Plötzlicher und unerwarteter Tod bei Patienten mit chronischen Schmerzen und Fibromyalgie

Bei einem Patienten mit schweren chronischen Schmerzen kann es zu plötzlichen und unerwarteten Todesfällen kommen, und das terminale Ereignis kann nicht mit einer medizinischen Therapie in Zusammenhang stehen. Glücklicherweise ist der plötzliche Tod bei Patienten mit Schmerzen nicht so häufig wie in den letzten Jahren, wahrscheinlich aufgrund eines besseren Zugangs zu mindestens einer gewissen Behandlung. Es kommt jedoch immer noch zu einem plötzlichen Tod, und Fachleute müssen wissen, wie sie einen “Risikopatienten” identifizieren können.

Unerwarteter plötzlicher Tod aufgrund schwerer Schmerzen wird kaum gewürdigt, da viele Beobachter schwere Schmerzen immer noch als harmloses Ärgernis betrachten und nicht als potenzielle physiologische Katastrophe. In vielen Fällen, kurz vor dem Tod, informiert der Patient die Familie, dass sie sich kranker fühlen als üblich und sich vom Bett oder vom Sofa Erleichterung holen lassen. Leider wachen einige dieser Patienten nicht auf. Andere Patienten sterben während des Schlafes ohne Warnung oder sind auf dem Boden zusammengebrochen. Die aggressive Toxikologie der modernen Medizin und die forensischen Verfahren nach dem Tode führten zu einem schlechten Verständnis der Gefahr des Todes von Schmerz. In einigen Fällen starb ein Patient mit Schmerzen, der ordnungsgemäß mit einer Opioid- oder anderen Überdosierung oder einem potenziellen Missbrauchsarzt behandelt wurde, plötzlich und unerwartet.

Dieser Artikel soll teilweise darauf aufmerksam machen, dass die Entdeckung von Drogen, die bei der Autopsie missbrauchsfähig sind, nicht notwendigerweise bedeutet, dass die Medikamente zum Tod geführt haben. In der Tat können Drogen den Tod verschoben haben. Einige Ärzte wurden fälschlicherweise beschuldigt, Todesfälle aufgrund übermäßiger medikamentöser Behandlung verursacht zu haben, obwohl eine unzureichende Behandlung der Schmerzen möglicherweise zum Tod geführt hat. Darüber hinaus werden die bei der Autopsie eines plötzlich verstorbenen Patienten festgestellten Opioidblutspiegel irrtümlicherweise als versehentliche Überdosierung betrachtet, da der Pathologe nicht weiß, dass Patienten mit chronischen Schmerzen in einer stabilen Dosis von Opioiden mit den bisher erreichten Serumspiegeln ihrer Opioide voll funktionsfähig sein können tödliche Werte bei unbehandelten Patienten mit Opioiden. 1

Klicken Sie hier, um den Laden zu besuchen und vieles mehr zu erfahren …

Hier sind die Mechanismen des plötzlichen und unerwarteten Todes bei Patienten mit Schmerzen und einige Schutzmaßnahmen angegeben, die die Praktizierenden ergreifen müssen, um nicht fälschlicherweise beschuldigt zu werden, einen plötzlichen und unerwarteten Tod verursacht zu haben. Am wichtigsten sind hier einige klinische Tipps, die helfen sollen, Patienten mit chronischen Schmerzen zu identifizieren, bei denen das Risiko eines plötzlichen und unerwarteten Todes besteht, sodass die aggressivsten Schmerzbehandlungen verarbeitet werden können.

Eine kurze Geschichte Anekdoten
Als leitender Medizinstudent an der University of Kansas in den frühen 1960er Jahren wurde ich aufgefordert, einen ländlichen Präzeptorat mit einem Arzt aus dem Hinterland mitzunehmen. Als wir eines Tages die Runde zum Pflegeheim des Bezirks machten, hörte ich die Frau eines Landwirts erklären: “Der Schmerz hat meine Mutter gestern Nacht umgebracht.” Seitdem habe ich wiederholt gehört, dass der Schmerz einen geliebten Menschen getötet hat. In der Folklore wird oft erwähnt, dass Menschen “vor Schmerzen” und “vor Schmerzen” sterben. Es gibt jedoch nur wenige schriftliche Angaben zu diesen Ereignissen.

In den ersten Jahren meiner Schmerzpraxis, die 1975 begann, hatte ich mehrere Patienten, die plötzlich und unerwartet verstarben. Dies passiert mir heute selten, da ich gelernt habe, “auf das Unerwartete zu warten” und herauszufinden, bei welchen Patienten das Risiko eines plötzlichen Todes besteht. In den letzten Jahren habe ich mehrere Fälle von Rechtsstreitigkeiten und Vernachlässigung eines plötzlichen und unerwarteten Todes bei Patienten mit chronischen Schmerzen analysiert. In einigen dieser Fälle wurde Ärzten vorgeworfen, sie hätten zu viel oder zu wenig verschrieben und einen plötzlichen und unerwarteten Tod verursacht, auch wenn der Patient über längere Zeit stabilisierte Dosen von Opioiden und anderen Medikamenten eingenommen hatte. Darüber hinaus zeigte die Autopsie keinen Hinweis auf ein Lungenödem (ein Signal, das Überdosierung und Atemdepression definiert). In Fällen, in denen der Arzt falsch beschuldigt wurde,

Szenario und Ursache
Unerwartete Todesfälle bei Patienten mit chronischen Schmerzen treten in der Regel zu Hause auf. Manchmal liegt der Tod in einem Krankenhaus oder in einem Entgiftungszentrum. Die Geschichte dieser Patienten ist ziemlich typisch. Die meisten sind zu krank, um ihr Zuhause zu verlassen und verbringen viel Zeit im Bett oder auf der Couch. Der Tod tritt normalerweise im Schlaf auf oder wenn der Patient aufsteht, um auf die Toilette zu gehen. In einigen Fällen berichtet die Familie, dass der Patient vor dem Zusammenbruch und dem Tod außerordentlich viel Zeit im Badezimmer verbrachte. Plötzlicher und unerwarteter Tod kann jedoch jederzeit und überall auftreten, wie Schmerzpatienten, die unerwartet starben und plötzlich bei der Arbeit oder im Auto gefunden wurden.

In den meisten Fällen sind koronare Spasmen und / oder Herzrhythmusstörungen, die zu Herzstillstand oder Asystolie führen, die offensichtliche Todesursache, da keine makroskopische Pathologie gefunden wurde, die mit der Autopsie übereinstimmt. 2-5 Der  sofortige Herzstillstand scheint für den plötzlichen Zusammenbruch oder den Tod während des Schlafes verantwortlich zu sein. Möglicherweise können Verstopfung und die Anstrengung im Stuhl Stuhlgang verursachen, da einige Patienten mit Schmerzen während des Stuhlgangs sterben. Akute Sepsis aufgrund von Nebenniereninsuffizienz und Immunsuppression kann für einige plötzliche Todesfälle verantwortlich sein.

Bildergebnis für plötzlichen und unerwarteten Tod bei Patienten mit chronischen Schmerzen

Zwei Mechanismen des Herztodes
Schwere Schmerzen sind eine schreckliche Belastung. 6,7  Akute Krisen akuter oder chronischer Schmerzen führen dazu, dass die Hypothalamus-Hypophysen-Nebennierenachse Glukokortikoide (Cortisol, Pregnenolon) und Katecholamine (Adrenalin und Noradrenalin) produziert, um den Stress biologisch zu begrenzen. 8,9 Katecholamine haben eine direkte und starke Stimulationswirkung auf das Herz-Kreislauf-System und führen zu einer schweren Tachykardie und Hypertonie. 10 Häufig können Pulsraten auf über 100 Schläge pro Minute und mehr als 130 Schläge pro Minute ansteigen. Der Blutdruck kann mehr als 200 mmHg systolisch und mehr als 120 mmHg diastolisch betragen. Neben der Freisetzung von Nebennieren-Katecholaminen verursachen Schmerzzustände Hyperaktivität des autonomen und sympathischen Nervensystems, was die durch Katecholamin induzierte Tachykardie und Hypertonie zusätzlich stimuliert. Körperliche Anzeichen von autonomer und sympathischer Hyperaktivität können neben Tachykardie und Hypertonie Mydriasis (erweiterte Pupillen), Schwitzen, Vasokonstriktion bei kalten Extremitäten, Hyperreflexie, Hyperthermie, Übelkeit, Durchfall und Erbrechen einschließen.

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  109. Although I am experimenting with trying to set my own spin on it, Anyhow, I really like keto so far.
    It’s important to be flexible with your daily diet, even if you’re locked into some thing such
    as”keeping carbohydrates low”. I would like to shed weight, but I
    do not wish to be the individual eating out with friends which orders
    something odd off the menu, or nothing at all. If your diet comes at the
    cost of your joy, if you ask me it’s just flat out not worth it.
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    Been doing my best to attempt to do quality study, so things like this helps.
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    You wish to start losing weight ASAP like I get,
    however you have to be inclined to do a bit of research. If you do not do your
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    to have issues.

  110. Anyway just wanted to say thanks for your site.
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    keep me. I hope that you continue to grow, along with
    can discover it! Fantastic luck and thanks again.
    Although I’m experimenting with trying to put my own spin on it,
    anyway, I really like keto so far. It’s important to be flexible with your
    diet, even if you’re locked into something such as”keeping carbohydrates low”.
    I do not want to be the person eating out with friends that orders something weird off the menu, or nothing at all, although I want to shed weight.
    It’s just flat out not worth it, if you ask me, if your diet
    comes at the cost of your joy. xoxo That is GREAT.
    Been doing my best to attempt to do quality research,
    so things like this helps. Anyone else think the biggest issue people
    have with weight loss comes from them not putting at work?
    You wish to start losing weight ASAP like I do, but you have to be inclined to do a bit of research first.
    If you do not do your part, I am sorry to say you’re just
    probably going to have problems.

  111. Although I am experimenting with trying to put my own spin, Anyhow, I love
    keto up to now. It is important to be flexible with your diet, even if you’re locked into some thing
    like”keeping carbs low”. I would like to lose weight, but I do not wish to be
    the individual eating out with friends which orders something weird off the menu,
    or nothing at all. It’s just flat out not worthwhile if you ask me, if your daily diet comes at the cost of your
    happiness. xoxo Anyhow just wanted to say. Materials like this
    helps me stay on track and helps to keep me. I hope that you continue to grow,
    along with other people who need this can find it!

    Good luck and thanks again. That is all GREAT. Been doing my very best to try and do quality study, so things like this
    actually helps. Anyone else believe the biggest issue people have with weight loss comes from them not putting at work?
    You have to be willing to do a little research first, although you want to begin losing
    weight ASAP like I get. I’m sorry to say you are just going to have issues if you don’t
    do your part.

  112. Anyhow just wanted to say thanks for your site.
    Stuff like this helps keep me out of being gloomy and allow me to stay on track.
    I am hoping that you continue to develop, along with
    can find it! Thanks and Fantastic luck again.
    Although I’m experimenting with trying to put my own spin, Anyhow, I really like keto so far.
    It’s essential to be flexible with your daily diet, even when you’re locked into something such as”keeping carbohydrates low”.
    I don’t want to be the person eating out with friends that orders something weird off the
    menu, or nothing at all, although I would like to lose weight.

    It is just flat out not worthwhile, if you ask me, if your
    diet comes at the cost of your joy. xoxo This is all GREAT.
    Been doing my very best to attempt to do quality research, so stuff like this helps.

    Anyone else believe that the biggest problem people have with
    weight reduction comes from them not putting at work first?

    You have to be inclined to do a bit of research first, although like I get you want to start losing weight ASAP.
    I am sorry to say you’re just going to have issues if you don’t do
    your part.

  113. Anyhow just wanted to say thanks for your site.
    Materials like this allow me to stay on track and helps to keep me
    from being miserable. I hope that you continue
    to develop, along with can discover it! Good luck and thanks again. Although I’m experimenting with trying to put my own spin Anyhow, I love keto up to now.
    It is essential to be flexible with your daily diet, even when you’re locked into some thing like”keeping carbs low”.

    I do not want to be the person eating out which orders something weird the menu,
    or nothing in any way off, although I would like to lose weight.
    If your daily diet comes at the expense of your happiness, if you ask
    me it’s just flat out not worthwhile. xoxo That is all GREAT.
    Been doing my very best to attempt to do quality study, so things like this
    actually helps. Anyone else think the biggest issue people have with
    weight loss comes from them not putting at work ? You must be
    inclined to do a bit of research first, although you wish to start
    losing weight ASAP like I do. If you do not do your part, I
    am sorry to say you are just going to have problems.

  114. Anyway just wanted to say thanks for your site. Stuff like this helps to keep
    me and allow me to stay on track. I hope that you continue to develop,
    along with can find it! Thanks and Fantastic luck again. Although
    I’m experimenting with trying to set my own spin anyway, I really like keto up to now.
    It is essential to be flexible with your daily diet, even if you’re
    locked into some thing such as”keeping carbohydrates low”.
    I would like to lose weight, however I do not wish to be the individual eating out which orders something odd off the menu, or nothing at all.
    It is just flat out not worth it if you ask me, if your diet comes at the cost of your joy.
    xoxo That is all GREAT. Been doing my very best to try and do quality study,
    so things like this really helps. Anyone else think that the biggest issue people have
    with weight loss comes from them not putting in the job?
    You wish to begin losing weight ASAP like I do, but you must be willing to do
    a bit of research first. I’m sorry to say you’re just likely
    going to have problems, if you do not do your part.

  115. Anyway, I really like keto so far, although I’m experimenting with trying to set my own spin. It is essential to be flexible with your diet, even when you’re locked
    into something such as”keeping carbohydrates low”. I would like to lose weight, however I don’t want to be the person eating out
    that orders something weird the menu, or even nothing at all off.
    If your diet comes at the expense of your joy, if
    you ask me it’s just flat out not worthwhile.
    xoxo Anyhow just wanted to say thanks for your website.

    Materials like this allow me to stay on track and helps keep me.
    I am hoping that you continue to develop, and can discover it!
    Thanks and Fantastic luck . This is all GREAT. Been doing my very
    best to try and do quality research, so stuff like this helps.

    Anyone else believe that the biggest problem people have with weight loss comes
    from them not putting at work ? Like I get you want to begin losing weight ASAP, however you have to be inclined to do a bit of research first.
    I’m sorry to say you’re just going to have issues if you don’t do your part.

  116. Although I am experimenting with trying to set my own spin anyway,
    I love keto up to now. It’s important to be
    flexible with your daily diet, even when you’re locked into something like”keeping carbohydrates low”.
    I would like to shed weight, but I do not wish to be the individual eating out with friends which orders something
    odd off the menu, or nothing at all. If your daily diet comes
    at the cost of your happiness, if you ask me it is just flat out not worth it.
    xoxo Anyway just wanted to say. Materials like this helps to keep me and helps me stay on track.
    I am hoping that you continue to develop, along with can discover it!
    Thanks and good luck . That is all GREAT. Been doing my
    very best to attempt to do quality research, so things like
    this really helps. Anyone else believe the biggest issue people
    have with weight reduction comes from them not putting
    at job first? You wish to start losing weight ASAP like I do,
    however you have to be inclined to do a little research.
    I’m sorry to say you’re just going to have problems if you don’t do your part.

  117. Anyhow just wanted to say. Stuff like this allow
    me to stay on track and helps keep me. I hope that
    you continue to grow, and other people that need this can discover it!

    Thanks and Fantastic luck again. Although I am experimenting with trying to set my own spin on it, anyway, I really like keto
    so far. It is essential to be flexible with your daily diet, even when you’re
    locked into some thing such as”keeping carbohydrates low”.
    I don’t want to be the individual eating out that orders something odd off
    the menu, or even nothing at all, although I want to shed weight.

    If your diet comes at the cost of your happiness,
    if you ask me it is just flat out not worth it.
    xoxo That is all GREAT. Been doing my very best to attempt to do quality research, so things like this helps.
    Anyone else think that the biggest problem people have with weight
    loss comes from them not putting in the work?

    You have to be willing to do a bit of research, although like I get you wish to begin losing weight ASAP.
    If you do not do your part, I’m sorry to say you are just going to have problems.

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