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急性重度创伤性脑损伤的处理

Authors
J Claude Hemphill, III, MD, MAS
Nicholas Phan, MD, FRCSC, FACS
Section Editor
Michael J Aminoff, MD, DSc
Deputy Editor
Janet L Wilterdink, MD
Translators
黄齐兵, 副主任医师

引言

在北美1-45岁个体中，创伤性脑损伤(traumatic brain injury, TBI)是最主要的死亡原因[1]。许多幸存者留有严重残疾，也造成了沉重的社会经济负担。2000年在美国，据估计TBI对经济的影响为92亿美元的终生医疗费用及512亿美元的生产损失。

过去的20年间，在重度头部损伤患者诊治方面取得的重大进展之一是建立了遵照国际和国家指南的标准化处理方法[2-5]。这些指南的目的就是利用现有的证据为当前的诊治提供推荐，以减少医疗不一致性和改善患者结局。遗憾的是，仍然缺乏针对重度TBI患者诊治多方面的随机临床试验，这也就意味着大多数治疗理念的支持资料的强度均相对较弱。尽管如此，有证据证明在具备神经外科支持的医疗中心，尤其是在有基于上述指南运作的标准化流程的神经科重症监护病房(intensive care unit, ICU)环境中进行的治疗，与更好的患者结局有关[6-11]。许多专家小组推荐，严重TBI的治疗应该集中在能够提供神经外科治疗并可进行专门的神经重症监护的大型创伤中心。

重度头部损伤患者可经常伴有内部器官、肺部、四肢或者脊髓的其他创伤性损伤。因此，重度头部损伤患者的处理常比较复杂并且需要多学科联合，使其适用于依据流程性的治疗和上述指南中的整套标准化医嘱。

本专题将讨论急性重度TBI的处理。TBI的流行病学及病理生理学、轻度脑外伤的处理、急性脊髓损伤以及创伤患者诊治的其他方面将单独讨论。 (参见“创伤性脑损伤：流行病学、分类及病理生理学”和“脑震荡和轻度创伤性脑损伤”和“急性创伤性脊髓损伤”和“成人颅骨骨折”)

初始评估和治疗

院前处理 — 重度头部损伤患者院前处理的主要目的是预防低血压和缺氧，这两种全身性损伤是人们所熟知的TBI后继发性损伤的重要原因[12-17]。在一项针对多个临床试验和人群研究的meta分析中，出现缺氧(PaO2＜60mmHg)和低血压(收缩压＜90mmHg)的患者分别占50%和30%，两者均与患者不良结局的可能性具有较高相关性：缺氧(OR 2.14)、低血压(OR 2.67)[13]。院前处理目的是为了纠正氧合和血压，氧合和血压的正常化可以改善结局[18-22]：

                            

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Literature review current through: 2017-06 . | This topic last updated: 2015-02-10.
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