重癥顱腦損傷指南課件

GuidelinesforthemanagementofSevereHeadInjury,2ndedition

2014級(jí)急診專業(yè)研究生Guidelinesforthemanagement1Content1、introduction2、Recommendedgrade3、Pre-hospitalcare4、Imitialtreatmenttoprotectthebrain5、ICUmanagementContent1、introduction21、introductionIn2000,thefirstguidelineswerepublishedRevisedtheGuidelines7timesbetween2003and20051、introductionIn2000,thefir3TargetpatientsClosedheadinjuriesinadultswithaGlasgowComaScale（GCS）scoreof8orlessafterresuscitationGCSscoreafterresuscitationis9orabovebutdeteriorateto8orlessafteradmissionduetosecondarybraindamageMultipleheadinjuriesandheadinjuriescomplicatedbyspinalcordinjurywereexcludedfromthiseditionTargetpatientsClosedheadinj42、Recommendedgrade

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

2、Recommendedgrade1，…isdesi53、Pre-hospitalcareTheobjectiveofpre-hospitalcareistominimizesecondarybraindamageSecuringtheairwayCorrectionofhypoxiaCorrectionofhypotensionProtectionoftheneckFirstaidforadditionalinjuries3、Pre-hospitalcareTheobjecti6Table1JapanComaScale(JCS)scoresGradeConsciousnesslevel1-digitcodeThepatientisawakewithoutanystimulation,andis:1Almostfullyconscious2Unabletorecognizetime,place,andhim/herself3Unabletorecallnameordateofbirth2-digitcodeThepatientcanbearoused（thenrevertstopreviousstateaftercessationofstimulation）10easilybybeingspokento(orisresponsivewithpurposefulmovements,phrases,orwords)20withloudvoiceorshakingofshoulders(orisalmostalwaysresponsivetoverysimplewordslikeyesorno,ortomovements)30onlybyrepeatedmechanicalstimuli3-digitcodethepatientcannotbearousedwithanyappliedmechanicalstimuli,and:100respondswithmovementstoavoidthestimulus200respondswithslightmovementsincludingdecerebrateanddecorticateposture300doesnotrespondatallexceptforchangeofrespiratoryrateandrhythmTable1JapanComaScale(JCS)7Table2GlasgowComaScale(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.NoneTable2GlasgowComaScale(GC8重癥顱腦損傷指南課件9重癥顱腦損傷指南課件10重癥顱腦損傷指南課件114-1InitialExaminationandTreatmentofInjuriesPrimaryassessmentandresuscitationtosecurestabilityofthegeneralconditionareasfollows：1.Itisdesirabletoresuscitateimmediatelywhenabnormalphysiologicparametersisdetected2.Resuscitationisoftenperformedintheorderofairway,respiration,andcirculation3.ItisdesirabletosecuretheairwaybyendotrachealintubationwhenGCSscoreis8orless,whileprotectthecervicalspine4-1InitialExaminationandTr124.Itisdesirabletomaintainsufficientoxygenationandventilation5.Itisdesirabletostarttreatmentimmediatelyifalife-threateningthoracicinjuryisdetected6.Itisdesirabletopromptlyperformchestandpelvicradiographyandabdominalultrasonographyifthereisabnormalrespirationorcirculation7.Iftherearesymptomsofshock,itisdesirabletogiveinitiallyrapid1–2linfusionforextracellularfluidsupplementationandexamineresponse,aswellastoexaminewhetherthereisobstructiveshock(cardiactamponade,tensionpneumothorax)4.Itisdesirabletomaintain138.Itisdesirabletoexaminethefollowingneurologicalclinicalparameters,inparticular:GCS,pupillaryfindings,andpresenceoffocaldeficit:hemiplegia9.IftheGCSscoreis8orless,oriftheGCSscorehasdeterioratedrapidlyby2ormore,andanisocoriaorhemiplegia(signsofcerebralhernia)isobserved,itisdesirabletocontactimmediatelyanexpertandperformaCT.10.Undressingisoftennecessarytosearchforlife-threateninginjuries.11.Ifthepatienthasahighfever,itisdesirabletopromptlydecreasethebodytemperaturetothenormalrange.12.Ifhypothermicpatientsareatriskofmassivehemorrhage,itisdesirabletowarmthempromptlyforpreservationofbloodcoagulationandhemostaticproperties8.Itisdesirabletoexaminet14ABCDEapproachAirway,evaluationandsecuringtheairwayandprotectionofthecervicalspineBreathing,respiratoryevaluationandtreatmentforlife-threateningthoracicinjuriesCirculation,cardiovascularevaluation,resuscitation,andhemostasisDysfunctionofcentralnervoussystem,evaluationoflife-threateningdisordersofthecentralnervoussystemExposureandenvironmentalcontrol,undressingandbodytemperaturemanagementABCDEapproachAirway,evaluati154–2SecuringtheAirwayandRespiratoryManagementTrachealintubationisdesirableiftheGCSscoreis8orless,orifthebestmotorresponseoftheGCSscoreis5orlessEndotrachealintubationshouldbeperformedorallyIfintubationisexpectedtobedifficultduetoobesity,ashortneck,nasalorendoscopicintubationisoftenselectedTheuseofshort-actingsedativesisdesirableItisdesirabletoavoidlaryngealdistentionortheuseofdepolarizingmusclerelaxantsunderinsufficientsedationIftrachealintubationisdifficultduetomarkedfacialinjury,etc,asurgicalproceduretosecuretheairwaysuchasthyrocricotomyisoftenselectedThecervicalcollarshouldberemovedifitinterfereswithlaryngealextension4–2SecuringtheAirwayandRe164–2Indicationsforsecuringtheairwayininjurypatients

AirwayobstructionSecuringtheairwayinanticipationofrespiratorymanagement:apnea;hypoventilationandhypoxemia(notcorrectedbyoxygenadministration)Severehemorrhagicshock/cardiacarrestDecreaseinthelevelofonsciousness(GCSscore<8)4–2Indicationsforsecuringt174–2RespiratorymanagementHigh-concentrationoxygen(at10–15l/minusingafacemaskwithareservoir)Targets:arterialbloodoxygensaturation(SpO2>95%,arterialbloodoxygenpartialpressure(PaO2>80mmHgarterialbloodcarbondioxidepartialpressure(PaCO2)orend-tidalcarbondioxidetension(PetCO2)－30–35mmHgduringaperiodofelevatedICP,35–45mmHgduringaperiodofnormalICP,andPaCO2maybetemporarilycontrolledto30mmHgorlessduringthepreparationforsurgicaldecompressionItisdesirabletotreatthefollowingconditionsassoonastheyaredetected:flailchest,openpneumothorax,tensionpneumothorax,massivepneumothorax,andmassiveairwayhemorrhage4–2RespiratorymanagementHigh184–3CardiovascularManagementTargetsofcirculatorymanagement

Patientswithuncomplicatedheadinjuries:systolicbloodpressure>90–100mmHgandhemoglobin7–10g/dlPatientswithcomplicatedheadinjuries:systolicbloodpressure>120mmHg,meanarterialbloodpressure>90mmHg,cerebralperfusionpressure(CPP)>60–70mmHg(iftheICPismeasured),andhemoglobin>10g/dl4–3CardiovascularManagementT194–4RecognitionandTreatmentofLife-ThreateningBrainHerniationAGCSscoreof8orless,rapidexacerbationoftheGCSscoreby2ormore,anisocoria,hemiplegia,etc.,oftenindicatealife-threateningbrainherniationAlargespace-occupyinglesion,a5-mmorgreaterbrainmidlineshift,andcompressionordisappearanceofthebasalcisternsoftenindicatelifethreateningbrainherniation

4–4RecognitionandTreatment205、ICUManagementIndicationsforICPMonitoringGCSscoreof8orlesshypotension(systolicarterialbloodpressure<90mmHg)abnormalCTfindings,e.g.midlineshift,compressedbasalcisternsreceivingbarbiturateorhypothermiatreatmentsevereheadinjuryandnormalCTfindings.alteredlevelofconsciousnessduetoheavysedation5、ICUManagementIndicationsfo215-1Sedation,PainControl,ImmobilizationDiazepamMidazolamBarbituratesPropofolDexmedetomidineVecuronium5-1Sedation,PainControl,Im225-2ElevationoftheHeadElevationoftheheadisusefulforthecontrolofICPTheangleisoftenadjustedto15–30°Elevationoftheheadby30°ormoreisundesirable5-2ElevationoftheHeadEleva235-3HyperventilationTherapyIfthereisnoincreaseintheICP,itisdesirabletomaintainPaCO2at25mmHgoraboveBlindhyperventilationshouldbeavoidedDuringhyperventilationtherapy,monitoringarterialbloodgasanalysis,theend-tidalpartialcarbondioxidepressure,ICPandSjO2HyperventilationtherapyisofteninitiatediftheICPcannotbecontrolledat20mmHgorless5-3HyperventilationTherapyIf245-4Mannitol,Glycerol,DiureticsInpatientsshowingorsuspectedtohaveICP,theappropriateadministrationofmannitolorglycerolisusefulforthecontroloftheICPItisdesirablefortheplasmaosmoticpressurebeforeadministrationtobe310mOsmorlessAneffectivedoseisusually0.25–1.0g/kg.Itisoftensuggestedthatrepeatedbolusadministrationsaremoreeffectivethancontinuousadministration5-4Mannitol,Glycerol,Diuret255-5BarbiturateTherapyInitiationofbarbituratetherapymaybeconsideredifintracranialhypertensioncouldnotbecontrolledwithmaximumstandardtreatmentUsualdose:pentobarbital2–5mg/kgbodyweightorthiopental2–10mg/kgasabolusFollowedbycontinuousinfusionofpentobarbital0.5–3mg/kg/hrorthiopental1–6mg/kg/hr5-5BarbiturateTherapyInitiat265-6SteroidsWhilethenegativeviewthatglucocorticoids(steroids)areineffectiveforthetreatmentofheadinjuriesissharedbymanyresearchers,prednisoloneorbetamethasonemay,inpractice,beadministeredintravenouslySufficientattentiontogastrointestinalbleedingandhyperglycemiaassideeffectsofsteroidsisalsonecessary5-6SteroidsWhilethenegative275-7Hypothermia(BrainHypothermia)AlthoughhypothermiareducestheICP,itdoesnotimprovetheoutcomeHypothermiahasunfavorableoutcomeinelderlypeople,buthasfavorableoutcomeinchildrenHypothermiamayincreasetheincidencesofcomplicationssuchasinfection,arrhythmia,hypokalemia,andthrombocytopeniaConcerninghypothermia,noconsensushasbeenreachedregardingthetargetbodytemperature,duration,temperaturerecoverymethod,patientselection5-7Hypothermia(BrainHypother285-8TherapeuticProceduresforIncreasedICPForICP>15–25mmHgForICP>20–25mmHg5-8TherapeuticProceduresfor295-9Antiepileptics

Antiepilepticsmaybeadministeredtothefollowingpatients:i)patientsshowingabnormalitiesonCT,particularlythosefoundtohavebrainparenchymalinjuriesii)patientswithearly-onsetepilepsyiii)youngpatientsPhenytoin,carbamazepine,zonisamide,andphenobarbitalareoftenused

5-9AntiepilepticsAntiepilept305-10NutritionEnteralorparenteralnutritionshouldbeinitiatedearlyinordertoattainfullcaloricreplacementbyday7afterinjuryBloodglucoselevelshouldbecontrolledwithintherangeof100–200mg/dl5-10NutritionEnteralorparen31Thanksforyourattention!Thanksforyourattention!32GuidelinesforthemanagementofSevereHeadInjury,2ndedition

2014級(jí)急診專業(yè)研究生Guidelinesforthemanagement33Content1、introduction2、Recommendedgrade3、Pre-hospitalcare4、Imitialtreatmenttoprotectthebrain5、ICUmanagementContent1、introduction341、introductionIn2000,thefirstguidelineswerepublishedRevisedtheGuidelines7timesbetween2003and20051、introductionIn2000,thefir35TargetpatientsClosedheadinjuriesinadultswithaGlasgowComaScale（GCS）scoreof8orlessafterresuscitationGCSscoreafterresuscitationis9orabovebutdeteriorateto8orlessafteradmissionduetosecondarybraindamageMultipleheadinjuriesandheadinjuriescomplicatedbyspinalcordinjurywereexcludedfromthiseditionTargetpatientsClosedheadinj362、Recommendedgrade

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

2、Recommendedgrade1，…isdesi373、Pre-hospitalcareTheobjectiveofpre-hospitalcareistominimizesecondarybraindamageSecuringtheairwayCorrectionofhypoxiaCorrectionofhypotensionProtectionoftheneckFirstaidforadditionalinjuries3、Pre-hospitalcareTheobjecti38Table1JapanComaScale(JCS)scoresGradeConsciousnesslevel1-digitcodeThepatientisawakewithoutanystimulation,andis:1Almostfullyconscious2Unabletorecognizetime,place,andhim/herself3Unabletorecallnameordateofbirth2-digitcodeThepatientcanbearoused（thenrevertstopreviousstateaftercessationofstimulation）10easilybybeingspokento(orisresponsivewithpurposefulmovements,phrases,orwords)20withloudvoiceorshakingofshoulders(orisalmostalwaysresponsivetoverysimplewordslikeyesorno,ortomovements)30onlybyrepeatedmechanicalstimuli3-digitcodethepatientcannotbearousedwithanyappliedmechanicalstimuli,and:100respondswithmovementstoavoidthestimulus200respondswithslightmovementsincludingdecerebrateanddecorticateposture300doesnotrespondatallexceptforchangeofrespiratoryrateandrhythmTable1JapanComaScale(JCS)39Table2GlasgowComaScale(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.NoneTable2GlasgowComaScale(GC40重癥顱腦損傷指南課件41重癥顱腦損傷指南課件42重癥顱腦損傷指南課件434-1InitialExaminationandTreatmentofInjuriesPrimaryassessmentandresuscitationtosecurestabilityofthegeneralconditionareasfollows：1.Itisdesirabletoresuscitateimmediatelywhenabnormalphysiologicparametersisdetected2.Resuscitationisoftenperformedintheorderofairway,respiration,andcirculation3.ItisdesirabletosecuretheairwaybyendotrachealintubationwhenGCSscoreis8orless,whileprotectthecervicalspine4-1InitialExaminationandTr444.Itisdesirabletomaintainsufficientoxygenationandventilation5.Itisdesirabletostarttreatmentimmediatelyifalife-threateningthoracicinjuryisdetected6.Itisdesirabletopromptlyperformchestandpelvicradiographyandabdominalultrasonographyifthereisabnormalrespirationorcirculation7.Iftherearesymptomsofshock,itisdesirabletogiveinitiallyrapid1–2linfusionforextracellularfluidsupplementationandexamineresponse,aswellastoexaminewhetherthereisobstructiveshock(cardiactamponade,tensionpneumothorax)4.Itisdesirabletomaintain458.Itisdesirabletoexaminethefollowingneurologicalclinicalparameters,inparticular:GCS,pupillaryfindings,andpresenceoffocaldeficit:hemiplegia9.IftheGCSscoreis8orless,oriftheGCSscorehasdeterioratedrapidlyby2ormore,andanisocoriaorhemiplegia(signsofcerebralhernia)isobserved,itisdesirabletocontactimmediatelyanexpertandperformaCT.10.Undressingisoftennecessarytosearchforlife-threateninginjuries.11.Ifthepatienthasahighfever,itisdesirabletopromptlydecreasethebodytemperaturetothenormalrange.12.Ifhypothermicpatientsareatriskofmassivehemorrhage,itisdesirabletowarmthempromptlyforpreservationofbloodcoagulationandhemostaticproperties8.Itisdesirabletoexaminet46ABCDEapproachAirway,evaluationandsecuringtheairwayandprotectionofthecervicalspineBreathing,respiratoryevaluationandtreatmentforlife-threateningthoracicinjuriesCirculation,cardiovascularevaluation,resuscitation,andhemostasisDysfunctionofcentralnervoussystem,evaluationoflife-threateningdisordersofthecentralnervoussystemExposureandenvironmentalcontrol,undressingandbodytemperaturemanagementABCDEapproachAirway,evaluati474–2SecuringtheAirwayandRespiratoryManagementTrachealintubationisdesirableiftheGCSscoreis8orless,orifthebestmotorresponseoftheGCSscoreis5orlessEndotrachealintubationshouldbeperformedorallyIfintubationisexpectedtobedifficultduetoobesity,ashortneck,nasalorendoscopicintubationisoftenselectedTheuseofshort-actingsedativesisdesirableItisdesirabletoavoidlaryngealdistentionortheuseofdepolarizingmusclerelaxantsunderinsufficientsedationIftrachealintubationisdifficultduetomarkedfacialinjury,etc,asurgicalproceduretosecuretheairwaysuchasthyrocricotomyisoftenselectedThecervicalcollarshouldberemovedifitinterfereswithlaryngealextension4–2SecuringtheAirwayandRe484–2Indicationsforsecuringtheairwayininjurypatients

AirwayobstructionSecuringtheairwayinanticipationofrespiratorymanagement:apnea;hypoventilationandhypoxemia(notcorrectedbyoxygenadministration)Severehemorrhagicshock/cardiacarrestDecreaseinthelevelofonsciousness(GCSscore<8)4–2Indicationsforsecuringt494–2RespiratorymanagementHigh-concentrationoxygen(at10–15l/minusingafacemaskwithareservoir)Targets:arterialbloodoxygensaturation(SpO2>95%,arterialbloodoxygenpartialpressure(PaO2>80mmHgarterialbloodcarbondioxidepartialpressure(PaCO2)orend-tidalcarbondioxidetension(PetCO2)－30–35mmHgduringaperiodofelevatedICP,35–45mmHgduringaperiodofnormalICP,andPaCO2maybetemporarilycontrolledto30mmHgorlessduringthepreparationforsurgicaldecompressionItisdesirabletotreatthefollowingconditionsassoonastheyaredetected:flailchest,openpneumothorax,tensionpneumothorax,massivepneumothorax,andmassiveairwayhemorrhage4–2RespiratorymanagementHigh504–3CardiovascularManagementTargetsofcirculatorymanagement

Patientswithuncomplicatedheadinjuries:systolicbloodpressure>90–100mmHgandhemoglobin7–10g/dlPatientswithcomplicatedheadinjuries:systolicbloodpressure>120mmHg,meanarterialbloodpressure>90mmHg,cerebralperfusionpressure(CPP)>60–70mmHg(iftheICPismeasured),andhemoglobin>10g/dl4–3CardiovascularManagementT514–4RecognitionandTreatmentofLife-ThreateningBrainHerniationAGCSscoreof8orless,rapidexacerbationoftheGCSscoreby2ormore,anisocoria,hemiplegia,etc.,oftenindicatealife-threateningbrainherniationAlargespace-occupyinglesion,a5-mmorgreaterbrainmidlineshift,andcompressionordisappearanceofthebasalcisternsoftenindicatelifethreateningbrainherniation

4–4RecognitionandTreatment525、ICUManagementIndicationsforICPMonitoringGCSscoreof8orlesshypotension(systolicarterialbloodpressure<90mmHg)abnormalCTfindings,e.g.midlineshift,compressedbasalcisternsreceivingbarbiturateorhypothermiatreatmentsevereheadinjuryandnormalCTfindings.alteredlevelofconsciousnessduetoheavysedation5、ICUManagementIndicationsfo535-1Sedation,PainControl,ImmobilizationDiazepamMidazolamBarbituratesPropofolDexmedetomidineVecuronium5-1Sedation,PainControl,Im545-2ElevationoftheHeadElevationoftheheadisusefulforthecontrolofICPTheangleisoftenadjustedto15–30°Elevationoftheheadby30°ormoreisundesirable5-2ElevationoftheHeadEleva555-3HyperventilationTherapyIfthereisnoincreaseintheICP,itisdesirabletomaintainPaCO2at25mmHgoraboveBlindhyperventilationshouldbeavoidedDuringhyperventilationtherapy,monitoringarterialbloodgasanalysis,theend-tidalpartialcarbondioxidepressure,ICPandSjO2HyperventilationtherapyisofteninitiatediftheICPcannotbecontrolledat20mmHgorless5-3HyperventilationTherapyIf565-4Mannitol,Glycerol,DiureticsInpatientsshowingorsuspectedtohaveICP,theappropriateadministrationofmannitolorglycerolisusefulforthecontroloftheICPItisdesirablefortheplasmaosmoti