# 重度TBI後6小時神經ICU病人,ICP監測8分鐘維持24 mmHg、MAP 78 mmHg。護理師應先執行?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=374964&lang=zh-tw  
> language: zh-TW  
> subject: NCLEX-RN  
> category: PA

## 題目

重度TBI後6小時神經ICU病人,ICP監測8分鐘維持24 mmHg、MAP 78 mmHg。護理師應先執行?

## 選項

1. 確認床頭抬高30度且頸部中線對齊 **✔ 正確答案**
2. 給予23.4%高張食鹽水單次推注
3. 過度換氣使PaCO2達28 mmHg
4. 降低propofol以利神經評估

**正確答案: 1**

## 解析

第一線ICP控制從簡單生理因素優化開始:床頭30度、頸部中線(促進頸靜脈回流)、充分鎮靜止痛、正常碳酸。高滲透療法前先確認這些。高張食鹽水適當但屬第二線。PaCO2低於30的預防性過度換氣會引起腦血管收縮與缺血,僅用於即將腦疝。降低鎮靜會升高ICP。

## 深入解析

BTF第一線組合:體位、鎮靜、正常碳酸、正常體溫、CSF引流。反射性過度換氣已不在指引中(僅作手術前短暫橋接)。

## 臨床情境

GCS 7T,插管,propofol鎮靜。床頭30度、頸部中線。機械通氣PaCO2 38 mmHg。最近CPP 54 mmHg。

## 重要概念

- **腦灌流壓** — CPP=MAP-ICP。成人TBI目標60-70 mmHg。
- **高滲透療法** — 以高張食鹽水或mannitol減輕腦水腫。
- **Monro-Kellie定律** — 顱內容積固定 — 任一成分(血、CSF、腦)增加,除非他成分減少,否則ICP升高。

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