Unklare akute Kreislaufinstabilität nach Stromunfall: eine (un-)gewöhnliche Komplikation

Zusammenfassung

Kritisch kranke Patienten können aufgrund unterschiedlicher Krankheitsbilder eine akute hämodynamische Instabilität entwickeln. Die Diagnostik und Therapie ist insbesondere dann erschwert, wenn die eigentliche Ursache der Kreislaufinstabilität von Begleiterkrankungen maskiert wird. Wir berichten über einen Patienten, der auf der Schwerverbrannten-Intensivstation wenige Tage nach einem schweren Stromunfall eine akute Kreislaufinstabilität zunächst unklarer Genese entwickelte.

Abstract

First aid and treatment of burn patients pose a challenge to responsible physicians. Primary assessment should include an evaluation of the degree and extent of the burn injuries as well as a physical examination for other trauma injuries and trauma caused by the inhalation of toxic agents. One should focus on removal of the burning source, preservation of body temperature, sterile coverage of the burnt areas, pain management and sufficient hemodynamic stabilization. Grade IIb and more severe burns are most likely subject to surgical intervention to assure sufficient healing. Our case report illustrates a burn patientʼs initial treatment and clinical course, which includes the development of an acute pulmonary embolism with severe hemodynamic instability. As other critically ill patients, burn patients are at particular risk for complications like infections or other causes for hemodynamic instability. Every cardiovascular event is possibly suspicious for acute pulmonary arterial embolism (PAE). A high or increasing gap between expiratory and arterial CO₂ tension accompanied by typical symptoms like tachycardia and hypotension or respiratory distress may be caused by PAE. An echocardiogram can provide information about possible pathophysiological changes typical for PAE, nevertheless, CT-angiography is todayʼs clinical gold standard for the diagnosis of PAE. As therapeutic measures, heparin should be administered, and thrombolysis should be considered in case of persisting hemodynamic instability, attentively taking possible contraindications into account.

Schlüsselwörter

Verbrennung - akute Kreislaufinstabilität - Lungenarterienembolie

Key words

burn injury - acute hemodynamic instability - pulmonary arterial embolism

• Literatur

• 1 Gianfaldoni R, Gianfaldoni S, Lotti J. et al. The importance of first aid to burned patients: 30 years of experience at the Burns Centre in Pisa. Open Access Maced J Med Sci 2017; 5: 420-422 doi:10.3889/oamjms.2017.131
• 2 Fadeyibi IO, Ibrahim NA, Mustafa IA. et al. Practice of first aid in burn related injuries in a developing country. Burns 2015; 41: 1322-1332 doi:10.1016/j.burns.2015.02.018
• 3 Deutsche Gesellschaft für Verbrennungsmedizin e.V. (DGV). AWMF Sk2-Leitlinie „Behandlung thermischer Verletzungen des Erwachsenen“. 2018. AWMF Registernummer 044-001. Im Internet: https://www.awmf.org/leitlinien/detail/ll/044-001.html Stand: 14.12.2019
• 4 Timmermann A, Byhahn C, Wenzel V. et al. Handlungsempfehlung für das präklinische Atemwegsmanagement. Notfallmed up2date 2012; 7: 105-120 doi:10.1055/s-0032-1314951
• 5 Van Marcke C, Daoudia A, Penaloza A. et al. CO₂ measurement for the early differential diagnosis of pulmonary embolism-related shock at the emergency department: A case series. Respir Med Case Rep 2015; 16: 106-108 doi:10.1016/j.rmcr.2015.09.004
• 6 Konstantinides SV, Torbicki A, Agnelli G. et al. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2014; 35: 3033-3069 3069a–3069k doi:10.1093/eurheartj/ehu283
• 7 Dewachter L, Dewachter C. Inflammation in right ventricular failure: does it matter?. Front Physiol 2018; 9: 1056 doi:10.3389/fphys.2018.01056
• 8 Huang W, Goldberg RJ, Anderson FA. et al. Secular trends in occurrence of acute venous thromboembolism: the Worcester VTE study (1985–2009). Am J Med 2014; 127: 829-839.e5 doi:10.1016/j.amjmed.2014.03.041
• 9 Tagalakis V, Patenaude V, Kahn SR. et al. Incidence of and mortality from venous thromboembolism in a real-world population: the Q-VTE Study Cohort. Am J Med 2013; 126: 832.e13-832.e21 doi:10.1016/j.amjmed.2013.02.024
• 10 Oger E. Incidence of venous thromboembolism: a community-based study in Western France. EPI-GETBP Study Group. Groupe dʼEtude de la Thrombose de Bretagne Occidentale. Thromb Haemost 2000; 83: 657-660
• 11 Andersson T, Soderberg S. Incidence of acute pulmonary embolism, related comorbidities and survival; analysis of a Swedish national cohort. BMC Cardiovasc Disord 2017; 17: 155 doi:10.1186/s12872-017-0587-1
• 12 Wilkens H, Held M. Lungenarterienembolie: Status 2018. Dtsch Arztebl 2018; 115: 8 doi:10.3238/PersPneumo.2018.06.15.002
• 13 Goldhaber SZ, Bounameaux H. Pulmonary embolism and deep vein thrombosis. Lancet 2012; 379: 1835-1846 doi:10.1016/S0140-6736(11)61904-1
• 14 Hecker M, Sommer N, Hecker A. et al. Lungenembolie. Med Klin Intensivmed Notfmed 2016; 111: 163-175 doi:10.1007/s00063-015-0114-z
• 15 Schellhaass A, Walther A, Konstantinides S. et al. The Diagnosis and Treatment of Acute Pulmonary Embolism. Dtsch Arztebl Int 2010; 107: 589-595 doi:10.3238/arztebl.2010.0589
• 16 Konstantinides SV, Torbicki A, Agnelli G. et al. 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2014; 35: 3033-3080 doi:10.1093/eurheartj/ehu283
• 17 Dudzinski DM, Giri J, Rosenfield K. Interventional treatment of pulmonary embolism. Circ Cardiovasc Interv 2017; 10: pii:e004345 doi:10.1161/CIRCINTERVENTIONS.116.004345
• 18 Gille J, Fischer H, Willms-Jones J-C. Versorgung von Brandverletzten. Notfallmed 2012; 7: 29-44 doi:10.1055/s-0031-1298245