内科加护病房常见之.pptVIP

內科加護病房常見之神經科問題 神經內科 林俊豪 何時緊急找 Neurologist ? Mental change Weakness of limbs Fever with headache Convulsion 何時緊急找 Neurologist ? Unilateral limbs weakness +/- facial asymmetry or slurred speech ,easy choking ? stroke, brain tumor…. Weakness of bilateral legs or four limbs without cranial nerve dysfunction ?spinal cord lesion, AIDP, myopathy Fever with headache or mental change? CNS infection 意識改變的原因 造成意識改變的原因有許多都不是先從腦部疾病造成的 例如藥物中毒,缺氧,肝昏迷,內分泌如血糖過高或過低,酸鹼不平衡,敗血症,高血壓腦病變… 其他腦部疾病包括腦出血，腦梗塞，腦脫疝，腦膜炎或腦炎 呼吸現象評估 呼吸現象評估 瞳孔反應 簡單來說 光刺激由第二對視神經傳入 瞳孔收縮由第三對動眼神經執行 瞳孔擴張經由交感神經路徑控制 瞳孔反應 眼位與身體姿勢及無力 意識不清，單側肢體無力又兩眼偏移：極有可能是腦部問題 眼球偏向無力側—對側橋腦 眼球偏離無力側---大腦病灶，位在無力肢體對側 ---記住一點，通常腦部病灶在無力肢體對側 癲癇也會造成眼球偏移 角膜反射 使用棉花尖端碰觸角膜，經第五對三叉神經傳入，在橋腦及延腦間傳遞，再經由兩側顏面神經傳出而眨眼 stroke Infarction Hemorrhage— SAH ICH Headache, vomiting, seizure, coma---hemorrhage is more likely TIA – transient ischemic attack Stroke Management Diagnostic tests brain CT—如懷疑brain stem infarction, focus posterior fossa ECG clinical chemistry--- complete blood count and platelet count, PT,INR, PTT serum electrolytes, blood glucose, ABG, Hepatic and renal chemical analysis Thrombolytic treatment – rt-PA rt-PA : 0.9 mg/kg,10% bolus in one minutes Time window : 3 hours 切記 NIH stroke scale 6-25 Exclusion: age 18 y/o or 80 y/o 非絕對 bleeding tendency or other active bleeding BP : SBP 185 or DBP 110mmHg blood sugar : 50 or 400 mg/dL Stroke Management The European Stroke Initiative Executive Committee and the EUSI Writing Committee Update 2003 General stroke treatment Vital signs Glasgow coma scale NIH stroke scale Pupil size and light reflex ( large infarction or brain stem infarction in evolution) Pulmonary function and airway protection oxygen supply at low flow rates ：沒有證據在human brain infarction 有幫助 Little evidence that stroke patients benefit from hyperbaric oxygen therapy Intubation : unconscious patient (GCS8 ?) at high risk for aspiration Blood pressure management Many patie