Wir überwinden Grenzen

(23.09.2016) It was a violent but non-violent argument that Julia F.* had with her boyfriend that day. When the 29-year-old medical student became increasingly agitated in the hours that followed and felt a tingling sensation in her hands and feet, she decided to go to the emergency room at Freiburg University Hospital. "She herself suspected a nervous breakdown or a hysterical seizure," says PD Dr. Hans-Jörg Busch, Medical Director of the University Emergency Center at the Freiburg University Medical Center. "It was fitting that the patient's pulse and respiratory rate were significantly increased and that she did not report any pain," says the emergency physician.

If the gas exchange in the lungs and blood functions normally, as is the case with psychological causes of hyperventilation such as panic attacks, too much carbon dioxide is exhaled. Conversely, the low carbon dioxide content in the blood signals a very good oxygen supply to the body. This leads to a shift in electrolytes, also known as blood salts, and thus to hyperexcitability of the nervous system and muscles with typical tingling and pawing. "In these cases, the most effective first aid measure is for those affected to breathe into a bag a few times. This means that less carbon dioxide is exhaled and the vicious circle is broken," explains Dr. Busch.

However, this did not reduce the patient's breathing rate. The analysis of the blood sample further irritated the doctors. "The lactate levels were significantly elevated. This happens during sport, for example, when the muscle is not supplied with enough oxygen. However, hyperventilating should have the opposite effect," says Dr. Busch. The woman was now pale, her lips were slightly purple and her hands had a blotchy coloration. "The blood values and physical changes contradicted a psychological cause and clearly pointed to a physical problem such as impaired gas exchange in the lungs or inadequate blood circulation," says emergency physician Dr. Busch.

When the patient was finally able to undergo a detailed physical examination due to a sedative, no pulse could be felt in her arms or legs. Dr. Busch and his team used a special ultrasound device to examine the area around the heart. "We discovered that the main artery in the area of the heart was significantly dilated. We highly suspected that the aorta had torn, a so-called aortic dissection. In the computer tomogram, which was ordered immediately, we could see that the aorta had been torn over a length of several centimetres and that the blood was flowing into the intermediate wall of the artery," says Dr. Busch.

Such an aortic dissection is life-threatening, as the arterial wall can rupture completely at any time. The result would be an undersupply of blood to the brain and severe internal bleeding. "This is an absolute emergency that requires a well-coordinated interdisciplinary team to treat," says emergency physician Dr. Busch. Julia F. was operated on the same day. In an operation lasting several hours, cardiac surgeons replaced the patient's damaged aorta with an artificial tissue tube.

The most important indication of an aortic dissection is a sudden onset of severe pain in the chest area, which is often felt as stabbing and can even lead to unconsciousness. "However, there are always people like our patient who do not feel this pain. Why this is the case is unknown," says Dr. Busch. Those affected can also suffer from shortness of breath, pain in the arms or legs and signs of paralysis.

Almost three weeks later, Julia F. was allowed to leave Freiburg University Hospital. In retrospect, it turned out that the patient's mother had suffered a similar aortic rupture at the early age of 40. "We don't know exactly why the patient didn't suffer from the typical stabbing pains in her chest, but it could be due to a weakness in the connective tissue," says Dr. Busch. At a follow-up examination a few weeks later, Julia F. had already recovered well. And there have been no more psychological complaints since then.

* Name changed by the editors