血压高达210/120 mmHg,究竟是谁在捣鬼?

2017-08-10 奔跑的阿托品 医学界心血管频道

昨天收治了一例高血压危象的患者,庆幸的是,由于患者就医及时,处理得当,病情很快得到了控制,现在病人正处在恢复期,进修的医生让我讲一下高血压危象的知识。

昨天收治了一例高血压危象的患者,庆幸的是,由于患者就医及时,处理得当,病情很快得到了控制,现在病人正处在恢复期,进修的医生让我讲一下高血压危象的知识。

其实目前关于高血压危象的诊断和治疗都已经很规范了,“循规蹈矩”的治疗问题不会太大,可是其中特殊的情况,才是需要考虑的问题。

我没有直接讲解高血压危象,而是给他们讲了我遇到的一个病人,这个人的高血压危象的治疗,可谓是一波三折。

很多的刚工作不久的医生可能会经历一段特殊的时刻,那就是很多的“疑难杂症”、少见的疾病,会时不时的出现在自己的面前,并且工作时间很长的医生也没有遇到过,自己才上班不久,就会“有幸”见到。

患者血压高达210/120mmHg

记得那是我刚工作不久,有一天值夜班,院前急救打来电话,说一会送一个高血压危象的患者过来,对于刚上班的我来说,既兴奋又紧张,兴奋的是来了病情紧急的病人,可以“大显身手”,让患者转危为安,很有成就感;紧张的是,万一患者病情复杂,自己处理不了,解决不了问题。

不容多想,和护士交代,准备床位,准备吸氧监护等一系列准备工作。不一会,120将病人送了过来。

和院前急救简单做一交接大概了解了患者的病情:

患者,男,48岁,突发剧烈头痛2小时。

患者既往高血压病史10余年,最高达190/110 mmHg,未规律服用降压药,未规律监测血压。2小时前情绪激动后突发剧烈头痛,伴有心慌,恶心,呕吐一次,呕吐物为胃内容物,全身大汗。

就诊于当地诊所,当时测血压,高达210/120 mmHg。诊所不敢耽搁,直接联系了医院的120。

血压这么高,会是继发性高血压么?

大概了解了患者的病情,一边让护士给患者监护、开通静脉通路,一边头脑进行快速思考,患者年纪不大,高血压病史却很长,而且血压这么高,会不会是继发性高血压?

“血压以前看过没?做过什么相应的检查?家里的老人有高血压没?吃过什么降压药?”我把一连串的问题一口气说完,等待跟随而来的患者的家属的答案。

“血压以前也看过,吃过很多的降压药,但是血压一直比较高,他自己也没有什么不舒服,就没有再看,药也不能么吃。他爸妈都有高血压,”患者的妻子带着惊慌的口吻,回答了我的问题。

一边下医嘱,一边继续思考患者的病情,有高血压家族史,原发性高血压可能性大,之前血压经过治疗,还是比较高,是因为没有规范降压药的服用,还是有其他的原因?为什么这次情绪激动能使血压出现这么高的情况?

“哦,对了医生,以前在我们那里的医院看过,当时医生告诉我们查彩超,说是看看是不是别的疾病引起的,当时也做了,医生说正常。”患者的儿子向我说道。

“检查结果呢?查的什么彩超?”我问到。

“当时好像是肾上腺,报告单早就不见了。”

看来,在此之前也有医生怀疑过继发性高血压的情况,可是这年龄段的患者,继发性还是需要排除的。

急查CT,竟然是嗜铬细胞瘤!

一边处理病人,一边联系影像科,经过处理,患者症状稍有缓解,赶紧去急查头颅CT和肾上腺CT。

半个小时后,结果回报,“考虑嗜铬细胞瘤”!嗜铬细胞瘤!在此之前彩超没查出来,可能是由于比较小,不容易查出。此时向家属交代病情,请示上级医师,后来将患者转到了泌尿外科,准备行手术治疗……

一波三折,术后又出现低血压

我再次见到这个患者,是在5天以后,那天泌尿外科请急会诊,我们科都是二线医师会诊,当天是主任值二线班,当我知道是这个病人时,也就跟了过去,因为我想看一看这个病人病情的发展,因为嗜铬细胞瘤临床上还是相对少见的。

来到泌尿外科,我看到这个病人呼吸急促、面色苍白、意识有一些模糊,心电监护上心率110次/分,血压70/40 mmHg。

患者现在的情况和刚入院的时候,简直判若两人。

这时主管医生向主任介绍,患者转入后,经过对症治疗,血压稍有下降,上午进行了嗜铬细胞瘤手术,术后血压出现了下降,给予泵入多巴胺升压,但是血压仍较低,并且不容易维持。

“你怎么考虑?”主任转过头,向我问道。

“术后血压低,并且多巴胺较难维持,我能想到两个方面:一是入量不够,导致的患者血容量不足;二是术后出血,会不会腹腔内有出血部位。”说完,我看着主任。

你考虑的还算可以,接着主任又把头转向了外科的主管医生,“刚才他的问题,你能解答一下吗?”

“主任,病人到目前补液大概有1800 mL,对于我们术后的病人,这个液体量已经比较多了。

另外,您看,我们的引流管现在并没有引流出血性液体,腹腔出血的可能性也不大。”外科医生回答了主任的问题,却加重了我的疑惑。

“那这到底怎么办?”我一边心里暗暗思考,一边看着主任。

“再开一路,把去甲肾上腺素吊上。”主任考虑了一会说道。

大概半个小时以后,病人血压逐渐上升,最后恢复正常,生命体征也逐渐平稳了。

主任揭秘其中的“奥秘”

看着我们疑惑的表情,主任道出了其中的“奥秘”~

嗜铬细胞瘤患者往往会出现高血压,那是因为人体内的去甲肾上腺素出于相对高的水平,此时血管的收缩较强,张力较高,血压升高。手术后,α受体密度降低,体内的去甲肾上腺素水平下降,血管的张力就会明显下降,再加上血容量不足的原因,血压就会明显下降。

多巴胺是去甲肾上腺素生物合成的前体,主要激动α、β和外周的多巴胺受体,而去甲肾上腺素主要激动α受体,具有很强的血管收缩作用,使全身的小动脉和小静脉都收缩,外周阻力增高,血压上升。

知道了问题所在,治疗起来就会得心应手。后来患者经过半个月的住院治疗,病情好转出现。

进修的医生听得入了迷,很久才回过神来,“王老师,要不是你讲,可能我自己看书学习也得不到其中的精髓!”我听了以后,哈哈一笑,就像当年主任说我们一样,“那你就好好学,掌握其中的精髓!”

医学既要学习,又要经历,前赴后继,才能发展,口耳相传,加深实践。患者不是“小白鼠”,生命只有一次,作为一个医生,对患者负责,也是对医学事业负责。

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    2017-08-14 明崖

    学习了,受益匪浅,期望多点这类的病历

    0

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    2017-08-12 明天会更好!

    谢谢分享,学习了很好!

    0

  3. [GetPortalCommentsPageByObjectIdResponse(id=233528, encodeId=600b23352821, content=学习了,受益匪浅,期望多点这类的病历, beContent=null, objectType=article, channel=null, level=null, likeNumber=119, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=73441710184, createdName=明崖, createdTime=Mon Aug 14 19:06:51 CST 2017, time=2017-08-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=232855, encodeId=0002232855e5, content=谢谢分享,学习了很好!, beContent=null, objectType=article, channel=null, level=null, likeNumber=97, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160914/IMG57D82E721DB581755.jpg, createdBy=4fc81933929, createdName=明天会更好!, createdTime=Sat Aug 12 12:14:18 CST 2017, time=2017-08-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=232854, encodeId=ebdb2328549e, content=谢谢分享,学习了很好!, beContent=null, objectType=article, channel=null, level=null, likeNumber=104, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160914/IMG57D82E721DB581755.jpg, createdBy=4fc81933929, createdName=明天会更好!, createdTime=Sat Aug 12 12:14:04 CST 2017, time=2017-08-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=232450, encodeId=011823245033, content=受益匪浅学习了谢谢, beContent=null, objectType=article, channel=null, level=null, likeNumber=1, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c0a61971598, createdName=往日如昨, createdTime=Fri Aug 11 11:52:24 CST 2017, time=2017-08-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=232342, encodeId=7a1d232342be, content=学习了啊, beContent=null, objectType=article, channel=null, level=null, likeNumber=102, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=5e291719269, createdName=大旺旺, createdTime=Fri Aug 11 06:52:00 CST 2017, time=2017-08-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=232324, encodeId=48f62323249a, content=我实习的时候见过一例,术前院内会诊,做好血压骤降等风险的充分抢救准备。, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/08/11/a76ad32315bb91d3ab947fa66c16f1f3.jpg, createdBy=342c2108578, createdName=ymell, createdTime=Fri Aug 11 06:15:36 CST 2017, time=2017-08-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=232252, encodeId=7b7a232252f7, content=学习了谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=61, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib06iaV3D9Tg5Kzuf9u71gZhPYMiajRtENwicoAABeQtfXOlic8ibhYSy6DvJZWUDVtjRvTfqBffr1XJ6JLtFB5kHicthl/0, createdBy=d41c2055892, createdName=184****9840, createdTime=Thu Aug 10 22:35:23 CST 2017, time=2017-08-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=232241, encodeId=4e722322416e, content=学了。。。。。。。。, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4Neru1qt53a14aACuSzg3TZhkTcsPYVibyHibhTZ5L4k9qIBWiaej4lgomIsGptf8N16E4mTuIq2DVdJXjPjmwZKrLib/0, createdBy=5a0f2055853, createdName=135****7952平儿, createdTime=Thu Aug 10 22:05:38 CST 2017, time=2017-08-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=232228, encodeId=34f9232228b6, content=可以写一篇case report了~, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfGccQGCB4aeJK5D3ibPlZfB4mO50cwGAa6xz9uorDUr0FT59IwUMUYkiaFauF3AlibI8nVj81lYz9dfMEAp6IOrHX/0, createdBy=74421964351, createdName=ishtar, createdTime=Thu Aug 10 19:14:21 CST 2017, time=2017-08-10, status=1, ipAttribution=)]
    2017-08-12 明天会更好!

    谢谢分享,学习了很好!

    0

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    2017-08-11 往日如昨

    受益匪浅学习了谢谢

    0

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    2017-08-11 大旺旺

    学习了啊

    0

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    2017-08-11 ymell

    我实习的时候见过一例,术前院内会诊,做好血压骤降等风险的充分抢救准备。

    0

  7. [GetPortalCommentsPageByObjectIdResponse(id=233528, encodeId=600b23352821, content=学习了,受益匪浅,期望多点这类的病历, beContent=null, objectType=article, channel=null, level=null, likeNumber=119, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=73441710184, createdName=明崖, createdTime=Mon Aug 14 19:06:51 CST 2017, time=2017-08-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=232855, encodeId=0002232855e5, content=谢谢分享,学习了很好!, beContent=null, objectType=article, channel=null, level=null, likeNumber=97, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160914/IMG57D82E721DB581755.jpg, createdBy=4fc81933929, createdName=明天会更好!, createdTime=Sat Aug 12 12:14:18 CST 2017, time=2017-08-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=232854, encodeId=ebdb2328549e, content=谢谢分享,学习了很好!, beContent=null, objectType=article, channel=null, level=null, likeNumber=104, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160914/IMG57D82E721DB581755.jpg, createdBy=4fc81933929, createdName=明天会更好!, createdTime=Sat Aug 12 12:14:04 CST 2017, time=2017-08-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=232450, encodeId=011823245033, content=受益匪浅学习了谢谢, beContent=null, objectType=article, channel=null, level=null, likeNumber=1, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c0a61971598, createdName=往日如昨, createdTime=Fri Aug 11 11:52:24 CST 2017, time=2017-08-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=232342, encodeId=7a1d232342be, content=学习了啊, beContent=null, objectType=article, channel=null, level=null, likeNumber=102, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=5e291719269, createdName=大旺旺, createdTime=Fri Aug 11 06:52:00 CST 2017, time=2017-08-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=232324, encodeId=48f62323249a, content=我实习的时候见过一例,术前院内会诊,做好血压骤降等风险的充分抢救准备。, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/08/11/a76ad32315bb91d3ab947fa66c16f1f3.jpg, createdBy=342c2108578, createdName=ymell, createdTime=Fri Aug 11 06:15:36 CST 2017, time=2017-08-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=232252, encodeId=7b7a232252f7, content=学习了谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=61, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib06iaV3D9Tg5Kzuf9u71gZhPYMiajRtENwicoAABeQtfXOlic8ibhYSy6DvJZWUDVtjRvTfqBffr1XJ6JLtFB5kHicthl/0, createdBy=d41c2055892, createdName=184****9840, createdTime=Thu Aug 10 22:35:23 CST 2017, time=2017-08-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=232241, encodeId=4e722322416e, content=学了。。。。。。。。, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4Neru1qt53a14aACuSzg3TZhkTcsPYVibyHibhTZ5L4k9qIBWiaej4lgomIsGptf8N16E4mTuIq2DVdJXjPjmwZKrLib/0, createdBy=5a0f2055853, createdName=135****7952平儿, createdTime=Thu Aug 10 22:05:38 CST 2017, time=2017-08-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=232228, encodeId=34f9232228b6, content=可以写一篇case report了~, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfGccQGCB4aeJK5D3ibPlZfB4mO50cwGAa6xz9uorDUr0FT59IwUMUYkiaFauF3AlibI8nVj81lYz9dfMEAp6IOrHX/0, createdBy=74421964351, createdName=ishtar, createdTime=Thu Aug 10 19:14:21 CST 2017, time=2017-08-10, status=1, ipAttribution=)]
    2017-08-10 184****9840

    学习了谢谢分享

    0

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    2017-08-10 135****7952平儿

    学了。。。。。。。。

    0

  9. [GetPortalCommentsPageByObjectIdResponse(id=233528, encodeId=600b23352821, content=学习了,受益匪浅,期望多点这类的病历, beContent=null, objectType=article, channel=null, level=null, likeNumber=119, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=73441710184, createdName=明崖, createdTime=Mon Aug 14 19:06:51 CST 2017, time=2017-08-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=232855, encodeId=0002232855e5, content=谢谢分享,学习了很好!, beContent=null, objectType=article, channel=null, level=null, likeNumber=97, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160914/IMG57D82E721DB581755.jpg, createdBy=4fc81933929, createdName=明天会更好!, createdTime=Sat Aug 12 12:14:18 CST 2017, time=2017-08-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=232854, encodeId=ebdb2328549e, content=谢谢分享,学习了很好!, beContent=null, objectType=article, channel=null, level=null, likeNumber=104, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160914/IMG57D82E721DB581755.jpg, createdBy=4fc81933929, createdName=明天会更好!, createdTime=Sat Aug 12 12:14:04 CST 2017, time=2017-08-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=232450, encodeId=011823245033, content=受益匪浅学习了谢谢, beContent=null, objectType=article, channel=null, level=null, likeNumber=1, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c0a61971598, createdName=往日如昨, createdTime=Fri Aug 11 11:52:24 CST 2017, time=2017-08-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=232342, encodeId=7a1d232342be, content=学习了啊, beContent=null, objectType=article, channel=null, level=null, likeNumber=102, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=5e291719269, createdName=大旺旺, createdTime=Fri Aug 11 06:52:00 CST 2017, time=2017-08-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=232324, encodeId=48f62323249a, content=我实习的时候见过一例,术前院内会诊,做好血压骤降等风险的充分抢救准备。, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/08/11/a76ad32315bb91d3ab947fa66c16f1f3.jpg, createdBy=342c2108578, createdName=ymell, createdTime=Fri Aug 11 06:15:36 CST 2017, time=2017-08-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=232252, encodeId=7b7a232252f7, content=学习了谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=61, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib06iaV3D9Tg5Kzuf9u71gZhPYMiajRtENwicoAABeQtfXOlic8ibhYSy6DvJZWUDVtjRvTfqBffr1XJ6JLtFB5kHicthl/0, createdBy=d41c2055892, createdName=184****9840, createdTime=Thu Aug 10 22:35:23 CST 2017, time=2017-08-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=232241, encodeId=4e722322416e, content=学了。。。。。。。。, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4Neru1qt53a14aACuSzg3TZhkTcsPYVibyHibhTZ5L4k9qIBWiaej4lgomIsGptf8N16E4mTuIq2DVdJXjPjmwZKrLib/0, createdBy=5a0f2055853, createdName=135****7952平儿, createdTime=Thu Aug 10 22:05:38 CST 2017, time=2017-08-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=232228, encodeId=34f9232228b6, content=可以写一篇case report了~, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfGccQGCB4aeJK5D3ibPlZfB4mO50cwGAa6xz9uorDUr0FT59IwUMUYkiaFauF3AlibI8nVj81lYz9dfMEAp6IOrHX/0, createdBy=74421964351, createdName=ishtar, createdTime=Thu Aug 10 19:14:21 CST 2017, time=2017-08-10, status=1, ipAttribution=)]
    2017-08-10 ishtar

    可以写一篇case report了~

    0