小儿重型颅脑损伤的临床特点与急救

小儿重型颅脑损伤是指颅脑外伤患者年龄小于 14岁 ,GCS评分 3～ 8分 ,伤后昏迷或再昏迷在 6h以上。由于小儿有自身的病理生理特点 ,故重型颅脑损伤亦有其独特性 ,笔者根据本科收治的 88例患儿结合临床分析如下。1　临床资料1 1　一般资料　本组 88例 ,男 5 6例 ,女 3 2例 ,年龄 <3岁 18例 ,3～ 7岁 2 8例 ,7～ 14岁 42例 ,平均年龄 8 6岁。致伤原因 :车祸伤 14例 ,打击伤 2 0例 ,跌伤 16例 ,坠落伤 3 8例 ;开放性颅脑损伤 18例 ,闭合性损伤 70例 ,合并颅骨骨折 62例 ,占 70 5 % ,颅底骨折 12例 ,合并四肢骨折 12例 ,胸腹部外伤 5例 ,癫…     

小儿急性颅脑损伤合并休克的急诊护理

小儿颅脑损伤合并休克时 ,由于伤情严重 ,变化复杂 ,不易观察等特点 ,使早期诊断及处理非常困难 ,急诊室死亡率很高〔1〕。但如能早期确诊并加强观察护理 ,可挽救许多患儿生命。我院急诊科近 5年来共接诊合并有休克的小儿急性颅脑损伤 10 2例 ,现将救治及护理体会介绍如下。1　临床资料1 1　一般资料　男 72例 ,女 30例 ,年龄 1～ 13岁 ,平均 7 2岁。致伤原因 :车祸伤 32例 ,坠落摔伤 5 1例 ,挤压伤 7例 ,击打伤 5例 ,其他 7例。1 2　颅脑损伤及合并伤类型　闭合性颅脑损伤 6 5例 ,开放性颅脑损伤 37例。 96例行头颅ＣＴ检查 ,发现脑挫裂伤 …     

21例小儿后尿道损伤的急症处理

目的：为了提高小儿后尿道损伤的急症救治水平。方法：对２１例小儿后尿道损伤病例进行回顾性分析和总结，男１４例，女７例。全部为车祸致后尿道损伤，其中９０．４％伴骨盆骨折和休克。本组１４例在抗休克后急症行尿道断端吻合。结果：１４例急症吻合者１３例Ⅰ期治愈。其他方法急症处置７例，Ⅰ期治愈仅２例。全部病例获得随访，无明显后遗症。结论：小儿后尿道损伤在纠正休克后应积极早期行尿道吻合术，因早期吻合可减少尿道狭窄的发生以及Ⅱ期手术给患儿所带来的痛苦。对于经抗休克后生命体征不稳定者，急症尿道吻合的指征应从严掌握     

小儿颅脑损伤急性期血糖变化的临床意义

目的　探讨小儿颅脑外伤急性期血糖变化与格拉斯哥昏迷评分 (GCS)和预后 (GOS)的关系 ,以及高血糖的处理。方法　测定并分析 1998年 1月至 2 0 0 2年 1月期间收治并从中选择的 14 5例颅脑外伤患儿的急性期血糖值。结果　按GCS评分分为三组 (GCS 3～ 8分 2 7例 ,9～ 12分 2 7例 ,13～ 15分 91例 ) ,入院时血糖平均值分别为 (16 .2 6± 2 .33)mmol/L、(10 .4 7± 2 .15 )mmol/L、(5 .92± 1.2 1)mmol/L ;按预后分为三组 (良好 12 6例 ,差 13例 ,死亡 6例 ) ,其入院时血糖值分别为 (7.73±3.2 5 )mmol/L、(12 .2 5± 2 .99)mmol/L、(2 2 .5 4± 3.97)mmol/L。随机选取 2 8例高血糖患儿予控制糖入量、使用胰岛素等降糖处理 ,并在伤后≤ 6h、2 4h、4 8h作血糖动态监测 ,血糖值分别为 (12 .70±3.0 2 )mmol/L、(8.34± 2 .71)mmol/L、(5 .6 3± 1.75 )mmol/L ,致残率、死亡率显著下降 ,预后良好。结论　血糖测定有助于评价小儿颅脑损伤的严重程度及预后 ,积极的综合治疗可改善高血糖患儿的预后     

儿童创伤性脑损伤后血清皮质醇的变化及对预后的影响

目的 研究儿童创伤性脑损伤(traumatic brain injury,TBI)后血清皮质醇的变化规律,以及对预后的影响.方法 2014年6月至2015年12月伤后24 h内入住南京市儿童医院外科ICU的52例TBI患儿,按照格拉斯哥昏迷评分(glasgow coma scale,GCS)分为轻度损伤组(19例,GCS评分≥13分)、中度损伤组(16例,8分相似文献   

重症小儿胸部损伤诊治的临床观察

目的 探讨重症小儿胸部损伤的诊断治疗原则.方法 回顾分析1998年3月～2007年10月收治的117例重症胸部损伤患儿,其中男83例(71%),女34例(29%),车祸伤50例,锐器伤46例,高处坠落伤15例,挤压伤4例,枪弹伤2例.发生休克29例(32%).92例(79%)给予胸腔闭式引流等保守治疗,25例(21%)接受剖胸手术.结果 109例(93%)患儿治疗后恢复良好,8例(7%)死亡,均为多发伤,其中手术中死亡2例,分别为合并颅脑损伤和脾破裂.结论 小儿胸部损伤病情多样,正确及时的诊治措施是抢救患儿生命的关键.     

高压氧治疗儿童中重型颅脑外伤的疗效分析

目的分析高压氧治疗对儿童中重型颅脑外伤的疗效。方法选择61例儿童颅脑外伤病例,将其随机分为高压氧治疗组(36例)和对照组(25例),分别于入院时和受伤后第14天及治疗后3个月、6个月观察两组患儿的疗效。结果治疗前两组患儿GCS评分无统计学差异(P0.05),治疗后第14天,高压氧治疗组GCS评分高于对照组,差异有统计学意义(P0.05)。随访第3个月和第6个月,高压氧治疗组GOS评分高于对照组,差异有统计学意义(P值均0.05)。结论高压氧是一种治疗儿童中重型颅脑外伤的有效方法,值得推广。     

儿科重症监护病房严重颅脑外伤的预后因素分析

目的调查儿科重症监护病房（PICU）影响急性严重颅脑外伤预后的因素。方法2001年1月~2006年9月PICU收治的格拉斯哥昏迷评分（GCS）≤8分且至少存活5 d以上的急性严重颅脑外伤患儿,入院时行血气分析、血压监测,d1、3、5检测血WBC及评估GCS,d1~5检测血糖并行高血糖评分（HS）。结果严重颅脑外伤患儿82例,死亡36例。单因素回归分析显示低血压、低GCS、高血WBC计数和高血糖评分是急性严重颅脑外伤儿童死亡的独立危险因素（Pa〈0.001）,其死亡与性别、年龄和低氧血症无关（Pa〉0.05）。多因素回归分析显示低血压、低GCS和高HS是急性严重颅脑外伤死亡的高危因素。结论低GCS、高HS和低血压是影响急性严重颅脑外伤儿童预后的高危因素。     

TINS评分在婴幼儿颅脑损伤中的应用

目的介绍和评价一种新的颅脑损伤评分方法——TINS评分。方法回顾性分析28例婴幼儿颅脑损伤的TINS评分及其与患儿治疗效果、预后之间的关系，并与GCS评分方法相比较。结果与GCS评分方法相比，TINS评分与婴幼儿的临床表现、治疗效果有较好的相关性。结论TINS评分是一种较为可靠、客观的评分方法，建议在婴幼儿颅脑损伤中常规应用。     

小儿颅脑复合伤的诊治

小儿颅脑复合伤的诊治较单纯颅脑损伤及成人复合伤复杂、困难。我院自1995年8月～2003年6月共收治这类病人64例,报告如下。1临床资料1. 1 一般资料 本组64例,男性42例,女性22例,年龄3个月～14岁。受伤原因:车祸31例,坠落伤25例,砍伤2例,跌伤6例。开放性颅脑损伤14例,合并颅内血     

影响小儿重型颅脑损伤预后的危险因素分析

目的分析各种危险因素对小儿重型颅脑损伤预后的影响。方法用寿命表分析，单变量和多变量分析等统计学方法分析年龄、损伤类型、颅骨骨折、颅内血肿、反射消失、癫痫、脑肿胀／脑水肿、格拉斯哥昏迷计分（GCS）、低血压、低氧血症等因素对预后的影响。结果91例患儿，死亡31例（34．1％），死亡大多发生在伤后1周以内，预后与原发性损伤的严重程度有关，GCS记分是影响预后的最主要因素，GCS记分5～8分者88．9％存活，而GCS小于5分者仅14．3％存活；伤后6个月时的致残率为23．1％。单变量分析发现癫痫大发作（P〈0．0001）、多发性损伤（P=0．0112）、反射消失（P〈0．0001）、外伤后急性弥漫性脑水肿／脑肿胀（P〈0．0001）是影响预后的因素，年龄、颅骨骨折和颅内血肿对预后的影响无统计学意义。用Cox模型进一步分析发现治疗前的反射消失、外伤后急性弥漫性脑水肿／脑肿胀是影响预后的最主要因素（P〈0．0009），年龄、颅骨骨折、颅内血肿对预后无影响。结论原发性反射消失、GCS记分是预测预后的最好指标，脑水肿／脑肿胀是影响预后的最主要因素。所以，为了改善患儿的预后，应将颅脑损伤患儿的治疗重点放在预防和减低脑肿胀／脑水肿上。     

颅脑损伤患儿血浆内毒素变化及其临床意义分析

目的　研究颅脑损伤患儿血浆内毒素水平的变化及其临床意义。方法　以2017年10月1日至2018年12月31日中国医科大学附属盛京医院儿科重症监护室（PICU）住院的颅脑损伤患儿29例为病例组，分别于颅脑损伤后1 d、3 d和5 d采集外周血；以10例健康体检儿童为对照组。采用内毒素鳌定实验动态检测血浆内毒素水平，比较其颅脑损伤后1 d、3 d和5 d的内毒素水平变化情况；同时收集患儿发热情况、住院时间、喂养方式、手术史、机械通气等资料，评估影响血浆内毒素水平的临床因素。结果　颅脑损伤后1 d、3 d及5 d的病例组内毒素水平均明显高于对照组（P＜0.05），且损伤后3 d及5 d的内毒素水平高于1 d（P＜0.05）。昏迷评分（GCS）与内毒素水平呈负相关（P＜0.05）。重型颅脑损伤组内毒素水平高于轻型及中型组。多器官功能障碍综合征（MODS）组内毒素水平高于非MODS组。胃肠功能障碍组内毒素水平高于非胃肠功能障碍组。入院时肠内喂养、GCS是内毒素血症的独立影响因素（P＜0.05），小儿危重症评分（PCIS）与内毒素血症呈负相关，但不是其独立影响因素。结论　颅脑损伤患儿损伤后3 d内毒素水平明显升高，颅脑损伤越重，内毒素水平越高；胃肠功能障碍及MODS患儿血浆内毒素水平明显升高；入院时予肠内喂养可降低内毒素水平，GCS及PCIS越低，内毒素水平越高。     

腹膜透析治疗小儿重症颅脑损伤并严重高钠血症的临床研究

目的：观察腹膜透析对小儿重症颅脑损伤合并严重高钠血症的治疗效果。方法对47例重症颅脑损伤合并严重高钠血症患儿,观察腹膜透析前后血钠浓度变化及其规律,并经有创颅内压监测颅内压变化,评估腹膜透析对颅内压的影响,测定血浆晶体渗透压、血肌酐和血气分析、血压、心率等的变化,评估腹膜透析治疗的效果与安全性。结果与治疗前相比,血钠每天均下降,以第1天下降幅度大,速度快（187．49±2．91 vs 202．48±9．31,P＜0.05）,其后降钠速度减慢。持续颅内压监测颅内压逐渐下降,第1天下降明显（164．58±5．98 vs 177．83±7．47,P＜0.05）。腹膜透析期间,血浆晶体渗透压下降,酸中毒纠正,生命体征稳定。结论腹膜透析可有效治疗重型颅脑损伤后高钠血症,与其弥散、降低颅内压等因素有关,临床安全有效。     

Multiple trauma in children patterns of injury--treatment strategy--outcome.

TOPIC OF THE STUDY: In 1994 more than 50,000 children under 15 years were involved in a road accident in Germany. About one third of them received major injuries and 431 children died. These data obviously show the importance of multiple trauma in children in a developed country. METHODS: Between 1985 and 1990, 64 multi-traumatized children were evaluated after receiving treatment at the Aachen University Hospital. It was possible to evaluate 66% of the patients at the follow-up examination after 1 and 5 years. The results have been measured with the ALOS (Aachen long-term outcome score) and the GOS (Glasgow outcome score) in relation to the degree of trauma. OWN RESULTS: 12.5% died mainly from the effects of a cerebral injury. 25% developed different complications. Again the effects of craniocerebral trauma determined the long-term outcome. All other injuries can be managed by aggressive treatment without major consequences. CONCLUSIONS: In multi-traumatized children, craniocerebral trauma is the key injury regarding both lethality and long-term outcome. Therefore, prevention is of primary importance. Aggressive treatment of thoracic and abdominal trauma can usually help to cure completely these injuries. Especially osteosynthetic procedures, exerting little strain and performed as appropriate for children, have made injuries of the limbs less critical.     

儿童腹部损伤的诊断与治疗

目的 探讨儿童腹部损伤的保守治疗及手术探查的指征,提高儿童腹部损伤的诊疗水平.方法 回顾性分析我院89例腹部损伤患儿的临床资料,根据损伤部位情况进行分类,并逐一对其进行分析.结果 (1)89例腹部损伤患儿中,25例肝损伤,1例行剖腹探查;48例脾损伤,46例保守治疗,1例行脾切除术,1例予修补;14例胃肠道损伤,4例急诊剖腹探查,1例住院4 d后出现迟发穿孔;8例胰腺损伤,6例肾、肾上腺挫伤,予保守治疗;1例子宫、膀胱损伤,急诊手术治疗.(2)与成人不同,肝脾损伤患儿绝大多数经保守治疗能治愈,静脉补液后输血仍超过40 ml/kg,且血压不稳定者应及时手术探查.(3)CT检查对怀疑有胃肠道损伤,而不宜行腹部X线立位平片者有重要临床意义,合并气腹或腹胀明显加重,或出现腹膜炎表现的患儿,应及时手术探查,尤其注意迟发消化道穿孔的可能.(4)排除有胰腺横断的患儿,胰腺损伤多应保守治疗.(5)膀胱及子宫损伤患儿,外伤多较严重,需及时剖腹探查.结论 基层医院儿童腹部损伤应高度重视,实质脏器损伤导致的内出血是患儿死亡的最主要原因,空腔脏器损伤延误诊治是导致患儿死亡的另一重要原因,因此,早期准确诊断,积极治疗,以及综合处理其他严重的合并伤、并发症是成功救治该类患儿的关键.     

地震灾害中儿童创伤危重症的救治

儿童自我防护能力较差,在自然灾害中,儿童是最易受到伤害的群体。地震中死亡的主要原因包括心搏呼吸骤停、严重颅脑损伤、休克、挤压综合征及多脏器功能衰竭。优先实施对儿童的集中、有效救治,并实现多学科交叉合作,将危重患儿集中在有条件的PICU平台上,可提高重症患儿的存活率、降低致残率。     

Severe injury mechanisms in two paediatric trauma centres: Determination of prevention priorities

BACKGROUND

To meet community needs, injury prevention programs for children should be targeted to trends in objective data on mechanisms of injury. The aim of the present study was to identify the most important severe injury mechanisms.

METHODS

The present study retrospectively reviewed severe paediatric trauma patients in two regional trauma centres. Injury prevention priority scores were computed using different severity measures – injury severity score (ISS), revised trauma score, trauma-related injury severity score, Glasgow Coma Scale (GCS) and mortality – to identify prevention priorities.

RESULTS

A total of 3732 children with severe injury were identified; mean age (±SD) was 9.0±5.2 years and 2469 (66.2%) were boys. The GCS was 7 or lower in 209 patients (5.6%) and the median ISS was 9. Overall, there were 77 deaths (2.1%). ‘Fall from height’ was the most frequent mechanism of injury, and ‘motor vehicle traffic injury’ resulted in the most severe injury. The most significant mechanisms of injury, using ISS, were ‘fall from height’, ‘motor vehicle traffic injury’, ‘pedestrian struck by motor vehicle’, ‘bicycle injuries’ and ‘child abuse’. Different priorities were identified depending on the severity measures used – ‘fall from height’ would be the priority with ISS, revised trauma score and trauma-related injury severity score; ‘motor vehicle traffic injury’ with mortality and ‘drowning/submersion’ with GCS. ‘Fall from height’ was the highest ranked mechanism of injury in one centre compared with ‘motor vehicle traffic injury’ in the other. Younger children tended to have injuries as a result of falls, while adolescents had more motor vehicle occupant injuries. Failure to use safety devices, such as helmets and seat belts, was a common finding among severely injured children.

CONCLUSION

The present study shows that the severe injury prevention priorities identified vary depending on the severity measures used. The variations seen across age groups and between the two centres are also important factors that must be taken into account when developing prevention programs or considering research initiatives.     

Incidence and mortality of moderate and severe traumatic brain injury in children: A ten year population-based cohort study in Norway

ObjectiveIn this study we wanted to estimate population-based rates of incidence and mortality of moderate and severe traumatic brain injury (TBI) in children in one specific region in Norway.MethodsIn the region there are seven acute care hospitals (ACHs) in addition to a Level 1 trauma centre. Of 702 869 inhabitants (2014), 145 395 were children aged 0–16 years. Data were collected during ten years (2004–2014). All children aged 0–16 years with moderate (Glasgow Coma Scale [GCS] score 9–13) or severe (GCS score ≤ 8) TBI admitted to the Level 1 trauma centre were prospectively included. Children treated outside the Level 1 trauma centre were retrospectively included from the ACHs. Children who died from TBI prehospitally were included from the National Cause of Death Registry. Poisson regression was used to estimate incidence rate ratios (with a 95% confidence interval) comparing age, sex, and time periods.ResultsA total of 71 children with moderate or severe TBI were identified. Crude incidence rates were 2·4 (95% CI 1·7–3·3) for moderate and 2·5 (95% CI 1·8–3·4) for severe TBI per 100 000 person-years (py). Mortality rate from TBI was 1·2 (95% CI 0·7–1·9) per 100 000 py, and 88% were prehospital deaths.ConclusionThe incidence rates and mortality of moderate and severe TBI were low compared to international reports. Most likely explained by successful national prevention of TBI.