7¬“µâ“πæ‘… Ò
‚´‡¥’¬¡‰π‰µ√å∑(Sodium nitrite)
√Õß»“ µ√“®“√¬å𓬷æ∑¬å«‘π—¬ «π“πÿ°Ÿ≈
¿“§«‘™“Õ“¬ÿ√»“ µ√å
§≥–·æ∑¬»“ µ√å‚√ß欓∫“≈√“¡“∏‘∫¥’ ¡À“«‘∑¬“≈—¬¡À‘¥≈
¬“µâ“πæ‘… ”À√—∫¿“«–æ‘…‡©’¬∫æ≈—π®“°‰´¬“‰π¥å (cyanide poisoning) ‰¥â·°à ‚´‡¥’¬¡‰π‰µ√å∑ (sodium
nitrite) ‰Œ¥√Õ°‚´‚§∫“≈“¡’π (hydroxocobalamin) ·≈–‚§∫Õ≈Õ’¥‘‡∑µ (cobalt edentate) π—Èπ ‚´‡¥’¬¡‰π‰µ√å∑
∂◊Õ‰¥â«à“‡ªìπ¬“∑’Ë¡’°“√„™â¡“π“π∑’Ë ÿ¥ ª√– ∫°“√≥å¢Õß°“√„™â¬“™π‘¥π’È¡’¡“°°«à“¬“µ—«Õ◊ËπÊ ∂÷ß·¡â«à“®–‡ªìπ
¬“Õ—πµ√“¬∑’ËÕ“®®–°àÕ„À⇰‘¥º≈Õ—π‰¡àæ÷ߪ√– ߧ剥⠷µàÀ“°„™âÕ¬à“ß∂Ÿ°µâÕß·≈–‡À¡“– ¡·≈â«‚´‡¥’¬¡‰π‰µ√å∑
®—¥«à“‡ªìπ¬“∑’Ë¡’ª√– ‘∑∏‘¿“楒„π°“√√—°…“¿“«–æ‘…‡©’¬∫æ≈—π¢Õ߉´¬“‰π¥å ‚¥¬‡©æ“–„™â√à«¡°—∫‚´‡¥’¬¡
‰∏‚Õ´—≈‡øµ
‚´‡¥’¬¡‰π‰µ√å∑ ‡ªìπ “√Õπ‘π∑√’¬å¡’ Ÿµ√‡§¡’ Na2NO
2 “√≈–≈“¬ “√‰π‰µ√å∑„™â‡ªìππÈ”¬“ ”À√—∫·™à‡§√◊ËÕß
¡◊Õ·æ∑¬å‡æ◊ËÕªÑÕß°—π π‘¡ ®÷߇ªìπ¬“∑’Ë “¡“√∂‡µ√’¬¡‡Õ߉¥âßà“¬ ·≈–¡’√“§“∑’ˉ¡à·æ߇¡◊ËÕ‡∑’¬∫°—∫‰Œ¥√Õ°‰´‚§-
∫“≈“¡’π
‡¿ —™«‘∑¬“·≈–‡¿ —™®≈π»“ µ√å
¢∫«π°“√À“¬„®‚¥¬„™âÕÕ° ‘́‡®π (aerobic respiration) ¢Õ߇´≈≈凰‘¥¢÷Èπ„π‰¡‚µ§Õπ‡¥√’¬ (mitochondria)
¢∫«π°“√À“¬„®‚¥¬„™âÕÕ°´‘‡®ππ’ÈÕ“»—¬°“√‡§≈◊ËÕπ¬â“¬Õ‘‡≈Á°µ√Õπ (electron transportation) √–À«à“߉´‚µ‚§√¡
ÕÕ°´‘‡¥ (cytochrome oxidase) ∑”„À≥âæ≈—ßß“π∑’Ë®—¥‡°Á∫„π√Ÿªæ—π∏–øÕ ‡øµ∑’ˇ√’¬°«à“ ç‡Õ∑’æ’ (ATP, adenosine
triphosphate) ‚§√ß √â“ߢÕ߉´‚µ‚§√¡ÕÕ°´‘‡¥ π—Èπ¡’Õ–µÕ¡‡À≈Á°∑’Ë¡’ª√–®ÿ‡ªìπ∫«° “¡ (Fe3+) ´÷Ë߇√’¬°«à“
ç‡øÕ√å√‘° (ferric)é Õ¬Ÿà
‰´¬“‰π¥å´÷Ëß¡’ Ÿµ√‡§¡’§◊Õ CN ‡ªìπ‚¡‡≈°ÿ≈¢π“¥‡≈Á° ‡¡◊ËÕ “√‰´¬“‰π¥å‡¢â“ Ÿà√à“ß°“¬ ®÷ß “¡“√∂‡¢â“‰ª
„πÕÕ√å°“‡π≈¢Õ߇´≈≈åµà“ßÊ ¢Õß√à“ß°“¬‰¥â¥’ ‚¥¬ “¡“√∂‡¢â“‰ª∂÷ß„π‰¡‚µ§Õπ‡¥√’¬ ·≈–‡π◊ËÕß®“°‰´¬“‰π¥å
“¡“√∂®—∫°—∫‡À≈Á°„π√Ÿª¢Õ߇øÕ√å√‘°‰¥â¥’ ‡¡◊ËÕ‡¢â“‰ª„π‰¡‚µ§Õπ‡¥√’¬ ‰´¬“‰π¥å¡—°®—∫°—∫‰´‚µ‚§√¡ÕÕ°´‘‡¥
¡’º≈„À⢗¥¢«“ߢ∫«π°“√‡§≈◊ËÕπ¬â“¬Õ‘‡≈Á°µ√Õπ ´÷ËßÀ¡“¬∂÷ߢ∫«π°“√À“¬„®‚¥¬„™âÕÕ°´‘‡®π≈¥≈ß ‡π◊ÈÕ‡¬◊ËÕ„π
√à“ß°“¬®÷߉¡à “¡“√∂„™âÕÕ° ‘́‡®π‰¥âµ“¡ª°µ‘ ‡°‘¥‡ªìπ¿“«–∑’ˇ√’¬°«à“ ç°“√¢“¥ÕÕ° ‘́‡®π„π√–¥—∫‡´≈≈å (histotoxic
hypoxia)é
“√‚´‡¥’¬¡‰π‰µ√å∑¡’§ÿ≥ ¡∫—µ‘‡ªìπ “√ÕÕ°´‘‰¥´å (oxidizing agent) ‡¡◊ËÕ©’¥‡¢â“À≈Õ¥‡≈◊Õ¥¥”®–
oxidize ‡À≈Á°„πŒ’‚¡‚°≈∫‘π´÷Ëß¡’ª√–®ÿ∫«° Õß (Fe2+) ∑’ˇ√’¬°«à“‡øÕ√å√— (ferrus) „À⇪ìπ‡øÕ√å√‘°∑’Ë¡’ª√–®ÿ∫«° “¡
(Fe3+) ¡’º≈„À⌒‚¡‚°≈∫‘π„π‡¡Á¥‡≈◊Õ¥·¥ß‡ª≈’ˬπ‡ªìπ‡¡∏Œ’‚¡‚°≈∫‘π (methemoglobin) ´÷Ëß “¡“√∂®—∫°—∫ “√
‰´¬“‰π¥å‰¥â¥’ °≈“¬‡ªìπ‰´¬“‚π‡¡∏Œ’‚¡‚°≈∫‘π (cyanomethemoglobin) ¡’º≈„À≴‚µ‚§√¡ÕÕ° ‘́‡¥ „π‰¡‚µ§Õπ‡¥√’¬
8 ¬“µâ“πæ‘… Ò
‡ªìπÕ‘ √–·≈–‡´≈≈å¡’°“√À“¬„®‚¥¬„™âÕÕ°´‘‡®πµ“¡‡¥‘¡µ“¡√Ÿª∑’Ë 1
√Ÿª∑’Ë 1 · ¥ß°≈‰°°“√‡°‘¥æ‘…¢Õ߉´¬“‰π¥å·≈–°≈‰°°“√·°âæ‘…¢Õß‚´‡¥’¬¡‰π‰µ√å∑
πÕ°®“°°≈‰°¢â“ßµâπ·≈â« ‚´‡¥’¬¡‰π‰µ√å∑¡’°≈‰°°“√ÕÕ°ƒ∑∏‘ÏÕ◊Ëπ‚¥¬ºà“π∑“߉πµ√‘°ÕÕ°‰´§å (nitric
oxide) ‡π◊ËÕß®“°‰π‰µ√å∑‡ªìπ “√µ—Èßµâπ (precursor) ¢Õ߉πµ√‘°ÕÕ°‰´§å ́ ÷Ëß¡’º≈„ÀâÀ≈Õ¥‡≈◊Õ¥·¥ß¢¬“¬µ—« ∑”„Àâ
¡’‡≈◊Õ¥·≈–ÕÕ°´‘‡®π Ÿà‡´≈≈å‡æ‘Ë¡¢÷Èπ
¢âÕ∫àß„™â
1. „™â√—°…“¿“«–æ‘…‡©’¬∫æ≈—π¢Õ߉´¬“‰π¥å ‚¥¬„™â√à«¡°—∫‚´‡¥’¬¡‰∏‚Õ´—≈‡øµ (sodium thiosulfate)
¬°‡«âπ °√≥’¿“«–æ‘…‡©’¬∫æ≈—π¢Õ߉´¬“‰π¥å∑’ˇ°‘¥®“°°“√ Ÿ¥¥¡§«—πæ‘…®“°°“√‡º“‰À¡â (smoke inhalation)
2. Õ“®®–„™â‡æ◊ËÕ√—°…“¿“«–æ‘…‡©’¬∫æ≈—π¢Õ߉Œ‚¥√‡®π´—≈‰øµå ¿“¬„π 30 π“∑’·√°¢Õß°“√‡°‘¥æ‘…
¢âÕÀâ“¡„™â
1. ºŸâªÉ«¬¡’√–¥—∫‡¡∏Œ’‚¡‚°≈∫‘π Ÿß (¡“°°«à“√âÕ¬≈– 40) √à«¡¥â«¬µ—Èß·µà°àÕπ°“√√—°…“¥â«¬‚´‡¥’¬¡
‰π‰µ√å∑
2. ¿“«–µàÕ‰ªπ’È ‰¡à∂◊Õ«à“‡ªìπ¢âÕÀâ“¡ ¡∫Ÿ√≥å·µàµâÕß√–¡—¥√–«—߇ªìπ摇»…
2.1 ºŸâªÉ«¬¡’¿“«–§«“¡¥—π‚≈À‘µµË” À√◊Õ™ÁÕ§ ‡π◊ËÕß®“°‚´‡¥’¬¡‰π‰µ√å∑Õ“®®–∑”„À⧫“¡¥—π
‚≈À‘µµË”¡“°¢÷Èπ
2.2 ¡’¿“«–§“√å∫Õπ¡ÕπÕÕ°‰´§å‡ªìπæ‘…√à«¡¥â«¬ ‡π◊ËÕß®“°°“√„Àâ‚´‡¥’¬¡‰π‰µ√å∑°àÕ„À⇰‘¥
¿“«–‡¡∏Œ’‚¡‚°≈∫‘ππ’‡¡’¬ (methemoglobinemia) ´÷Ëß∑”„Àâ°“√¢π àßÕÕ°´‘‡®π‰ª¬—߇π◊ÈÕ‡¬◊ËÕµà“ßÊ ≈¥≈ß
9¬“µâ“πæ‘… Ò
¿“«–Õ—π‰¡àæ÷ߪ√– ߧ宓°¬“
1. À“°‚´‡¥’¬¡‰π‰µ√å∑∑’Ë„ÀⷰຟâªÉ«¬‡Àπ’ˬ«π”„À⌒‚¡‚°≈∫‘π‡ª≈’ˬπ‡ªìπ‡¡∏Œ’‚¡‚°≈∫‘π¡“°‡°‘π‰ª
®–∑”„À⇰‘¥Õ—πµ√“¬·°àºŸâªÉ«¬‰¥â ¢π“¥¬“∑’Ë·π–π”¡—°®–‡Àπ’ˬ«π”∑”„À⇰‘¥‡¡∏Œ’‚¡‚°≈∫‘π√âÕ¬≈– 8-15 ‡∑à“π—Èπ
√–¥—∫‡¡∏Œ’‚¡‚°≈∫‘π∑’Ë Ÿß√à«¡°—∫‰´¬“‰π¥å‡ÕßÕ“®∑”„À⺟âªÉ«¬¡’¿“«–æ√àÕßÕÕ° ‘́‡®π√ÿπ·√ß®πÕ“®∑”„À⇠’¬™’«‘µ‰¥â
2. °“√∫√‘À“√¬“‚´‡¥’¬¡‰π‰µ√å∑“ßÀ≈Õ¥‡≈◊Õ¥¥”‡√Á«‡°‘π‰ª Õ“®∑”„À⧫“¡¥—π‚≈À‘µµ°‰¥â
3. Õ“°“√ª«¥»’√…– §≈◊Ëπ‰ â À—«„®‡µâπ‡√Á«·≈–‡Àß◊ËÕÕÕ°¡“° æ∫‰¥âπâÕ¬„πºŸâªÉ«¬∑’ˉ¥â√—∫¬“ ∫“ߧ√—Èß
√à«¡°—∫¿“«–§«“¡¥—π‚≈À‘µµË”≈ß
ªØ‘°‘√‘¬“µàÕ¬“Õ◊Ëπ
1. À“°¡’√–¥—∫·Õ≈°ÕŒÕ≈å„π‡≈◊Õ¥ À√◊Õ„™â¬“¢¬“¬À≈Õ¥‡≈◊Õ¥™π‘¥Õ◊Ëπ√à«¡¥â«¬ ®–∑”„À⧫“¡¥—π
‚≈À‘µµË”≈ß¡“°
2. °“√∫√‘À“√¬“‡¡∏‘≈’π∫≈Ÿ (methylene blue) ‡¡◊ËÕ‡°‘¥¿“«–‡¡∏Œ’‚¡‚°≈∫‘ππ’‡¡’¬ ®“°¬“‚´‡¥’¬¡‰π‰µ√å∑
®–∑”„À⇰‘¥¿“«–æ‘…‡©’¬∫æ≈—π¢Õ߉´¬“‰π¥å°≈—∫¡“„À¡à ®÷߉¡à§«√∫√‘À“√¬“‡¡∏‘≈’π∫≈Ÿ√à«¡°—∫¬“‚´‡¥’¬¡‰π‰µ√å∑
¢π“¥·≈–«‘∏’ „™â
°“√√—°…“¿“«–æ‘…‡©’¬∫æ≈—π¢Õ߉´¬“‰π¥å¥â«¬¬“‚´‡¥’¬¡‰π‰µ√∑å „™â√à«¡°—∫¬“‚´‡¥’¬¡‰∑‚Õ´—≈‡øµ
‚¥¬©’¥‚´‡¥’¬¡‰∑‚Õ´—≈‡øµ µ“¡À≈—߬“‚´‡¥’¬¡‰π‰µ√∑剥â∑—π∑’
1. ºŸâ„À≠à
¢π“¥ 300 ¡‘≈≈‘°√—¡ (10 ¡‘≈≈‘≈‘µ√¢Õß “√≈–≈“¬ 3% ‚´‡¥’¬¡‰π‰µ√å∑) ©’¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”
„π‡«≈“¡“°°«à“ 3-5 π“∑’
2. „π‡¥Á°
¢π“¥ 10 ¡‘≈≈‘°√—¡/°‘‚≈°√—¡ À√◊Õ 0.33 ¡‘≈≈‘≈‘µ√/°‘‚≈°√—¡¢Õß “√≈–≈“¬ 3% ‚´‡¥’¬¡‰π‰µ√å∑
·µà‰¡à§«√¡“°°«à“ 10 ¡‘≈≈‘≈‘µ√ (300 ¡‘≈≈‘°√—¡) ©’¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”
πÕ°®“°π—Èπ§«√µ√«®√–¥—∫Œ’‚¡‚°≈∫‘π·≈–ª√—∫¢π“¥¬“µ“¡Œ’‚¡‚°≈∫‘𠵓¡µ“√“ߢâ“ß≈à“ßπ’È
Œ’‚¡‚°≈∫‘π
°√—¡/‡¥´‘≈‘µ√
7
8
9
10
11
12
13
¢π“¥¬“ 3% ‚´‡¥’¬¡‰π‰µ√å∑
¡‘≈≈‘°√—¡/°‘‚≈°√—¡
5.8
6.6
7.5
8.3
9.1
10.0
10.8
¢π“¥¬“ 3% ‚´‡¥’¬¡‰π‰µ√å∑
¡‘≈≈‘≈‘µ√/°‘‚≈°√—¡
0.19
0.22
0.25
0.27
0.30
0.33
0.36
10 ¬“µâ“πæ‘… Ò
‡¡◊ËÕ„À⬓‚´‡¥’¬¡‰π‰µ√å∑·≈⫧«√µ“¡¥â«¬¬“‚´‡¥’¬¡‰∏‚Õ —́≈‡øµ‡ ¡Õ ¬“¡—°®–ÕÕ°ƒ∑∏‘χµÁ¡∑’Ë¿“¬„π
30 π“∑’ À≈—ß®“° 30 π“∑’‰ª·≈â« À“°¬—߉¡à‡ÀÁπ°“√µÕ∫ πÕßÕ“®æ‘®“√≥“„Àâ´È”Õ’°§√÷ËßÀπ÷ËߢÕß¢π“¥‡√‘Ë¡µâπ
Õ’° 1§√—Èß
√Ÿª·∫∫¢Õ߬“
“√≈–≈“¬ 3% ‚´‡¥’¬¡‰π‰µ√å∑À≈Õ¥≈– 10 ¡‘≈≈‘≈‘µ√ (30 ¡‘≈≈‘°√—¡/ ¡‘≈≈‘≈‘µ√) º≈‘µ‚¥¬ ∂“π‡ “«¿“
¿“°“™“¥‰∑¬
‡Õ° “√ª√–°Õ∫°“√‡√’¬∫‡√’¬ß
1. WHO: Antidotes and other substances used in poisonings. 2008. Chapter:4. WHO Model Formulary. Page
65-66. www.who.int/selection_medicines/list/WMF2008.pdf Date accessed:07/12/2009
2. US DHHS: Medical Management Guidelines for Hydrogen Cyanide. 2007. Medical Management Guidelines
page12,18. http://www.atsdr.cdc.gov/MHMI/mmg8.html Available from:14/12/2009
3. Holdstege CP, Isom GE, Kirk, MA. Cyanide and hydrogen sulfide. In: Flomenbaum NE, Goldfrank LR,
Hoffman RS, Howland MA, Lewin NA, Nelson LS, eds. Goldfrankû toxicologic emergencies.8th ed. New York:
McGraw-Hill; 2006:p1712-24.
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Phillips SD, Donovan JW, eds. Critical care toxicology: Diagnosis and management of the critically poisoned
patient. Philadelphia: Mosby Inc;2005:p987-98.
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NA, Nelson LS, eds. Goldfrankû toxicologic emergencies.8th ed. New York: McGraw-Hill; 2006:p1725-27.
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toxicology: Diagnosis and management of the critically poisoned patient. Philadelphia: Mosby Inc; 2005:
p1539-42.
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McGraw-Hill;2007:p484-5.
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Thai 1992;75:304-309.