每日一题_2022.07.07

A 48-year-old woman has been in the ICU for the past nine days with urosepsis. Her condition has improved greatly with antibiotics and fluid resuscitation, but her course has been complicated by sick sinus syndrome, requiring placement of a dual-chamber permanent pacemaker. Before the procedure, she was awake, hemodynamically stable, and saturating 98% on 3-liter nasal cannula. Recent chest radiograph suggests moderate pulmonary edema, and she has been responding well to diuretic therapy. She returns to the ICU from the catheterization laboratory under conscious sedation with midazolam and fentanyl. The pacemaker is set at DDD with a backup rate of 70 beats per minute (bpm). Ten minutes later, she is noted to be agitated, dyspneic, tachycardic, and hypotensive. ECG reveals sinus tachycardia, with no apparent pacemaker activity. She is somnolent and confused. Vital signs are: temperature 36.8°C (98.2°F), blood pressure 79/63 mm Hg, heart rate 128 beats/min, respiratory rate 34 breaths/min, and oxygen saturation 89% on 10-liter face mask. The incision site over her right chest is clean and dry. Physical examination reveals equal and reactive but small pupils bilaterally, greatly diminished breath sounds on the right, weak but palpable radial pulses, and elevated jugular venous distention. Which of the following is the most appropriate intervention?

A. Endotracheal intubation

B. Reversal of sedation with IV naloxone and flumazenil 

C. Needle thoracostomy of the right chest

D. Immediate CT angiogram of the chest

答案解析：

经锁骨下入路植入永久性起搏器并发气胸的发生率低于1%～2.6%。尽管如此，在简单病例中并不总是进行常规术后胸片检查。考虑到右侧呼吸音大大减弱、颈静脉扩张升高、心动过速、低血压伴脉压变窄、呼吸急促和低氧血症的一系列临床表现，该患者最可能的诊断是张力性气胸。最关键的即刻干预是在血流动力学完全塌陷发生前进行针或管状胸廓造口术以缓解张力并重新扩张肺。如果进行紧急减压性胸廓造口术，气管插管可能是不必要的，并且在存在张力性气胸的情况下耐受麻醉诱导的可能性是可疑的。虽然肺栓塞也是一种可能性，但该手术后立即无呼吸音应增加张力性气胸的可能性。胸部 CT 血管造影将有助于区分这两种潜在诊断，但仅会延迟恢复血流动力学稳定性所需的紧急治疗。此外，不建议在目前不稳定的状态下通过送她进行 CT 来损害该患者的情况。

正确答案：C