卒中时间窗与颅内压升高

🧠 为什么重要

STROKE（卒中）识别：FAST，面部下垂、手臂漂移、言语困难、及时打电话。确定 LAST KNOWN WELL（最后已知正常）时间；对于缺血性卒中，IV 溶栓药（alteplase 或 tenecteplase）在最后已知正常后 4.5 小时内给予，前提是 CT 扫描排除出血且血压控制在约 185/110 以下；超过这个时间，只有少数经高级影像评估有利的患者才符合条件，而大血管血栓仍可在 24 小时内通过取栓术清除。在通过吞咽筛查之前保持 NPO，体位为抬高头部，并密切监测神经状态。LEFT（左侧）半球卒中导致右侧无力和失语；RIGHT（右侧）半球卒中导致左侧无力、忽视、冲动和安全判断力差。INCREASED INTRACRANIAL PRESSURE（颅内压升高）：早期体征是 LEVEL OF CONSCIOUSNESS（意识水平）改变（最早且最敏感）、坐立不安、头痛、呕吐和瞳孔改变；晚期体征是 CUSHING'S TRIAD（库欣三联征，包括脉压增宽伴高血压、心动过缓、呼吸不规则）、瞳孔固定散大和异常姿势。干预措施包括床头抬高至 30 度并保持头部居中，避免髋部屈曲超过 90 度，预防咳嗽、用力和 Valsalva 动作（使用大便软化剂），吸引时间不超过 10 至 15 秒并预先高浓度给氧，将护理活动分散开，治疗发热，维持 PaCO2 正常，并按医嘱给予 mannitol 或高渗 saline 等渗透治疗。SEIZURES（惊厥发作）：保护头部，转向一侧，松开衣物，计时，绝不能约束患者或往嘴里放任何东西；status epilepticus（癫痫持续状态）即持续超过 5 分钟的发作，用 IV lorazepam 治疗。

STROKE recognition: FAST, face droop, arm drift, speech difficulty, time to call. Establish the LAST KNOWN WELL time; IV thrombolytics (alteplase or tenecteplase) are given within 4.5 hours of last known well for ischemic stroke, after a CT scan rules out hemorrhage and the blood pressure is controlled below about 185/110; later than that, only selected clients with favorable advanced imaging qualify, and a large-vessel clot may still be removed by thrombectomy up to 24 hours. Keep NPO until a swallow screen is passed, position with the head elevated, and monitor neuro status closely. A LEFT-hemisphere stroke causes right-sided weakness and aphasia; a RIGHT-hemisphere stroke causes left-sided weakness, neglect, impulsivity and poor safety judgment. INCREASED INTRACRANIAL PRESSURE: early signs are a change in LEVEL OF CONSCIOUSNESS (the earliest and most sensitive), restlessness, headache, vomiting and pupil changes; late signs are CUSHING'S TRIAD (widened pulse pressure with hypertension, bradycardia, irregular respirations), fixed dilated pupils and posturing. Interventions: head of bed at 30 degrees with the head midline, avoid hip flexion beyond 90 degrees, prevent coughing, straining and Valsalva (stool softeners), suction for no more than 10 to 15 seconds with hyperoxygenation, space nursing activities apart, treat fever, maintain normal PaCO2, and give osmotic therapy such as mannitol or hypertonic saline as ordered. SEIZURES: protect the head, turn to the side, loosen clothing, time it, never restrain or put anything in the mouth; status epilepticus, a seizure over 5 minutes, is treated with IV lorazepam.

🏥 真实场景

🕐 家属说患者在 1900 的晚餐时还“很好”，在 0600 被发现言语含糊且无力。最后已知正常时间是 1900，即十一小时前，所以标准溶栓时间窗已经关闭，只有高级影像才能显示血栓是否仍可治疗；护士对这个时间的记录决定了整个治疗方案。睡眠中发作的卒中正是为什么问题是“他们最后一次正常是什么时候”，而不是“你什么时候注意到的”。

🕐 The family says the client was 'fine at dinner' at 1900 and found slurred and weak at 0600. Last known well is 1900, eleven hours ago, so the standard thrombolytic window has closed and only advanced imaging can show whether the clot can still be treated; the nurse's documentation of that time shapes the whole treatment plan. Sleep-onset strokes are why the question is 'when were they last normal', not 'when did you notice'.

📌 要点总结

• 最后已知正常后 4.5 小时内溶栓，且 CT 排除出血后Thrombolytics within 4.5 hours of last known well, after CT excludes bleeding
• 左脑卒中：右侧无力、失语；右脑卒中：左侧无力、忽视Left brain stroke: right weakness, aphasia; right brain stroke: left weakness, neglect
• ICP：先有 LOC 改变，Cushing's triad 晚期出现；HOB 30，保持居中，不要做 ValsalvaICP: LOC change first, Cushing's triad late; HOB 30, midline, no Valsalva

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