每日一题_2022.4.21

A 50-year-old woman with a history of hypertension treated with lisinopril, and depression currently being treated with a selective serotonin reuptake inhibitor, presents to the emergency department with right lower quadrant abdominal pain. She also reports weight loss, fatigue, poor appetite, and palpitations. She has not seen her primary care provider in years. Vitals signs are: temperature 38.5°C (101.3°F), heart rate 130 beats/min, respiratory rate 24 breaths/min, blood pressure 150/90 mm Hg, oxygen saturation 100% on room air. CT reveals appendicitis, and she undergoes an urgent appendectomy. At the end of the procedure she develops atrial fibrillation at a ventricular rate of 150 beats/min. After treatment with metoprolol, 5 mg, the rate decreases to 120 beats/min, then converts to sinus rhythm, and she is moved to the ICU for observation. In the ICU she is confused, diaphoretic, mildly agitated, and has one or two episodes of emesis. Vitals signs are: temperature 40°C (104°F), heart rate 120 beats/min, respiratory rate 30 breaths/min, blood pressure 195/95 mm Hg, oxygen saturation 95% on room air. Physical examination is notable for a supple neck, soft abdomen, and warm extremities without rigidity or clonus. Laboratory results are pending.

Which of the following is the most appropriate next pharmacologic intervention?

A. Cyproheptadine and IV benzodiazepines

B. IV dantrolene

C. Enalaprilat

D. IV propranolol, propylthiouracil, and dexamethasone

答案解析：

甲状腺危象是一个具有挑战性的诊断，特别是没有疾病史和其他混杂因素。该患者有未确诊的甲状腺功能亢进，表现为术前无力、疲乏和心悸。她随后发生了阑尾炎，感染的压力以及手术，使她陷入了甲状腺危象。

甲状腺危象是甲状腺功能亢进的一种罕见但潜在危及生命的并发症，通常由身体应激（如感染）触发。症状包括高热、心动过速、精神状态改变、胃肠道症状和潜在的高输出量性心力衰竭。必须立即开始治疗，通常在获得实验室结果之前，以达到最佳结局。IV β受体阻滞剂，如普萘洛尔，可有效控制心率，并有助于阻断外周甲状腺素向三碘甲状腺原氨酸转化。还需要丙基硫氧嘧啶和他巴唑等抗甲状腺药物来阻断甲状腺激素的产生。给予类固醇以防止伴随的肾上腺功能不全，并防止外周甲状腺转化。只有在开始使用抗甲状腺药物后才能加用碘。

恶性高热和5-羟色胺综合征可能看起来与甲状腺危象相似，但存在一些细微的差异。在恶性高热中，预期诱导后会更快发作以及肌肉僵硬和呼吸性酸中毒。5-羟色胺综合征也与肌肉强直有关，常伴有阵挛。可通过IV ACE抑制剂依那普利拉控制高血压，但其甲状腺危象的初始治疗将治疗其血压升高的根本原因。

正确答案：D

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