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 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 給您全新的重症神經學體驗 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 病人以其是clear的嗎? 原本的狀態 (baseline) 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 英文小提醒 知道自己與外界環境 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

Syncope Sleep Coma Brain death Vegetative state Locked-in state Unaroused & Unaware Aroused & Unaware Aroused & Aware Syncope Sleep Dementia Coma Delirium Brain death Vegetative state Locked-in state

Delirium (瞻妄), dementia Vegetative state (植物人): 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 Stroke/hemorrhage, trauma, encephalitis, seizure Drugs, EtOH (withdraw), thiamine deficiency, toxin CPCR, hyper/hypothyroidism IV drugs, line infection, sepsis ↓pO2, ↑pCO2, ARDS CHF, hyper/hypotension Heaptiobiliary Pancreatitis, hyper/hypoglycemia Adrenal insufficiency Uremia, urosepsis, electrolyte (↑↓Na, ↑Ca, ↓P) Fat embolism 1 2 3 4 5 6 7 8 9 10 11

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, mid- position, 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 右側手、腳無力+雙眼偏右：左側腦幹病灶 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 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

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