每日一题_2022.1.5

xujunzju • 2022年1月5日 14:45 • 习题训练 • 阅读 597

A 75-year-old woman with a medical history of atrial fibrillation and hypertension is brought to the emergency department by her husband for sudden onset of aphasia（失语）, left hemiparesis（偏瘫）, and dysarthria（构音障碍） two hours ago. She takes warfarin for stroke prevention. Vital signs are: blood pressure 208/108 mm Hg, heart rate 108 beats/min, respiratory rate 16 breaths/min, oxygen saturation 96%, and temperature 36.8°C (98.2°F). On examination, she has aphasia, is unable to name or repeat objects, and appears confused（混乱的）. She has no withdrawal of the right upper and lower extremity, and her gaze（凝视） does not pass the midline. White blood cell count is 14,500/μL, INR is 1.6, partial thromboplastin time is 28 sec, and platelet count is 190,000/μL. CT is shown below.

Which of the following is the most appropriate intervention?

A. Administer IV recombinant tissue plasminogen activator（重组组织型纤溶酶原激活剂） (rtPA) and delay treatment of blood pressure until repeat CT is obtained.

B. Treat blood pressure immediately to a goal systolic blood pressure <185 mm Hg and administer IV rtPA.

C. Administer fresh frozen plasma.

D. Administer IV phosphenytoin for seizure prophylaxis.

投票情况如下：

答案解析：

该患者发生急性缺血性卒中；她在使用IV重组组织型纤溶酶原激活剂(rtPA)进行血运重建的3小时时间窗内；但是，她的血压应纠正，因为IV rtPA可能禁忌用于血压非常高的患者。她似乎未经历发作事件，如癫痫发作。癫痫发作可视为鉴别诊断的一部分，但不应延迟IV rtPA给药。有证据表明，对于急性缺血性卒中患者，不应将症状发作时的癫痫发作视为IV rtPA的绝对禁忌症。她不需要新鲜冷冻血浆，因为如果INR小于1.7且CT上观察到的高信号是侧脑室蛛网膜过程中的钙化，则可以安全地给予rtPA。CT显示在鳃盖和岛叶带状区域轻微缺乏左侧灰白质分化，这被认为是大脑半球梗死的早期体征。

SCCM, Self-Assessment in Adult Multiprofessional Critical Care 8th Edition

References:

1.Jauch EC, Saver JL, Adams HP Jr, et al; American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council onClinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013 Mar;44(3):870-947.

2.Selim M, Kumar S, Fink J, Schlaug G, Caplan LR, Linfante I. Seizure at stroke onset: should it be an absolute contraindication to thrombolysis? Cerebrovasc Dis. 2002;14(1):54-57.

3.[No authors listed]. Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med. 1995 Dec 14;333(24):1581-1587.