重症颅脑损伤指南——本

Guidelines for the management of Severe Head Injury,2nd edition,2014级急诊专业研究生周生虎,Content,1、introduction 2、Recommended grade3、Pre-hospital care4、Imitial treatment to protect the brain5、ICU management,1、introduction,In 2000, the first guidelines were publishedRevised the Guidelines 7 times between 2003 and 2005,Target patients,Closed head injuries in adults with a Glasgow Coma Scale（GCS）score of 8 or less after resuscitationGCS score after resuscitation is 9 or above but deteriorate to 8 or less after admission due to secondary brain damageMultiple head injuries and head injuries complicated by spinal cord injury were excluded from this edition,2、Recommended grade,1，is desirable2，is often（performed）3，can be（performed）4，may be（performed）5， is undesirable6，may be regarded as a contraindication,3、Pre-hospital care,The objective of pre-hospital care is to minimize secondary brain damageSecuring the airway Correction of hypoxiaCorrection of hypotensionProtection of the neck First aid for additional injuries,Table 1 Japan Coma Scale (JCS)scores,Table 2 Glasgow Coma Scale (GCS) scores easdale,Jennett; Lancet, 1974),4-1 Initial Examination and Treatment of Injuries,Primary assessment and resuscitation to secure stability of the general condition are as follows：1.It is desirable to resuscitate immediately when abnormal physiologic parameters is detected2.Resuscitation is often performed in the order of airway, respiration,and circulation3.It is desirable to secure the airway by endotracheal intubation when GCS score is 8 or less,while protect the cervical spine,4.It is desirable to maintain sufficient oxygenation and ventilation5.It is desirable to start treatment immediately if a life-threatening thoracic injury is detected6.It is desirable to promptly perform chest and pelvic radiography and abdominal ultrasonography if there is abnormal respiration or circulation7.If there are symptoms of shock, it is desirable to give initially rapid 12 l infusion for extracellular fluid supplementation and examine response, as well as to examine whether there is obstructive shock (cardiac tamponade, tension pneumothorax),8.It is desirable to examine the following neurological clinical parameters, in particular: GCS, pupillary findings, and presence of focal deficit: hemiplegia9.If the GCS score is 8 or less, or if the GCS score has deteriorated rapidly by 2 or more, and anisocoria or hemiplegia (signs of cerebral hernia) is observed, it is desirable to contact immediately an expert and perform a CT.10.Undressing is often necessary to search for life-threatening injuries.11.If the patient has a high fever, it is desirable to promptly decrease the body temperature to the normal range.12.If hypothermic patients are at risk of massive hemorrhage, it is desirable to warm them promptly for preservation of blood coagulation and hemostatic properties,ABCDE approach,Airway, evaluation and securing the airway and protection of the cervical spineBreathing, respiratory evaluation and treatment for life-threatening thoracic injuriesCirculation, cardiovascular evaluation, resuscitation,and hemostasisDysfunction of central nervous system, evaluation of life-threatening disorders of the central nervous systemExposure and environmental control, undressing and body temperature management,42 Securing the Airway and Respiratory Management,Tracheal intubation is desirable if the GCS score is 8 or less, or if the best motor response of the GCS score is 5 or lessEndotracheal intubation should be performed orally If intubation is expected to be difficult due to obesity, a short neck, nasal or endoscopic intubation is often selectedThe use of short-acting sedatives is desirableIt is desirable to avoid laryngeal distention or the use of depolarizing muscle relaxants underinsufficient sedationIf tracheal intubation is difficult due to marked facial injury, etc, a surgical procedure to secure the airway such as thyrocricotomy is often selectedThe cervical collar should be removed if it interferes with laryngeal extension,42 Indications for securing the airway in injury patients,Airway obstructionSecuring the airway in anticipation of respiratory management: apnea; hypoventilation and hypoxemia (not corrected by oxygen administration)Severe hemorrhagic shock/cardiac arrestDecrease in the level of onsciousness (GCS score 95%, arterial blood oxygen partial pressure (PaO280 mmHg arterialblood carbon dioxide partial pressure (PaCO2) or end-tidal carbon dioxide tension (PetCO2) 3035mmHg during a period of elevated ICP, 3545mmHg during a period of normal ICP, and PaCO2 may be temporarily controlled to 30 mmHg or less during the preparation for surgical decompressionIt is desirable to treat the following conditions as soon as they are detected: flail chest, open pneumothorax, tension pneumothorax, massive pneumothorax, and massive airway hemorrhage,43 Cardiovascular Management,Targets of circulatory management Patients with uncomplicated head injuries:systolic blood pressure90100 mmHg andhemoglobin 710 g/dlPatients with complicated head injuries: systolic blood pressure 120 mmHg,mean arterial blood pressure 90 mmHg, cerebral perfusion pressure (CPP) 6070 mmHg (if the ICP is measured), and hemoglobin 10 g/dl,44 Recognition and Treatment of Life-Threatening Brain Herniation,A GCS score of 8 or less, rapid exacerbation of the GCS score by 2 or more, anisocoria, hemiplegia, etc.,often indicate a life-threatening brain herniationA large space-occupying lesion, a 5-mm or greater brain midline shift, and compression or disappearance of the basal cisterns often indicate lifethreatening brain herniation,5、ICU Management,Indications for ICP MonitoringGCS score o