醫學筆記匯整 ED Notes

* GCS :

• 輕度 (GCS 13~15)
• 中度 (GCS 9~12)
• 重度 (GCS 8分以下)

→ 重度頭部創傷需給予插管；中度創傷可考慮給預防性癲癇用藥

 

腦部傷害分成
  原發性：當下contussion (coup, counter coup), axonal injury
  次發性：受傷後, 出血, 高腦壓, 細胞分子機轉等造成

顱底骨折的線索：
 - 熊貓眼 (Raccoon eye)
 - 鼻子流CSF (驗beta-2 transferrin)
 - 耳後乳突瘀青 (Battle's sign)

 

GCS
JOMAC
Injury mechanism : 先中風失去意識才撞到 ?
ILOC : initial lose of conscious
Headache
Nausea, vomiting : 有 vomting 真的就擔心 IICP
Retrograde amnesia

Withness
Neck tenderness,  limited ROM 

PE : muscle power, sensory level

 

先 r/o C spine injury, 一定要做 Meningeal sign r/o SAH
NE findings : Cranial nerves, FNF, Gait … 

傷後重點觀察 72 hr

* 頭部外傷病人氣管插管的時機
  1. 病患昏迷無法保護呼吸道
  2. GCS ≤ 8
  3. 嚴重顏面骨骨折
  4. 需要使用肌肉鬆弛劑

 Guidelines for the Management of Severe Traumatic Brain Injury 
 Nurosurgery 2017 

- Prophylactic hypothermia :
   Early (within 2.5 h), short-term (48 h post-injury), prophylactic hypothermia
   is not recommended to improve outcomes in patients with diffuse injury.

- Hyperosmolar therapy :
   Mannitol is effective for control of raised ICP
   at doses of 0.25 to 1 g/kg.
   SBP <90 mmHg should be avoided.
 

- CSF drainage : 
   Use of CSF drainage to lower ICP in patients
   with an initial GCS <6 during the first 12h after injury may be considered.
 

- Ventilation therapies : 
   Prolonged prophylactic hyperventilation with PaCO2 of ≤25 mm Hg
   is not recommended.
   
   Hyperventilation is recommended as a temporizing measure
   for the reduction of elevated ICP.

- Steroids : ​​​​​​​not recommended for improving outcome or reducing ICP
- Seizure prophylaxis : 
   只對預防早期 seizure 有幫助, 對 delayed seizure, outcome 皆無差別
   guideline 建議 phenytoin, 預防性用 Depakine 不錯 ( loading 20 mg/kg iv ) ​​​​​​​

- BP :  
   50 to 69 y/o : SBP at ≥100 mmHg 
   15 to 49 or >70 years  y/o : SBP at ≥110 mmHg

- ICP :
   Treating ICP >22 mmHg

 - CPP :
   The recommended target CPP is between 60 and 70 mmHg 

 

三總套餐 for TBI : Vit K,C, Transamin, PPIs, AEDs