每日一题_2022.07.18

A 77-year-old man is transferred to the ICU for tachypnea, hypoxemia, and hemoptysis. He has a past history of laryngeal mass, which was resected six days ago and was complicated by a non-ST elevation myocardial infarction three days ago. At that time, he underwent cardiac catheterization and stent insertion in the left anterior descending, circumflex coronary, and posterior descending arteries. Since going to the catherization laboratory, he has been on a continuous heparin infusion. On examination, he is sitting upright and is actively suctioning bright red blood via a Yankauer catheter. His vital signs are: blood pressure 97/54 mm Hg, heart rate 131 beats/min, respiratory rate 38 breaths/min, oxygen saturation as measured by pulse oximetry 90% on 10-liter nasal cannula. He reports that his breathing is becoming more difficult. 

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

A. Left lateral decubitis position

B. Noninvasive ventilation

C. Venovenous extracorporeal membrane oxygenation 

D. Direct laryngoscopy

E. Cricothyroidectomy

答案解析：

该患者有症状的气道大出血，需要气道管理，以防止完全阻塞和缺氧。可视喉镜检查可能比直接喉镜检查更困难，因为照相机视图被血液阻塞。即使他患有声门上阻塞，双水平气道正压通气可能驱动血液和血栓深入气管，使他自己的清除机制不太有效。静脉-静脉体外膜肺氧合插管不是恢复氧合的最快方法，需要一些抗凝治疗，这可能会加重出血。清醒环甲膜切开术可能是必要的，但不是第一步，除非传统的直接喉镜被认为是不可能的。对于局限于单个肺的咯血，将出血肺向下定位可能有助于预防非出血肺中抽吸诱导的低氧血症。

正确答案：D