157.3 🩺 內科專科考前版

157.3.0.1 1️⃣ Autonomic Storm Management

• Week 2-3 of clinical course = peak autonomic instability → 主要死因
• BP/HR swings, 大汗, arrhythmia
• Magnesium sulfate — 第一選擇 control
• β-blocker (esmolol) — labile BP; 避免 long-acting (overshoot hypotension)
• Clonidine, dexmedetomidine — α-2 agonist
• 避 fluid overload (autonomic 不穩 → flash pulmonary edema)
• ICU central monitoring

157.3.0.2 2️⃣ Magnesium Sulfate — Thwaites Trial

• Lancet 2006 Vietnam RCT
• 不降 mortality 但減 BZD 用量, 減 ventilation need
• 4 g IV bolus → 1.5-3 g/h infusion (titrate)
• Monitor DTR (loss → toxic)

157.3.0.3 3️⃣ 為什麼疫苗 preventable 但仍見

• 老年人 wane immunity
• 街友, IDU, 未接種移民
• Wound 忽略 (尤其 puncture)
• 盧醫師 hint: 50 歲後病人都 ask Td 史; DM/腎 dialysis 病人特別 wane

157.3.0.4 4️⃣ 鑑別 Diagnosis

• Strychnine poisoning: 類似 spasm 但 no trismus, relaxation between spasms
• Dystonic reaction: phenothiazine, metoclopramide — IV benadryl 立刻 reverses
• Stiff person syndrome: chronic, anti-GAD Ab
• Hypocalcemic tetany: Chvostek/Trousseau, Ca low
• Encephalitis with rigidity: NMDA, ADEM

157.3.0.5 5️⃣ Neonatal Tetanus Elimination

• WHO MNT 計畫
• 母 vaccine in pregnancy + 清潔分娩
• 大幅減 cases 但仍 endemic in African + Asian rural

157.3.0.6 6️⃣ 健保 / Taiwan

• DTaP series 公費 ≤ 5 yr
• 11-12 yr Tdap 公費
• 50+ Tdap booster 公費 (2022-)
• 孕婦 27-36 wk Tdap (推薦, 自費或公費 by county)

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