Transcript (Head Injury) 頭部創傷 陳俊逸 高雄榮民總醫院 神經外科

頭部創傷(Head Injury)
陳俊逸
高雄榮民總醫院 神經外科
Glasgow Coma Scale
Classifications of Severity
• Mild head injury (GCS= 14-15)
• Moderate head injury (GCS=9-13)
• Severe head injury (GCS≦ 8)
Immediate Management of
Head Injury
• General principles:
– Not a single disorder.
– Tailored therapeutic plans for the specific
lesion and individual patient from time to
time.
• No stable hemodynamics, no accurate
GCS score.
Begin at the trauma scene
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Airway with cervical spine control
Breathing
Circulation with hemorrhage control
Stabilizing the cervical and thoracolumbar
spine (Disability) ==> C-spine, CXR, pelvis
• Identifying and stabilizing Extracranial injuries
• Mini-neurologic Examination.
• 記ABCDEE
Mini-neurological Examination
• Level of consciousness (E4V5M1???)
• Pupillary function (unilateral? L/R? Doll
eye sign?)
• Lateralized extremity weakness
Risk Factors (5H-CSI)
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Hypotension  double mortality rate
Hypoxia  add hypotension  75% mortality
Intracranial Hypertension (IICP)
Hyperthermia
Electrolyte disturbance (H)
Coagulopathy
Seizure
Infection
Mild Head Injury (GCS 14-15)
• Brain concussion (initial loss of consciousness)
• All head-injured patients should have a CT
scan, except the true asymptomatic patients.
• If CT scan is not available  admission and
observation for 1-2 days.
• 2-3% serious intracranial insult.
• Abnormal CT scan: 18%  5% need op
Mild Head Injury
• Risk factors of neurological deterioration:
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Older age and anticoagulant therapy
CPR
Alcohol or drug abuse
Presence of subdural effusion or hematoma at the
initial CT scan
– Epilepsy
– Previous neurosurgical treatment.
• 記: 開過腦的老人喝酒吃藥跌個硬膜下出血,結
果癲癇又急救.
Mild Head Injury
• Admission criteria: (至少建議於ER留觀一晚)
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Penetrating head injuries
Abnormal CT scan or skull fracture
Loss of consciousness or amnesia
Moderate to severe headache or vomiting
Worsening in GCS score
Pneumocephalus or CSF leakage
Associated extracranial injuries
Alcohol or drug abuse, coagulopathy and other
risk factors for deterioration
– No reliable assistance at home
Mild Head Injury
• While being discharged, give a warning
sheet (頭部外傷須知)
• Within 1-2 weeks, OPD F/U.
Moderate Head Injury (GCS 9-13)
• CT scan should be done in all cases of
moderate head injury. (abnormal CT: 40%)
• Admission criteria
• In non-severe head injury, causes of mortality
are inadequate observation and extracranial
injuries.
• Higher risk of deterioration:
– Older
– An initial abnormal CT scan
– Lower GCS motor score
Moderate Head Injury
first CT scan
normal
nonoperative
neurological deterioration
2nd CT before discharged
2nd CT within 12 o 24 hours
immediate CT
Severe Head Injury (GCS <=8)
• First priority (before calling NS Drs)
– Securing airway, breathing, and circulation (ABC).
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Emergent intubation !!
Avoid hypoxia (PaO2<60mmHg)
Avoid hypotension (SBP<90mmHg)
Avoid electrolyte imbalance: Na, K, Glu, Mg
Other system injury (life threatening): check
chest and abdomen
Acute treatment for severe head injury
ABCDE
E
5H-CSI
To control ICP should be
started empirically even
before a CT scan is obtained.
• Comatose patients
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Decline in GCS
Pupillary asymmetry
Hemiparesis
Any signs of
presence of a
traumatic mass
lesion.
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Intubation
Mild hyperventilation
IV bolus of mannitol
Prophylactic phenytoin
Sedation
CT room
頭部外傷的進步
• 二次大戰以來，在頭部外傷的治療上有
兩項主要的改變：
一、是加護照護觀念的興起，這包括了呼吸道
及呼吸器的使用， 癲癇的控制，感染和體溫
的調控。
二、是電腦斷層的普及(since 1973)，這使得
早期手術成為可能。
神經加護照顧及腦部監測
•主要面對的是腦部的二度傷害
(secondary injury )，如顱內出血、腦
水腫、血氧不足及缺血(常因顱內壓升高
或休克)等。因此需要有良好腦部監測系
統才能及時找出問題，以避免二度腦傷
害的發生，或是使它的傷害減到最少的
程度。
神經加護照顧及腦部監測
• 神經學檢查及生理監測(neurological examination
monitoring)
• 顱內壓監測((ICP monitor)
• 穿顱都卜勒超音波(Transcranial Doppler, TCD)
• 頸靜脈竇氧氣飽和度(jugular bulb oxygen
saturation , SjvO2)
• 腦部氧飽和度(brain oxygen saturation monitoring)
• 神經電生理監測(neurophysiology monitoring):主要
包括腦波(EEG)及誘發電位(evoked potential, EP)
• 神經代謝監測(neurometabolic monitoring)
• 腦內氧氣分壓(PaO2)、二氧化分壓(PaCO2)、及酸鹼值
(pH)的監測
神經學檢查及生理監測
•昏迷指數(GCS)、瞳孔及各種反射等神經學檢
查在神經加護病房是最基本的監測。
•連續性的生理監測，如血壓、血氧飽和度
(SaO2)、心電圖(ECG)、中心靜脈壓(CVP)、體
溫及潮氣末二氧化碳(End tidal CO2)等也是現
代神經加護病房所不可或缺的。
•連續性顯示的中心靜脈壓、體溫及潮氣末二氧
化碳常被忽略，這三項唯有連續性的監測才能
對顱內壓與腦灌流壓以及腦部代謝做即時的調
控。
•系統性的問題也會造成二度傷害，尤其是低血
壓(hypotension)和缺氧(hypoxia)。
為什麼要測量顱內壓?
•許多的腦病變所引起腦部的死亡都和顱
內高壓有密切的相關。
•以嚴重頭部外傷為例，早期文獻均報告
當顱內壓持續大於二十五毫米汞柱時，
則預後不好。
•死後的解剖研究發現，缺血是腦死的主
要原因。
什麼是顱內壓?
•Monro-Kellie假說: 在人體密閉的顱腔
內， 腦實質、血液容積及腦脊液三者的
體積總和為定數，成年人約為1500-1900
西西。
•在這密閉的容器中一定體積產生均佈的
壓力稱之為顱內壓(intracranial
pressure, ICP)
Monro-Kellie假說
Total
1700ml
腦實質 Parenchyma
1400ml
腦脊液 CSF
血液容積 Blood
150ml
150ml
腦室內
Intraventricular space
50ml
蜘蛛網膜下腔
Subarachnoid space
100ml
顱內壓之病理生理變化
•顱內壓力上升
–當顱內成份增加，例如腦瘤、顱內出血
–腦脊髓液循環障礙：水腦症
–腦水腫
–血液成份增加：腦充血，靜脈回流受阻
•代償機轉
–血液容積及腦脊液再分佈
腦循環的流體力學
•腦血流與腦灌流壓(cerebral perfusion
pressure，CPP)成正比。
CBF=CPP/CVR
•腦灌流壓又等於平均動脈壓(mean
arterial pressure，MAP)減顱內壓。
CPP=MAP-ICP
•在腦血管自動調節下，腦血流維持恒定。
正常的顱內壓值
•正常的顱內壓值隨年紀而異:
–成年人的正常值為10-15mmHg
–小孩的顱內壓為3-7mmHg
–嬰兒則更低約1.5-6mmHg
•正常成人的腦灌流壓: 60-80mmHg
顱內高壓
•多數學者認為,當顱內壓大於二十至二十
五毫米汞柱即稱為顱內高壓
(intracranial hypertension)。
顱內高壓之症狀及病徵
•顱內壓上升可能沒有症狀，須要隨時提
高警覺。
•頭痛。
•噁心及嘔吐。
•視乳頭水腫(papilledema) 。
•意識障礙--顱內壓升高之晚期。
•腦疝脫(herniation)。
顱內高壓之症狀及病徵
•Cushing triad: 庫欣氏三徵象
–心跳緩慢、高血壓、呼吸不規則。
–為晚期徵象，表示橋腦或延腦已經受到壓迫
或損傷。
顱內壓監測適應症
• Severe head injury with an abnormal
admission CT scan.
• Severe head injury with a normal CT scan if
two or more of the following features are
noted at admission:
– Age over 40 years,
– unilateral or bilateral motor posturing
– Systolic blood pressure < 90mmHg.
• Not routinely indicated in patients with mild
or moderate head injury.
ICP monitor techniques
• The gold standard technique for ICP
monitoring is by means of an intra-ventricular
catheter. (ventriculostomy, EVD: external
ventricular drainage 腦室外引流)
• Alternative techniques:
– Parenchymal, subdural, or epidural catheter.
• Complication: parenchymal injury, infection,
hemorrhage, malfunction, or malposition.
• Up to one week and providing prophylactic
antibiotics.
顱內高壓的監測與治療
傳統顱內高壓的控制:
維持適當腦灌流壓：
• 限水(fluid
restriction)
• 高滲透壓利尿劑(例如
mannito1、glycerol)
• 過度通氣(hyperventilation)
• 降低體溫(hypothermia)
以降低代謝率等方式
• 「將含氧的血擠入腫脹
的腦中(squeezing the
oxygenated blood
through a swollen
brain)」
• CPP = MAP - ICP
Focus on CPP!!
避免顱內壓升高的基本原則
•在考慮降低顱內壓之前,應先懂得避免顱內壓
升高:
–頭部抬高30度(比平躺顱內壓低5~6mmHg)
–頸部保持正中(比左右轉顱內壓低5~6 mmHg)
–病人疼痛躁動不安
–吐氣末正壓(PEEP)
–腹壓上升(Valsalva maneuvers)
–例行之護理工作(如抽痰、翻身拍背、擦澡)均會使
得顱內壓上升
–高血壓或低血壓
–發燒或發抖
–貧血或缺血
–血中二氧化碳過高(大於45mmHg)或氧氣太低
–癲癇
維持穩定的血液循環
•保持腦灌流壓大於70mmHg。
•體液至少為正常容積狀態。
(normovolemia)
•中心靜脈壓應保持在6-15cmH2O
•肺動脈楔壓12-15mmHg。
•體液的維持以等張晶狀液(isotonic
crystalloid)或膠狀液(colloid)為主；
避免使用低張溶液。
引發反應性血管收縮之良性循環
提高血壓
CBF=CPP/CVR
CPP=MAP-ICP
腦灌流壓提高
CSF引流，
顱骨減壓術
顱內壓下降
降低血液黏稠度，
血管收縮 過度通氣，
代謝率減少
腦部血容積減少
頭抬高30度，頸部維持正中
減少病人疼痛，鎮定劑的使用
腦灌流壓降低，引發反應性血管
舒張之惡性循環
血壓下降，
脫水
CBF=CPP/CVR
CPP=MAP-ICP
腦灌流壓降低
水腦、
腦水腫
顱內壓上升
血液黏稠度增加，
血管舒張 二氧化碳累積，
代謝率增加
腦部血容積增加
靜脈回流受阻，病人躁動
與呼吸器對抗，胸腹壓增加
第一線療法
血氧飽和度100%、體液為正常容積狀態(euvolemia)、中心靜脈壓維持
在6-15cmH2O 、或者是肺動楔壓12-15mmHg、腦灌流壓大於
70mmHg，及血中二氧化碳分壓35mmHg
使用鎮靜劑及神經肌肉阻斷劑
顱內壓監測器，腦脊髓液引流
高張利尿劑(mannitol) 0.25-1gm/kg
輕微的過度通氣，PaCO2 30-35mmHg
頸靜脈竇氧氣飽和度(SjvO2)的監測
穩定鎮靜引流利尿輕通氣
第二線療法
巴比妥酸昏迷、低溫療法(hypothermia)、高血壓療法、
高度的過度通氣(PaCO2<30mmHg)
減壓開顱術(decompression craniectomy)
鎮靜劑(sedation)及
神經肌肉阻斷劑 (neuromuscular
blockade)
•一方面使得呼吸器的使用容易控制，另
一方面可降低顱內壓。
•常用的鎮靜劑如midazolam， propofo1；
神經肌肉阻斷劑如atracurium，
pancuronium， vecuronium。
•當顱內壓小於20mmHg超過24小時，則可
以將藥量逐漸降低。
腦脊髓液引流(CSF drainage)
•如果有腦室引流導管(ventriculostomy),
腦脊髓液引流是第一個考慮的方法。
•每次引流3-5 ml，可達到良好的降壓效
果。
•一般建議每8小時引流75 ml.屬安全範圍。
高張利尿劑(osmotic
diuretics)
•最常用的藥物是 mannitol 或 glycerol
•降低顱內壓的機轉是增加血管內滲透壓，而使
腦部細胞外的水進可入血管，如此能改善腦水
腫而降低顱內壓。
•另減低血液黏調度、降低血比容，使得血液流
速變快,引起反應性的血管收縮,如此能減少腦
部血液的體積而降低顱內壓。
•在給藥後15分鐘內開始作用。
•建議使用方法是單次靜脈快速給藥(bolus,
rapid infusion)。
高張利尿劑(osmotic
diuretics)
•建議使用劑量為0.25-1 g/4-6hrs，必要
時可以縮短使用間隔。
•應監測血清滲透壓，避免滲透壓大於320
mOsm/L，以免造成腎衰竭。
高張利尿劑(osmotic
diuretics)
•主要的缺點是會造成低血壓(hypotension)、
低容積量(hypovolemia)電解質不平衡及腎衰
竭。但是在腦灌流壓的處理流程(CPP
protocol)卻很少見到以上的併發症。
•利尿劑 lasix 常可和 mannitol 合併使用效
果更好。使用劑量:20-40mg/3-4hrs (0.3 to
0.5 mg/kg)，要注意的是液體的補充以免造成
低血壓及低容積量而產生腦部缺血。
Steroids
• Although steroids clearly are useful in
reducing the perifocal edema associated
with brain tumors, their value in head
injury has not been demonstrated.
Anticonvulsants
• Post-traumatic epilepsy: 15-30% of severe
H.I.; 5% of mild H.I.
• 90% occur within the first 24 hours
• Indication:
– GCS ≦10 on admission
– Acute EDH, SDH, ICH (supratentorial)
– Open depressed skull fracture with parenchymal
injury
– Cortical contusion on CT scan
– Seizure within the first 24 hrs after injury
– Penetrating brain injury
– History of significant alcohol abuse.
D/C of anticonvulsants
• Taper after 1 week of therapy except in
the following:
– Penetrating brain injury
– Development of late seizure
– Prior seizure therapy
– Patients undergoing craniotomy
• The above four situations: maintain for
6-12 months.
Indication for Surgery
• Critical factors:
– Patient’s neurological status
– Imaging findings
– Presence and severity of extracranial
lesions.
• Time is life.
Significant Mass Effect
• Displacement of midline structures≧
5mm.
• Effacement of basal cisterns on CT scan.
EDH (epidural hematoma)
• Located in the temporal region: tear of the
middle meningeal vessel, sinus injury
• In 50% of patients there is no radiographic
evidence of a fracture.
• Small, stable, asymptomatic  conservative
• All acute traumatic extraaxial hematoma 1cm
or greater in thickness  op
• Outcome: children better than adult.
SDH (subdural hematoma)
• 30% of severe head injury
• Bleeding of lacerated brain and cortical
vessels avulsed bridging vein
• No significant mass effect without brain
swelling  conservative
• Larger craniotomy
• Worsen prognosis than EDH
• Golden time: 4 hours
Contusional and intracerebral
hematomas (ICH)
• Located in anterior frontal and temporal lobes.
• Awake and alert conservative
• >2cm(surface), mass effect, uncontrolled ICP
 op
• Early surgical intervention for temporal and
posterior fossa lesions.
• Adult with GCS of 3, non-reactive & dilated
pupil without spontaneous respiration
 conservative
• Over 75 Y/O, GCS of 5 or less
 conservative
Skull fracture
• Non-op: closed, linear, non-depressed
skull fracture  heal spontaneously.
• OP:
– open fractures or fractures depressed more
than the thickness of the skull required
surgical elevation or repair.
– Cosmetic consideration.
• Near a major dural sinus  non-op,
even occluded sinus.
Skull fracture
• There is no evidence to support the
theory that correction of a depressed
skull fracture reduces the risk of
subsequent seizures.
Growing skull fracture
• Inspecting the site of injury for a palpable,
non-tender swelling.
• A linear fracture separated more than 3 mm
on CT scan suggest an associated dural tear.
• OP or F/U
• They rarely occur in children over 18 months
of age and rarely show after 6 month from
injury.
Skull Fracture
Battle’s sign
Raccoon’s eye sign
The End!!