Ward J D, Chisholm A H, Prince V T, Gilman C B, Hawkins A M
Crit Care Nurs Q. 1994 May;17(1):79-89. doi: 10.1097/00002727-199405000-00008.
Penetrating head injuries are a significant public health problem in the United States, with an estimated 33,000 gun-related deaths and many more nonfatal shootings per year. Initial treatment for a penetrating head injury is similar to that of a closed head injury. That is, all efforts must be made to prevent any secondary insults, hypoxia, or ischemia. This translates into the standard methodology of care of the trauma patient. The basic neurologic examination consists of using the Glasgow Coma Score and estimation of pupillary function and some estimation of brain stem function and motor power. The radiologic test of choice for a penetrating head injury is the computed tomography scan. There are several indications for surgery: the patient's condition will be improved or significant neurologic sequelae will be averted; the patient is sufficiently stabilized from any other injuries such that he or she can tolerate surgery; the condition of the patient is not so poor that surgery will have no effect; and the area of penetration is reasonably accessible to surgical intervention. Three main goals of medical management of a penetrating head injury include (1) control of hypertension, (2) maintenance of adequate cerebral circulation oxygenation, and (3) prevention of secondary complications. Outcome after a penetrating head injury is related to the extent of brain tissue damage caused either directly or indirectly by the missile as well as any indirect insults. The most significant indicator, particularly in terms of survival versus death, has consistently been the patient's presenting neurologic status. Some investigators have recommended that a patient presenting with a Glasgow Coma Scale Score of > 5 should not be treated. Others have said that patients with a low coma score and transventricular gunshot wounds should not be treated because of the high mortality. If the patient survives a penetrating head injury, he or she generally goes on to experience a relatively good functional outcome. Only if all components of a good treatment regimen are in place will patients and their families obtain the best possible outcome.
穿透性头部损伤在美国是一个重大的公共卫生问题，据估计每年有33000例与枪支相关的死亡，还有更多非致命枪击事件。穿透性头部损伤的初始治疗与闭合性头部损伤相似。也就是说，必须尽一切努力防止任何继发性损伤、缺氧或局部缺血。这转化为创伤患者的标准护理方法。基本的神经系统检查包括使用格拉斯哥昏迷评分、评估瞳孔功能以及对脑干功能和运动能力进行一些评估。穿透性头部损伤的首选影像学检查是计算机断层扫描。手术有几个指征：患者的病情将得到改善或可避免严重的神经后遗症；患者已从其他损伤中充分稳定下来，能够耐受手术；患者的病情不至于太差以至于手术无效；并且穿透区域可通过手术干预合理到达。穿透性头部损伤医疗管理的三个主要目标包括：（1）控制高血压；（2）维持充足的脑循环氧合；（3）预防继发性并发症。穿透性头部损伤后的结果与导弹直接或间接造成的脑组织损伤程度以及任何间接损伤有关。最重要的指标，特别是在生存与死亡方面，一直是患者就诊时的神经状态。一些研究人员建议，格拉斯哥昏迷量表评分>5的患者不应接受治疗。其他人则表示，昏迷评分低且有经脑室枪伤的患者不应接受治疗，因为死亡率很高。如果患者在穿透性头部损伤后存活下来，他或她通常会有相对较好的功能预后。只有当良好的治疗方案的所有组成部分都到位时，患者及其家属才能获得最好的结果。
