Obere gastrointestinale Blutung mit hämorrhagischem Schock am Ende einer Urlaubsreise: Präklinische und innerklinische Versorgung eines gastrointestinalen Notfalls

Zusammenfassung

Nach der Rückkehr aus dem Urlaub wurde ein 55-jähriger Patient mit Teerstuhl und hämorrhagischem Schock im Zugabteil eines InterCity der Deutschen Bahn notfallmedizinisch versorgt und in ein Krankenhaus der Maximalversorgung eingeliefert. Hier erfolgte zunächst die weitere notfallmedizinische Behandlung, in deren Rahmen in der internistischen Notaufnahme in interdisziplinärer Zusammenarbeit eine Stabilisierung der Hämodynamik sowie die Sicherung der Atemwege und Atemfunktion erfolgten. Anschließend wurde eine Notfall-Endoskopie des oberen Gastrointestinaltrakts durchgeführt. Ursächlich für das hämorrhagische Schockgeschehen war eine arteriell spritzende, endoskopisch nicht zu stillende Blutung im Duodenum. Die definitive Blutungsstillung gelingt schließlich im Rahmen einer notfallmäßigen Laparatomie. Durch ein an die Versorgung traumatologischer Patienten angelehntes, aber für gastroenterologische Patienten mit Schockgeschehen nicht regelhaft vorhandenes Schockraum-Management konnte im vorliegenden Falle eines hochgradig instabilen Patienten durch die spontane Übernahme von etablierten Algorithmen aus der interdisziplinären Versorgung von Trauma-Patienten eine adäquate Kreislaufstabilisierung sowie Blutungskontrolle erreicht werden. Auch wenn ein Großteil der oberen gastrointestinalen Blutungen spontan sistieren, sollte wie für hier berichtete internistische Notfälle mit hämorrhagischem Schockgeschehen eine notfallmedizinische Versorgung nach Algorithmen entwickelt und implementiert werden. Am vorliegenden Fall wird ein mögliches beispielhaftes Vorgehen diskutiert sowie ein Vorschlag für ein mögliches Schockraum-Protokoll für diese Patientengruppe entwickelt.

Abstract

Upon returning from holidays, a 55-year-old patient presenting with melena and haemorrhagic shock was admitted to a University hospital after receiving first emergency medical care in a German InterCity train. In an interdisciplinary effort, haemodynamics were stabilised and the airway and respiratory function were secured. Under emergency care conditions the patient then underwent an emergency upper GI endoscopy where a spurting arterial upper gastrointestinal bleeding (Forrest 1a) was found. While the bleeding could not be controlled with endoscopic techniques, definitive haemostasis was achieved with a surgical laparotomy. While not commonly established for patients with severe GI bleeding, by spontaneous implementation of an interdisciplinary trauma room approach following established trauma algorithms the team was able to achieve stabilisation of vital functions and final control of bleeding in this highly unstable patient. Although the majority of upper gastrointestinal bleedings spontaneously cease, emergency care algorithms should be developed and implemented for patients with severe gastrointestinal bleedings in shock. Following the case vignette, we discuss a potential approach and develop an exemplary protocol for shock room management in this patient subgroup.

Schlüsselwörter

obere gastrointestinale Blutung - hämorrhagischer Schock - Schockraum - Notfallendoskopie

Key words

upper gastrointestinal bleeding - haemorrhagic shock - shock room - emeregency endoscopy

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