背景:心肺复苏是急诊医疗服务的一项关键技能。由于高风险低频事件给提供者带来了巨大的精神负担,船员资源管理的概念,非技术技能和人为错误的科学旨在为高压情况下的医疗保健提供者做好准备。然而,发生医疗错误,组织和机构面临的挑战是提供无责任的错误文化,以通过避免将来的类似错误来实现持续改进。在这种情况下,我们报告了与过敏反应相关的心脏骤停期间的严重医疗错误,它的处理和患者意想不到的但有利的结果。
方法:在因化疗引起的过敏反应引起的院外心脏骤停期间,由于通过中心静脉端口导管在沟通和标准化方面存在缺陷,一名患者接受了10倍剂量的肾上腺素.患者从不可电击的心律转变为无脉室性心动过速,随后转变为心室纤颤。在服用10mg肾上腺素后仅6分钟,患者被心脏复律并除颤,自发循环恢复并伴有严重的低血压。患者存活,没有任何残留物或神经损伤。
结论:此案例证明了沟通中的缺陷和偏离标准协议的潜在有害影响,尤其是在紧急情况下。这里,精确的指示,闭环通信和注射器的明确标签可能会避免这种情况下肾上腺素过量。有趣的是,这个严重的错误可能挽救了病人的生命,因为它导致了可电击节奏的发展。此外,因为患者在服用10毫克肾上腺素后仍处于深度低血压状态,这种高剂量可能抵消了与过敏反应相关的心脏骤停时的严重血管停搏状态.最后,因为病人正在接受晚期恶性肿瘤的治疗,在初次不可电击的心脏骤停中终止复苏的可能性是显著的,并且可能由于用药错误而得以避免.
BACKGROUND: Cardiopulmonary resuscitation is a crucial skill for emergency medical services. As high-risk-low-frequency events pose an immense mental load to providers, concepts of crew resource management, non-technical skills and the science of human errors are intended to prepare healthcare providers for high-pressure situations. However, medical errors occur, and organizations and institutions face the challenge of providing a blame-free error culture to achieve continuous improvement by avoiding similar errors in the future. In this case, we report a critical medical error during an anaphylaxis-associated cardiac arrest, its handling and the unexpected yet favourable outcome for the patient.
METHODS: During an out-of-hospital cardiac arrest due to chemotherapy-induced anaphylaxis, a patient received a 10-fold dose of epinephrine due to shortcomings in communication and standardization via a central venous port catheter. The patient converted from a non-shockable rhythm into a pulseless ventricular tachycardia and subsequently into ventricular fibrillation. The patient was cardioverted and defibrillated and had a return of spontaneous circulation with profound hypotension only 6 min after the administration of 10 mg epinephrine. The patient survived without any residues or neurological impairment.
CONCLUSIONS: This case demonstrates the potential deleterious effects of shortcomings in communication and deviation from standard protocols, especially in emergencies. Here, precise instructions, closed-loop communication and unambiguous labelling of syringes would probably have avoided the epinephrine overdose central to this case. Interestingly, this serious error may have saved the patient\'s life, as it led to the development of a shockable rhythm. Furthermore, as the patient was still in profound hypotension after administering 10 mg of epinephrine, this high dose might have counteracted the severe vasoplegic state in anaphylaxis-associated cardiac arrest. Lastly, as the patient was receiving care for advanced malignancy, the likelihood of termination of resuscitation in the initial non-shockable cardiac arrest was significant and possibly averted by the medication error.