一例药物过敏性休克死亡的医疗问题鉴定分析

目的探讨药物（低分子右旋糖酐）过敏性休克医疗纠纷案件的法医学鉴定思路及关键点，从而为审判提供划分侵权责任及医疗赔偿的科学依据。方法详细报道一例低分子右旋糖酐药物过敏性休克死亡的两级医疗事故鉴定，法医学鉴定及二次不同的法院判决结果的医疗纠纷案例。结果两级医疗事故鉴定均认为该例属医疗意外，不属医疗事故，一审判决驳回起诉。法医学鉴定认为在对该例的抢救过程中确存在不当之处；患者确因药物（低右）过敏性休克死亡，未发现院方有违反医疗常规的行为，对该例的治疗方案属非必要治疗措施。在抢救过程中，肾上腺素没有作为首选用药，肾上腺素应用不及时，药量不充足。因抢救地点的限制致使抢救质量不好。据此，二审判决被告院方对患者方予以赔偿。结论药物过敏性休克的法医学鉴定应注重：①全面审查所提供的详细医疗材料，分析整个医疗过程的临床变化特点；②全面尸检；③进行药品检验、毒物分析；④排除疾病及其它死因；⑤进行确证死因的检验。在此基础上分析确定死因及医疗过程是否存在问题，如存在医疗不当之处，分析此种医疗不当在患者的死亡中的关系比例，并适当表述鉴定意见。

Forensic medicine expertise about malpractice disputation with fatal allergy shock of low molecular dextran

Objective To explore the gist of forensic medicine expertise about medical malpractice with fatal allergy shock of low molecular dextran (ASLMD), and provide scientific authority in defining liability for tort and compensation. Methods Two malpractice expertises by two-levels department of sanitation, a forensic medicine expertise and two difference judgment were detail described. Results in two malpractice expertises, this case was considered as ASLMD-related accident death, unrelation with medical treatment. Therefore, the complaint was dismissed in first trial. However, forensic medicine expertise pointed out that, although this case died certainly from ASLMD according to the clinical features, postmortem examination, pharmo-toxiological and serological analysis, some unsuitable in resume process were existed as follows: (1) The countermeasures of medical treatment in this case was uncorresponded with first-aid guideline, adrenalin should be first-select drug, not dopamine. In addition, use of adrenalin was not in time and unenough. (2) The effect of first-aid was restricted as treatment site. Base on forensic medicine expertise, compensation should obtain by plaintiff as the court judgment in second trial. Conclusion This case suggest that ASLMD forensic medicine expertise should depend on (1) whole information of medical treatment; (2) clinical features; (3) completely autopsy; (4) pharmotoxiological detection; (5) special serological analysis such as IgE, LTs LTB4, LTD4, TXB2 ect. (6) excluding the possibility of other fatal diseases. Meanwhile, the contributory of malpractise in event should be including in forensic medicine expertise.