34例主动脉夹层破裂死亡引发医疗纠纷案例的法医学资料分析

摘要

目的 探讨主动脉夹层(aortic dissecting,AD)动脉瘤(又称AD)破裂死亡引发医疗纠纷的原因、诊疗过程中存在的医疗过失与患者死亡后果之间的因果关系及参与程度的判定.方法 收集本中心2001-2016年受理的34例引发医疗纠纷、经系统的法医病理学检验证实为AD破裂猝死案例,对照法医病理学检验结果审查病历资料,分析诊疗过程中引发医疗纠纷的原因,并结合文献对医疗损害与患者死亡之间的因果关系及参与程度进行分析.结果 本组案例中23例医疗纠纷发生于县区级医疗机构,11例发生于地市级医疗机构;34例均伴发其他疾病,其中27例有明确的高血压病史;31例因心包填塞死亡,3例因失血性休克死亡.镜下可见的病理改变有:主动脉中层囊性坏死、冠状动脉粥样硬化、冠状动脉管腔狭窄(Ⅰ～Ⅳ级)等,其中15例可见冠状动脉合并主动脉粥样硬化改变,另有1例合并有肺动脉夹层改变.本组34例入院后均未能对AD给予明确临床诊断及有效治疗,诊疗过程中的误诊、误治与患者死亡之间存在因果关系.结论 AD发病机制复杂,基层医师易误诊、误治.在AD破裂患者猝死引发的医疗纠纷中,误诊、误治行为与患者死亡之间存在间接因果关系.%Objective To investigate the reasons for the death of patients,the relationship of medical disputes with their death by aortic dissecting (AD) aneurysm (known as AD) ruptures during diagnostic and therapeutic procedures and the judgement for contribute ratios.Methods A total of 34 sudden death cases due to AD were collected from 2001 to 2016 due to medical tangle and underwent forensic pathological analysis.Clinical data were checked according to the results of forensic pathology.The reasons for the death of patients and the relationship of medical disputes with their death and contribute ratios of medical disputes were analyzed according to literature reports.Results In the 34 cases,23 cases were from medical institutions at the country level,and 11 cases were from municipal medical institutions.All patients had other diseases,in whome 27 cases had definite hypertension,31 cases died of cardiac tamponade,and 3 cases of hemorrhagic shock.The pathological analysis showed that aorta cystic in the middle necrosis,coronary atherosclerosis and coronary artery stenosis (grade Ⅰ-Ⅳ).Fifteen cases had coronary and aortic atherosclerosis,and 1 case had pulmonary artery dissection.All cases were not given definite clinical diagnosis and effective treatment for AD.Therefore,there was cause-and-effect relationship between clinical procedures of misdiagnosis and mistreatment and the death of patients.Conclusions The pathogenesis of AD is complicated,and a lack of awareness in grass-roots doctors leads to the misdiagnosis and mistreatment easily primary care doctor.In medical disputes of sudden death induced by AD,clinical procedures of misdiagnosis and mistreatment lead to indirect causal relationship with the death of patients.