Gefäßnotfälle im Notarztdienst – Teil 2: rupturiertes Bauchaortenaneurysma und akute Aortendissektion

Zusammenfassung

Im 2. Teil der CME-Fortbildung „Gefäßnotfälle“ werden anhand von Fallbeispielen das rupturierte Bauchortenaneurysma und die akute Aortendissektion besprochen. Zu diesen Themen werden Informationen zu Inzidenz und Ätiologie gegeben und das diagnostische Vorgehen sowie leitlinienkonforme therapeutische Sofortmaßnahmen vorgestellt.

Abstract

Precise information concerning the current incidence of vascular emergencies within the scope of the emergency medical service (EMS) cannot be found in literature. Regardless of this circumstance vascular emergencies have to be treated as soon as possible in any case. Thereby hemorrhage allows no delay in emergency or surgical therapy. Acute vascular occlusions have to be treated within a narrow time frame to avoid unrecoverable tissue damage. Therefore the EMS-physician plays a crucial role for the outcome of patients suffering from vascular emergencies.

The subsequent paper (2nd of 2 parts) pays attention to the disease pattern of ruptured abdominal aortic aneurysm and acute dissection of the aorta and provides information concerning the etiology, incidence and symptoms of those diseases as well as information about the first diagnostic measures and the emergency therapy measures, compliant to the current guidelines. Furthermore additional information concerning the subsequent emergency room treatment and surgical therapy are provided with the objective to enable the EMS-physician to make a timely decision, which capabilities (vascular surgery and/or interventional expertise) the receptive hospital should have in order to provide optimal therapy for the individual patient.

Schlüsselwörter

rupturiertes Bauchaortenaneurysma - akute Aortendissektion - Notarztdienst - Rettungsdienst - Gefäßnotfall

Key words

ruptured abdominal aortic aneurysm - acute dissection of the aorta - emergency physician - rescue service - vascular emergency

• Literatur

• 1 Pongratz J, Reeps C, Eckstein HH. Häufigkeit und Ursachen operationsbedürftiger vaskulärer Komplikationen bei nicht gefäßchirurgischen Patienten. Zentralbl Chir 2011; 136: 485-490 doi:10.1055/s-0030-1247472
• 2 Deutsche Gesellschaft für Gefäßchirurgie und Gefäßmedizin (DGG). Leitlinien zum Bauchaortenaneurysma und Beckenarterienaneurysma. Leitlinie der DGG. Im Internet: http://www.gefaesschirurgie.de/fileadmin/websites/dgg/download/LL_Aneurysmen_Bauch_Becken_2011.pdf Stand: 24.01.2018
• 3 Debus ES, Gross-Fengels W. Operative und interventionelle Gefäßmedizin. Berlin: Springer;; 2012
• 4 Gawenda M, Brunkwall J. Ruptured abdominal aortic aneurysm: the state of play. Dtsch Arztebl Int 2012; 109: 727-732 doi:10.3238/arztebl.2012.0727
• 5 Trenner M, Haller B, Storck M. et al. Trends in patient safety of intact abdominal aortic aneurysm repair: German Registry Data on 36,594 Procedures. Eur J Vasc Endovasc Surg 2017; 53: 641-647 doi:10.1016/j.ejvs.2016.12.024
• 6 Laukontaus SJ, Aho PS, Pettila V. et al. Decrease of mortality of ruptured abdominal aortic aneurysm after centralization and in-hospital quality improvement of vascular service. Ann Vasc Surg 2007; 21: 580-585 doi:10.1016/j.avsg.2007.03.019
• 7 Dutton RP, Mackenzie CF, Scalea TM. Hypotensive resuscitation during active hemorrhage: impact on in-hospital mortality. J Trauma 2002; 52: 1141-1146
• 8 Mapstone J, Roberts I, Evans P. Fluid resuscitation strategies: a systematic review of animal trials. J Trauma 2003; 55: 571-589 doi:10.1097/01.TA.0000062968.69867.6F
• 9 van der Vliet JA, van Aalst DL, Schultze Kool LJ. et al. Hypotensive hemostatis (permissive hypotension) for ruptured abdominal aortic aneurysm: are we really in control?. Vascular 2007; 15: 197-200 doi:10.2310/6670.2007.00028
• 10 Hardy JF, De Moerloose P, Samama M. et al. Massive transfusion and coagulopathy: pathophysiology and implications for clinical management. Can J Anaesth 2004; 51: 293-310 doi:10.1007/BF03018233
• 11 Knapp J, Bernhard M, Rauch H. et al. Anästhesiologisches Vorgehen bei elektiven Eingriffen an der Aorta. Anaesthesist 2009; 58: 1161-1182 doi:10.1007/s00101-009-1630-0
• 12 Deutsche Gesellschaft für Gefäßchirurgie und Gefäßmedizin. Leitlinie Aortale Dissektion (LL Diagnostik und Therapie von Typ B-Dissektionen). (ed. DGG) 2008; 1-21 Im Internet: http://www.gefaesschirurgie.de/fileadmin/websites/dgg/download/LL_Aortendissektion_2011.pdf Stand: 25.01.2018;
• 13 Wilson SK, Hutchins GM. Aortic dissecting aneurysms: causative factors in 204 subjects. Arch Pathol Lab Med 1982; 106: 175-180
• 14 Erbel R. Diseases of the thoracic aorta. Heart 2001; 86: 227-234
• 15 Debus ES. Akutes Aortensyndrom. In: Debus ES, Gross-Fengels W. Hrsg. Operative und interventionelle Gefäßmedizin. Berlin: Springer; 2012: 477-490
• 16 Meszaros I, Morocz J, Szlavi J. et al. Epidemiology and clinicopathology of aortic dissection. Chest 2000; 117: 1271-1278
• 17 Wheat jr. MW, Palmer RF. Dissecting aneurysms of the aorta: present status of drug versus surgical therapy. Prog Cardiovasc Dis 1968; 11: 198-210
• 18 Jex RK, Schaff HV, Piehler JM. et al. Early and late results following repair of dissections of the descending thoracic aorta. J Vasc Surg 1986; 3: 226-237
• 19 Cambria RP, Brewster DC, Moncure AC. et al. Spontaneous aortic dissection in the presence of coexistent or previously repaired atherosclerotic aortic aneurysm. Ann Surg 1988; 208: 619-624
• 20 Svensson LG, Labib SB, Eisenhauer AC. et al. Intimal tear without hematoma: an important variant of aortic dissection that can elude current imaging techniques. Circulation 1999; 99: 1331-1336
• 21 Hagan PG, Nienaber CA, Isselbacher EM. et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 2000; 283: 897-903
• 22 Mehta RH, Manfredini R, Bossone E. et al. The winter peak in the occurrence of acute aortic dissection is independent of climate. Chronobiol Int 2005; 22: 723-729 doi:10.1080/07420520500179605
• 23 Mehta RH, Manfredini R, Bossone E. et al. Does circadian and seasonal variation in occurrence of acute aortic dissection influence in-hospital outcomes?. Chronobiol Int 2005; 22: 343-351
• 24 Mehta RH, Manfredini R, Hassan F. et al. Chronobiological patterns of acute aortic dissection. Circulation 2002; 106: 1110-1115
• 25 von Kodolitsch Y, Csosz SK, Koschyk DH. et al. Intramural hematoma of the aorta: predictors of progression to dissection and rupture. Circulation 2003; 107: 1158-1163
• 26 Ohmi M, Tabayashi K, Moizumi Y. et al. Extremely rapid regression of aortic intramural hematoma. J Thorac Cardiovasc Surg 1999; 118: 968-969
• 27 Muluk SC, Kaufman JA, Torchiana DF. et al. Diagnosis and treatment of thoracic aortic intramural hematoma. J Vasc Surg 1996; 24: 1022-1029
• 28 Nallamothu BK, Mehta RH, Saint S. et al. Syncope in acute aortic dissection: diagnostic, prognostic, and clinical implications. Am J Med 2002; 113: 468-471
• 29 Syed MA, Fiad TM. Transient paraplegia as a presenting feature of aortic dissection in a young man. Emerg Med J 2002; 19: 174-175
• 30 Cambria RP, Brewster DC, Gertler J. et al. Vascular complications associated with spontaneous aortic dissection. J Vasc Surg 1988; 7: 199-209
• 31 Suzuki T, Katoh H, Watanabe M. et al. Novel biochemical diagnostic method for aortic dissection. Results of a prospective study using an immunoassay of smooth muscle myosin heavy chain. Circulation 1996; 93: 1244-1249
• 32 Eggebrecht H, Naber CK, Bruch C. et al. Value of plasma fibrin D-dimers for detection of acute aortic dissection. J Am Coll Cardiol 2004; 44: 804-809 doi:10.1016/j.jacc.2004.04.053
• 33 Shinohara T, Suzuki K, Okada M. et al. Soluble elastin fragments in serum are elevated in acute aortic dissection. Arterioscler Thromb Vasc Biol 2003; 23: 1839-1844 doi:10.1161/01.ATV.0000085016.02363.80
• 34 Erbel R, Alfonso F, Boileau C. et al. Diagnosis and management of aortic dissection. Eur Heart J 2001; 22: 1642-1681 doi:10.1053/euhj.2001.2782