颅脑损伤双瞳孔散大病人的急救

目的：探讨颅脑损伤双瞳孔散大病人的急救措施，降低病死率。方法：分析了１０４例双瞳孔散大病人在抢救室行气管插管、颈内动脉注射甘露醇、颅骨钻孔减压、再根据瞳孔回缩情况决策是否手术及术式的抢救经验。结果：按ＧＯＳ判断，恢复良好３１．７％，中残４．８％，重残３．８％，植物生存３．８％，病死５５．７％。结论：紧急气管插管、颈内动脉注射甘露醇、颅骨外事 也减压是有效的急救措施；若瞳孔回缩后开颅手术疗效好，若不     

重型颅脑损伤双瞳孔散大与预后

本文通过５４例严重颅脑损伤双瞳孔散大病人的临床、ＣＴ及预后分析，结果发现：注射甘露醇后一侧或双侧瞳孔缩小，ＧＣＳ－Ｍ≥分且脑池均存在者，几乎者能存活，预后良好，注射甘露醇后瞳孔无缩小，ＧＣＳ－Ｍ〈３分。且脑池全部闭塞者几乎不能存活，即使存活意识也不能恢复。作者认为：这类病人如果注射甘露醇后瞳孔有缩小，ＧＣＳ－Ｍ≥３分，且致少有一个脑池存在，经积极抢救均有意识恢复的可能。     

重型颅脑损伤脑疝患者瞳孔散大与转归的临床分析

目的探讨重型颅脑损伤脑疝形成瞳孔散大与转归的关系。方法回顾性分析110例重型颅脑损伤脑疝形成患者的诊断和急救治疗，着重分析瞳孔变化和持续时间与转归的关系。结果均行开颅手术清除血肿去骨瓣减压。51例恢复良好，中残25例，重残4例，植物生存4例，死亡26例。结论重型颅脑损伤脑疝形成瞳孔散大患者要及时紧急开颅手术，清除血肿去骨瓣减压，并配合脱水等减少脑水肿治疗。     

2例多次脑疝病人的护理体会

我科1995年11～12月份收治2例颅脑外伤病人,伤后及术后发生多次脑疝。经积极抢救及护理而痊愈。现将我们的护理体会报告如下。 1 病例介绍 例1患者女性,32岁。汽车撞伤头部,昏迷20小时。于12月26日入院。查体:呈深昏迷状态。格拉斯哥计分为3分。双瞳孔等大,同圆,约2mm,光反射消失。CT诊断“脑挫裂伤,蛛网膜下腔出血”。入院当晚、呼吸深慢,右侧瞳孔散大4mm,相继呼吸停止。立即行气管插管、气囊人工辅助呼吸,静滴甘露醇。10分钟后瞳孔回缩至2mm,自主呼吸恢复。留置气管插管。并行静脉切开、保持静脉输液通畅。该患于27、28、29日各发生脑疝一次。行气囊人工辅助呼吸,快速静点脱水药物。每次约在10分钟后恢复自主呼吸。气管插管留置19天。病情平稳后拔管。病人可自行翻身、咯痰,格拉     

重症颅脑损伤病人在急诊科的抢救护理配合

通过对83例重症颅脑损伤病人进行抢救,围绕“急”、“快”、“准”、“细”实施护理措施：迅速对病人的病情作出判断．快速准确实施降低颅内压、吸氧、吸痰、气管内插管、伤口包扎止血等急救措施,细心、严密观察病人意识、瞳孔和生命体征变化及病情发展趋势,做好紧急手术的术前准备,为抢救病人生命赢得了时间。     

急诊手术抢救脑疝42例临床分析

我院颅脑外科1993年1月～1997年9月共行急诊开颅手术抢救外伤性及自发性颅内血肿伴急性脑疝病人42例。本文回顾手术时间、抢救措施对病人预后的影响，进一步探讨提高抢救效果，降低残死率的方法。1临床资料1．1一般资料：42例中男34例，女8例，年龄12～76岁，平均39．9岁，其中20～50岁27例，占64％。病因；外伤性颅内血肿35例，自发性脑内血肿7例（高血压性脑出血5例，脑血管畸形出血2例）。血肿类型：硬膜外9例，硬膜下20例，脑内8例（其中4例破入脑室），多发性血肿5例（包括幕上伴幕下血肿2例）。术前瞳孔改变：一侧瞳孔散大26例，双侧…     

插管次数对手术室外紧急气管插管并发症的影响

目的 分析手术室外紧急气管插管相关并发症，并探讨与插管次数之间的关系。方法 前瞻性收集95例紧急气管插管患者有关资料，包括年龄、性别、诊断、插管适应证、插管前SpO2和BP、插管用药、插管次数、既定的各种气道和血流动力学并发症。结果所有病例均完成气管插管。71例（74．7％）发生各种并发症，包括低氧血症（54．7％）、低血压（23．2％）、高血压（17．9％）、心动过缓（38．9％）、心动过速（16．8％）、异位心律失常（2．1％）、食道插管（20．0％）、返流（34．7％）、误吸（8．4％）、心跳骤停（7．4％）。插管次数超过2次显著增加了并发症例数（29／30vs42／65，OR=15．88，95％CI=2．03-124．26）．并发症发生率：低氧血症（73．3％VS46．2％，OR=3．2，95％CI=1．25～8．25）、心动过缓（60．0％VS29．2％，OR=3．6．95％CI=1．47～8．98）、心动过速（30．0％vs10．8％，OR=3．6，95％CI=1．17～10．74）、返流（60．0％VS23．1％，0a=5．0，95％CI=1．98一12．68）、食道插管（46．7％VS7．7％，OR=10．5，95％CI=3．29～33．51）、误吸（20．0％VS3．1％，OR=7．9．95％CI：1．49。41．7）、心跳骤停（16．7％VS3．1％，OR=6．3，95％CI=1．15～34．62）。结论 手术室外紧急气管插管常伴有各种并发症，尤其插管次数超过2次时。提高快速插管成功率，控制插管次数，能降低并发症发生率。     

现场气管插管在院前抢救中的应用

目的：总结在院前现场急救中应用气管插管的经验，以提高急救水平．方法：回顾性分析我科院前气管插管抢救危重病78例的临床资料．结果：78例患者院前现场施行气管插管，插管时间均少于2分钟，其中重度海洛因杀虫药中毒4例和重度有机磷杀虫药中毒2例现场插管成功建立人工通气后，经进一步抢救全部存活；因重型颅脑损伤行气管插菅的病人68例，均安全转运至专科治疗；现场心肺复苏插管4例中3例未能恢复有效循环死亡。结论：气管插管用于院前抢救是危重病人安全转运的基础，对提高危重患者抢救成功率有重要意义，     

延脑出血破入脑室高龄病人抢救成功1例

患者男，75岁，于2003年1月25日突然头昏，继之昏迷，家属即呼“120”，医务人员到达时患者已处于深昏迷状态，双瞳孔对光反射迟钝，呼吸浅慢，4次/min，立即予可拉明、洛贝林、甘露醇、参附芪等中两医处理，并行气管插管、简易球囊呼吸器人工呼吸，病人心率升至60次／min，自主呼吸6～8次/min，维持补液并急送回院抢救。回院后病人仍处于昏迷状态，行CT示：延脑出     

改良胃管留置方法在经口气管插管病人中的应用

气管插管是急危重病人的急救措施之一,而危重症病人在行气管插管后常需留置胃管予鼻饲药物、胃肠减压或进行营养支持。虽然胃管置入法是临床护士的常规护理操作,但由于气管插管后气管导管对气管内壁的推压,间接压迫食管壁,往往造成置管困难甚至失败,给病人带来痛苦。我科对带气管插管病人在传统胃管留置方法基础上加以改良,并与传统方法进行对照,效果良好。现将研究结果介绍如下。     

颅脑损伤昏迷病人院前救护程序改进的效果观察

目的探讨改良颅脑损伤昏迷病人院前急救护理程序的效果。方法按颅脑损伤昏迷病人救护车出诊先后顺序编号，单号为观察组60例，双号为对照组59例。观察组实施改良的救护程序：第1步先进行快速护理诊断，根据GCS昏迷评分标准确定昏迷等级；第2步保持呼吸道和静脉通道有效开放；第3步测定瞳孔、脉搏、血压、呼吸、血氧饱和度，为进一步采取急救措施提供依据；第4步，应对措施处于预启动状态，包括心肺复苏、抗休克、伤口处理、头部CT检查和术前准备，形成院前救护-CT室一手术室的绿色通道。对照组实施常规急救护理流程。比较两组接到“120”呼救电话至气管插管、头部CT检查、入手术室时间，两组术后3d内意识进展情况、并发症发生率和死亡率。结果与对照组比较，观察组接到呼救电话至入手术室时间、至头部CT检查时间、至气管插管／气管切开时间均较对照组提前（P〈0．05）；术后3d内意识好转、意识恢复率提高（P〈0．05或P〈0．01），2周内并发症的发生率和死亡率明显降低（P〈0．05或P〈0．01）。结论改良院前救护程序能有效缩短颅脑损伤昏迷病人的院前急救时间，是减少并发症及死亡率的有效急救护理措施。     

急救气管插管预防颅脑外伤昏迷患者吸入性肺炎的对照研究

目的 研究早期气管插管对颅脑外伤昏迷患者吸入性肺炎发生率的影响.方法 颅脑外伤昏迷患者89例,按急诊科接诊日期随机分为两组,研究组(42例)于急救现场或接诊后立即气管插管;对照组(47例)实施常规气道管理,在需要使用呼吸机时才置入气管插管,其他医疗措施按诊疗常规进行.随访24 h,比较两组性别构成、年龄分布、颅脑损伤严重程度、伤后0.5 h气管插管使用率、伤后4 h呕吐发生率、伤后24 h呼吸机使用率、伤后24 h吸入性肺炎发生率等情况.结果 研究组伤后0.5 h气管插管使用率显著高于对照组,伤后24 h吸入性肺炎发生率显著低于对照组(P均＜0.05);两组其他各项指标比较差异均无统计学意义(P均＞0.05).结论 早期气管插管可以显著降低颅脑外伤昏迷患者吸入性肺炎发生率,有效保障气道安全.     

AANA journal course: update for nurse anesthetists. The SLAM Emergency Airway Flowchart: a new guide for advanced airway practitioners

Advanced airway practitioners in anesthesiology, emergency medicine, and prehospital care can suddenly and unexpectedly face difficult airway situations that can surface without warning during mask ventilation or tracheal intubation. Although tracheal intubation remains the "gold standard" in airway management, it is not always achievable, and, when it proves impossible, appropriate alternative interventions must be used rapidly to avoid serious morbidity or mortality. The SLAM Emergency Airway Flowchart (SEAF) is intended to prevent the 3 reported primary causes of adverse respiratory events (ie, inadequate ventilation, undetected esophageal intubation, and difficult intubation). The 5 pathways of the SEAF include primary ventilation, rapid-sequence intubation, difficult intubation, rescue ventilation, and cricothyrotomy. It is intended for use with adult patients by advanced airway practitioners competent in direct laryngoscopy, tracheal intubation, administration of airway drugs, rescue ventilation, and cricothyrotomy. The SEAF has limitations (eg, suitable only for use with adult patients, cannot be used by certain categories of rescue personnel, and depends heavily on assessment of Spo2). A unique benefit is provision of simple alternative techniques that can be used when another technique fails.     

早期气管插管抢救重型颅脑损伤的疗效研究

目的 探讨早期气管插管对蓖型颅脑损伤的救治效果.方法 将134例行气管插管的重型颅脑损伤患者(GCS≤8分)采用随机对照的研究方法分为两组,即早期气管插管组58例和常规气管插管组76例,两组在气管插管前后呼吸生理指标变化、上机概率、呼吸机治疗和ICU监护时间、并发症发生率及重残死亡率等方面进行比较.结果 两组呼吸和生理监测指标在气管插管前后均有不同程度的提高,两组气管插管前后PaO_2、PaCO_2、SaO_2、HR和RR比较差异均有统计学意义.两组在上机概率、机械辅助呼吸治疗时间、ICU监护时间以及并发ALI或ARDS、难治性肺炎、消化道出血、MODS和重残死亡等方面比较均具有统计学意义.结论 重型颅脑损伤早期气管插管能更好地改善机体的缺氧,降低并发症发生率和重残死亡率,改善预后.     

肾上腺髓质素对局灶性脑缺血/再灌注损伤大鼠神经元凋亡及早期生长反应基因-1的影响

目的探讨肾上腺髓质素（ADM）对局灶性脑缺血/再灌注（I/R）损伤大鼠神经元凋亡、梗死体积及早期生长反应基因-1（Egr-1） mRNA表达的影响,进一步研究ADM在局灶性脑I/R损伤中的作用。方法将54只SD大鼠随机分为假手术组、I/R损伤组以及ADM股静脉组、颈内动脉组和侧脑室组。采用线栓法制备大鼠大脑中动脉（MCA）I/R损伤模型,于阻断血流2h后分别经股静脉、颈内动脉和侧脑室3条途径注射ADM进行干预后再灌注22h。应用氯化三苯四唑（TTC）染色法测定梗死体积,用末端脱氧核苷酸转移酶介导的dUTP缺口末端标记法（TUNEL）检测神经元凋亡,用原位杂交法检测Egr-1 mRNA阳性细胞表达。结果大鼠局灶性脑I/R损伤并经股静脉、颈内动脉、侧脑室注射ADM后,脑梗死体积显著小于I/R损伤组;且颈内动脉和侧脑室注射ADM在减少脑梗死体积方面明显优于股静脉注射ADM（P均〈0.05）。I/R损伤组大鼠缺血侧大脑皮质、海马CA1区凋亡阳性细胞数明显多于假手术组（P均〈0.01）,给予ADM后阳性细胞数显著少于I/R损伤组,以ADM颈内动脉组和侧脑室组更为明显（P均〈0.01）。假手术组大鼠大脑皮质有少量Egr-1 mRNA阳性细胞表达,I/R损伤后缺血侧大脑皮质、海马CA1区Egr-1 mRNA阳性细胞表达多于假手术组（P均〈0.01）,应用ADM的3组大鼠大脑皮质、海马CA1区Egr-1 mRNA阳性细胞的表达明显多于I/R损伤组（P均〈0.01）,但颈内动脉和侧脑室给予ADM组的Egr-1 mRNA阳性细胞表达增高最为明显（P均〈0.01）。结论股静脉、侧脑室和颈内动脉给予外源性ADM能减少神经元凋亡和梗死体积,激活Egr-1 mRNA,对局灶性脑I/R损伤可能有治疗作用。     

78例急诊创伤死亡病例回顾性分析及临床意义

目的：通过对急诊科创伤死亡病例的回顾性分析,探讨急救患者死亡的原因,为进一步加强急救网络医院急诊科内涵建设提供客观依据。方法：对我院2010-01-2012-12 78例急诊创伤死亡的病例填写调查表,用Profox6.0建立数据库,分析患者死亡年龄分布、致伤原因、抢救措施、出车时间,并采用SPSS l6.0软件进行统计学处理。结果：平均平均死亡年龄为44.8岁,以40~59岁年龄段最多。死亡原因依次为交通事故、高处坠落、重物砸伤、锐器伤、挤压伤。进行气管插管者占74.3%（58/78）,呼吸机维持呼吸者占80.7%（63/78）,实施胸外按压者占85.8%（67/78）。结论：急诊创伤死亡病例的年龄、致伤原因已发生明显变化。要重视院前死亡。监测和评估急诊科急救工作的时间因素、技术因素和质量因素等非常有必要,可依此加强管理。     

预见性气管插管治疗急性重度药物中毒临床观察

目的:探讨重度药物中毒患者的气管插管时机对治疗效果的影响。方法:对57例出现呼吸困难的重度药物中毒患者,进行密切观察,在常规治疗的基础上,随机分为预见性气管插管组与延时气管插管组;以并发症发生情况及抢救成功率进行统计学处理,比较两组患者的抢救效果。结果:各种并发症发生情况两组比较P>0.05差异无统计学意义,可能与中毒的量及中毒时间有关;不同时机气管插管抢救成功率两组比较P<0.05,有一定的可比性。结论:预见性气管插管有助于重度药物中毒患者的抢救,气管插管最佳时机为呼吸衰竭早期。     

Noninvasive Intracranial Cerebral Flow Velocity Evaluation in the Emergency Department by Emergency Physicians

Transcranial Doppler (TCD) is an accepted modality for the evaluation of cerebral blood flow velocities. OBJECTIVES: The purpose of this study was to test the feasibility of bedside TCD measurement in the emergency department (ED) with critically ill, intubated patients. METHODS: A prospective convenience sample of patients presenting to a university hospital over a two-month period underwent TCD evaluation of the middle cerebral artery. Intubated patients with head trauma and any patient requiring tracheal intubation were eligible. A 2-MHz Doppler probe was positioned over the temporal bone to acquire blood flow velocities. An emergency medicine resident and research assistant obtained measurements. Continuous TCD tracings were recorded on a video cassette recorder tape for quality assurance review and data collection. Vital signs and therapeutic interventions were also recorded. Flow velocities were measured in cm/s; the peak Resistance Index (RI) was calculated for each patient. RESULTS: A total of 30 patients were enrolled in the study. Adequate tracings were obtained in 25 patients (83%) without a disruption of resuscitation. Tracings could not be obtained in five patients; they were listed as TCD failures. However, in two of these patients, adequate flow velocity tracings were obtained after resuscitation. Four patients were evaluated during tracheal intubation. One patient was monitored successfully during cardiopulmonary resuscitation. The median time required for data acquisition was 1.9 minutes. The mean highest RI for those who expired was 0.84. For those who survived, the mean highest RI was 0.52. The difference of 0.32 was statistically significant (p = 0.04). CONCLUSIONS: Noninvasive blood flow velocity monitoring of the middle cerebral artery using TCD is feasible in the ED when performed at the bedside on intubated patients with traumatic brain injury and others during tracheal intubation and resuscitation.     

Near hanging

Abstract Objectives: To review the literature on near hanging, focusing on the pathophysiology, and relating this to the clinical features and management. Methods: English language articles published in the past 15 years and major textbooks of emergency and forensic medicine were searched. Eight case series and six relevant single case reports were identified. Only articles concerned with non-judicial near hanging were reviewed. Data concerning the incidence of cervical spine injury, laryngeal injury, pulmonary complications and mortality were extracted. Not the case series documented the presence or absence of all these factors, resulting in differing total patient numbers in each category. Unusual complications of near hanging were documented from case reports. Results: Cervical spine injury occurred in four of 689 patients (0.6%). Pulmonary complications occurred in 15 of 133 patients (11%). The in-hospital mortality rate was 23% (29 deaths of 128). No clinically significant laryngeal injuries were reported. Unusual complications documented included hyperthermia, status epilepticus, carotid artery dissection, subarachnoid haemorrhage and pneumoperitoneum. Conclusions: Cervical spine injury, although uncommon, does occur in near hanging, and emergent airway management should take this into account. Laryngeal injury sufficiently severe to interfere with endotracheal intubation does not appear to occur. Cerebral oedema, aspiration pneumonia and acute respiratory distress syndrome are the commonest in-hospital complications. Management of near hanging involves establishment of a safe airway, plus treatment of pulmonary and cerebral oedema along standard lines. In-hospital mortality remains high.     

Characteristics and outcome of prehospital paediatric tracheal intubation attended by anaesthesia-trained emergency physicians

Aim

To collect data regarding prehospital paediatric tracheal intubation by emergency physicians skilled in advanced airway management.

Methods

A prospective 8-year observational study of a single emergency physician-staffed emergency medical service. Self-reporting by emergency physicians of all children aged 0–14 years who had prehospital tracheal intubation and were attended by either anaesthesia-trained emergency physicians (group 1) or by a mixture of anaesthesia and non-anaesthesia-trained emergency physicians (group 2).

Results

Eighty-two out of 2040 children (4.0%) had prehospital tracheal intubation (58 in group 1). The most common diagnoses were trauma (50%; in school children, 73.0%), convulsions (13.4%) and SIDS (12.2%; in infants, 58.8%). The overall tracheal intubation success rate was 57 out of 58 attempts (98.3%). Compared to older children, infants had a higher number of Cormack–Lehane scores of 3 or 4, “difficult to intubate” status (both 3 out of 13; 23.1%) and a lower first attempt success rate for tracheal intubation (p = 0.04). Among all 82 children 71 (86.6%) survived to hospital admission and 63 (76.8%) to discharge. Of the 63 survivors, 54 (85.7%) demonstrated a favourable or unchanged neurological outcome (PCPC 1–3). The survival and neurological outcomes of infants were inferior compared to older children (p < 0.001). On average an emergency physician performed one prehospital tracheal intubation in 3 years in a child and one in 13 years in an infant.

Conclusions

Anaesthesia-trained emergency physicians working in our system report high success rates for prehospital tracheal intubation in children. Survival and neurological outcomes were considerably better than reported in previous studies.