Carrel M, Moeschler O, Ravussin P, Favre J B, Boulard G
Service d'Anesthésiologie, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne Suisse.
Ann Fr Anesth Reanim. 1994;13(3):326-35. doi: 10.1016/s0750-7658(94)80041-3.
Advanced supportive therapy at the site of the accident, associated with direct transfer to a trauma centre increases survival and reduces morbidity rates. Patients with severe head injury, especially those with multiple injuries, often arrive in the emergency department with potentially causes of serious secondary systemic insults to the already injured brain, such as acute anemia (Hematocrit < or = 30%), hypotension (systolic arterial pressure (Pasys) < or = 95 mmHg, 12.7 kPa), hypercapnia (Paco2 > or = 45 mmHg, 6 kPa) and/or hypoxemia (Pao2 < or = 65 mmHg, 8.7 kPa). The incidence of such insults and their impact on mortality were studied in a group of 51 consecutive adults suffering from non penetrating severe head injury (Glasgow score < or = 8, mean age 31 +/- 17 yrs) rescued by a medicalized helicopter. Each patient received medical care on the site of the accident by an anaesthesiologist of a university hospital (UH) complying with an advanced trauma life support protocol including intubation, hyperventilation with FiO2 = 1, restoration of an adequate Pasys and direct transportation to the UH. Mean delay from call to arrival of the rescue team on the site was 15 +/- 5 min. Mean scene time was 32 +/- 10 min in cases not requiring extrication. Nineteen patients (Group I) were admitted without secondary systemic insults to the brain, 13 with isolated head injury, and 6 with multiple injuries, with a low Glasgow Outcome Score (GOS 1-3) of 42% at 3 months. In 32 patients (Group II), despite advanced supportive measures at the scene of the accident and during transportation, one or more secondary systemic insults to the brain were detected upon arrival at the emergency room, one with isolated head injury, 31 with multiple injuries, with a bad GOS of 72% at 3 months. We conclude that: 1) advanced trauma life support prevents from secondary systemic insults in the great majority of isolated severe head injured patients. 2) secondary systemic insults to the already injured brain are frequent in patients with multiple injuries and are difficult to avoid despite rapid aeromedical trauma care, 3) secondary systemic insults to the brain have a catastrophic impact on the outcome of severely head injured patients.
事故现场的高级支持性治疗，再加上直接转运至创伤中心，可提高生存率并降低发病率。重度颅脑损伤患者，尤其是多发伤患者，常常在抵达急诊科时就伴有可能对已受伤的大脑造成严重继发性全身损害的因素，如急性贫血（血细胞比容≤30%）、低血压（动脉收缩压（Pasys）≤95 mmHg，12.7 kPa）、高碳酸血症（动脉血二氧化碳分压（Paco2）≥45 mmHg，6 kPa）和/或低氧血症（动脉血氧分压（Pao2）≤65 mmHg，8.7 kPa）。在一组由医疗直升机救援的51例非穿透性重度颅脑损伤（格拉斯哥评分≤8，平均年龄31±17岁）的连续成年患者中，研究了这些损害的发生率及其对死亡率的影响。每位患者在事故现场均由大学医院（UH）的麻醉医生按照高级创伤生命支持方案进行医疗护理，包括插管、吸入氧分数（FiO2）为1的过度通气、恢复足够的Pasys以及直接转运至大学医院。从求救到救援团队抵达现场的平均延迟时间为15±5分钟。在无需解救的情况下，平均现场时间为32±10分钟。19例患者（第一组）入院时无大脑继发性全身损害，其中13例为单纯颅脑损伤，6例为多发伤，3个月时格拉斯哥预后评分（GOS 1 - 3）低的比例为42%。32例患者（第二组）尽管在事故现场和转运过程中采取了高级支持措施，但在抵达急诊室时仍检测到一项或多项大脑继发性全身损害，其中1例为单纯颅脑损伤，31例为多发伤，3个月时不良GOS比例为72%。我们得出以下结论：1）高级创伤生命支持可在绝大多数单纯重度颅脑损伤患者中预防继发性全身损害。2）多发伤患者中，对已受伤大脑的继发性全身损害很常见，尽管有快速的空中医疗创伤护理，仍难以避免。3）大脑继发性全身损害对重度颅脑损伤患者的预后具有灾难性影响。
