每日一题_2022.4.11

A 38-year-old man with a history of hypertension and traumatic brain injury is evaluated for three generalized tonic-clonic seizures that he had at home. En route to the hospital via ambulance, he had one additional seizure with worsening mental status, and was treated with oxygen; normal saline, 1,000 mL; IV thiamine; and glucose, 25 g. On arrival at the emergency department he is stuporous and hypoxic, so he is immediately intubated using rocuronium. Vital signs are: blood pressure 158/100 mm Hg, heart rate 108 beats/min, respiratory rate 16/min (per ventilator), temperature 37.2°C (99°F), and oxygen saturation 99%. Neurologic examination shows bilateral 3-mm reactive pupils and normal fundus. The rest of the examination is unobtainable since he has residual chemical paralysis.

Which of the following is the most appropriate course of action at this point?

A. Mannitol, 1 g/kg IV

B. Lorazepam, 0.1 mg/kg IV

C. Brain MRI with and without contrast 

D. Fosphenytoin, 20 mg/kg IV

答案解析：

该患者出现数次癫痫发作，但未恢复至其神经系统基线水平。他符合癫痫持续状态(SE)的标准：持续癫痫发作活动5分钟或连续癫痫发作而意识未恢复。仅仅因为他是化学瘫痪并不意味着他没有主动抓取。有证据表明，SE的最佳一线干预是IV劳拉西泮，0.1 mg/kg。最佳二线干预是磷苯妥英或丙戊酸。没有迹象表明他患有小脑幕切迹疝。MRI可能发挥重要作用，但不适用于SE的急性治疗。

正确答案：B

补充内容：

癫痫持续状态（status epilepticus，SE）是癫痫发作的严重状态，是指癫痫连续多次发作，两次发作间期病人意识不恢复，或一次癫痫发作持续时间超过30分钟以上者。

随着临床试验和基础研究的不断深入，SE发作持续时间的限定从最早的30min，逐渐缩短至每次惊厥发作持续5 min以上，或2次以上发作，发作间期意识未能完全恢复。

其年发病率为41/10万～61/10万，1岁以内及65岁以上发病率最高。15％的癲痫患者曾有癲痫持续状态，10％～20％的儿童癫痫患者至少曾有1次癫痫持续状态。9％的癫痫儿童以持续状态为首发症状。