每日一题_2022.07.15

A 37-year-old man sustains a traumatic brain injury with subarachnoid hemorrhage and subdural hematoma in a motorcycle crash. He undergoes evacuation of the hematoma, after which he is extubated and transferred to the ICU with a Glasgow Coma Scale score of 15. He is started on levetiracetam for seizure prophylaxis. On postoperative day two, he becomes acutely agitated and is tremulous. Temperature is 38.8°C (101.8°F), blood pressure 180/110 mm Hg, heart rate 136/min, and respiratory rate 34 breaths/min. On examination, he is moaning, trying to get out of bed, and diaphoretic. Pupils are equal and reactive; lungs are clear to auscultation bilaterally.

Which of the following is the most appropriate next step in management?

A. Immediate repeat head CT

B. Hypertonic saline bolus

C. Rapid-sequence intubation for airway protection 

D. Lorazepam 2 mg IV

答案解析：

该患者精神状态急性改变有多种可能的病因。鉴别诊断包括复发性颅内出血、脑水肿、电解质异常、戒酒和感染。虽然应进行重复 CT 以排除脑水肿恶化或复发性出血，但控制他的激越和首先评价他的电解质是合理的。如果有低钠血症和/或脑水肿的证据，可以推注高渗盐水，但除非有脑疝的急性体征（瞳孔散大、库欣反射），最好先检查电解质。酒精戒断综合征 (AWS) 以心动过速、高血压、发热、躁动、出汗、震颤、谵妄为特征。这些体征和症状通常在患者末次饮酒后48-96小时内出现，如果治疗不及时，可能进展为震颤谵妄和癫痫发作。AWS 急性体征的主要治疗药物是苯二氮卓类药物，如劳拉西泮。任何怀疑 AWS 的患者也应给予硫胺素和叶酸。急性症状得到控制后，应进行全面检查，包括全血细胞计数、生化、血培养和影像学检查，以排除其他病因。

正确答案：D