1例地震伤致颅内伤的护理

总结1例因地震导致脑外伤,脑挫裂伤并脑血肿患儿的护理体会,包括昏迷期护理和意识恢复期的护理。认为在昏迷期间的全方位护理与意识恢复期的康复训练对患儿的治愈起到积极作用,康复训练对患儿后期的恢复意义重大。

南沙重度颅内伤急救后送1例

1临床资料 某型护卫舰在南沙执行护渔巡航任务期间，该舰机电部门某战士在后甲板窗口盖处因不慎掉入近2．1m深处的甲板上。查体：左侧卧位、意识消失、头皮完好、未见包块，四肢无畸形、鼻孔及外耳道未见流液，双侧瞳孔等大等圆，

刀刺入颅内自伤1例

自伤有多种多样的方式,但用刀刺入颅内近10cm的案例实属罕见.现报道1例.

Early enteral nutrition supplemented with probiotics improved the clinical outcomesin patients with severe head injury： protocol for a meta-analysis of randomizedcontrolled trials

Objective： The aim of this systematic review of randomized controlled trials （RCTs） is to determine the effects of earlyenteral nutrition supplemented with probiotics on clinical outcomes in patients with SHI.Methods and analysis： A systematic search will be carried out in PubMed, Cochrane Central Register of ControlledTrials （CENTRAL）, China National Knowledge Infrastructure （CNKI）, WanFang database, and Chinese BiomedicalLiterature （CBM） in order to identify the randomized controlled trials （RCTs） investigated the potential of early enteralnutrition supplemented with probiotics on patients with severe head injury, as well as we will also manually check thebibliographies of eligible studies and topic-related reviews. We will assign two investigators to independently search allpotential citations, extracted data, and appraised risk of bias accordingly, and then STATA software version 12.0 will beused to statistically analyze all data.Ethics and dissemination： The ethics approval and patient written informed consent will not be required because allanalyses in the present study will be performed based on data from published studies. We will submit our systematicreview to a peer-reviewed scientific journal for publication.

Clinical, brain electric earth map, endothelin and transcranial ultrasonic Doppler findings after hyperbaric oxygen treatment for severe brain injury

目的 探讨高压氧治疗重型颅脑损伤的疗效及机制。方法 重型颅脑损伤患者 35例为治疗组 ,2 0例为对照组 ,观察高压氧治疗前后临床 (GCS)、脑电地形图 (BEAM)、血内皮素 (ET)、经颅多普勒超声 (TCD)及预后 (GOS)的变化。结果 治疗组患者经高压氧治疗后临床 (GCS)、脑电地形图及预后均明显改善 ,与对照组相比有统计学意义。高压氧治疗 1个疗程后 ,治疗组血内皮素由 91 2 4± 12 18ng/L下降到 6 8 88± 14 37ng/L(P <0 0 1) ;经颅多普勒超声示大脑中动脉Vm也由 6 4 2± 4 8cm/s下降到 51 6± 4 2cm/s(P <0 0 1) ;同时 ,大脑中动脉VsPI也明显下降。统计学有显著性意义 (P <0 0 1)。结论 高压氧治疗能够明显改善重型颅脑损伤患者的临床、脑电地形图及预后 ,并且通过降低急性期血内皮素、改善大脑中动脉血流速度及血管阻力来改善重型颅脑损伤后脑血管痉挛及脑缺血缺氧。同时 ,降低颅内压是高压氧治疗重度颅脑损伤的重要机制之一。

Early changes of endothelin,nitric oxide and arginine-vasopressin in patients with acute cerebral injury

Objective: To investigate the early changes and clinical significance of plasma endothelin (ET), nitric oxide (NO) and arginine vasopressin (AVP) in patients with acute moderate or severe cerebral injury. Methods: The early (at 24 hours after injury) plasma concentrations of ET, NO and AVP were measured with radioimmunoassay and Green technique in 48 cases of acute moderate (GCS≤8 in 27cases ) or severe (GCS>8 in 21 cases) cerebral injury (Group A), in 42 cases of non cerebral injury (Group B) and in 38 normal individuals (Group C), respectively. Results: The early plasma concentrations of ET ( 109.73 ng/L±12.61 ng/L ), NO ( 92.82 μmol/L± 18.21 μmol/L ) and AVP ( 49.78 ng/L±14.29 ng/L ) in Group A were higher than those in Group B ( 67.90 ng/L ±11.33 ng/L , 52.66 μmol/L±12.82 μmol/L and 29.93 ng/L±12.11 ng/L , respectively, P<0.01 ) and Group C ( 50.65 ng/L±17.12 ng/L , 36.12 μmol/L ±12.16 μmol/L and 5.18 ng/L ± 4.18 ng/L , respectively, P<0.001 ). The amounts of ET, NO and AVP in patients with severe cerebral injury were 116.18 ng/L± 18.12 ng/L , 108.19 μmol/L±13.28 μmol/L and 58.13 ng/L±16.78 ng/L , respectively, which were significantly higher than that of the patients with moderate cerebral injury ( 92.33 ng/L±16.32 ng/L , 76.38 μmol/L ±12.71 μmol/L and 36.18 ng/L±12.13 ng/L respectively, P<0.01 ). The early levels of ET, NO and AVP in Group A were negatively related to the GCS scales. The amounts of ET, NO and AVP were 126.23 ng/L± 15.23 ng/L , 118.18 μmol/L±10.12 μmol/L and 63.49 ng/L±14.36 ng/L respectively in patients with subdural hematoma, which were significantly higher than those in patients with epidural hematoma ( 81.13 ng/L ±12.37 ng/L , 68.02 μmol/L±13.18 μmol/L and 45.63 ng/L±12.41 ng/L respectively, P<0.01 ). The plasma concentrations of ET, NO and AVP in stable duration (at 336 hours after injury) in Group A and Group B were similar to those in Group C. Conclusions: ET, NO and AVP were related to the pathophysiological process that occurs in the early stage of acute cerebral injury and the values of ET, NO and AVP correlate positively with the clinical manifestations. The changes of plasma ET, NO and AVP can be regarded as important indices to assess the severity of acute cerebral injury.

Correlation of cell apoptosis with brain edema and elevated intracranial pressure in traumatic brain injury

Objective: To study the correlation between brain edema, elevated intracranial pressure (ICP) and cell apoptosis in traumatic brain injury (TBI). Methods: In this study, totally 42 rabbits in 7 groups were studied. Six of the animals were identified as a control group, and the remaining 36 animals were equally divided into 6 TBI groups. TBI models were produced by the modified method of Feeney. After the impact, ICP of each subject was recorded continuously by an ICP monitor until the animal was sacrificed at scheduled time. The apoptotic brain cells were detected by an terminal deoxynucleotide-transferase-mediated dUTP-digoxigenin nick end labeling (TUNEL) assay. Cerebral water content (CWC) was measured with a drying method and calculated according to the Elliott formula. Then, an analysis was conducted to determine the correlation between the count of apoptotic cells and the clinical pathological changes of the brain. Results: Apoptotic cell count began to increase 2 h after the impact, and reached its maximum about 3 days after the impact. The peak value of CWC and ICP appeared 1 day and 3 days after the impact, respectively. Apoptotic cell count had a positive correlation with CWC and ICP. Conclusions: In TBI, occurrence of brain edema and ICP increase might lead to apoptosis of brain cells. Any therapy which can relieve brain edema and/or decrease ICP would be able to reduce neuron apoptosis, thereby to attenuate the secondary brain damage.

Management of patients with severe traumatic brain injury guided by intraventricular intracranial pressure monitoring： a report of 136 cases

Objective： To evaluate the effect of the treatment modality guided by intraventricular intracranial pressure （ICP） monitoring on patients with severe traumatic brain injury （TBI）. Methods： The clinical data of a group of 136 severely brain-injured patients admitted to Shanghai Neurosurgical Emergency Center from December 2004 to February 2006 were studied. Results： The intraventricular ICP monitor was placed in all the 136 patients via Kocher＇s pathway, Paine＇s pathway or intraoperative opened ventricle. In this series, the probe was placed during the procedure of craniotomy in 98 patients; for other 38 patients, the probe was placed initially to measure or to monitor ICE A stepwise protocol targeting at ICP control （420 mm Hg） and optimal cerebral perfusion pressure （CPP） maintenance （60-90 mm Hg） was deployed.Among them, 76 patients survived with good recovery, 14 with moderate disability, 24 with severe disability, 10 with vegetative state, and 12 died. Complications associated with intraventricular ICP monitoring included hemorrhage and infection. Hemorrhage occurred in 1 patient and infection in 5 patients. There were no unacceptable complications related to ICP monitoring. Conclusions： Ventricular access for 1CP monitoring can be safely and accurately achieved. ICP monitoring via ventriculostomy may facilitate an early and accurate intervention for severely brain-injured patients. The intraventricular ICP monitoring is a low-risk procedure and can yield great benefits for management of patients with severe TBI.

Relationship between surgical time and postoperative complications in senile patients with hip fractures

Objective：To elucidate the relationship between surgical time and postoperative complications in senile patients with hip fractures, and try to find out other factors which are related to these complications.Methods： Sixty-two patients, 28 males aged from 65 to 72 years with a mean age of 76.3 years and 34 females aged from 65 to 95 years with a mean age of 78.1 years, who had undergone orthopedic surgery because of hip fractures,were enrolled in a retrospective cohort study. The surgical time and pattern, the type of fracture, preoperative comorbidities, American Society of Anesthesiologists （ASA） score and the volume of blood transfusion during operation were obtained from these patients who were followed up by telephone calls for postoperative complications.All the patients were followed up at least for 1 year and were divided into subgroups according to their clinical characteristics and the results were analyzed by the Statistical Analysis System software.Results：There was no significant difference in the morbidity of postoperative eomplications with the gender,age,surgical time and pattern,or ASA score. There was significant difference in the morbidity of postoperative complications related to preoperative comorbidities and the volume of blood transfusion. There was a significant causality between preoperative comorbidities and postoperative complications. The morbidity of postoperative complications was 1.651 times higher in patients with preoperative comorbidities than those without.Conclusions：There is no relationship between the surgical time and postoperative complications in senile patients who received surgery for hip fracture within 1 year.No correlation is found between the postoperative complications and gender,age,type of fracture, surgical pattern,ASA score and the volume of blood transfusion. Preoperative comorbidities are an independent predictor for postoperative complications.

Analysis on the risk factors of intracranial infection secondary to traumatic brain injury

Objective： To discuss the characteristics and risk factors for intracranial infection post traumatic brain injury to prevent and better the clinical care. Methods： Retrospective study of 520 patients with traumatic brain injury were included, 308 male and 212 female. The risky factors of intracranial infection were identified. Results： Thirty two cases （6.54%, 321520） of intracranial infection were diagnosed, lntracranial infection most likely happened 4-10 days after injury. Cerebrospinal fluid leakage, drainage, multiple craniotomies were significant related to intracranial infection. Logistic regression predicted cerebrospinal fluid leakage and drainage as independent factors. Conclusion： Intracranial infection is a serious complication after traumatic brain injury, Patients with drainage or cerebrospinal fluid leakage are more risky for intracranial infection, Aggressive precaution should be taken to better outcome.

The risk factors of nosocomial infection in severe craniocerebral trauma

Objective: To explore the risk factors of nosocomial infection in severe craniocerebral trauma and the way of prevention.Methods: The clinical data of 387 patients with severe craniocerebral trauma were reviewed.Results: The total nosocomial infection rate of this study was 22.99 %. Pulmonary nosocomial infection presented most frequently. The G bacilli were the most common infectious bacteria. The mortality rate of the infection group was 38.20 %.Conclusions: Complications of nosocomial infection affect the prognosis of craniocerebral trauma patients. Nosocomial infection is related to the age of the patients, craniocerebral trauma severity, unreasonable utilization of antibiotics and invasive operations, such as tracheal cannula, mechanical ventilation, urethral catheterization and deep venous catheterization. Patients with severe craniocerebral trauma should be carefully treated and nursed to avoid nosocomial infection. In order to reduce the rate of nosocomial infection, intensive measurement should be adopted.

Effects of mild hypothermia on patients with lower intracranial pressure following severe brain injury

Objective: To study the effects of mild hypothermia therapy on severe brain-injured patients whose intracranial pressure (ICP) could be maintained below 25 mm Hg.Methods: Forty severe brain-injured patients with ICP below 25 mm Hg were divided randomly into one treatment group (n=20, mild hypothermia therapy) and one control group (n=20, normothermia therapy) to observe the changes of the concentration of excitatory amino acids (glutamate and glycine) and cytokines (interleukin-1β and interleukin-6). Results: There were no significant differences in the daily changes of the concentration of excitatory amino acid and cytokines between two groups. The outcome of two groups had no significant differences. Conclusions: Mild hypothermia has no additional beneficial effects on severe brain-injured patients compared with normothermia therapy if ICP can be maintained below 25 mm Hg by using conventional therapy.

Spironolactone in preventing hypokalemia following traumatic brain injury

Objective： Hypokalemia is a frequent complication observed after traumatic brain injury （TBI）.We evaluated the effect of spironolactone on preventing hypokalemia following moderate to severe TBI.Methods： Patients with moderate to severe TBI, whose Glasgow Coma Scale （GCS） scores of 9-12 and ＜9,respectively, were equally randomized into intervention and control groups, matching with severity of trauma and baseline serum level of potassium. For the intervention group, we administrated spironolactone （1 mg/kg per day）on the second day of admission or the first day of gavage tolerance and continued it for seven days. No additional intervention was done for controls. Hypokalemia （mild： 3-3.5 mg/L, moderate： 2.5-3 mg/L, and severe： ＜2.5 mg/L serum K＋） and other electrolyte abnormalities were compared between the two groups at the end of the intervention.Results： Sixty-eight patients （58 males and 10 females）were included with mean age=（33.1±11.8） years, and GCS=7.6±2.8. The two groups were similar in baseline characteristics.Patients who received spironolactone were significantly less likely to experience mild, moderate, or severe hypokalemia （8.8%, 2.9%, and 0） compared with controls （29.4%, 11.7%,and 2.9%, respectively, P＜0.05）. No significant difference was observed between the two groups in the occurrence of other electrolyte abnormalities, hyperglycemia or oliguria.Conclusion： Spironolactone within the first week of head injury could prevent the occurrence of late hypokalemia with no severe side effects.

Clinical analysis of 28 children suffering from intracranial hematoma and multiple injuries following traffic accidents

Objective: To evaluate the result of diagnosis and treatment of intracranial hematoma and multiple injuries caused by road traffic accidents. Methods: Twenty-eight patients, aged from 1 to 14 years, receiving craniotomy and other surgical treatments were retrospectively reviewed. Results: Among the 28 cases, 23 cured with the recovery rate of (82.3)%, 2 had a sequel of moderate disability, and 3 died from severe brain injury, hemorrhagic shock, and other visceral complications. The clinical sympotoms and signs were severe and perplexing. The major characters included: severe head injury, usually combined by multiple injuries, and easy of access to missed diagnosis and misdiagnosis. Conclusions: The occurrence of infection is high after traffic accidents as a result of depression of humoral and cellular immunity, long-term bed rest, and fractures of limbs. Hence, on the basis of maintaining vital signs, the management of primary wound is essential to reduce infection and underlying death. In addition to the management of brain injury, concurrent injuries should also be highlighted so as to reach a good result for their patients.

Clinical diagnosis and treatment of abdominal visceral injury complicated by craniocerebral injury

Objective ： To improve the cure rate of patients with abdominal visceral injury complicated by craniocerebral injury. Methods： Clinical data of 176 cases of abdominal visceral injury complicated by craniocerebral injury were retrospectively analyzed. Results： In this series, 44 cases died and the mortality was 25.0%. The main cause of death is abdominal visceral injury combined with shock and severe craniocerebral injury. Conclusions： It is essential to improve the cure rate by accurate diagnosis at early stage. Abdominal paracentesis and CT should be performed promptly and dynamically. Priority should be given to the treatment of life-threatening injuries.

Effect of intracranial pressure and cerebral perfusion pressure on outcome prediction of severe traumatic brain injury

To investigate the influence of intracranial pressure (ICP) and cerebral perfusion pressure (CPP) on neurological deterioration and outcome of severe traumatic brain injury (STBI). Methods: A total of 245 patients with severe traumatic brain injury were studied retrospectively with univariate and multivariate studies to evaluate the contribution of ICP/CPP to neurological deterioration and outcome. Results: The mortality rates rose from 16.2 % in 142 patients whose course of disease was smooth to 66.7 % in 103 patients who suffered from neurological deterioration. Correspondingly, the favorable outcome fall from 54.2 % in the patients without neurological deterioration to 18.3 % in those with neurological deterioration. In the patients with clinical evidence of neurological deterioration, the relative influence of the ICP and the CPP on outcome was assessed. The most powerful predictors of neurological deterioration was the presence of intracranial hypertension (ICP>30 mm*!Hg , 1 mm*!Hg= 0.133 kPa). The CPP also had a prognostic power on neurological deterioration when its level less than 60 mm*!Hg. Conclusions: It suggests that its very important to lower the intracranial hypertension and keep the CPP not less than 60 mm*!Hg during the treatment of STBI.