特重型颅脑损伤患者的综合救治(附253例报告)

Emergency treatment of very severe craniocerebral injury: a report of 253 cases

目的:探讨影响特重型颅脑伤预后的因素及提高救治成功率的关键。方法:收集我院1990年6月至2002年8月间收治的253例特重型颅脑伤(GCS 3-5分)患者的临床资料,分析其伤情,伴脑疝、脑挫裂伤情况,颅内血肿类型等与病死率的关系,同时对不同阶段,即1990年6月至1994年12月(A组,采用传统救治方案)、1995年1月至1997年1月(B组,在常规救治措施的基础上重点建立与完善了颅脑创伤救治体系)、1997年2月至2002年8月(C组,采用综合救治措施)的救治结果进行比较。结果:有脑疝形成、脑挫裂伤、多发颅内血肿者病死率均显著高于无脑疝形成和脑挫裂伤以及有硬膜外血肿者,分别为66.0％(136／206)vs29.8％(14／47,P<0.01)、64.2％(115／179)vs 47.3％(35／74,,P<0.05)和68.6％(59／86)vs 40.0％(8／20,P<0.05)。A、B、C组病死率分别为69.6％(48／69)、60.4％(32／53)和53.4％(70／131),C组较A组显著下降(P<0.05)。结论:脑疝、弥漫性脑肿胀致恶性高颅压是患者早期死亡的主要原因,后期死亡的主要原因是多器官功能衰竭。早期发现和清除颅内血肿、有效去大骨瓣减压,重视早期脑保护,加强术后监护,维持内环境稳定,是提高特重型颅脑伤救治成功率的关键。

Objective:To explore the factors influencing the prognosis of patients with very severe craniocerebral injury and to analyze their death causes. Methods: The clinical data of 253 patients with very severe craniocerebral injury (Jun. 1990 to Aug. 2002) were collected, and the relationship between the mortality and Glasgow coma score (GCS),brain hernia, contusion and intracranial hematoma were studied. The outcomes of 3 different periods groups[Jun. 1990 to Dec. 1994(group A),Jan. 1995 to Jan. 1997 (group B),Feb. 1997 to Aug. 2002 (group C)] were compared. Results: The mortalities in patients with brain hernia, contusion and multiple hematomas were significantly higher than those without,being 66. 0%(136/ 206 ) TO 29. 8%(14/47),P<0. 01; 64. 2%(115/179) vs 47. 3% (35/74) ,P<0. 05;and 68. 6%(59/86) TO 40. 0%(8/20),P< 0. 05,respectively. The main death causes were brain hernia and malignant high intracranial pressure caused by diffused brain swelling at early stage and multiple organ failure at later stage. The mortalities in group A,B,C were 69. 6% (48/69) ,60. 4% (32/53) and 53. 4% (70/131) respectively,with significant difference existing between group C and group A(P<0. 05). Conclusion ; The keys for emergency treatment of patients with the very severe craniocerebral injury are the establishment of rapid emergency treatment system with standard guidelines, diagnosis and elimination of intracranial hematoma at early stage, effective decompression through discarding large bone flap, early brain protection,post-operation monitoring, maintanance of homeostasis, and nutrition support treatment.