“蜜蜂蜇伤导致严重过敏”的文章爆款，符合《指南》吗？

这两天，一篇题为《北京医生“垂死一刻自救经历”刷爆朋友圈！转发可救人一命！》的文章被广泛转发。...

其实这篇文章里写的就是蜜蜂蜇伤导致的严重过敏（过敏性休克、喉头水肿），应该如何急救。我对文章有些不同的看法，还好，我认识作者，和他聊了两句：



大家做做选择题吧：

不知道您选的哪些答案，我们先看看ERC（欧洲复苏委员会）有关过敏性休克的急救指南吧。如果您英文好，可以指出我翻译的错误，如果您中文好可以找出我翻译的问题
：

Recognition of an anaphylaxis

识别严重过敏

Patients can have either an airway and/or breathing and/or circulation problem:患者会出现，气道、呼吸和循环方面的问题：

Airway problems 气道问题

• Airway swelling, e.g., throat and tongue swelling (pharyngeal/laryngeal oedema).气道水肿，比气道和舌头肿胀（喉头水肿）

• Hoarse voice.声音嘶哑

• Stridor.哮鸣音

Breathing problems 呼吸问题

• Shortness of breath. 呼吸困难

• Wheeze. 喘

• Confusion caused by hypoxia. 缺氧导致的神志不清

• Respiratory arrest.呼吸暂停

• Life-threatening asthma with no features of anaphylaxis can be

triggered by food allergy. 食物引发的致命性哮喘可能没有严重过敏的表现

Circulation problems 循环问题

• Pale, clammy. 苍白，湿冷

• Tachycardia. 心动过速

• Hypotension. 低血压

• Decreased conscious level. 意识水平下降

•Myocardial ischaemia and electrocardiograph (ECG) changes even in individuals with normal coronary arteries. 冠状动脉正常的患者出现心肌缺血和心电图改变

• Cardiac arrest. 心跳骤停

Circulation problems (often referred to as anaphylactic shock) can be caused by direct myocardial depression, vasodilation and capillary leak, and loss of fluid from the circulation. Bradycardia is usually a late feature, often preceding cardiac arrest. 循环问题（通常是说过敏性休克）是由于直接的心肌抑制、血管扩张、毛细血管渗漏、液体损失的原因造成。心动过缓往往是晚期表现，通常是心跳骤停的前兆。

Skin and, or mucosal changes 皮肤和粘膜的变化

These should be assessed as part of the exposure when using the ABCDE approach. 当评估患者使用ABCDE流程时，评估到暴露的时候可以看到

• They are often the first feature and present in over 80% of anaphylaxis cases. 皮肤和粘膜的变化往往是80%严重过敏的首发表现

• They can be subtle or dramatic. 皮肤和粘膜的变化可能是缓慢的，也可能是急速的

• There may be just skin, just mucosal, or both skin and mucosal changes any where on the body. 可能仅仅是皮肤，也可能仅仅是粘膜，也可能都有，可以在身体的任何部位。

• There may be erythema, urticaria (also called hives, nettle rash, weals or welts), or angioedema (eyelids, lips, and sometimes in the mouth and throat). 可能有红斑，荨麻疹，或血管神经性水肿（眼睑，嘴唇，有时在口腔和喉咙）。

Most patients who have skin changes caused by allergy do not go on to develop anaphylaxis. 大多数因过敏引起皮肤变化的患者不会继续发生过敏反应。

Treatment of an anaphylaxis

治疗严重过敏Use an ABCDE approach to recognise and treat anaphylaxis. Treat life-threatening problems as you find them. The basic principles of treatment are the same for all age groups. All patients who have suspected anaphylaxis should be monitored (e.g., by ambulance crew, in the emergency department etc,) as soon as possible. Minimal monitoring includes pulse oximetry, non-invasive blood pressure and 3-lead ECG. 使用ABCDE的方法识别和治疗严重过敏。当发现有威胁生命的问题的时候，立即进行处理。对于所有年龄的患者治疗的原则是一致的。所有怀疑会发生严重过敏的患者，都应该立即开始严密监护（比如：救护人员、急诊室内）。至少要监护：血氧饱和度、非侵入式血压、三导心电图监护。

Patient positioning 患者的体位

Patients with anaphylaxis can deteriorate and are at risk of cardiac arrest if made to sit up or stand up. All patients should be placed in a comfortable position. Patients with airway and breathing problems may prefer to sit up as this will make breathing easier. Lying flat with or without leg elevation is helpful for patients with a low blood pressure (circulation problem). 严重过敏的患者如果取坐位或者站立位，会随时出现心跳骤停。所以，必须让他们采取最舒服的姿势休息。有气道和呼吸问题的患者应该坐位，因为这样有助于呼吸。对于低血压（循环问题）的患者，应该平躺，并抬高或者不抬高下肢。

Remove the trigger if possible 去除过敏因素

Stop any drug suspected of causing anaphylaxis. Remove the stinger after a bee sting. Early removal is more important than the method of removal. Do not delay definitive treatment if removing the trigger is not feasible. 立即停止一切可能导致严重过敏产生的药物。去除蜜蜂的毒刺。早期去除比去除方法更重要。如果去除过敏因素不现实，立即开始确定性治疗。



AHA的HS课程里建议去除毒刺的方法

Cardiorespiratory arrest following an anaphylaxis 严重过敏导致的呼吸心跳骤停

Start cardiopulmonary resuscitation (CPR) immediately and follow current guidelines. Prolonged CPR may be necessary. Rescuers should ensure that help is on its way as early advanced life support (ALS) is essential. 立即开始心肺复苏，心肺复苏的时间应该延长。急救者一定要确保高级救援人员已经在路上，因为高级生命支持十分重要。

Airway obstruction 气道梗阻

Anaphylaxis can cause airway swelling and obstruction. This will make airway and ventilation interventions (e.g., bag-mask ventilation, tracheal intubation, cricothyroidotomy) difficult. Call for expert help early. 严重过敏患者会气道肿胀或气道梗阻。这会导致通气（球囊面罩、气管插管、环甲膜切开）困难

Drugs and their delivery 药物的应用

Adrenaline (epinephrine) 肾上腺素

Adrenaline is the most important drug for the treatment of anaphylaxis. Although there are no randomised controlled trials, adrenaline is a logical treatment and there is consistent anecdotal evidence supporting its use to ease breathing and circulation problems associated with anaphylaxis. As an alpha-receptor agonist, it reverses peripheral vasodilation and reduces oedema. Its beta-receptor activity dilates the bronchial airways, increases the force of myocardial contraction, and suppresses histamine and leukotriene release. There are beta-2 adrenergic receptors on mast cells that inhibit activation, and so early adrenaline attenuates the severity of IgE-mediated allergic reactions. Adrenaline seems to work best when given early after the onset of the reaction but it is not without risk, particularly when given intravenously. Adverse effects are extremely rare with correct doses injected intramuscularly (IM). 肾上腺素是治疗严重过敏反应最重要的药物。尽管没有随机对照试验，但肾上腺素是一种合理的治疗方法，并且有一致的证据支持其用于缓解与严重过敏反应相关的呼吸和循环问题。 作为α受体激动剂，它可以逆转外周血管舒张，减轻水肿。 其β受体活性扩张支气管气道，增加心肌收缩力，抑制组胺和白三烯释放。 肥大细胞上存在抑制活化的β-2肾上腺素能受体，因此早期肾上腺素减弱了IgE介导的过敏反应的严重程度。在反应开始后早期给予肾上腺素似乎效果最好，但并非没有风险，特别是静脉注射时。 肌肉注射正确剂量（IM）时，副作用极为罕见。

Adrenaline should be given to all patients with life-threatening features. If these features are absent but there are other features of a systemic allergic reaction, the patient needs careful observation and symptomatic treatment using the ABCDE approach. 对于有所有致命性表现的患者都必须给予肾上腺素。如果没有那些严重过敏的表现，也要使用ABCDE的流程严密监护和系统性治疗。

Intramuscular (IM) adrenaline. 肌肉注射肾上腺素

The intramuscular (IM) route is the best for most individuals who have to give adrenaline to treat anaphylaxis. Monitor the patient as soon as possible (pulse, blood pressure, ECG, and pulse oximetry). This will help monitor the response to adrenaline. The IM route has several benefits: 肌肉注射肾上腺素。肌肉注射是针对严重过敏症患者使用肾上腺素的最佳途径。尽早的监护患者（脉搏、血压、心电、血氧）。这些指标可以用来观察患者对肾上腺素的反应。肌肉注射有如下好处：

• There is a greater margin of safety. 安全范围更大。

• It does not require intravenous access.不需要静脉通路

• The IM route is easier to learn. 肌肉注射容易学会

The best site for IM injection is the anterolateral aspect of the middle third of the thigh. The needle for injection needs to be long enough to ensure that the adrenaline is injected into muscle. The subcutaneous or inhaled routes for adrenaline are not recommended for the treatment of anaphylaxis because they are less effective than the IM route. 最佳的肌肉注射位置是大腿中间三分之一的前外侧。针头的长度要确保肾上腺素可以注射到肌肉内。皮下和吸入的方式不如肌肉注射有效。

Adrenaline IM dose. 肾上腺素肌肉注射剂量

The evidence for there commended doses is weak. Doses are based on what is considered to be safe and practical to draw up and inject in an emergency. (The equivalent volume of 1:1000 adrenaline is shown in brackets) 具体注射剂量的推荐证据不强。但是基于紧急情况下安全和实用的原则制定的。（括号中显示的为1：1000肾上腺素的等效体积）

[list][*]>12 years and adults 大于12岁的患者: 500ug IM (0.5 ml)

[/*][*]>6–12 years 6-12岁的患者: 300ug IM (0.3 ml)

[/*][*]>6 months–6 years 6个月到6岁的患者: 150ug IM (0.15 ml)

[/*][*]

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