Diseases, Emergency Medicine, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Shandong University, Jinan, Shandong, China.

出版信息

Front Pharmacol. 2025 Jan 9;15:1426006. doi: 10.3389/fphar.2024.1426006. eCollection 2024.

Abstract

BACKGROUND

Compound schizonepeta fumigation lotion is a type of Chinese patent medicine for external use. It has the effect of dispelling wind, eliminating dampness, reducing swelling, and relieving pain. Clinically, it is used for anal fumigation and treatment of external hemorrhoids, anal fissures, and other diseases. Aconitum species are widely used in the field of traditional Chinese medicine. However, improper use and overdose can easily cause acute poisoning, leading to malignant arrhythmias, cardiogenic shock, and even death.

METHODS

This study retrospectively analyzed the clinical data of eight patients who were treated in our hospital from June 2023 to February 2024 after taking compound schizonepeta fumigation lotion by mistake.

CASE PRESENTATION

We report 8 cases of patients who took compound schizonepeta fumigation lotion by mistake. Most patients were illiterate and older, and poisoning was attributed to the misuse of an external drug. The affected patients exhibited different degrees of arrhythmia, with 2 receiving tracheal intubation, assisted ventilation, and hemoperfusion. Finally, all patients were clinically cured and subsequently discharged.

CONCLUSION

A considerable number of accidental aconitine poisoning cases were reported over a short period, alerting clinicians to their growing incidence. Meanwhile, when prescribing medications, clinicians must provide clear instructions on proper usage and ensure that patients strictly adhere to the dosage and administration guidelines outlined in the drug instructions. Additionally, patients should be informed that any errors in medication administration require urgent medical attention. Health professionals should aim to improve public understanding of safe medication practices, promote health literacy.

摘要

背景

复方荆芥熏洗剂是一种外用中成药。具有祛风、除湿、消肿、止痛的作用。临床上用于肛门熏蒸及治疗外痔、肛裂等疾病。乌头属植物在中药领域应用广泛。然而,使用不当和过量容易导致急性中毒,引发恶性心律失常、心源性休克,甚至死亡。

方法

本研究回顾性分析了2023年6月至2024年2月在我院误服复方荆芥熏洗剂的8例患者的临床资料。

病例介绍

我们报告了8例误服复方荆芥熏洗剂的患者。大多数患者为文盲且年龄较大,中毒原因是外用药物使用不当。受影响的患者出现了不同程度的心律失常,2例接受了气管插管、辅助通气和血液灌流。最后,所有患者均临床治愈并随后出院。

结论

在短时间内报告了相当数量的意外乌头碱中毒病例,提醒临床医生其发病率在不断上升。同时,在开药时,临床医生必须提供关于正确用法的明确说明,并确保患者严格遵守药品说明书中规定的剂量和给药指南。此外,应告知患者任何用药错误都需要紧急就医。卫生专业人员应致力于提高公众对安全用药做法的认识,促进健康素养。

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