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Bài Viết: Blunt trauma là gì
StatPearls . Treasure Islvà (FL): StatPearls Publishing; 2020 Jan-.
Nội Dung
Introduction
Traumatic Brain Injury (TBI) is a significant cause of morbidity với mortality in the United States, with an annual occurrence of more than 1.5 million. Patients with moderate với severe TBI comprise about 20% of TBI, và those with moderate TBI have a mortality of about 15% while those with severe TBI have associated mortality approaching 40%. The majority (approximately 80%) of patients with TBI have sầu mild TBI which is associated with a less than 0.5% mortality, but about 25% experience extended post-concussive symptoms including a headađậy, dizziness, difficulty concentrating, và depression.
Etiology
Falls are the most common cause of TBI, và motor vehicle-related incidents are the second leading cause of TBI. Motor vehicle-related TBI includes autosản phẩm điện thoại, motorcycle, với bicycle accidents và pedestrians struông chồng by those vehicles. Sports, recreation, và work-related injuries are the third leading cause of TBI, cùng assaults are the fourth leading cause of TBI. Blast injuries are the leading cause of TBI in active duty military personnel in war zones.
Epidemiology
TBI is the most common cause of death in people younger than the age of 25. The majority of fatal TBI is due to lớn motor vehicle-related incidents, falls, và assaults. Mortality due lớn motor vehicle accidents is greathử nghiệm in the young-adult age group attributed khổng lồ alcohol use với excessive sầu tốc độ. Mortality due to lớn falls is greakiểm tra in patients over age 65, which is also the age group with the highest mortality in any TBI. Neurosurgical intervention such as craniotomy, elevation of skull fracture, intracranial pressure (ICP) monitor, or ventriculostomy is required in about 40% of patients with severe TBI cùng about 10% of patients with moderate TBI.
Pathophysiology
Most patients with moderate khổng lồ severe TBI have sầu a combination of intracranial injuries. The majority of patients with moderate lớn severe TBI have related diffuse axonal injury to lớn some degree. The diffuse axonal injury typically is caused by a rapid rotational or deceleration force that causes stretching và tearing of neurons, leading khổng lồ focal areas of hemorrhage cùng edema that are not always detected on the initial computed tomogram (CT) scan. Subarachnoid hemorrhage (SAH) is the most common CT finding in TBI cùng is caused by tears in the pial vessels. Subdural và epidural hematomas are the most frequent type of mass lesion identified in TBI. Cerebral contusions occur in about a third of patients with moderate lớn severe TBI, caused by direct impact or acceleration-deceleration forces that cause the brain to strike the frontal or temporal regions of the skull. Intracerebral bleeding or hematoma, caused by coalescence of contusions or a tear in a parenchymal vessel, occurring in up lớn a third of patients with moderate lớn severe TBI.
History với Physical
The majority of patients with TBI have sầu a straightforward clinical presentation, but it is also important lớn solicit the mechanism of injury, current anticoagulation use, symptoms of the head or neck pain, post-traumatic seizure, với any history of repeat head injury or past central nervous system surgeries.
The initial resuscitation should proceed in a step-wise fashion to lớn identify all injuries cùng optimize cerebral perfusion by maintaining hemodynamic stabilization với oxygenation. The initial survey also should include a brief, focused neurological examination with attention to lớn the Glasgow Coma Scale (GCS), pupillary examination, cùng motor function.
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After addressing any airway or circulatory deficits, a thorough head-to-toe physical examination must be performed with vigilance for occult injuries và careful attention lớn detect any of the following warning signs:
Fundoscopic examination for retinal hemorrhage (a potential sign of abuse in children) cùng papilledema (a sign of increased ICP)Optic nerve sheath diameter of greater than 5 mm on ultrasound has been shown to lớn correlate well with increased intracranial pressure in patients with TBIPalpation of the scalp for hematoma, crepitus, laceration, cùng bony deformity (markers of skull fractures)Auscultation for carotid bruits, painful (*54*) syndrome or facial/neck hyperesthesia (markers of carotid or vertebral dissection)Evaluation for cervical spine tenderness, paresthesias, incontinence, extremity weakness, priapism (signs of spinal cord injury)
Evaluation
Non-contrast cranial CT is the imaging modality of choice for patients with TBI. CT findings associated with a poor outcome in TBI include midline shift, subarachnoid hemorrhage inkhổng lồ the verticals, với compression of the basal cisterns. Magnetic Resonance Imaging scan may be indicated when the clinical picture remains unclear after a CT to lớn identify more subtle lesions.
Treatment / Management
Airway adjuncts are indicated in patients not able to lớn maintain an open airway or maintain more than 90% oxygene saturation with supplementary oxygene. Oxygenation parameters should be monitored using continuous pulse oximetry with a target of more than 90% oxygene saturation. Ventilation should be monitored with continuous capnography with an end-tidal CO2 target of 35 mmHg to 40 mmHg. Placement of a definitive airway is recommended in the patient with a Glasgow Coma Scale (GCS) score of less than 9.
Systemic hypotension negatively impacts the outcome in the setting of TBI, và current studies have sầu demonstrated improved outcomes in patients with systolic blood pressure (BP) greater than or equal to lớn 120 mmHg. Isotonic crystalloids should be used to lớn prsự kiện với correct hypotension; colloidal solutions have not been shown to improve outcomes.
Serial neurological examinations allow for early identification of patients with elevated ICPhường, cùng subsequent implementation of primary bedside interventions to improve sầu venous outflow cùng reduce metabolic demands. Initial bedside approaches lớn increase ICP. include elevating the head of the patient”s bed 30 degrees, ascertaining that the cervical collar is not impeding venous outflow, cùng appropriate analgesics và sedation.
Routine hyperventilation should be avoided during the first 24 hours, với should only be used as a temporizing measure in the setting of impending herniation. Hyperosmolar therapy such as mannitol or hypertonic saline can further reduce intracerebral volume. ICPhường monitoring is indicated in patients with TBI when they have a GCS score of less than 9, an abnormal CT, và the approach to lớn refractory elevated intracranial pressure includes high-dose barbiturates và possibly a decompressive hemicraniectomy.
Thể Loại: Chia sẻ Kiến Thức Cộng Đồng
Bài Viết: Blunt Trauma Là Gì – Cấp Cứu Chấn Tmùi hương Số 54
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