# 一名護理師於神經重症加護病房照顧裝有外部腦室引流(EVD)的35歲嚴重外傷性腦損傷病人。下列何者顯示顱內壓(ICP)升高,需立即通知醫師?(複選)

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=366305&lang=zh-tw  
> language: zh-TW  
> subject: Medical Emergencies  
> category: PA

## 題目

一名護理師於神經重症加護病房照顧裝有外部腦室引流(EVD)的35歲嚴重外傷性腦損傷病人。下列何者顯示顱內壓(ICP)升高,需立即通知醫師?(複選)

1

雙側瞳孔3 mm等大、對光反射正常

2

意識降低合併新發瞳孔不對稱

3

BP 122/78、HR 76、RR 16、人時地清醒正常

4

Cushing三聯症: BP 188/52 mmHg、HR 48、不規則呼吸

5

無噁心之突發嘔吐與劇烈頭痛

## 解析

ICP升高徵象: 後期Cushing三聯症(脈壓增寬之高血壓、心搏過緩、不規則呼吸)、意識下降與瞳孔變化(早期)、無噁心之噴射性嘔吐與劇烈頭痛。生命徵象穩定且意識清楚、瞳孔等大反應正常為神經學正常。

## 深入解析

臨床判斷
ICP升高早→晚: 意識變化、頭痛、無噁心嘔吐、瞳孔變化→Cushing三聯症為晚期且不祥。正常ICP<15 mmHg;治療閾值ICP>22 mmHg。維持CPP(MAP-ICP) ≥60-70 mmHg。避免缺氧與低血壓。

記憶口訣
Cushing三聯症=晚期: 高血壓+心搏過緩+不規則呼吸 — 疝出風險

韓 vs 美
Brain Trauma Foundation與臺灣神經外科學會指引一致: ICP閾值>22、CPP目標≥60、HOB 30度、ICP急升時mannitol/3%食鹽水、難治者外科減壓。

## 臨床情境

臨床指引
ICP管理組合:
- HOB 30度且頭部中立位以促進靜脈回流
- 避免缺氧與低血壓;SpO2 ≥92、SBP ≥100
- 鎮靜止痛以降低代謝需求
- ICP急升時高滲療法: mannitol 0.25-1 g/kg或3%食鹽水
- 有EVD時引流CSF
- 避Valsalva: 集中照護、軟便劑
- 難治者減壓開顱

注意
Cushing三聯症代表即將或正在發生腦疝。勿等三聯齊全 — 意識變化與瞳孔變化為更早期徵象,需立即處置。維持CPP並備急救。

## 重要概念

- **Cushing三聯症** — 重度ICP升高之晚期徵象,顯示腦幹受壓與即將腦疝。三聯症: 脈壓增寬之高血壓、心搏過緩、不規則呼吸。時效關鍵 — 不可等三聯齊全。
- **腦灌流壓(CPP)** — 驅動腦血流之壓力: CPP = MAP - ICP。Brain Trauma Foundation於成人TBI目標≥60-70 mmHg。<50=缺血風險;>90-100=ARDS風險。提高MAP或降低ICP管理。
- **外部腦室引流(EVD)** — 於側腦室置放導管以監測ICP及引流CSF。可精確測ICP並治療性排CSF。需嚴格無菌;CLABSI為主要風險。傳感器應對齊耳屏並依協定歸零。

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