Transcript 1000423神經重症part-I

神經內外科加護訓練課程班
part I
謝鎮陽醫師
台南新樓醫院神經內科
成功大學藥學生物科技研究所博士班
2011/04/23
課程大綱 part I
• 基本神經學知識回顧
• 「意識障礙」概念再教育
• 加護病房病患意識障礙之評估
Neurophobia
• 係一全球性的現象
• 包括醫師、護理人員
• 原因
– 複雜的神經解剖學
– 困難的評估方式、臨床技巧
– 艱深的神經藥理學
– 不良的預後
• 給您全新的重症神經學體驗
ICU神內會診常見問題
• 神內醫師：「這個病人之前baseline的
conscious怎麼樣?」
• 主護：「嗯…啊…我今天第一天care，之前
交班沒有提到…」
• 然後負責的神內醫師，必需會客時自己去
問病史
• 然後一不小心，病人的主治醫師每天都叫
神內醫師自己去跟家屬解釋病情
升官發財
勿走神內
神經重症病患入院評估
• 病史 (history taking) 永遠是王道
– 列入交班重點!
• 病人以其是clear的嗎?
• 原本的狀態 (baseline)
– 吃、喝、拉、撒、睡、說話
– 穿衣、洗澡、其他日常生活
• 這次住院，是因為發生了什麼變化?
– 急性 (acute, 1-2天)、亞急性 (subacute, 3-14
天)、慢性 (chronic, >14天)、急上慢性 (acute
on chronic)…
病程的重要性
• 病程 (course)
– 急性：腦血管疾病
– 亞急性、急上慢性：
• 中樞神經感染
• 覆發性 (recurrent) 腦血管疾病
• 毒性、代謝性腦病變 (toxic-metabolic
encephalopathy)
有人會說…
• 問那麼多幹什麼，brain CT切一切不就好了?
• 可惜光靠brain CT只能解決30-40%的問題
– 腦內出血 (ICH)
– 硬腦膜下出血 (SDH)
– 腦內腫瘤 (tumor)、膿瘍 (abscess)
• 有2/3的神經重症病患，無法光靠一張brain
CT來診斷
– 配合病史、理學檢查、其他臨床檢驗數據
– 綜合判斷、鑑別診斷
世上有幾個難以回答的問題
1. 病人為什麼會發燒?
簡單的大家都會
難的大家都查不出來
2. 病人的conscious為什麼不好?
或者是問題1.+2.
3. 老婆問你外面有沒有小三?
Consciousness, 意識
• Awareness of self and surroundings
– 知道自己與外界環境
• 英文小提醒
– 不要說conscious disturbance
– 因為conscious是形容詞
– 正確的說法是disturbance of consciousness或
consciousness disturbance
Mental Function, Cognition, 心智
• Awareness of self and surroundings
– 知覺
• Ability to accurately perceive what is
experienced (sensory input, orientation)
– 接收
• Ability to store, retrieve information (memory)
– 儲存
• Ability to process input data to generate more
meaningful information (judgment, reasoning)
– 思考, 理解
Disorder of Mental function
• Disorders (disturbances) of consciousness
• Disorders (disturbances) of cognition
Cognition
Consciousness
Disorders of Consciousness
• Arousal (wakefulness)
– Level of consciousness
• Awareness (responsiveness)
– Content of consciousness
Unaroused &
Unaware
Aroused &
Unaware
Dementia
Syncope
Sleep
Coma
Brain death
Aroused &
Aware
Delirium
Vegetative
state
Locked-in
state
• Normal:
– awareness (wakefulness), arousability (sleep)
• Delirium (瞻妄), dementia
– Arousal, with varying degree of awareness
• Vegetative state (植物人):
– Arousal (eyes open), no awareness
– Spontaneous, but purposeless movement
• Locked-in (閉鎖) state
– Bilateral injury of motor pathway, except vertical eye
movement and eye blinking
– Fully awake, aware
• Coma, brain death
– Unarousable unawareness
Etiologies of Altered Consciousness
1. Stroke/hemorrhage, trauma,
encephalitis, seizure
1
2. Drugs, EtOH (withdraw), thiamine
deficiency, toxin
2
3
3. CPCR, hyper/hypothyroidism
4
4. IV drugs, line infection, sepsis
5
5. ↓pO2, ↑pCO2, ARDS
6
7
8
9
6. CHF, hyper/hypotension
10
7. Heaptiobiliary
8. Pancreatitis, hyper/hypoglycemia
9. Adrenal insufficiency
10
11
10. Uremia, urosepsis, electrolyte
(↑↓Na, ↑Ca, ↓P)
11. Fat embolism
Septic Encephalopathy
感染性腦病變
• Most common (non-traumatic): 50-70%
– Infection outside CNS, elderly
• Mechanism
– Abnormal BBB, cerebral edema
– Inflammatory mediators, aromatic amino acid,
amonia (~hepatic encephalopathy)
– Cerebral blood flow↓60%
• Hyperventilation (response to metabolic acidosis)
– Multiorgan injury associated with systemic
inflammatory response syndrome (SIRS)
Delirium, 瞻妄
• Attention deficits, disordered thinking or
altered level of consciousness
– Acute onset, fluctuating (D.D. dementia)
• 87% patients with ventilator
• 40% delirium patient had psychotic
symptoms (visual hallucination)
– “ICU psychosis”
– Delirium with psychotic features
– 66% unnoticed
Drugs
Alcohol (withdraw)
Amphotericin
Amionglycosides
ACEI
Anticholinergics
Anticonvulsants
Antiarrhythmic (amiodarone,
quinidine)
Acyclovir
Benzodiazepam
Beta-blockers
Cephalosporins
Cocaine
Corticosteroid (high-dose)
Digitalis
H2-blockers (cimetidine, ranitidine)
Isoniazid
Anesthetics (lidocaine, bupivacine)
Metoclopramide
Metronidazole
NSAIDs (ibuprofen)
Opioids (merperidine)
Penicillin (high-dose)
Trimethoprim-sulfamethoxazole
Coma, 昏迷: Anatomic Basis
• Diffuse, bilateral cerebral lesion (brainstem
reflexes intact)
• Unilateral cerebral lesion, midline shift,
compressing contralateral cerebral
hemisphere
• Posterior fossa (後顱窩) mass, direct
brainstem compression
• Toxic or metabolic disorders (small, midposition, reactive pupils)
鑑別診斷
•
•
•
•
•
•
病史: 外傷, 癲癇, 中毒; Baseline (吃喝拉撒說話)
血壓: 降低 (shock), 升高 (中風, 高血壓性腦病變)
體溫
呼吸: Cheyne-Stokes (大腦,間腦病變)
膚色: cyanosis (缺氧), pink (CO中毒)
瞳孔: 兩側放大 (缺氧性腦病變, 中風, 抗乙烯膽鹼
中毒); 兩側縮小 (中毒,橋腦中風)
• 單側肢體癱瘓: 有 (中風), 無(代謝性,感染性腦病
變,中風)
• 頸部僵硬
肌力 Muscle power
5: Full
4: Resistance
3: Antigravity
2: Horizontal
1: Trivial
0: No
Right-way and Wrong-way eye
簡單記法
• 右側手、腳無力：左側腦部病灶
• 右側手、腳無力+雙眼偏左：左側大腦病灶
– 常見左側 MCA stroke
• 右側手、腳無力+雙眼偏右：左側腦幹病灶
– 常見左側 pontine stroke
哇！你這個護士怎麼這麼厲害
Coma
• Cardiac arrest (31%)
• Stroke/hemorrhage (36%)
• Less than 10% survive coma without
significant disability
• IICP, Cushing triad
– Hypertension (BP↑)
– Bradycardia (HR↓)
– Tachypnea (RR↑)
Syncope vs. Seizure
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病因
Onset
先驅症狀
意識障礙
血壓
脈搏
呼吸
膚色, cold sweating
肢體抽搐
失禁
謝謝聆聽!!
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