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Conf. dr. Diana Cimpoeşu
Disciplina Medicina de UrgentaU.M.F. “Gr. T. Popa” Iaşi
UPU-SMURD Sp. Cl. Judeţean de Urgenţă
“Sf. Spiridon” Iaşi
Soc anafilactic de
cauza rara
UPU – SMURD
IAŞI
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•B.S.I. 21 ani student
VS
•Ambulanta C2
•Coma de etiologie
neprecizata
•Instalare brusc in
prespital
•Sp. Neurochirurgie-
IOT fara sedare
•CT craniocerebral
nativ- fara leziuni
2 iunie ora 18.51- UPU
Sp. Clinic Jud. de Urg.
Sf. Spiridon Iasi
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UPU- Examen fizic:
•edem facial,•edem al buzei superioare,•hipersecreţie bronsica,•TA nemăsurabila,•SaO2= semnal nedetectat,•FC= 120/min,•GCS 6 (M 4 O1 V1),•pupile intermediare reactive, •ROT diminuate bilateral,•fara focalizare neurologica
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UPU: gaze arteriale, biochimie
pH= 7,28
pCO2= 39 mmHg
pO2= 91 mmHg
Na= 141 mEq/L
K= 3,3 mEq/L
Ca++= 1,10 mmol/L
Glu= 129 mg/dL
Lactat= 10,0 mmol/L
Hct= 46 %
HCO3= 20,9 mmol/l
Uree= 29 mg/dl
Creatinina= 1,5 mg/dl
CK-MB= 59 ui
RA= 16 mEq
LDH= 275 ui
Glicemie= 162 mg/dl
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DIAGNOSTIC DE ETAPA. PROBLEME?
Coma (GCS = 6) de etiologie hipoxica. IOT+VM
Obs. soc anafilactic
Confirmare?
Anamneza?- efort fizic anterior evenimentului
Etiologie?
Sepsis?
Management in urgenta?
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UPU 02.06. EXPLORARI POINT OF CARE
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UPU: EXPLORARI
WBC= 24,2*10³/µL
PLT= 356*10³/µL
- Ly= 7,6 %
- Mo= 2,6 %
- GR= 89,8 %
Consult boli infectioase:
s-a recoltat LCR
PT= 31,7 sec
AP= 26,255
INR= 2,75 %
APTT =
incoagulabil
Fibrinogen= 1,93 %
Recoltare
hemoculturi
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UPU: EXPLORARI
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UPU: ECOGRAFIE ABDOMINALA
•Ficat, RD,RS, splina
normale ecografic,
fara adenopatii
abdominale
•Fara lichid liber in
peritoneu
•Adiacent varfului
cordului cateva
imagini lichidiene cu
diam max 55 mm
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MANAGEMENT UPU
Ventilatie mecanica SIMV cu FiO2 100 %
Adrenalina 2 mcg/min piv
Fluide: Ringer, SF
Corticoizi HHC+dexametazona
Inhibitori de receptori H2
Ca gluconic i.v
Sedare
Monitorizare
ATB
Plasma proaspata congelata
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Examen cardiologic si
ecocardiografic
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Ecocardiografie
Transesofagiana:
formatiune chistica
pediculata atasata intre
VCS si VS:12/17 mm
Transtoracica:
inel Ao=24, AS=52/47/58, SIV=8, VS=60, PPVS=8,
VP, AD,VM, Vao,VCI, crosa Ao=N
imagini polichistice intra si parapericardice apex+
VS cu compresiune posibila pe art. pulm
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CT NATIV
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CT
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CT
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Internare terapie intensiva cardiologie. Evolutie
3.06.
GCS - 15
Detubat, constient,
cooperant,
Stabil hemodinamic
SaO2 - 99 %
Consult boli infectioase-
albendazol 400 mg x 2/zi
Epistaxis ant dr- consult
+ trat ORL
-pH= 7,283
-pCO2= 41,5 mmHg
-pO2= 77,1 mmHg
-SaO2= 90,9 %
-FO2Hb= 89,3 %
-K+= 4,6 mmol/L
-Na+= 148 mmol/L
-Ca++= 0,93 mmol/L
-Cl-= 118 mmol/L
-Glu= 129 mg/dl
-Lac= 65 mg/dl
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DIAGNOSTIC FINAL
Chisti hidatici multipli rupti in pericard
Soc anafilactic
Epistaxis anterior drept oprit
Ablatia chirurgicala a chistilor pericardici
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CUTANATE
Angioedem
Urticaria
Eritem
Prurit
SNC
Confuzie
Comă
RESPIRATOR
Wheezing
Dispnee
Rinită
stridor
Hipoxie
GASTROINTESTINALE
Greaţa
Diaree
Dureri abdominale
CARDIOVASCULAR
Hipotensiune
Tahicardie
Aritmii
Chist hidatic
- In fazele incipiente (dimensiuni mici),
este relativ asimptomatic.
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EPISODUL AL-II-LEA
25.10.2011 ORA 6.40 UPU
B.S.I., 23 ani,
Parestezii la niv. extremitatilor membre
inf. si sup.
Dureri abdominale difuze
GCS- 15
UPU – SMURDIAŞI
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TA- 110/65 mmHg
SaO2- 98 %
FC- 70/min
FR- 14/min
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RX. TORACIC
Film rotat (in OAD)
- Plamani fara leziuni evolutive
- Cord normal
- Simfiza pleurodiafragmatica bazal stang
- Fire de cerclaj sternal vizibile
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ECOGRAFIE ABDOMINALA
ficat hipertrofic, LSH= 73 mm, structura
omogena, reflectivitate normala
colecist fara calculi
VP, CBP, pancreas normale
RD, RS = normali
splina dimensiuni normale, omogena
VU evacuata
absenta lichid liber in Douglas si Morrison
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ECOCARDIOGRAFIE
Cord hiperkinetic, cavitati libere
Valva aorta normala
Prolaps de valva mitrala grad I,
Langa peretele liber al VS- chisti (?)
Pericard ingrosat
Recomandari: CT de torace
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2011- CT NATIV
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2011- CT- TIMP ARTERIAL
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2011- TIMP ARTERIAL
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TIMP VENOS
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TIMP VENOS
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TIMP VENOS
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CONSULTURI DE SPECIALITATE
Boli infectioase
Echinococoza
pericardica
recidiva
Albendazol 400
mgx2
Hepatoprotectoare
Necesita
reinterventie
chirurgicala
Chirurgie cardio-
vasculara
Necesita rezectia
chisturilor prin
toracotomie
Necesita o perioada mai
lunga trat cu albendazol
inainte de rezectie
Chistii de la niv. carinei
sunt greu abordabili
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