每日一题_2022.09.04

A 48-year-old woman with a history of severe traumatic brain injury one year ago presents to the emergency department (ED) unresponsive after a witnessed episode of three minutes of generalized shaking, for which she is given lorazepam, 4 mg. While en route to have a head CT, she begins to have generalized tonic-clonic movements. She is given lorazepam, 4 mg, and the movements resolve. Head CT reveals bifrontal encephalomalacia. Her temperature is 37°C (98.6°F), heart rate 105 beats/min, blood pressure 163/90 mm Hg, respiratory rate 16 breaths/min, and weight 60 kg (132 lbs). On examination, her eyes are closed and she is not responsive to verbal stimuli; pupils are equal, round and reactive; corneal reflexes are present bilaterally; cough and gag reflexes are present; and she flexes to noxious stimuli in all four extremities. There is concern for airway compromise, and the ED team is intubating her.

Which of the following is the most appropriate next treatment for the patient’s presenting symptoms?

A. Propofol infusion

B. IV levetiracetam load

C. Lorazepam, 2 mg intravenous push

D. Midazolam infusion

答案解析：

令人担忧的是，患者处于癫痫持续状态 (SE)，定义为 5 分钟或更长时间的持续临床（和/或电图）癫痫发作活动或反复发作活动，而癫痫发作之间没有恢复。 SE 使用苯二氮卓类药物作为紧急初始治疗。 根据最新的神经重症监护协会指南，苯二氮卓类药物治疗后应进行紧急控制抗癫痫药物治疗，包括静脉注射磷苯妥英/苯妥英钠、丙戊酸盐或左乙拉西坦。 C 不正确，因为患者已经接受了 8 mg 劳拉西泮（最大剂量为 0.1 mg/kg）。 A 和 D 不正确，因为这些是难治性 SE 的治疗方法。 神经重症监护协会指南将难治性 SE 定义为对标准治疗方案无反应的 SE，例如最初使用苯二氮卓类药物，然后使用另一种抗癫痫药物。 该患者还需要持续的脑电图来排除非惊厥性癫痫发作。

正确答案：B