Nakayama D K, Waggoner T, Venkataraman S T, Gardner M, Lynch J M, Orr R A
Department of Pediatric Surgery, Children's Hospital of Pittsburgh, Pennsylvania 15213-3417.
Ann Surg. 1992 Aug;216(2):205-11. doi: 10.1097/00000658-199208000-00011.
Most patients who require emergency airway control receive drugs to induce rapidly sufficient anesthesia for direct laryngoscopy and endotracheal intubation, but there are no protocols that outline the use of specific drugs in general use. Drugs should safely and rapidly produce (1) unconsciousness; (2) paralysis; and (3) blunt intracranial pressure (ICP) responses to airway procedures. Consequences to be considered include increased ICP, hemorrhagic shock, and a full stomach. To refine the use of drugs used for airway procedures in pediatric trauma patients, the authors reviewed all cases of emergency endotracheal intubation over a recent 12-month period (1) to see whether medications used met the goals of producing unconsciousness and paralysis and blunting ICP responses were met safely; and (2) to identify potential drug-related complications. From July 1, 1990, to June 30, 1991, 60 of 791 children (7.6%) required endotracheal intubation at the scene of injury, at the referring hospital, or in our emergency department (15; 25%). Ten patients died (16.7%). Three fourths were younger than 9 years of age. All except one suffered blunt injuries. Nearly all (95%) suffered head injuries, isolated in 39 of 57 (68.4%) and combined with injuries in other regions in 18 (31.6%). Fifteen patients were in apnea (25%); seven were both apneic and pulseless. Three fourths (45 of 60) had diminished levels of consciousness; one fourth (15 of 60) were awake. Immediate endotracheal intubation proceeded appropriately without drugs in all seven patients in cardiopulmonary arrest. Only eight of the remaining 53 patients (15.1%) received an optimal medication regimen. Many patients with head injury were inadequately protected against increases in ICP. Thiopental, an effective anesthetic agent that effectively lowers intracranial pressure, was not used in 25 of 35 stable patients with isolated head injury (71.4%). Intravenous lidocaine was not used in 38 of 50 head-injured patients in whom it would have been an appropriate adjunct to control increases in ICP (76%). Eight patients received paralyzing agents alone, without sedatives or narcotics. Medications were thought inadequate to relieve the pain and discomfort of laryngoscopy and endotracheal intubation in 32 of the 53 patients who should have received them (60.4%). No paralyzing agents were used in 36 of the 53 instances where it would have been appropriate (67.9%). In two of 11 instances (18.3%) where succinylcholine was administered, no prior nondepolarizing agent was used. Complications of a full stomach at the time of emergency endotracheal intubation became evident in 10 patients (16.7%) who vomited during procedures to control the airway. Two patients (3.3%) aspirated.(ABSTRACT TRUNCATED AT 400 WORDS)
大多数需要紧急气道控制的患者会接受药物治疗，以便迅速产生足够的麻醉效果用于直接喉镜检查和气管插管，但目前尚无概述常用特定药物使用方法的方案。药物应能安全、迅速地产生：（1）意识丧失；（2）麻痹；（3）减轻气道操作引起的颅内压（ICP）反应。需要考虑的后果包括颅内压升高、失血性休克和胃内容物潴留。为优化用于小儿创伤患者气道操作的药物使用，作者回顾了最近12个月内所有紧急气管插管病例：（1）观察所用药物是否安全地达到了产生意识丧失、麻痹以及减轻ICP反应的目标；（2）确定潜在的药物相关并发症。从1990年7月1日至1991年6月30日，791名儿童中有60名（7.6%）在受伤现场、转诊医院或我们的急诊科需要气管插管（分别为15例；25例）。10名患者死亡（16.7%）。四分之三的患者年龄小于9岁。除1例外，均为钝性损伤。几乎所有患者（95%）都有头部损伤，其中57例中有39例（68.4%）为单纯头部损伤，18例（31.6%）合并其他部位损伤。15名患者出现呼吸暂停（25%）；7名患者呼吸暂停且无脉搏。四分之三（60例中的45例）意识水平降低；四分之一（60例中的15例）清醒。所有7例心肺骤停患者在未使用药物的情况下立即进行了适当的气管插管。其余53例患者中只有8例（15.1%）接受了最佳药物治疗方案。许多头部受伤的患者在预防颅内压升高方面未得到充分保护。硫喷妥钠是一种能有效降低颅内压的麻醉剂，35例单纯头部损伤的稳定患者中有25例（71.4%）未使用。50例头部受伤患者中有38例（76%）未使用静脉利多卡因，而利多卡因本可作为控制颅内压升高的合适辅助药物。8例患者仅接受了麻痹剂，未使用镇静剂或麻醉剂。在53例本应接受药物治疗的患者中，有32例（60.4%）的药物被认为不足以缓解喉镜检查和气管插管的疼痛与不适。在53例本应使用麻痹剂的情况中，有36例（67.9%）未使用。在11例使用琥珀酰胆碱的情况中有2例（18.3%）未预先使用非去极化剂。10例患者（16.7%）在气道控制操作过程中呕吐，紧急气管插管时胃内容物潴留的并发症明显。2例患者（3.3%）发生误吸。（摘要截选至400字）
