每日一题_2022.06.08

A 65-year-old man with a medical history of Parkinson disease is admitted to the hospital for evaluation of renal failure in the setting of dehydration. He is admitted to the general medical ward, where an infusion of normal saline is started. During the night, he is found to be lethargic and confused, and falls in the bathroom. Vital signs are: heart rate 42 beats/min, respiratory rate 18 breaths/min and shallow, blood pressure 90/58 mm Hg, temperature 37.1°C (98.8°F), and oxygen saturation 92%. Neurologic examination reveals a Glasgow Coma Scale score of 11. He is lethargic and not following commands, has weakness in the upper extremities, and cannot move his lower extremities. He is intubated and transferred to the ICU, where a cervical spine CT is performed (shown below).

Based on this evaluation, which of the following is the most appropriate next therapy for this patient?

A. IV ceftriaxone, 2g, immediately

B. IV dexamethasone, 10 mg bolus

C. Immobilization of cervical spine with stiff collar

D. Assessment of cranial nerves, including oculocephalic nerves

答案解析：

该患者在医院跌倒，锁骨上方可能遭受创伤，包括头部和颈椎。临床检查符合急性高位脊髓损伤。对其进行适当插管。他应该立即制动，因为他有C1齿突骨折，应该被认为是不稳定的，直到治疗。血压优化的作用值得商榷，但观察性研究表明，在急性脊髓损伤中，平均动脉压水平高于80 mmHg可能与结局改善相关。在最近的NASCIS III研究的基础上，类固醇在急性脊髓损伤中的应用也值得商榷，该研究显示无结局效应。

2013年，根据现有证据，美国神经外科医师协会和神经外科医师大会表示，不推荐在急性脊髓损伤中使用糖皮质激素。加拿大急诊医师协会的立场声明，并得到美国急诊医学学会的认可，同意糖皮质激素治疗是一种治疗选择，而不是一种治疗标准。此时患者似乎不需要静脉注射抗生素。

正确答案：C