阵发性交感神经兴奋

PSH李祥全WHATISPSH〉PSH：ParoxysmalSympatheticHyperactivityParoxysmal：阵发性SympatheticHyperactivity：交感活性增高WHATISPSHWHATISPSH〉交感神经兴奋是一种应激反应，起到一定的机体保护作用WHATISPSH〉交感兴奋时可有以下变化：心率加快胃肠道血管收缩呼吸增快汗腺分泌瞳孔扩大糖原分解膀胱逼尿肌松弛、括约肌收缩肌张力升高WHATISPSHWHATISPSH平衡是机体正常的生理需求WHATISPSH〉PSH：unbalancedsympatheticsurgescausing1.hyperthermia2.diaphoresis3.tachycardia4.hypertension5.tachypnea6.dystonicposturingdevelopabruptlyandlastforashorttime交感发作.mp4WHATISPSHWHATISPSH〉characteristic：Thefirstepisodeoccurredonaverage5.9±3.7daysafterbraininjuryThedurationofeachepisodewasonaverage31min(range,15–50min)anditsfrequencywasonaverage5.6/day(range,3―8/day)Only20%ofpatientswhowerefollowedupat12monthsafterinjuryshowedcontinuedsignsofPSHYoungerageandmalegenderhavebeencitedasriskfactorsWHATISPSH〉characteristic：Increasesindopamine,adrenaline,andnoradrenalinelevelsduringtheepisodeshavebeenreportedPatientswhoexperiencePSHhaveworseGlasgowOutcomeScalescoresandworsefunctionalindependentmeasuresthantheirounterpartslongerICUstays,longerhospitalstay,moremechanicalventilationdays,moreinfectiousepisodes,moretracheostomy,andhigherhealthcarecostsWHATISPSH〉PSHoccursinstages：1.asymptomaticduetosedation;2.onsetofsymptomclusters;3.declineinposturinganddystoniaReasonforPSH〉CausedbyTBIsubarachnoidhemorrhageencephalitistumorshydrocephalusotherdiseasesMechanisms〉Unknownfunctionalorstructuraldisconnectionlesionsinthemesencephaloncausedisruptionsinrelayfromthemedulla/hypothalamusexcitatory–inhibitoryratio(EIR)modeldysfunctionofthediencephalic-brainsetminhibitorycenterthatnormallycontrolsafferentstimulusprocessinginthespinalcordoccursDiagnosticWorkups〉ExclusiondiagnosisInfectionsandsepsisshouldberuledoutinpatientswithfeverandtachycardiaOpiatewithdrawalfromprolongedsedationshouldbeaddressedEEGtoruleoutseizuresDiagnosticWorkupsCFS-AM量表特点得分临床症状同时发生1突发性1轻微刺激引起症状发作1发作症状持续≥3天1脑损伤持续大于≥周1其他治疗后症状无缓解1药物可缓解交感神经症状1发作≥2次/d1无副交感兴奋表现1排除其他原因1获得性脑损伤病史1不可能(＜8分)，可能(8～16分)，很可能(＞17分)Management〉nodirecttreatmentoptionsareavailable〉controlofsymptoms〉MedicaltreatmentsforPSHincludeα2-agonists,β-blockers,benzodiazepines,dopamineagonists,opioids,GABAergicagents,antrolene,andgabapentin；Management〉Clonidine(可乐定)：presynapticα2-receptoragonistwhichreducescentralsympatheticoutflowfromthehypothalamusandventrolateralmedulla〉Dexmedetomidine（右美托咪定）:anintravenoussedativeandthefirstandonlycurrentlyapprovedintravenousα2-agonistManagement〉Baclofen（巴氯芬）:structuralanalogoftheinhibitoryneurotransmitterγ-minobutyricacid(GABA),indicatedfortreatmentofspasticityandtoimprovemobility〉Gabapentin（加巴喷丁）：analogofGABAManagement〉Bromocriptine（溴隐亭）:syntheticdopamineagonistthatstimulatesdopaminetype2receptorsandantagonizestype1receptorsinthehypothalamusandtheneostriatumofthebrain〉Dantrolene（丹曲林）:decreasesmusclecontractionbydirectlyinterferingwithcalciumionreleasefromthesarcoplasmicreticulumwithinskeletalmusclecells.Management〉Propranolol（普萘洛尔）:β-Blockers〉Morphine（吗啡）:μ-opioidreceptoragonist;startingwithintravenouslydministeredmorphineandthenswitchingtoascheduledoralrouteofadministrationofmorphineoroxycodoneManagement〉Benzodiazepines（苯二氮卓类）:Short-actingbenzodiazepinesarepreferableforpatientsearlyinthecourse,longer-actingagentstodecreasetheboutsofhyperactivity;