Pomen hitrega ukrepanja za upešno zdravljenje možganske kapi viktor Švigelj1

Prevoz in začetno zdravljenje

Začetno zdravljenje je usmerjeno v zagotovitev prostih dihalnih poti, dihanja in krvnega obtoka, s kliničnim nevrološkim pregledom in ugotovitvijo žariščnih nevroloških znakov. Še posebno moramo biti pozorni na zunanje znake poškodbe (bolnik je lahko ob nastopu krvavitve padel). Če je dlje časa ležal na tleh, moramo biti pozorni na znake podhlajenosti, rabdomiolize in preležanin. Pri hujšem zožanju zavesti moramo bolnika intubirati, v primeru motenega dihanja pa tudi umetno predihavati. Potrebna je primerna oksigenacija (nasičenost s kisikom 95 % ali več). Za intubacijo se ne odločamo glede na Glasgowsko točkovno lestvico, kot npr. pri poškodbi glave, temveč nam je vodilo motnja dihanja (porast CO₂ v izdihanem zraku, padec nasičenja s kisikom kljub dodanemu kisiku). Da preprečimo vdihnenje hrane, vstavimo tudi nazogastrično sondo. Nastavimo tudi iv. periferni kanal.
Medikamentozno zdravljenje pred in med prevozom obsega dajanje analgetične terapije (kot pri SAK), antiemetika in pa uravnavanje krvnega tlaka. Optimalni nivo krvnega tlaka je odvisen od več individulanih dejavnikov kot je kronična arterijska hipertenezija, znakov zvišanega znotrajlobanjskega tlaka, starosti bolnika, predvidenega vzroka krvavitve in časa od nastanka simptomov in znakov krvavitve. Izjemoma kortikosteroidno simptomatsko zdravljenje uporabimo le pri krvavečih primarnih ali metastatskih tumorjih osrednjega živčevja, če je na računalniško tomografskem slikanju glave poleg krvavitve viden tudi edem okoli tumorja. Pri zniževanju krvnega tlaka ne smemo biti agresivni, saj lahko porušimo avtoregulacijski mehanizem, ki zagotavlja primeren perfuzijski tlak skozi možgane. Za zniževanje krvnega tlaka uporabimo kaptopril 12,5–25 mg pod jezik ali enake odmerke urapidila i.v. Poleg tega uporabimo lahko tudi zaviralce receptorjev beta ali natrijev nitroprusid 0,5–10 µg/kg telesne mase/min. Pri bolnikih s kronično hipertenzijo vzdržujemo srednji arterijski tlak pod 130 mmHg. Krvni tlak merimo neinvazivno. Pri znakih zvišanega znotrajlobanjskega tlaka in preteči herniaciji uporabimo osmoterapijo (ne preventivno!), in sicer 20 % manitol (0,25–0,5 g/kg telesne mase), vzdržujemo normovolemično stanje in uporabimo tudi mišične relaksanse ter sedacijo in ustrezno protibolečinsko zdravljenje. Treba je vstaviti tudi stalni urinski kateter.

Motnje dihanja pri možganski kapi

Motnje dihanja, ki nastanejo pri MK, so posledica okvar različnih struktur možganov in osnovni opis teh motenj nam lahko služi za oceno potrebnosti intubacije in umetnega predihavanja ter medikamentoznega ukrepanja (slika 6).

Slika 6. Motnje dihanja.
Cheyne-Stokes oblika dihanja (slika 6a) je motnja dihanja, kjer se izmenjujeta obdobji hiperventilacije in apnoje. Je karaktetristična pri možganski kapi, brez jasne anatomske lokalizacije (117) in je lahko posledica tudi srčnega popuščanja (118). Centralna nevrogena hiperventilacija (slika 6b) je posledica okvare v ponsu, in sicer se pojavlja hiperpnoja tako v stanju budnosti kot spanju (119). Oblika dihanja, kjer vdihu sledi daljši premor, imenujemo apneustično dihanje (slika 6c) in je posledica okvare spodnjih struktur v ponsu (spodnji respiratoni nevroni) (120). Dihanje v skupkih (slika 6d) se pojavi pri okvari mezencefalona, in sicer bolnik hitro izmenjuje fazo hiperventilacije in apnoično fazo. Depresija dihanja (slika 6e) je ponavadi posledica intoksikacije.
Ataktično dihanje je posledica okvare podaljšane hrbtenjače (121, 122). Če je okvara v spodnjem delu podaljšane hrbtenjače, pa nastane t.i. Ondinino prekletstvo, to je stanje (klasično sicer opisano kot obporodna motnja), ki lahko nastopi tudi pri možganski kapi ali pa kot posledica poškodbe, in sicer je motena kemična kontrola dihanja, brez hotene motnje dihanja. Klasični sindrom (obporodna oblika) je opisan skupaj z želodčnopožiralnikovim refluksom in Hirschprungovo boleznijo in pomeni motnjo dihanja v povezavi s spanjem. Če ni ustrezne dihalne podpore, bolniki v spanju umrejo (123). Prvi znak transtentorialne herniacije (tentorij je duplikature trde možganske ovojnice) je Cheyne-Stokesova oblika dihanja, ki ji sledijo nevrogena hiperventilacija, evpnoja in hlastanje za zrakom, kar pa je preterminalno stanje (124).

Sklep

Kritičen bralec bo iz obsežnega prispevka razbral, da je najpomembnejši dejavnik za učinkovito zdravljenje možganske kapi ČAS. Pomembno je, da poznamo jasen in natančen začetek bolezni, da znamo jasno opredeliti simptome in potrditi najprej klinično znake nastale možganske kapi. Enako pomembna je tudi hitrost ukrepanja, ki mora biti brez nepotrebnih zamud v diagnostičnih postopkih ali čakanju na transport, če bolnik, ki je spoznal simptome možganske kapi, pravočasno pokliče. Izredno pomembna je vloga družinskega zdravnika v preprečevanju nastanka možganskožilnih bolezni in tudi osveščanju laične javnosti, da ob nastanku le-teh bolnik in njegovi najbližji takoj ukrepajo. Ne nazadnje, vloga urgentne prehospitalne službe je enakovredna kateremu koli členu v verigi preživetja, ne glede na to, za kakšno obliko možganske kapi gre.

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1 Asist. mag. Viktor Švigelj, dr.med., Klinični center Ljubljana, SPS Nevrološka klinika, KO za nevrologijo, Oddelek intenzivne nevrološke terapije, Zaloška 7, 1525 Ljubljana.

6. Fajdigovi dnevi, Kranjska Gora, 8. – 9. 10. 2004