การสังเกตสีช่วยอะไรได้เยอะครับ
ศูนย์รับแจ้งเหตุ แจ้งว่าพลเมืองดีพบพระหมดสติ มีอาการเกร็งกระตุก เลือดออกจากปาก ชาวบ้านนั่งประคองกันอยู่ในร้านค้า จึงส่ง EMS advance team ไปรับและนำส่งโรงพยาบาล พบว่าไม่ตอบสนองต่อเสียงเรียก, ไม่ลืมตา, ยังหายใจได้เอง มีเลือดที่มุมปากเล็กน้อย HR 64/min, BP 140/90 mmHg ค้นในย่ามพบยาเม็ดกลม สีเหลือง จำนวน 20 เม็ด จึงนำส่งโรงพยาบาล
แรกรับที่ ER , E1M3V1 , pupil - pinpoint , secretion ปริมาณมาก, เหงื่อแตกทั้งตัว เจาะ DTX 116 mg % , พบลักษณะคล้ายเกร็ง ๆ กระตุกเล็กน้อยทั่วทั้งตัว ภายหลังจากให้ Valium ใส่ ET tube แล้ว อาการเกร็งดีขึ้น , ใส่ NG tube ไม่ได้ coffee ground แต่ได้ลักษณะเป็น ข้าวต้มสีฟ้า (ไม่ใช่ที่ซื้อจากร้านสีฟ้านะครับ) 10 นาที ต่อมามีอาการเกร็ง ๆ กระตุกเห็นเป็นลักษณะกล้ามเนื้อพริ้ว (muscle fasciculation) อีกครั้ง
ลักษณะแบบนี้พอจะนึกออกมั้ยครับ ว่าควรคิดถึงการได้รับสารพิษตัวใด?
นอกจากใช้ลักษณะกลุ่มอาการทางพิษวิทยา (Toxidrome) ช่วยในการวินิจฉัย Cholinergic syndrome ซึ่งที่พบบ่อยในต่างจังหวัดบ้านเราก็เป็น organophosphate หรือ carbamate แล้ว สิ่งที่พบคือ สีฟ้า จากการล้างท้องช่วยได้มากครับ เพราะสันนิษฐานไว้ได้ก่อนเลยครับ ว่าน่าจะเป็น Lannate (กลุ่ม Carbamate)
ผล lab ก็ยืนยันวินิจฉัยนะครับ ส่ง serum cholinesterase ได้ค่าต่ำกว่าปกติมาก
แม้จะเป็นพระ แต่ก็มีโอกาส suicide ได้เช่นกัน (ถามประวัติเรื่องจิตเวช ย้อนไปก็พบว่า มีประวัติ รักษา schizophrenia อยู่ครับ)
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