每日一题_2022.09.15

A young man is involved in a high-speed motor vehicle collision while intoxicated. He is intubated in the emergency department with etomidate and succinylcholine. Head CT is notable for diffuse axonal injury, with scattered punctate hemorrhages. He is admitted to the ICU, where he is given midazolam and fentanyl infusions overnight. The next morning, while his sedation is held for an hour, his pupils are 5 mm and unreactive, and he has no cough or gag reflexes.

Which of the following is the best course of action?

A. Explain to his family that he has no brainstem reflexes, and he is therefore brain dead.

B. Perform apnea testing to confirm brain death.

C. Obtain neurovascular imaging to confirm brain death.

D. Continue to hold all sedation and follow his neurologic examination.

E. Administer flumazenil and naloxone in an attempt to wake him.

答案解析：

这名患者在机动车碰撞时喝醉了，他被连续输注了一夜的镇静剂。 在 ICU 团队确定所有混杂因素（例如镇静剂或中毒）已被排除之前，任何考虑脑死亡测试的想法都为时过早。 此外，患者应该是正常体温，没有电解质或代谢紊乱，如高钠血症或高碳酸血症，这可能会影响神经系统状态。 只有在消除了所有潜在的混杂因素之后，才能进行脑死亡测试。 虽然非惊厥性癫痫持续状态是创伤性脑损伤患者的一个合理问题，但在检查后保持镇静是适当的。 如果怀疑是非惊厥性癫痫持续状态，应进行脑电图检查。 在这种情况下，氟马西尼和纳洛酮都是禁忌的，因为患者可能会癫痫发作； 谨慎的选择是等待苯二氮卓类药物和麻醉剂清除。

正确答案：D