一位 25 歲男性，C6 脊髓損傷，突然出現乳頭線以上出汗、臉部潮紅與劇烈搏動性頭痛；損傷平面以下皮膚蒼白、冰冷並起雞皮疙瘩。生命徵象：血壓 230/120 mmHg、心跳 40 次/分。護理師優先的初步評估動作為何？
A 25-year-old male with a spinal cord injury at the C6 level develops sudden sweating above the nipple line, facial flushing, and a severe pounding headache. Below the injury level, the skin is pale, cool, and has goosebumps. Vital signs show blood pressure 230/120 mmHg and heart rate 40 bpm. What is the nurse's priority initial assessment action?
- AImmediately forcefully push high-dose intravenous antihypertensive medications (Nitroprusside) directly into the client's vein to violently crash the massive blood pressure spike.立即強力將高劑量靜脈注射降血壓藥物（Nitroprusside）直接注入病患靜脈，以暴力方式壓制劇烈的血壓飆升。
- BInstruct the bewildered client to fiercely perform the Valsalva maneuver to stimulate the dominant parasympathetic branch actively to lower the pounding heart rate.指示困惑的病患猛烈執行伐氏操作（Valsalva maneuver），以主動刺激副交感神經分支來降低急促的心率。
- CTightly warmly cover him heavily with enormous heated electric blankets explicitly attempting to correct the brutal, unnatural icy coldness gripping his paralyzed legs.用巨大的加熱電毯緊緊溫暖地覆蓋他，明確試圖糾正緊抓癱瘓雙腿的殘酷、不自然的冰冷感。
- DSit the client upright to harness gravity precisely, then immediately intensely hunt for an over-distended urinary bladder or a cruelly kinked Foley catheter tube.讓病患坐直以精確利用重力，然後立即積極尋找過度擴張的膀胱或嚴重扭曲的導尿管。正確答案
- D讓病患坐直以精確利用重力，然後立即積極尋找過度擴張的膀胱或嚴重扭曲的導尿管。
此為自律神經反射亢進（Autonomic Dysreflexia, AD），通常發生於T6（含）以上脊髓損傷的病人。當損傷平面以下受到強烈刺激（最常見為膀胱過度脹滿，其次為糞便嵌塞）時，會引發失控的交感神經反射，造成損傷平面以下血管收縮（皮膚蒼白冰冷）、血壓急劇飆升，大腦透過迷走神經代償性引發心搏過緩，並使損傷平面以上血管擴張（造成臉部潮紅、頭痛、流汗）。處置的第一步是移除誘發刺激而非急著給藥：讓病人坐直以利用重力降低血壓，接著立即檢查是否有導尿管阻塞打折或膀胱過度脹滿（選項D），因為膀胱脹滿是最常見的誘因，只要引流出尿液，危象通常能迅速解除。若移除誘因後收縮壓仍持續高於150-170 mmHg，才需給予降壓藥物（第一線為舌下nitroglycerin或captopril）。
- A立即強力將高劑量靜脈注射降血壓藥物（Nitroprusside）直接注入病患靜脈，以暴力方式壓制劇烈的血壓飆升。
盲目擊發重型降血壓藥物完全忽視了要去拆除那個正不斷主動為高血壓火災添加燃料的實際機械性觸發器（脹滿的膀胱）。
- B指示困惑的病患猛烈執行伐氏操作（Valsalva maneuver），以主動刺激副交感神經分支來降低急促的心率。
強行用力憋氣（伐氏操作）會激烈倍增顱內壓。在一個已經乘坐在 230/120 血壓火箭上的病患，這會完美地觸發一場毀滅性的出血性中風爆炸。
- C用巨大的加熱電毯緊緊溫暖地覆蓋他，明確試圖糾正緊抓癱瘓雙腿的殘酷、不自然的冰冷感。
拿極度加熱的設備去蓋著他，只是盲目治療表淺症狀。更糟的是，對癱瘓無感覺的腿部施加痛苦的燒燙傷，嚴格來說這扮演了一個全新且猛烈的刺激，將使自主神經風暴加劇化。
- D · 正確答案讓病患坐直以精確利用重力，然後立即積極尋找過度擴張的膀胱或嚴重扭曲的導尿管。
挺直坐起能靠重力砍斷大腦壓力。接著搜出並摧毀那個具刺激性的感官觸發點——絕大多數即漲痛的膀胱或打結的導尿管——就能瞬間且激進地終止這場狂暴的交感風暴。
「Autonomic Dysreflexia (自主神經反射異常) = T6以上損傷 + 血壓暴高/心跳超慢/上看紅下看白。 第一件事 = 搖高床頭 + 摸他膀胱通他導尿管」。全世界的神經科內科醫師與護理師無一例外將這三部曲列為考驗你是否及格的核心標準。
English explanation
Option D is correct because the findings indicate autonomic dysreflexia, which usually occurs with spinal cord injuries at or above T6. Strong stimulation below the injury, most often an overdistended bladder and next most often fecal impaction, triggers uncontrolled sympathetic activity. This causes vasoconstriction, pale cool skin below the injury, and a sudden severe blood pressure increase. The brain compensates through the vagus nerve, producing bradycardia, while vasodilation above the injury causes facial flushing, headache, and sweating. The initial response is to sit the client upright so gravity helps lower blood pressure, then immediately assess for bladder distention or a blocked or kinked urinary catheter. Draining the bladder often resolves the crisis quickly. Option A is incorrect because the triggering stimulus must be removed before antihypertensive medication is considered. If systolic pressure remains above 150-170 mmHg after removal of the cause, sublingual nitroglycerin or captopril may then be given.
最近修訂：2026-10-06