# 情境 45歲葛瑞夫茲病個案於1個月前停用methimazole，急診以疑似thyroid storm就診。表現：T 40.2°C、HR 158心房顫動、BP 168/96、躁動、混亂。護理師預期的藥物介入順序為何?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375116&lang=zh-tw  
> language: zh-TW  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PA

## 題目

情境 45歲葛瑞夫茲病個案於1個月前停用methimazole，急診以疑似thyroid storm就診。表現：T 40.2°C、HR 158心房顫動、BP 168/96、躁動、混亂。護理師預期的藥物介入順序為何?

## 選項

1. 先給予Aspirin 650 mg治療體溫過高，然後給予IV propranolol治療心房顫動，並加上外部降溫和靜脈輸液；在甲狀腺風暴期間不應使用抗甲狀腺藥物。
2. 為阻斷合成與周邊T4→T3轉換先給PTU、1小時後給碘以阻斷釋放、IV propranolol控制心率、IV hydrocortisone、降溫、IV輸液。 **✔ 正確答案**
3. 給予高劑量IV propranolol，每5分鐘1 mg以控制心率，同時積極降溫和靜脈輸液；這種beta阻斷效果足夠，無需額外抗甲狀腺藥物。
4. 先給予Potassium iodide (SSKI)溶液以阻斷已形成激素的釋放，然後給予methimazole 60 mg，接著給予IV propranolol、IV hydrocortisone、外部降溫和靜脈輸液。

**正確答案: 2**

## 解析

甲狀腺風暴為失代償的甲狀腺機能亢進(死亡率10~30%)，高燒(常超過39~40°C)、嚴重心搏過速或心房顫動、高血壓後低血壓、腸胃症狀、躁動到昏迷的神經變化。藥物組合多模、時間敏感。經典順序：(1) PTU 500~1000 mg負荷後250 mg q4h — 同時阻斷新荷爾蒙合成與周邊T4→T3轉換(具轉換阻斷效果，storm中優於methimazole)；(2) 碘(SSKI或Lugol)需在PTU後至少1小時給予 — 阻斷既存荷爾蒙釋放；單獨先給碘會成為合成燃料(Jod-Basedow)而不可行；(3) IV propranolol — 控制心率、抑制交感症狀(顫抖、躁動)、高劑量也可降T4→T3；氣喘者改心臟選擇性β阻斷劑；(4) hydrocortisone 100 mg IV q8h — 阻斷T4→T3轉換並治療相對腎上腺不全；(5) 支持治療：降溫毯、acetaminophen(aspirin會將T4自結合蛋白游離出，惡化危機，禁用)、IV NS、處置誘因(感染、手術、漏服、壓力)、ICU監測。Levothyroxine與目標相反。

## 深入解析

Storm的藥物順序為PTU → 碘 → propranolol → hydrocortisone加上降溫支持。PTU與碘間隔1小時與避免aspirin是NCLEX兩大陷阱。

## 重要概念

- **thyroid storm sequence** — PTU → 碘(1h後) → propranolol → hydrocortisone加冷卻加輸液，避免aspirin
- **Jod-Basedow phenomenon** — 碘負荷成為合成燃料惡化甲亢，storm中PTU後再給碘
- **cooling and acetaminophen** — 退燒，aspirin會把T4自結合蛋白游離出而禁用

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