1、Guidelines for the management of Severe Head Injury,2nd edition 2014级急诊专业研究生级急诊专业研究生Content1、introduction 2、Recommended grade3、Pre-hospital care4、Imitial treatment to protect the brain5、ICU management1、introductionIn 2000,the first guidelines were publishedRevised the Guidelines 7 times between 2003
2、 and 2005Target patientsvClosed head injuries in adults with a Glasgow Coma Scale（GCS）score of 8 or less after resuscitationvGCS score after resuscitation is 9 or above but deteriorate to 8 or less after admission due to secondary brain damagevMultiple head injuries and head injuries complicated by
3、spinal cord injury were excluded from this edition2、Recommended grade v1，is desirablev2，is often（performed）v3，can be（performed）v4，may be（performed）v5，is undesirablev6，may be regarded as a contraindication 3、Pre-hospital carevThe objective of pre-hospital care is to minimize secondary brain damagevSe
4、curing the airway vCorrection of hypoxiavCorrection of hypotensionvProtection of the neck vFirst aid for additional injuriesTable 1 Japan Coma Scale(JCS)scoresGradeConsciousness level 1-digit codeThe patient is awake without any stimulation,and is:1Almost fully conscious2Unable to recognize time,pla
5、ce,and him/herself3Unable to recall name or date of birth2-digit codeThe patient can be aroused（then reverts to previous state after cessation of stimulation）10easily by being spoken to(or is responsive with purposeful movements,phrases,or words)20with loud voice or shaking of shoulders(or is almost
6、 always responsive to very simple words like yes or no,or to movements)30only by repeated mechanical stimuli 3-digit codethe patient cannot be aroused with any applied mechanical stimuli,and:100responds with movements to avoid the stimulus200responds with slight movements including decerebrate and d
7、ecorticate posture300does not respond at all except for change of respiratory rate and rhythmTable 2 Glasgow Coma Scale(GCS)scores easdale,Jennett;Lancet,1974)Eye opening(E)Best verbalresponse(V)Best motor response(M)4.Spontaneous5.Oriented6.Obeying verbalcommands3.To verbal command 4.Confused conve
8、rsation5.Localizes pain2.To pain3.Inappropriate words 4.Flexion/withdrawal to pain1.None2.Incomprehensible3.Abnormal flexion duesounds to pain(upper limbs)1.None2.Extension to pain(upper limbs)1.None4-1 Initial Examination and Treatment of InjuriesvPrimary assessment and resuscitation to secure stab
9、ility of the general condition are as follows：1.It is desirable to resuscitate immediately when abnormal physiologic parameters is detected2.Resuscitation is often performed in the order of airway,respiration,and circulation3.It is desirable to secure the airway by endotracheal intubation when GCS s
10、core is 8 or less,while protect the cervical spine4.It is desirable to maintain sufficient oxygenation and ventilation5.It is desirable to start treatment immediately if a life-threatening thoracic injury is detected6.It is desirable to promptly perform chest and pelvic radiography and abdominal ult
11、rasonography if there is abnormal respiration or circulation7.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 pneumotho
12、rax)8.It is desirable to examine the following neurological clinical parameters,in particular:GCS,pupillary findings,and presence of focal deficit:hemiplegia9.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
13、)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 r
14、isk of massive hemorrhage,it is desirable to warm them promptly for preservation of blood coagulation and hemostatic propertiesABCDE approachAirway,evaluation and securing the airway and protection of the cervical spineBreathing,respiratory evaluation and treatment for life-threatening thoracic inju
15、riesCirculation,cardiovascular evaluation,resuscitation,and hemostasisDysfunction of central nervous system,evaluation of life-threatening disorders of the central nervous systemExposure and environmental control,undressing and body temperature management42 Securing the Airway and Respiratory Manage
16、mentvTracheal intubation is desirable if the GCS score is 8 or less,or if the best motor response of the GCS score is 5 or lessvEndotracheal intubation should be performed orally vIf intubation is expected to be difficult due to obesity,a short neck,nasal or endoscopic intubation is often selectedvT
17、he use of short-acting sedatives is desirablevIt is desirable to avoid laryngeal distention or the use of depolarizing muscle relaxants underinsufficient sedationvIf tracheal intubation is difficult due to marked facial injury,etc,a surgical procedure to secure the airway such as thyrocricotomy is o
18、ften selectedvThe cervical collar should be removed if it interferes with laryngeal extension42 Indications for securing the airway in injury patients vAirway obstructionvSecuring the airway in anticipation of respiratory management:apnea;hypoventilation and hypoxemia(not corrected by oxygen adminis
19、tration)vSevere hemorrhagic shock/cardiac arrestvDecrease in the level of onsciousness(GCS score 95%,arterial blood oxygen partial pressure(PaO280 mmHg arterialblood carbon dioxide partial pressure(PaCO2)or end-tidal carbon dioxide tension(PetCO2)3035mmHg during a period of elevated ICP,3545mmHg dur
20、ing a period of normal ICP,and PaCO2 may be temporarily controlled to 30 mmHg or less during the preparation for surgical decompressionvIt is desirable to treat the following conditions as soon as they are detected:flail chest,open pneumothorax,tension pneumothorax,massive pneumothorax,and massive a
21、irway hemorrhage43 Cardiovascular ManagementTargets of circulatory management Patients with uncomplicated head injuries:systolic blood pressure90100 mmHg andhemoglobin 710 g/dlPatients with complicated head injuries:systolic blood pressure 120 mmHg,mean arterial blood pressure 90 mmHg,cerebral perfu
22、sion pressure(CPP)6070 mmHg(if the ICP is measured),and hemoglobin 10 g/dl44 Recognition and Treatment of Life-Threatening Brain HerniationvA GCS score of 8 or less,rapid exacerbation of the GCS score by 2 or more,anisocoria,hemiplegia,etc.,often indicate a life-threatening brain herniationvA large
23、space-occupying lesion,a 5-mm or greater brain midline shift,and compression or disappearance of the basal cisterns often indicate lifethreatening brain herniation 5、ICU ManagementIndications for ICP MonitoringvGCS score of 8 or lessvhypotension(systolic arterial blood pressure1525 mmHgvFor ICP 2025
24、 mmHg 5-9 Antiepileptics vAntiepileptics may be administered to the following patients:i)patients showing abnormalities on CT,particularly those found to have brain parenchymal injuries ii)patients with early-onset epilepsy iii)young patientsvPhenytoin,carbamazepine,zonisamide,and phenobarbital are often used 5-10 NutritionvEnteral or parenteral nutrition should be initiated early in order to attain full caloric replacement by day 7 after injuryvBlood glucose level should be controlled within the range of 100200 mg/dl
