Cunitz G
Klinik für Anästhesie und operative Intensivtherapie, Ruhr-Universität Bochum.
Anaesthesist. 1995 May;44(5):369-91. doi: 10.1007/s001010050166.
The occurrence of severe head injury, isolated or in connection with polytrauma, is a challenge for all physicians working in emergency care at the scene of an accident or afterwards in hospital care. It is an advantage to have a basic knowledge of neurological assessment. The Glasgow Coma Scale is widely used in this context; we refer to mild, moderate, and severe injuries. It is very important to recognise concomitant injuries, which occur in about 40% of cases. As coexisting hypoxaemia and hypotension have an adverse effect on the time course of head injury by inducing secondary brain damage, it is essential in therapy to quickly restore the vital body functions. Unconscious patients are tracheally intubated and ventilated. Forced hyperventilation over a lengthy period seems to have an unfavourable effect on outcome. Anaesthetic drugs and adjuvant therapies are used that do not increase intracranial vessel diameter and consequently intracranial pressure (ICP). This applies to all i.v. anaesthetics, sedatives, and opioids, as long as no respiratory depression occurs. Ketamine has been useful for many years at the scene of an accident. An existing low blood pressure (BP) is raised while a significantly increased BP is moderately lowered. It is necessary to have adequate cerebral perfusion pressure (CPP), which is defined as mean BP minus ICP. In cases of polytrauma with heavy bleeding, e.g., from the liver or spleen, the blood loss must be stopped before the neurosurgeon begins. Excessive i.v. administration of Ringer's lactate should be avoided. Today, the routine use of osmodiuretics, e.g., mannitol, is not indicated. It has not yet been possible to show that using corticosteroids is definitely beneficial in human brain trauma; there may be a positive effect in connection with spinal trauma. New therapies are being investigated, such as increasing CPP, administering AMPA/NMDA-antagonists, 21-aminosteroids, or hypertonic-hyperoncotic solutions. However, they have not as yet been proven effective for general clinical use or clinical use et al.
严重头部损伤的发生，无论是单独出现还是与多发伤相关，对于在事故现场进行急救或后续医院护理工作的所有医生来说都是一项挑战。具备神经学评估的基础知识会很有帮助。格拉斯哥昏迷量表在此情况下被广泛使用；我们将损伤分为轻度、中度和重度。识别伴随损伤非常重要，伴随损伤约在40%的病例中出现。由于并存的低氧血症和低血压会通过引发继发性脑损伤对头损伤的病程产生不利影响，因此在治疗中迅速恢复重要的身体功能至关重要。昏迷患者需进行气管插管和通气。长时间的强制过度通气似乎对预后有不利影响。使用不会增加颅内血管直径进而不会增加颅内压（ICP）的麻醉药物和辅助治疗方法。只要不发生呼吸抑制，所有静脉麻醉药、镇静剂和阿片类药物均适用。氯胺酮多年来在事故现场一直很有用。现有低血压时予以升高，而血压显著升高时则适度降低。必须有足够的脑灌注压（CPP），其定义为平均血压减去颅内压。在伴有大量出血的多发伤病例中，例如来自肝脏或脾脏的出血，必须在神经外科医生开始治疗之前止血。应避免过量静脉输注乳酸林格液。如今，不建议常规使用渗透性利尿剂，例如甘露醇。尚未能够证明使用皮质类固醇对人类脑外伤肯定有益；在脊髓外伤方面可能有积极作用。正在研究新的治疗方法，例如提高脑灌注压、给予AMPA/NMDA拮抗剂、21 -氨基类固醇或高渗 - 高胶体渗透压溶液。然而，它们尚未被证明对一般临床使用或临床应用等有效。
