#1
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ñëó÷àé ñ áåãóíîì
Ìóæ÷èíà 39 ëåò, ðîñò: 190 ñì âåñ: 94 êã. Ó÷àñòâîâàë â ëþáèòåëüñêèõ ñîðåâíîâàíèÿõ ïî êðîññó íà 10 êì. Íà çàêëþ÷èòåëüíîé ÷àñòè äèñòàíöèè âíåçàïíî ïîòåðÿë ñîçíàíèå. Áûë äîñòàâëåí â áîëüíèöó ïî ìåñòó æèòåëüñòâà.
 òå÷åíèå 6 ÷àñîâ co ñëîâ ëå÷àùèõ âðà÷åé, íàõîäèëñÿ â êîìå, ïðè÷èíà êîòîðîé äëÿ íèõ îñòàëàñü íå âûÿñíåííîé. ×ÑÑ ïðè ïîñòóïëåíèè: 150 â ìèí (ÝÊà ïðèëàãàåòñÿ) ÀÄ 90/60 ìì ðò ñò. [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Êîæíûå ïîêðîâû áëåäíûå, âëàæíûå. Êà÷åñòâåííûé òðîïîíèíîâûé òåñò ïîëîæèòåëüíûé (òðèæäû). Ïî äàííûì ÝÕÎ-ÊÃ, ÊÒ ãîëîâíîãî ìîçãà, ÓÇÄà ñîñóäîâ íèæíèõ êîíå÷íîñòåé, ÓÇÈ âíóòðåííèõ îðãàíîâ - ïàòîëîãèè íå âûÿâëåíî.  àíàëèçàõ êðîâè îáðàùàëî íà ñåáÿ âíèìàíèå ïîâûøåíèå óðîâíÿ êðåàòèíèíà äî 250 ìêìîëü/ë, îáùåãî è ïðÿìîãî áèëèðóáèíà (äî 105 è 46 ìêìîëü/ë ñîîòâåòñòâåííî), ÀËÒ äî 2800 Åä/ë, ÊÔÊ äî 2000 Åä/ë. Áñòðàÿ ïîëîæèòåëüíàÿ äèíàìèêà â òå÷åíèè ñóòîê. Áîëüíîé ïåðåâåäåí â äðóãîé ñòàöèîíàð, äëÿ äàëüíåéøåé äèàãíîñòèêè è ëå÷åíèÿ, â óäîâëåòâîðèòåëüíîì ñîñòîÿíèè. Íà ìîìåíò ïåðåâîäà æàëîá íåò. ×ÑÑ 62 â ìèí, ÀÄ 120/70 ìì ðò ñò. Ïðè îñìîòðå ðåçêàÿ æåëòóøíîñòü êîæíûõ ïîêðîâîâ. [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]  àíàëèçàõ êðîâè: îáùèé áåëîê ñíèæåí 53,6 Ã/ë; ïîâûøåí óðîâåíü êðåàòèíèíà 194 ìêìîëü/ë, îáùåãî è ïðÿìîãî áèëèðóáèíà (180 è 70 ìêìîëü/ë ñîîòâåòñòâåííî), ïå÷åíî÷íûõ òðàíñàìèíàç (ÀËÒ 1630 Åä/ë, ÀÑÒ 2300 Åä/ë), ïîâûøåí óðîâåíü ÊÔÊ (12260 Åä/ë), ïðè ýòîì ÊÔÊ-Ì â íîðìå. Òàê æå îáðàùàåò íà ñåáÿ âíèìàíèå ñíèæåíèå óðîâíÿ òðîìáîöèòîâ äî 55.6 òûñ/ìêë. Âàøå ìíåíèå, óâàæàåìûå êîëëåãè, ïî ýòîìó ñëó÷àþ? |
#2
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íàõîäèëñÿ ëè ïàöèåíò íà ÈÂË?
íå âåðþ ÷òî íå ñäåëàëè ðåíòãåí îðãàíîâ ãðóäíîé êëåòêè, ìî÷à âûäåëÿëàñü? |
#3
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Ýëåêòðîëèòû? Ãèïîíàòðèåìè÷åñêàÿ êîìà?
Ïîâûøåííûé òðîïîíèí ó ïàöèåíòà ñ ïî÷å÷íîé íåäîñòàòî÷íîñòüþ ìîæåò ïîâûøàòüñÿ íåçàâèñèìî îò íàëè÷èÿ íåêðîçà ìèîêàðäà. Ïîâûøåíèå ÀÑÒ, ÀËÒ, îáùåé ÊÔÊ âîçìîæíî ñâÿçàíî ñ ìûøå÷íûìè íåêðîçàìè... |
#4
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Öèòàòà:
Ýëåêòðîëèòû â íîðìå. Ãèïîãëèêåìèÿ âî âðåìÿ ïîñòóïëåíèÿ 2,9. Êîëè÷åñòâåííûé òðîïîíèí T íà òðåòüè ñóòêè 0,59 (N ìåíåå 0,1) |
#5
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Ïî-ìîåìó, îïèñàííàÿ êëèíèêà (äàæå áåç äîïîëíèòåëüíûõ âîïðîñîâ è äàííûõ) âïîëíå óêëàäûâàåòñÿ â exertional heat stroke. À, êñòàòè, ïàöèåíòó òåìïåðàòóðó (öåíòðàëüíóþ, íå êîæíóþ) èçìåðÿëè?
Can Med Assoc J. 1980 May 24;122(10):1144-50.Related Articles, Links Exertional heat stroke: the runner's nemesis. Hart LE, Egier BP, Shimizu AG, Tandan PJ, Sutton JR. Heat stroke in distance runners is increasing in frequency. A case is reported of a 41-year-old man who collapsed during a 10-km "fun run" held when the temperature was 31.6 degrees C and the humidity 80%. Acute renal failure (serum creatinine level 1530 mumol/l [17.3 mg/dl]), rhabdomyolysis, disseminated intravascular coagulation and hepatic damage complicated the clinical picture. Repeated peritoneal dialysis and one cycle of hemodialysis because of a very high serum level of uric acid (1.23 mmol/l [20.7 mg/dl]) were required. Although the illness was prolonged, recovery was almost complete, and 4 months after the man's collapse the serum creatinine level had fallen to 133 mumol/l (1.5 mg/dl). Åñëè íå ñìîæåòå íàéòè ýòó ñòàòüþ â ñâîáîäíîì äîñòóïå, ÿ ìîãó ïîñëàòü âàì â ëè÷êó. Ïîñìîòðèòå òàê æå Pubmed íà ýòîò òîïèê: åñòü äîñòàòî÷íîå êîëè÷åñòâî case-reports. |
#6
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Öèòàòà:
Óêàçàííàÿ Âàìè ñòàòüÿ ëåæèò ñâîáîäíî â ñåòè: [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Áîëüøîå êîëè÷åñòâî èíôîðìàöèè ïî ñëó÷àþ óæå ñêà÷àíî. Äàííûé ñëó÷àé ïðèâåäåí â áîëüøåé ñòåïåíè íå äëÿ óñòàíîâëåíèÿ äèàãíîçà, à äëÿ îáìåíà ìíåíèÿìè.  ïîäîáíûõ îáñóæäåíèÿõ ÷àñòî âñêðûâàþòñÿ äîïîëíèòåëüíûå äåòàëè è íþàíñû, êîòîðûå ñóùåñòâåííî ðàñøèðÿþò êðóãîçîð. Íàïðèìåð: Âàì ïîïàäàëñÿ â ïðàêòèêå òåðìèí - Exercise-induced rhabdomyolysis? Íàïðèìåð: [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] |
#7
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Áóäó÷è "÷èñòûì" àíåñòåçèîëîãîì (èíòåíñèâîì íå çàíèìàþñü), ðàññóæäàòü íà êîíêðåòíóþ òåìó ìîãó òîëüêî òåîðåòè÷åñêè
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#8
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Öèòàòà:
À ÷òî Âû ñêàæèòå ïðî íèçêèé óðîâåíü ãëþêîçû ó áîëüíîãî? Íå ìîæåò ëè áûòü ïðè÷èíîé êîìû ãèïîãëèêåìèÿ? È åùå, Âû îáðàòèëè âíèìàíèå íà âòîðóþ ÝÊÃ? |
#9
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Öèòàòà:
__________________
Àííà, âðà÷-ýíäîêðèíîëîã Âîðîíåæ, êëèíèêà Íåïëàöåáî |
#10
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À ÷òî Âàì íå íðàâèòñÿ âî 2îé ÝÊÃ? ß íå êàðäèîëîã, ÷èòàþ ÝÊà â îáú¸ìå íåîáõîäèìîãî â ìîåé ðàáîòå ìèíèìóìà, íî íè÷åãî òàêîãî, ÷òî âûçâàëî áû ìîé "íåçäîðîâûé àæèîòàæ" ïî ïîâîäó äàííîé ïë¸íêè, ïðîñòî íå âèæó (ìîæåò, ÿ è íå ïðàâà
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#11
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Ìîæåò PQ êîðîòêèé? Ìîæåò áûòü îí ïîòåðÿë ñîçíàíèå îò àðèòìèè, êîòîðóþ çàôèêñèðîâàòü íå óäàëîñü? Íàïðèìåð íà ôîíå îñòðûõ íàðóøåíèé ýëåêòðîëèòíîãî îáìåíà.
Öèòàòà:
ß íàøëà òàêîé âîò îáçîð: [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Îñîáî ïðî íàðóøåíèÿ ñîçíàíèÿ íå ïèøóò, ïðèâîäÿò ñëó÷àé ïðî: "massive rhabdomyolysis developed in a 32-year-old physician who was accustomed to ninning 30 miles per week but had performed exhaustive exercise in hot weather. He ran in a marathon on a warm day (85°F [29°C]), and after nine miles he collapsed" (ïåðåøåë èç âåðòèêàëüíîãî ïîëîæåíèÿ â ãîðèçîíòàëüíîå? ![]() Áîëüøå ïîõîæå íà äèàãíîç, êîòîðàÿ óïîìÿíóëà äîêòîð Tasha_08_75, íî áåç ðàáäîìèîëèçà íàâåðíî òîæå íå îáîøëîñü. È ÊÔÊ ïîâûñèëîñü è ïî÷å÷íàÿ íåäîñòàòî÷íîñòü è òðîìáîöèòîïåíèÿ. |
#12
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1. Íåçàôèêñèðîâàííàÿ àðèòìèÿ, âûçâàâøàÿ êîìó íà 6 ÷àñîâ? Íå âåðþ
![]() 2. Íàñ÷¸ò ðàáäîìèîëèçà - òàê îí ÿâëÿåòñÿ íåîòúåìëåìîé ÷àñòüþ exertional heat stroke (è âïîëíå óêëàäûâàåòñÿ â äèàãíîç, òàê æå, êàê è ÄÂÑ ñèíäðîì). 3. È ïîñëåäíåå, ïî ïîâîäó "after nine miles he collapsed, experi- encing severe pain in his calves and thighs." (èñïûòûâàòü áîëü, áóäó÷è áåç ñîçíàíèÿ???). À âîîáùå-òî ïðè îïðîñå ïàöèåíòà (èëè ñâèäåòåëÿ) ïîñëå ñîîáùåíèÿ î òîì, ÷òî ïàöèåíò collapsed, ñëåäóåò âîïðîñ: "Did you (he/she) loose the consciousness?". Ìîæíî collapse ñ è áåç ïîòåðè ñîçíàíèÿ (ó ïàöèåíòà èç ïðèâåä¸ííîãî â ïóáëèêàöèè ïðèìåðà ýòî ïðîèçîøëî èç-çà ñèëüíûõ áîëåé â íîãàõ), ïîýòîìó â ïóáëèêàöèÿõ ïîòåðÿ ñîçíàíèÿ îãîâàðèâàåòñÿ îòäåëüíî, à íå ïîäðàçóìåâàåòñÿ àâòîìàòè÷åñêè. Íî ýòî - ëèðè÷åñêîå îòñòóïëåíèå íà òåìó "ìåäèöèíñêèé àíãëèéñêèé" ![]() |
#13
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Öèòàòà:
Òàê ÷òî âïîëíå âåðîÿòíî, ÷òî ïàöèåíò, èñïîëüçîâàâ çàïàñû ìûøå÷íîãî ãëèêîãåíà, ïåðåø¸ë íà ãëþêîçó êðîâè (â êà÷åñòâå ìåòàáîëè÷åñêîãî ñóáñòðàòà). Ê òîìó æå - ïîðàæåíèå ïå÷åíè. |
#14
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#15
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À ïðîâîäèëñÿ ëè òîêñèêîëîãè÷åñêèé àíàëèç è èñêëþ÷åíèÿ ðàäè èññëåäîâàíèÿ íà ïðèñóòñòâèå âèðóñîâ ãåïàòèòà?
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