·世界全科医学工作瞭望·
【译者按】在公共场合如果你听到“这里有没有医生”，如果你是全科医生，那么就是再好不过的志愿者了。全 科医生的整体人诊治原则，把症状翻译成疾病的能力，以及初级保健的第一接触特征，恰好适合这种紧急情况。Murtagh 教授在这个案例中还提示我们，常识并非是正确的。给急症患者吸氧似乎是个医学常识，但并非真理，呼吸性碱中毒的患者恰恰要减少过度换气增加二氧化碳的吸入。Murtagh 教授还指出，所有的医务人员都应该具有快速识别和正确处理紧急情况的能力，这应该成为医学教育和培训中必不可少的内容。 澳大利亚John Murtagh 全科病案研究（二十八）
John Murtagh （著），杨辉（译）
作（译）者单位：3165澳大利亚维多利亚州，澳大利亚Monash 大学
【关键词】 碱中毒，呼吸性；急救 【中图分类号】R 589.6 【文献标识码】B 【文章编号】1007-9572（2010）09-2855-02迷宫式油封
变径套
1 故事的开始
“这是机长向您广播，请问乘客中有没有医生？”这个广 播是我在飞机上听到的，当时我正乘坐澳大利亚航空公司的班机，飞向另外一个城市。听到这个广播之前，我已经注意到机舱的中部有些骚乱。我很好奇到底发生了什么，不过我还是坐在座位上，心想说不定这架飞机上还有其他的乘客也是医生呢。过了一会儿，机舱乘务员告诉大家情况已经得到了控制，一位乘客是很有经验的男护士，他去照看了那位出问题的老年女乘客。男护士说，“很显然嘛，她是癫痫发作”。
不过五分钟之后，那位乘务员来到我的座位前，跟我说那位乘客还是没有得到控制，变得更加焦躁不安。显然，乘务员已经从乘客资料中发现了我是一名医生。乘务员和我一起走到那位乘客旁边，跟我说，“我想她可能是中风了，你看她想站起来走，可是又站不起来，她的手也不听使唤”。我看了看这位乘客，看上去她在“抽搐”，神志还清楚，只不过表现得非常焦躁不安。我检查了她的手，她的双手在不停颤抖，手腕关节呈扭曲状态，手指向外张开（不包括掌骨指骨关节），拇指强有力地内收。
2 问题（1）你的初步诊断是什么？（2）你应该问患者什么问题？
（3）你应该采取哪些简单的应急措施？（4）怎样从生理学上解释这种疾病？
3 答案
（1）这是腕足痉挛症，是由于焦虑引发的换气过度而形
成的低血钾所造成的。至于这位患者的焦虑症，与她的飞行恐惧症有关。
（2）你可以问患者：①“你的嘴周围和手脚上有没有针扎的感觉？”②“你以前有没有出现过这种情况？”③“你有没有带医生或护士给你的病历资料？”④“你是不是对坐飞机或其他事情感到焦虑？”
（3）你可以告诉这位乘客慢慢地呼吸，或者让她对着纸袋呼吸，或者把手掌弯成杯形后对着手掌呼吸。
（4）从生理学上，这个案例属于呼吸性碱中毒，即身体的酸碱平衡紊乱。换气过度导致二氧化碳排出过多，使H +耗尽，并从血浆蛋白补充。蛋白阴离子不断蓄积，并消耗Ca 2+（阳离子）。Ca 2+的消耗造成低血钙性手足痉挛，重新补充二氧化碳才能恢复酸碱平衡。
4 进一步的病史
痉挛逐渐地放缓了患者的呼吸，并使血液中二氧化碳浓度
缓慢回升。患者告诉我，她的确有手脚和口周针扎样感觉，而且她也确实害怕坐飞机。
她已经80岁了，看上去有病态人格。她把一张纸放在我的手里，那是她的全科医生写的，上面说她患有精神疾病，需要经常服用镇静药。她说自己本不应该乘坐飞机的，只不过这次是要去看望住院的妹妹。
机长过来我，让我一直呆在这位老年女患者的机舱里。机长还问我，是不是应该让飞机掉头飞悉尼。我语气肯定地说，“不用”。可是一会儿，机长却给我接通了美国休斯敦医疗中心的电话，电话那头的美国值班医生似乎并不熟悉腕足痉挛。不管怎么样，飞机还是按预定计划飞向目的地，机舱里发生的这件事件的结果还让每个人都感到满意的。
5 从案例中学到的
在遇到紧急情况的时候，最重要的是了解和把握这个情况
金属型铸造机
的含义，所谓的紧急情况并非都是复杂的或难以处理的，往往紧急情况的诊断很简单，而且处置方法也很简单。
我因公务经常乘坐飞机，已经有6次被机长或乘务员叫去处理换气过度或手腕痉挛的乘客。我曾经遇到乘务员给患者戴上氧气面罩，但殊不知这样做适得其反，患者是二氧化碳排出过多，而不是吸入氧气不够，所以乘务员在帮倒忙，加重了症状并导致患者失去知觉。
在我遇到的情况中，患者涉及各种年龄，从儿童到老人，还有临盆的产妇，以及其他焦虑症导致的问题。记得我还在农村当全科医生的时候，曾接到一个高山滑雪场打来的紧急电话，说一个年轻的妇女病得很严重，据说是神经损伤。人们把
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她从滑雪场的空中吊椅上放下来，然后用了6个小时转送到我的诊所。结果发现这是因为她遇到了一个令人讨厌的性要求，而导致了手腕痉挛。给这个患者的处理方法很简单，就是让她放慢呼吸速度。这种简单而有效的处理紧急事件的方法，让在场的急救人员感到很尴尬。
投币器很多紧急情况是通过电话告诉医生的，在这种情况下，我经常会多问一些问题，多询问相关的症状。就在最近，一个痛苦的男患者冲进我的诊所，也是腕足痉挛，究其原因，是因为上班路上的交通严重拥堵把他“吓住了”。恐慌症和恐怖事件真的很折磨人。
译者注：（1）过度换气：可以是躯体疾病、心理问题、环境变化的表现。从心理上看，心理问题如焦虑和恐慌会造成过度换气。从精神病学上，癔病发作的患者也会过度换气。从生理上看，甲亢、发热、脑炎脑膜炎、脑肿瘤、脑血管意外和颅脑损伤的患者、水杨酸中毒的患者等也会过度换气。这个症状也会在妊娠妇女中出现。从环境上看，初进高原的人也会有同样问题。
（2）呼吸性碱中毒：最典型的临床表现是呼吸快而浅，或者间断性叹息样呼吸。患者主诉包括头痛、头晕和精神症状。口周和四肢麻木和针刺感，是血清Ca2+过低引起的神经末梢感觉异常。在躯体表现上，可能出现抽搐、痉挛。医生也可以用手用力压迫患者上臂静脉，使手部供血减少，以观察是否能诱发腕痉挛。如果患者在急救车或医院中，可以做血气分析
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Fits，Faints and Funny Turns；Here，There and Everywhere
John Murtagh
"This is the captain speaking.Is there a doctor on board the aircraft？".This is the not unfamiliar request that I heard when I was flying between two capital cities on a Qantas flight at about the time I had become aware of a commotion accompanied by a flurry of activity in the main cabin.Although one is curious to find out what it is all about I was apprehensive about coming forward and waited a⁃while in the hope that another doctor（if any）would volunteer.Then we were informed by the flight attendant that the situation was under control.An experienced male nurse was attending to an elderl
拉线护套y fe⁃male passenger who apparently was having a seizure-diagnosed by the nurse as some form of epilepsy.
However after5minutes or so the attendant，who must have i⁃dentified me as a doctor，requested me to attend the woman who was not under control and was becoming more agitated.When I reached her side the passenger alongside her said"I think she has had a stroke because she went to walk but couldn′t and cannot use her hands".I could see that she was′fitting′，was conscious but very restless and anxious.Inspection of her shaking hands revealed flexion of the wrists，extended fingers（except at the metacarpopha⁃langeal joints）which were joined together with strongly adducted thumbs.
Questions
（1）What is your provisional diagnosis？（2）What questions would you ask the person？（3）What simple first aid action would you undertake？（4）What is the physiological explanation of the condition？
Answers
（1）This is carpopedal spasm due to hypocalcaemia secondary to hyperventilation associated with anxiety.This anxiety is turn in this person is related to aviatophobia（the fear of flying）.（2）Do you have pins and needles in your hands and feet and around your mouth？Have you experienced anything like this before？Do you have with you a letter or information from a doctor or nurse a⁃bout your medical history？Do you feel anxious about flying or about anything else？（3）Instruct the person to take slow deep breaths and or get her to do this into a paper bag or into her cupped hands.（4）The basic problem is respiratory alkalosis which disturbs the body′s acid-base balance.Carbon dioxide loss from hyperventila⁃tion shifts the chemical equation to the left so that H+is depleted and replenished from plasma protein.Protein anions accumulate and take up calcium（a cation）.Thus ionised calcium is depleted cau⁃sing hypocalcaemic tetany.Replenishing carbon dioxide restores the acid-base equilibrium.
Further history
The spasm attack gradually abated with slowing of respirations and rebreathing her carbon dioxide.She acknowledged that she did have′pins and needles′in her hands，feet and perioral area and that she did have an anxiety with flying.
She was80years old and it was apparent that she had a per⁃sonality disorder.She handed me a note from her general practitioner indicating that she had a psychiatric disorder and took tranquilisers on a regular basis.She admitted that she should not be flying but wanted to visit her sister who was in hospital.
In the meantime the Captain requested my presence in the cab⁃in and asked if he should divert the plane to Sydney.I responded with an emphatic′no′but then found myself speaking to a medical centre in Texas where the doctor on duty did not seem to have a clear understanding of carpopedal spasm syndrome.However we continued the flight and everyone seemed happy with the outcome. Lessons to be learned
It is important to be mindful of this somewhat dramatic′emer⁃gency′especially as it is so simply diagnosed and treated.I have been called6times to help with the situation of hyperventilation and carpopedal spasm during air travel.It is not unusual to find the flight attendants giving the sufferers oxygen by mask-a treatment which aggravates the problem leading to unconsciousness.I have also en⁃countered it in all ages from children to the aged and in childbirth and other anxiety provoking circumstances.I recall one occasion in my rural practice where we received a call from a ski resort where a young woman was very sick with a so called neurological condi⁃tion.It took6hours to transfer
her from the mountain via a chair lift to our medical centre.She had carpopedal spasm brought on by an unwelcome sexual advance.There was great embarrassment when the attack was simply aborted by rebreathing her expired breath.Now I always ask for more information and symptoms since the condition can be diagnosed over the telephone.Only recently a distressed man rushed into our clinic with carpopedal spasm because he became′spooked′by the heavy traffic on his way to work.Panic disorder and panic attacks are terrible afflictions.
（收稿日期：2010-08-06）
（本文编辑：闫行敏）
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澳大利亚John Murtagh全科病案研究(二十八)——痉挛、晕倒、奇怪的事，这里、那里、到处都有
作者：John Murtagh， 杨辉
作者单位：3165澳大利亚维多利亚州，澳大利亚Monash大学
刊名：防火拉链
中国全科医学
英文刊名：CHINESE GENERAL PRACTICE
年，卷(期)：2010,13(25)
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