急性颅脑损伤诊疗指南

急性颅脑损伤诊疗指南引言急性颅脑损伤（AcuteTraumaticBrainInjury,ATBI）作为神经外科及急诊科常见的急危重症，其高致残率与致死率一直是临床救治的重点与难点。此类损伤通常由外力直接或间接作用于头部所致，可造成脑组织的原发性损伤，并继发一系列病理生理改变，严重威胁患者生命安全及生存质量。本指南旨在综合当前最新临床证据与实践经验，为从事ATBI救治的临床医师提供一套系统、规范且实用的诊疗思路与操作框架，以期提高救治成功率，改善患者预后。一、初始评估与处理ATBI患者的初始评估与处理强调“时间就是大脑”，需分秒必争，遵循ABC原则（Airway,Breathing,Circulation），并兼顾神经系统功能状态的快速判断。1.1现场急救与初步稳定现场急救的核心在于维持基础生命体征稳定，防止继发性脑损伤。首先确保气道通畅，对于昏迷患者（GCS≤8分）或存在气道梗阻风险者，应及时建立人工气道，优先考虑经口气管插管。同时，保障有效通气与氧供，避免低氧血症。维持循环稳定，积极纠正休克，目标收缩压应维持在合理水平，以保证脑组织的灌注。在搬运过程中，务必注意颈椎的固定与保护，防止因颈椎不稳定造成二次损伤。1.2急诊室评估患者抵达急诊后，需立即进行快速而全面的评估。1.2.1病史采集简明扼要地获取致伤机制、受伤时间、伤后意识变化（有无中间清醒期）、有无呕吐、抽搐及大小便失禁等关键信息。同时了解患者既往病史，如高血压、糖尿病、凝血功能障碍及服用抗凝药物史等，这些对后续治疗决策至关重要。1.2.2体格检查重点在于神经系统检查，包括Glasgow昏迷评分（GCS）的准确评定，这是判断脑损伤严重程度、指导治疗及评估预后的重要依据。同时，需检查瞳孔大小、形态及对光反射，肢体肌力、肌张力、生理反射及病理征，以及有无脑膜刺激征等。全身其他系统检查亦不容忽视，以排除合并伤。1.2.3影像学检查头颅计算机断层扫描（CT）是急性颅脑损伤的首选影像学检查方法，具有快速、便捷、分辨率高的特点，能够清晰显示颅骨骨折、颅内血肿、脑挫裂伤、脑水肿、脑肿胀及中线结构移位等。对于疑似ATBI患者，尤其是GCS评分<15分、有阳性神经系统体征、意识障碍进行性加重或有高危致伤因素者，均应紧急行头颅CT检查。1.2.4实验室检查常规进行血常规、血型、凝血功能、电解质、血糖、肝肾功能及动脉血气分析等检查，以评估全身状况，指导液体复苏及防治并发症。二、诊断与分型2.1诊断根据明确的头部外伤史、典型的临床表现（如意识障碍、头痛、呕吐、局灶性神经功能缺损等）以及头颅CT等影像学检查结果，急性颅脑损伤的诊断一般并不困难。关键在于早期识别，避免漏诊或误诊。2.2分型目前临床上常用的分型方法包括：2.2.1按损伤性质分型*脑震荡：表现为短暂的意识丧失，持续数分钟至数十分钟，醒后可有逆行性遗忘，神经系统检查及头颅CT多无明显异常。*脑挫裂伤：脑组织的器质性损伤，CT表现为脑实质内散在或片状的高密度或混杂密度影，常伴有脑水肿。*颅内血肿：包括硬膜外血肿、硬膜下血肿、脑内血肿及脑室内出血。CT上表现为边界清楚的高密度影。*弥漫性轴索损伤：因头部受到加速性旋转暴力所致，表现为广泛的脑白质损伤，CT可见胼胝体、脑干、大脑半球白质内点状高密度出血灶或弥漫性脑水肿，患者常呈持续性昏迷，预后较差。*颅骨骨折：可分为线性骨折、凹陷性骨折、粉碎性骨折等，CT骨窗像可清晰显示。2.2.2按格拉斯哥昏迷评分（GCS）分型*轻型：GCS13-15分，伤后昏迷时间<30分钟。*中型：GCS9-12分，伤后昏迷时间30分钟至6小时。*重型：GCS3-8分，伤后昏迷时间>6小时，或在伤后24小时内意识恶化并昏迷>6小时。三、治疗原则与策略急性颅脑损伤的治疗应采取个体化综合治疗措施，以挽救生命、降低颅内压、防治脑疝、保护神经功能、减少并发症及促进康复为主要目标。3.1一般治疗与监测*体位：对于无休克的患者，宜采取头高脚低位（头部抬高15°-30°），以利颅内静脉回流，减轻脑水肿。*吸氧与通气：维持血氧饱和度>95%，必要时行机械通气。对于重型颅脑损伤患者，需警惕低氧血症和高碳酸血症对脑代谢的不利影响。*营养支持：早期（伤后24-48小时内）开始肠内营养支持，无法经口进食者应留置胃管，注意监测胃残余量，预防反流误吸。*体温控制：积极控制高热，可采用物理降温或药物降温，目标体温维持在正常范围。*颅内压（ICP）监测：对于重型颅脑损伤、GCS≤8分、CT显示颅内血肿、脑水肿明显或中线结构移位者，建议行有创ICP监测，维持ICP<20mmHg，脑灌注压（CPP）>60mmHg。3.2手术治疗手术治疗的目的是清除颅内血肿、挫碎的脑组织及异物，解除脑受压，降低颅内压，防止脑疝形成。3.2.1手术指征*颅内血肿：*硬膜外血肿：幕上血肿量>30ml，幕下血肿量>10ml，或血肿厚度>1cm，伴有明显占位效应或神经功能障碍。*硬膜下血肿：幕上血肿量>50ml，或中线结构移位>1cm，或血肿厚度>1cm；幕下血肿量>10ml。对于急性硬膜下血肿合并脑挫裂伤，即使血肿量未达上述标准，但意识障碍进行性加重或ICP持续升高，亦应考虑手术。*脑内血肿：血肿量>30ml，或虽<30ml但位于重要功能区、引起明显神经功能障碍或ICP升高。***严重脑挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫挫