目的分析某电子厂1例洗板工接触清洗剂后死亡的原因。方法对死者工作场所进行现场职业卫生学调查、化学品调查和职业卫生监测,并收集患者发病和治疗等相关资料。结果患者于2011年3月2日开始从事电路板的洗板工作,同月23日开始出现发热、头痛、咽痛、干咳等不适症状,后相继出现全身皮疹(以颜面及双下肢为甚)、肝大、浅表淋巴结肿大、眼黄和尿色深等症状;4月1日出现严重肝功能衰竭及凝血功能障碍、肝性脑病、肝昏迷;2011年4月7日不治身亡。患者生前从事电路板手工洗板工作,每天接触“洗板水”(约20 d),同工种、同样工作环境下仅其1人发病。现场搜集检测的“洗板水”中三氯乙烯、苯、甲苯含量为8.23%、1.27%和1.27%;“清洗剂1025”中三氯乙烯、苯、甲苯含量分别为6.20%、0.95%和0.97%。洗板岗位三氯乙烯CTWA为11.4~15.8 mg/m3。结论该死者因接触含有三氯乙烯的清洗剂而引起职业性三氯乙烯药疹样皮炎。 Objective To analyze the cause of death after a panel washes in contact with a cleaning agent in an electronics factory. Methods On-the-spot occupational hygiene survey, chemical investigation and occupational health monitoring were conducted on the deceased’s workplace, and relevant information on patient’s onset and treatment was collected. Results The patient started to wash the circuit board on March 2, 2011. On the 23rd of the same month, fever, headache, sore throat and dry cough started to appear. After the systemic rash (with facial and lower extremities) appeared successively, Liver, superficial lymph nodes, ocular and urinary symptoms such as dark brown; April 1 serious liver failure and coagulation disorders, hepatic encephalopathy, hepatic coma; April 7, 2011 died. Before his death, the patient was engaged in manual handwashing of the circuit board. Every day he came into contact with the “boardwashing water” (about 20 days), and only one of the same type of workers was exposed to the same work environment. The concentration of trichlorethylene, benzene and toluene in the “wash water” was 8.23%, 1.27% and 1.27%, respectively; the content of trichlorethylene, benzene and toluene in the “cleaning agent 1025” was 6.20% , 0.95% and 0.97% respectively. Trichlorethylene CTWA washing board position 11.4 ~ 15.8 mg / m3. Conclusion The deceased was exposed to occupational trichlorethylene-like dermatitis due to exposure to a cleaning agent containing trichlorethylene.