GuidelinesforthemanagementofSevereHeadInjury,2ndedition

2014級急診專業(yè)研究生周生虎Content1、introduction2、Recommendedgrade3、Pre-hospitalcare4、Imitialtreatmenttoprotectthebrain5、ICUmanagement1、introductionIn2000,thefirstguidelineswerepublishedRevisedtheGuidelines7timesbetween2003and2005TargetpatientsClosedheadinjuriesinadultswithaGlasgowComaScale（GCS）scoreof8orlessafterresuscitationGCSscoreafterresuscitationis9orabovebutdeteriorateto8orlessafteradmissionduetosecondarybraindamageMultipleheadinjuriesandheadinjuriescomplicatedbyspinalcordinjurywereexcludedfromthisedition2、Recommendedgrade

1，…isdesirable2，…isoften（performed）3，…canbe（performed）4，…maybe（performed）5，…isundesirable6，…mayberegardedasacontraindication

3、Pre-hospitalcareTheobjectiveofpre-hospitalcareistominimizesecondarybraindamageSecuringtheairwayCorrectionofhypoxiaCorrectionofhypotensionProtectionoftheneckFirstaidforadditionalinjuriesTable1JapanComaScale(JCS)scoresGradeConsciousnesslevel1-digitcodeThepatientisawakewithoutanystimulation,andis:1Almostfullyconscious2Unabletorecognizetime,place,andhim/herself3Unabletorecallnameordateofbirth2-digitcodeThepatientcanbearoused（thenrevertstopreviousstateaftercessationofstimulation）10easilybybeingspokento(orisresponsivewithpurposefulmovements,phrases,orwords)20withloudvoiceorshakingofshoulders(orisalmostalwaysresponsivetoverysimplewordslikeyesorno,ortomovements)30onlybyrepeatedmechanicalstimuli3-digitcodethepatientcannotbearousedwithanyappliedmechanicalstimuli,and:100respondswithmovementstoavoidthestimulus200respondswithslightmovementsincludingdecerebrateanddecorticateposture300doesnotrespondatallexceptforchangeofrespiratoryrateandrhythmTable2GlasgowComaScale(GCS)scoreseasdale,Jennett;Lancet,1974)Eyeopening(E)Bestverbalresponse(V)Bestmotorresponse(M)4.Spontaneous5.Oriented6.Obeyingverbalcommands3.Toverbalcommand4.Confusedconversation5.Localizespain2.Topain3.Inappropriatewords4.Flexion/withdrawaltopain1.None2.Incomprehensible3.Abnormalflexionduesoundstopain(upperlimbs)1.None2.Extensiontopain(upperlimbs)1.None4-1InitialExaminationandTreatmentofInjuriesPrimaryassessmentandresuscitationtosecurestabilityofthegeneralconditionareasfollows：1.Itisdesirabletoresuscitateimmediatelywhenabnormalphysiologicparametersisdetected2.Resuscitationisoftenperformedintheorderofairway,respiration,andcirculation3.ItisdesirabletosecuretheairwaybyendotrachealintubationwhenGCSscoreis8orless,whileprotectthecervicalspine4.Itisdesirabletomaintainsufficientoxygenationandventilation5.Itisdesirabletostarttreatmentimmediatelyifalife-threateningthoracicinjuryisdetected6.Itisdesirabletopromptlyperformchestandpelvicradiographyandabdominalultrasonographyifthereisabnormalrespirationorcirculation7.Iftherearesymptomsofshock,itisdesirabletogiveinitiallyrapid1–2linfusionforextracellularfluidsupplementationandexamineresponse,aswellastoexaminewhetherthereisobstructiveshock(cardiactamponade,tensionpneumothorax)8.Itisdesirabletoexaminethefollowingneurologicalclinicalparameters,inparticular:GCS,pupillaryfindings,andpresenceoffocaldeficit:hemiplegia9.IftheGCSscoreis8orless,oriftheGCSscorehasdeterioratedrapidlyby2ormore,andanisocoriaorhemiplegia(signsofcerebralhernia)isobserved,itisdesirabletocontactimmediatelyanexpertandperformaCT.10.Undressingisoftennecessarytosearchforlife-threateninginjuries.11.Ifthepatienthasahighfever,itisdesirabletopromptlydecreasethebodytemperaturetothenormalrange.12.Ifhypothermicpatientsareatriskofmassivehemorrhage,itisdesirabletowarmthempromptlyforpreservationofbloodcoagulationandhemostaticpropertiesABCDEapproachAirway,evaluationandsecuringtheairwayandprotectionofthecervicalspineBreathing,respiratoryevaluationandtreatmentforlife-threateningthoracicinjuriesCirculation,cardiovascularevaluation,resuscitation,and

hemostasisDysfunctionofcentralnervoussystem,evaluationoflife-threateningdisordersofthecentralnervoussystemExposureandenvironmentalcontrol,undressingandbodytemperaturemanagement4–2SecuringtheAirwayandRespiratoryManagementTrachealintubationisdesirableiftheGCSscoreis8orless,orifthebestmotorresponseoftheGCSscoreis5orlessEndotrachealintubationshouldbeperformedorallyIfintubationisexpectedtobedifficultduetoobesity,ashortneck,nasalorendoscopicintubationisoftenselectedTheuseofshort-actingsedativesisdesirableItisdesirabletoavoidlaryngealdistentionortheuseofdepolarizingmusclerelaxantsunderinsufficientsedationIftrachealintubationisdifficultduetomarkedfacialinjury,etc,asurgicalproceduretosecuretheairwaysuchasthyrocricotomyisoftenselectedThecervicalcollarshouldberemovedifitinterfereswithlaryngealextension4–2Indicationsforsecuringtheairwayininjurypatients

AirwayobstructionSecuringtheairwayinanticipationofrespiratorymanagement:apnea;hypoventilationandhypoxemia(notcorrectedbyoxygenadministration)Severehemorrhagicshock/cardiacarrestDecreaseinthelevelofonsciousness(GCSscore<8)4–2RespiratorymanagementHigh-concentrationoxygen(at10–15l/minusingafacemaskwithareservoir)Targets:arterialbloodoxygensaturation(SpO2>95%,arterialbloodoxygenpartialpressure(PaO2>80mmHgarterialbloodcarbondioxidepartialpressure(PaCO2)orend-tidalcarbondioxidetension(PetCO2)－30–35mmHgduringaperiodofelevatedICP,35–45mmHgduringaperiodofnormalICP,andPaCO2maybetemporarilycontrolledto30mmHgorlessduringthepreparationforsurgicaldecompressionItisdesirabletotreatthefollowingconditionsassoonastheyaredetected:flailchest,openpneumothorax,tensionpneumothorax,massivepneumothorax,andmassiveairwayhemorrhage4–3CardiovascularManagementTargetsofcirculatorymanagement

Patientswithuncomplicatedheadinjuries:systolicbloodpressure>90–100mmHgandhemoglobin7–10g/dlPatientswithcomplicatedheadinjuries:systolicbloodpressure>120mmHg,meanarterialbloodpressure>90mmHg,cerebralperfusionpressure(CPP)>60–70mmHg(iftheICPismeasured),andhemoglobin>10g/dl4–4RecognitionandTreatmentofLife-ThreateningBrainHerniationAGCSscoreof8orless,rapidexacerbationoftheGCSscoreby2ormore,anisocoria,hemiplegia,etc.,oftenindicatealife-threateningbrainherniationAlargespace-occupyinglesion,a5-mmorgreaterbrainmidlineshift,andcompressionordisappearanceofthebasalcisternsoftenindicatelifethreateningbrainherniation

5、ICUManagementIndicationsforICPMonitoringGCSscoreof8orlesshypotension(systolicarterialbloodpressure<90mmHg)abnormalCTfindings,e.g.midlineshift,compressedbasalcisternsreceivingbarbiturateorhypothermiatreatmentsevereheadinjuryandnormalCTfindings.alteredlevelofconsciousnessduetoheavysedation5-1Sedation,PainControl,ImmobilizationDiazepamMidazolam

BarbituratesPropofolDexmedetomidine

Vecuronium5-2ElevationoftheHeadElevationoftheheadisusefulforthecontrolofICPTheangleisoftenadjustedto15–30°Elevationoftheheadby30°ormoreisundesirable5-3HyperventilationTherapyIfthereisnoincreaseintheICP,itisdesirabletomaintainPaCO2at25mmHgoraboveBlindhyperventilationshouldbeavoidedDuringhyperventilationtherapy,monitoringarterialbloodgasanalysis,theend-tidalpartialcarbondioxidepressure,ICPandSjO2HyperventilationtherapyisofteninitiatediftheICPcannotbecontrolledat20mmHgorless5-4Mannitol,Glycerol,DiureticsInpatientsshowingorsuspectedtohaveICP,theappropriateadministrationofmannitolorglycerolisusefulforthecontroloftheICPItisdesirablefortheplasmaosmoticpressurebeforeadministrationtobe310mOsmorlessAneffectivedoseisusually0.25–1.0g/kg.Itisoftensuggestedthatrepeatedbolusadministrationsaremoreeffectivethancontinuousadministration5-5BarbiturateTherapyInitiationofbarbituratetherapymaybeconsideredifintracranialhypertensioncouldnotbecontrolledwithmaximumstandardtreatmentUsualdose:pentobarbital2–5mg/kgbodyweightorthiopental2–10mg/kgasabolusFollowedbycontinuousinfusionofpentobarbital0.5–3mg/kg/hrorthiopental1–6mg/kg/hr5-6SteroidsWhilethenegativeviewthatglucocorticoids(steroids)areineffectiveforthetreatmentofheadinjuriesissharedbymanyresearchers,prednisoloneorbetamethasonemay,inpractice,beadministeredintravenouslySufficientattentiontogastrointestinalbleedingandhyperglycemiaassideeffectsofsteroidsisalsonecessary5-7Hypothermia(BrainHypothermia)AlthoughhypothermiareducestheICP,itdoesnot