一个可能挽救生命的错误:无意中高剂量的上腺素在过敏引起的心脏骤停;一个病例报告
Felix Patricius Hans1, Leo Benning2, Jan-Steffen Pooth2
1University Emergency Department, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany. Felix.Hans@uniklinik-freiburg.de.
International journal of emergency medicine
|June 29, 2024
概括
在过敏反应相关的心脏骤停期间涉及10倍上腺素剂量的医疗错误意外导致了令人震惊的节律和患者的生存率. 这一案例突出了沟通失败以及重症监护错误的潜在好处.
科学领域:
- 紧急医疗 紧急医疗
- 关键的护理关键的护理
- 医疗错误分析 医学错误分析
背景情况:
- 心肺复苏 (CPR) 对紧急医疗服务至关重要,但高风险事件挑战提供者.
- 机组人员资源管理和人为错误科学旨在提高高压情况下的性能.
- 医疗错误发生,需要一个无责文化,以持续改进.
研究的目的:
- 在过敏反应相关的心脏骤停期间报告严重的医疗错误.
- 分析错误的处理及其意想不到的有利结果.
- 讨论关键护理的沟通,协议和错误管理的影响.
主要方法:
- 病例报告:由于化疗诱导的过敏反应引起的非医院性心脏骤停.
- 由于通信和标准化问题,患者通过中央静脉口接受了10倍剂量的上腺素 (10毫克).
- 对心律的监测,对心转变/除的反应,以及自发循环的恢复.
主要成果:
- 患者的非震动节律转换为无脉动心室动心,然后心室,在上腺素过量后.
- 成功的心脏转换和除导致在6分钟内恢复自发循环.
- 患者在没有神经缺陷的情况下存活下来,尽管在药物后出现了严重的低血压.
结论:
- 通信失败和协议偏差可能会产生严重后果,正如在上腺素过量时所见的那样.
- 错误可能无意中通过诱导可震动的节律和抵消血管来挽救患者.
- 高剂量的上腺素可能会避免在患有晚期恶性瘤的患者中终止复苏.
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