2011年脑出血中医临床路径

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肂莄蒅袃肁薆蚀衿肀芆薃螅聿莈螈蚁肈蒀薁羀肇膀螇袆肇节薀螂膆莅螅蚈膅蒇薈羆膄膇莁羂膃荿蚆袈膂蒁葿螄膁膁蚄蚀膁芃蒇罿膀莅蚃袅艿蒈蒅螁芈膇蚁蚇芇芀蒄肆芆蒂蝿羂芅薄薂袈芅芄螈螄袁莆薀蚀袀葿螆羈罿膈蕿袄羈芁螄螀羈蒃薇螆羇薅莀肅羆芅蚅羁羅莇蒈袇羄葿蚄螃羃腿蒆虿肃芁蚂羇肂莄蒅袃肁薆蚀衿肀芆薃螅聿莈螈蚁肈蒀薁羀肇膀螇袆肇节薀螂膆莅螅蚈膅蒇薈羆膄膇莁羂膃荿蚆袈膂蒁葿螄膁膁蚄蚀膁芃蒇罿膀莅蚃袅艿蒈蒅螁芈膇蚁蚇芇芀蒄肆芆蒂蝿羂芅薄薂袈芅芄螈螄袁莆薀蚀袀葿螆羈罿膈蕿袄羈芁螄螀羈蒃薇螆羇薅莀肅羆芅蚅羁羅莇蒈袇羄葿蚄螃羃腿蒆虿肃芁蚂羇肂莄蒅袃肁薆蚀衿肀芆薃螅聿莈螈蚁肈蒀薁羀肇膀螇袆肇节薀螂膆莅螅蚈膅蒇薈羆膄膇莁羂膃荿蚆袈膂蒁葿螄膁膁蚄蚀膁芃蒇罿膀莅蚃袅艿蒈蒅螁芈膇蚁蚇芇芀蒄肆芆蒂蝿羂芅薄薂袈芅芄螈螄袁莆薀蚀袀葿螆羈罿膈蕿袄羈芁螄螀羈蒃薇螆羇薅莀肅羆芅蚅羁羅莇蒈袇羄葿蚄螃羃腿蒆虿肃芁蚂羇肂莄蒅袃肁薆蚀衿肀芆薃螅聿莈螈蚁肈蒀薁羀肇膀螇袆肇节薀螂膆莅螅蚈膅蒇薈羆膄膇莁羂膃荿蚆袈膂蒁葿螄膁膁蚄蚀膁芃蒇罿膀莅蚃袅艿蒈蒅螁芈膇蚁蚇芇芀蒄肆芆蒂蝿羂芅薄薂袈芅芄螈螄袁莆薀蚀袀葿螆羈罿膈蕿袄羈芁螄螀羈蒃薇螆羇薅莀肅羆芅蚅羁羅莇蒈袇羄葿蚄螃羃腿蒆虿肃芁蚂羇肂莄蒅袃肁薆蚀衿肀芆薃螅聿莈螈蚁肈蒀薁羀肇膀螇袆肇节薀螂膆莅螅蚈膅蒇薈羆膄膇莁羂膃荿蚆袈膂蒁葿螄膁膁蚄蚀膁芃蒇罿膀莅蚃袅艿蒈蒅螁芈膇蚁蚇芇芀蒄肆芆蒂蝿羂芅薄薂袈芅芄螈螄袁莆薀蚀袀葿螆羈罿膈蕿袄羈芁螄螀羈蒃薇螆羇薅莀肅羆芅蚅羁羅莇蒈袇羄葿蚄螃羃腿蒆虿肃芁蚂羇肂莄蒅袃肁薆蚀衿肀芆薃螅聿莈螈蚁肈蒀薁羀肇膀螇袆肇节薀螂膆莅螅蚈膅蒇薈羆膄膇莁羂膃荿蚆袈膂蒁葿螄膁膁蚄蚀膁芃蒇罿膀莅蚃袅艿蒈蒅螁芈膇蚁蚇芇芀蒄肆芆蒂蝿羂芅薄薂袈芅芄螈螄袁莆薀蚀袀葿螆羈罿膈蕿袄羈芁螄螀羈蒃薇螆羇薅莀肅羆芅蚅羁羅莇蒈袇羄葿蚄螃羃腿蒆虿肃芁蚂羇肂莄蒅袃肁薆蚀衿肀芆薃螅聿莈螈蚁肈蒀薁羀肇膀螇袆肇节薀螂膆莅螅蚈膅蒇薈羆膄膇莁羂膃荿蚆袈膂蒁葿螄膁膁蚄蚀膁芃蒇罿膀莅蚃袅艿蒈蒅螁芈膇蚁蚇芇芀蒄肆芆蒂蝿羂芅薄薂袈芅芄螈螄袁莆薀蚀袀葿螆羈罿膈蕿袄羈芁螄螀羈蒃薇螆羇薅莀肅羆芅蚅羁羅莇蒈袇羄葿蚄螃羃腿蒆虿肃芁蚂羇肂莄蒅袃肁薆蚀衿肀芆薃螅聿莈螈蚁肈蒀薁羀肇膀螇袆肇节薀螂膆莅螅蚈膅蒇薈羆膄膇莁羂膃荿蚆袈膂蒁葿螄膁膁蚄蚀膁芃蒇罿膀莅蚃袅艿蒈蒅螁芈膇蚁蚇芇芀蒄肆芆蒂蝿羂芅薄薂袈芅芄螈螄袁莆薀蚀袀葿螆羈罿膈蕿袄羈芁螄螀羈蒃薇螆羇薅莀肅羆芅蚅羁羅莇脑出血中医临床路径（2011年版）一、脑出血临床路径标准住院流程（一）适用对象。第一诊断为非外伤性脑实质内出血。（ICD10I61）（二）诊断依据。根据临床诊疗指南神经病学分册（中华医学会编著，人民卫生出版社）1临床表现急性起病，在起病1030分钟为进行性加重。出现头痛伴或不伴意识障碍，并伴有局灶症状和体征者。2头颅CT证实脑内出血改变。（1）CT检查可显示圆形或卵圆形均匀高密度血肿，边界清楚，并可确定血肿部位、大小、形态，以及是否破入脑室、血肿周围水肿带和占位效应等。（2）MRI可发现CT不能确定的脑干或小脑小量出血，能分辨病程45周后CT不能辨认的脑出血，区别陈旧性脑出血与脑梗死，显示血管畸形流空现象。（3）数字减影脑血管造影（DSA）可检出脑动脉瘤、脑动静脉畸形、MOYAMOYA病和血管炎等。3证候诊断（1）急性期风火上扰，肝阳暴亢辩证要点半身不遂，头痛头晕，口干口苦，舌红，脉弦数。痰热腑实，瘀阻清窍辩证要点半身不遂，神昏目赤，项强身热，便秘溲赤，舌红绛，苔焦黄，脉洪滑数。痰浊内盛，蒙蔽清窍辩证要点神疲肢冷，气短懒言，或神昏肢瘫，喉中痰鸣，舌黯淡，苔白腻，脉沉滑或沉缓。元气不固，神明散乱辩证要点头痛呕吐，四肢瘫痪，手撒肢冷，汗出如油，二便自遗，舌痿苔枯，舌黯脉微。痰瘀阻络，血溢脉外辩证要点肢瘫语謇，肢体麻木，头胀刺痛有定处，或猝然倒地，神昏烦躁，舌黯且散在瘀点，苔白腻，脉弦涩。（2）慢性期阳气虚衰，瘀血内阻辩证要点面黄肢软，气短懒言，口舌歪斜，语言不利，舌淡苔白，脉沉细涩。肝肾两亏，筋脉失养辩证要点眩晕耳鸣，语声低微或不语，神疲心烦，肢软无力，舌红苔少脉细。肝阳偏亢，脉络瘀阻辩证要点头晕头痛，口干口苦，头晕耳鸣，面红目赤，半身不遂，肢体僵硬，筋脉拘急，口舌歪斜，舌强语謇，舌红绛，苔黄，脉弦数。（三）治疗方案的选择。根据临床诊疗指南神经病学分册（中华医学会编著，人民卫生出版社）1一般治疗卧床休息，维持生命体征和内环境稳定，防治感染。2控制血压。3控制脑水肿、降低颅内压。4止血药和凝血药。5中医治疗方案在2003年的诊疗方案的基础上，根据临床常见症状，以宁脑汤为中心方剂，又制定了中风2号方、中风3号方和中风4号方，并进一步明确了实用细则，并简化了中脏腑中阳闭证的治疗方案。（1）出血性中风发病1272小时内给予宁脑汤口服或鼻饲，35天后如无消化道出血等征象则加用化瘀散。（2）在治疗过程中出现消化道出血征象则停用化瘀散，如吐血或黑便等出血明显则停用宁脑汤而改用止血剂辨证论治。（3）以3天为一疗程，并复查CT。37天后根据辨证论治选用中风2号、中风3号方、中风4号方。宁脑汤中风1号代赭石30G羚羊角粉1G钩藤25G石决明25G夏枯草30G天麻9G竹茹9G胆南星9G炒山栀9G川牛膝15G车前子15G大黄粉2G三七粉2G（冲服）化瘀散组成水蛭粉05G全蝎粉15G功效镇肝熄风，清化痰瘀。适应症出血性中风辩证属肝阳上亢，肝风内动，及中脏腑之阳闭症。加减法痰热腑实加全瓜蒌15G生大黄12G枳实12G阴虚风动加龟板15G白芍15G痰湿、多痰加半夏9G贝母9G僵蚕9G热甚加黄芩9G痰热内闭加天竺黄9G石菖蒲9G中风2号痰热瘀阻苔黄腻舌质红清热化痰通络黄连6G陈皮6G半夏9G枳实9G竹茹9G胆南星9G石菖蒲9G炒山栀9G夏枯草30G茯苓12G牛膝15G天麻9G化瘀散3G（冲服）中风3号（痰瘀阻络，血溢脉外）化痰开窍天麻9G半夏9G炒白术9G胆南星9G石菖蒲9G僵蚕9G郁金9G茯苓12G地龙15G桔红9G化瘀散3G（冲服）中风4号气虚血瘀症生黄芪3060G党参15G当归9G川芎9G牛膝9G白术9G地龙12G茯苓12G化瘀散3G（冲服）中药针剂09NS250ML黄芪注射液50ML丹参粉针剂80MG静点每日一次以上诸方应用时如有失语舌强之征均可加入解语丹。（4）神清、病情稳定者第5天可应用血塞通制剂静点，小剂量开始200250MG（5）醒脑静注射液（或清开灵注射液）2040ML，加入09氯化钠液250ML中静点，每日12次。用于中经络诸症及中脏腑闭证。657天如病情稳定、无继续出血征象可应用络泰、血栓通、灯盏细辛等针剂，开始小剂量静点。7辨证论治中经络痰瘀互阻中风3号或化痰脉通。如有化热之征则给于中风2号清热化痰通络肝阳暴亢，风火上炎治法平肝泻火、引血下行方药宁脑汤中风1号35天后改天麻钩藤饮或平肝脉通化裁肝肾阴虚、风阳上扰治法滋阴潜阳，镇肝熄风。方药镇肝熄风汤怀牛膝、龙骨、生白芍、天冬、麦芽、代赭石、牡蛎、玄参、川楝子、茵陈蒿、甘草、龟板。若面红口干，舌红少苔者，加生地、熟地、首乌、枸杞子；头目眩晕者加珍珠母、夏枯草；心中热甚者，加生石膏；痰多者，加胆星；大便不实者，去龟板、赭