非神经创伤性疑似缺氧缺血性昏迷的预后

Fang J F, Chen R J, Lin B C, Hsu Y B, Kao J L, Kao Y C, Chen M F

Department of Surgery, Chang-Gung Memorial Hospital, Chang-Gung University, Taoyuan, Taiwan, Republic of China.

J Trauma. 1999 Dec;47(6):1122-5. doi: 10.1097/00005373-199912000-00025.

BACKGROUND

The neurologic outcome of comatose patients has a wide variation from complete reawakening to death. Methods of predicting the outcome of coma caused by either head injury or cardiac arrest have been the subject of much discussion in the literature. However, prediction of neurologic prognosis in comatose trauma patients without head injury has rarely been discussed. We reviewed our experience in treating patients with presumptive hypoxic-ischemic coma after trauma and tried to identify factors relating to their neurologic outcomes.

METHODS

Thirty-six patients with normal brain computed tomographic scans, who remained comatose 10 minutes after stabilization of their hemodynamic status, were studied. Serial motor response, verbal response, pupillary light reflex, presence of spontaneous breathing and seizure, and blood glucose level were recorded to evaluate their roles in predicting neurologic outcomes.

RESULTS

There were five deaths (mortality rate, 14%) and 11 patients (31%) with neurologic deficits. An absence of spontaneous breathing, a blood glucose level greater than 300 mg/dL during resuscitation, and a presence of seizure signified a poor prognosis. Initial neurologic evaluation at 10 minutes after stabilization of hemodynamic status was not accurate in predicting outcome. A motor response worse than withdrawal from painful stimuli at 24 hours after injury and an absence of pupillary light reflex at 48 hours after injury predicted a poor neurologic outcome, with a 100% accuracy rate.

CONCLUSION

Hypoxic-ischemic coma in patients sustaining major trauma yielded a significantly better survival and neurologic outcome than that induced by cardiac arrest or head injury. Decision-making in the first 24 hours after injury should not be affected by the patient's neurologic status at that time. A motor response worse than withdrawal at 24 hours after injury and an absence of pupillary light reflex at 48 hours after injury predicted a poor neurologic outcome.

背景

昏迷患者的神经学转归差异很大，从完全苏醒到死亡不等。预测因头部受伤或心脏骤停导致的昏迷转归的方法一直是文献中诸多讨论的主题。然而，对于无头部损伤的昏迷创伤患者的神经学预后预测却鲜有讨论。我们回顾了我们在治疗创伤后疑似缺氧缺血性昏迷患者方面的经验，并试图确定与其神经学转归相关的因素。

方法

对36例脑计算机断层扫描正常、血流动力学稳定后仍昏迷10分钟的患者进行了研究。记录连续的运动反应、言语反应、瞳孔对光反射、自主呼吸和癫痫发作情况以及血糖水平，以评估它们在预测神经学转归中的作用。

结果

有5例死亡（死亡率为14%），11例患者（31%）有神经功能缺损。自主呼吸缺失、复苏期间血糖水平高于300mg/dL以及癫痫发作提示预后不良。血流动力学稳定后10分钟时的初始神经学评估在预测转归方面并不准确。受伤后24小时运动反应比躲避疼痛刺激差以及受伤后48小时无瞳孔对光反射预测神经学转归不良，准确率为100%。