重症颅脑损伤指南课件

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,Guidelines for the management of Severe Head Injury,2,nd,edition,2014级急诊专业研究生,Content,1、introduction,2、Recommended grade,3、Pre-hospital care,4、Imitial treatment to protect the brain,5、ICU management,1、introduction,In 2000,the first guidelines were published,Revised 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 resuscitation,GCS score after resuscitation is 9 or above but deteriorate to 8 or less after admission due to secondary brain damage,Multiple head injuries and head injuries complicated by spinal cord injury were excluded from this edition,2、Recommended grade,1，is desirable,2，is often（performed）,3，can be（performed）,4，may be（performed）,5，is undesirable,6，may be regarded as a contraindication,3、Pre-hospital care,The objective of pre-hospital care is to minimize secondary brain damage,Securing the airway,Correction of hypoxia,Correction of hypotension,Protection of the neck,First aid for additional injuries,Table 1 Japan Coma Scale(JCS)scores,Grade,Consciousness level,1-digit code,The patient is awake without any stimulation,and is:,1,Almost fully conscious,2,Unable to recognize time,place,and him/herself,3,Unable to recall name or date of birth,2-digit code,The patient can be aroused（then reverts to previous state after cessation of stimulation）,10,easily by being spoken to(or is responsive with purposeful movements,phrases,or words),20,with loud voice or shaking of shoulders(or is almost always responsive to very simple words like yes or no,or to movements),30,only by repeated mechanical stimuli,3-digit code,the patient cannot be aroused with any applied mechanical stimuli,and:,100,responds with movements to avoid the stimulus,200,responds with slight movements including decerebrate and decorticate posture,300,does not respond at all except for change of respiratory rate and rhythm,Table 2 Glasgow Coma Scale(GCS)scores easdale,Jennett;Lancet,1974),Eye opening(E),Best verbal,response(V),Best motor response(M),4.Spontaneous,5.Oriented,6.Obeying verbal,commands,3.To verbal command,4.Confused conversation,5.Localizes pain,2.To pain,3.Inappropriate words,4.Flexion/withdrawal to pain,1.None,2.Incomprehensible,3.Abnormal flexion due,sounds to pain(upper limbs),1.None,2.Extension to pain,(upper limbs),1.None,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 detected,2.Resuscitation is often performed in the order of airway,respiration,and circulation,3.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 ventilation,5.It is desirable to start treatment immediately if a life-threatening thoracic injury is detected,6.It is desirable to promptly perform chest and pelvic radiography and abdominal ultrasonography if there is abnormal respiration or circulation,7.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:hemiplegia,9.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,A,irway,evaluation and securing the airway and protection of the cervical spine,B,reathing,respiratory evaluation and treatment for life-threatening thoracic injuries,C,irculation,cardiovascular evaluation,resuscitation,and,hemostasis,D,ysfunction of central nervous system,evaluation of life-threatening disorders of the central nervous system,E,xposure 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 less,Endotracheal intubation should be performed orally,If intubation is expected to be difficult due to obesity,a short neck,nasal or endoscopic intubation is often selected,The use of short-acting sedatives is desirable,It is desirable to avoid laryngeal diste