重型颅脑损伤患者自主神经功能障碍的临床分析

目的 探讨重型颅脑损伤患者自主神经功能紊乱综合征发生率、临床症状、发病危险因素及预后.方法回顾性分析2008年1月-2010年3月收治的142例重型颅脑损伤患者,比较自主神经功能障碍组和对照组(无自主神经功能障碍患者)的临床特征;采用Logistic回归分析自主神经功能障碍发病的危险因素;伤后6个月采用GOS评分分析其预后.结果142例患者中生存并成功随访94例,自主神经功能障碍患者16例(17%),且其在GCS评分、昏迷时间、ICU时间、平均住院时间等方面较对照组差异有统计学意义(P<0.05);自主神经功能障碍患者预后较差(P<0.05),与弥漫性轴索损伤(DAI)密切相关(OR=11.25,95%CI 7.65～16.54).结论 自主神经功能障碍在严重颅脑损伤患者中发生率较高,临床表现重,DAI增加其发作风险,此类患者多预后不良.

Abstract：

Objective To investigate the incidence, clinical symptoms, correlative risk factors and prognosis of dysautonomia in patients with severe traumatic brain injury. Methods A total of 142patients with severe traumatic brain injury treated from January 2008 to March 2010 were retrospectively surveyed to compare the clinical features of dysautonomia group and control group. Logistic regression was used to analyze the risk factors for dysautonomia. At 6 months post-trauma, the Glasgow Outcome Score (GOS) was used to measure the outcome. Results Of all the patients, 94 patients survived and were followed up. There were 16 patients ( 17% ) diagnosed as dysautonomia depended on clinical symptoms,with statistical difference in aspects of GCS, coma duration, ICU time and average length of stay (ALOS)(P < 0.05). The patients with dysautonomia tended to have poorer outcome ( P < 0.05 ) and showed a positive association with diffuse axonal injury (DAI) ( OR = 11. 25, CI 7.65-16.54 ). Conclusion Dysautonomia has high incidence and is usually severe in patients with severe traumatic brain injury,when DAI may contribute to its occurrence and result in poor prognosis.     

Occlusion of the anterior cerebral artery after head trauma

Intracranial arterial occlusion is rarely encountered in association with head injury.Only six cases of traumatic occlusion of the anterior cerebral artery(ACA) have previously been reported.In this paper,the authors describe a case of a posttraumatic occlusion of ACA.A 35-year-old male presented to the emergency room with severe head injury.Computed tomography(CT) scan displayed diffuse brain swelling with multiple skull fractures.Follow up CT scan showed extensive cerebral infarction in the territory of ACA.The patient underwent CT angiography that demonstrated occlusion of the ACA by a fracture of the anterior fossa.He died after 3 d.ACA traumatic occlusion is a rare condition,with poor prognosis.In this case,fracture was responsible for dissection and direct obstruction of the artery.     

乳酸杆菌对重型颅脑损伤大鼠胃内菌群的影响

目的 观察添加乳酸杆菌的肠内营养对重型颅脑损伤大鼠胃内菌群的影响.方法采用重型颅脑损伤大鼠模型,分别用肠内营养、肠内营养添加乳酸杆菌或合生元(乳酸杆菌+纤维素)喂养后,检测1,3,7 d大鼠胃体、胃窦部黏膜菌群的变化.结果假手术组胃内细菌数量较少;伤后1 d,三组致伤大鼠胃内菌群条带明显增多,乳酸杆菌组优势菌群发生变化,致病菌数量减少.肠内营养组、乳酸杆菌组、合生元组大鼠变性梯度凝胶电泳(DGGE)图谱各聚一簇,相似性分别为65%、64%、53%,多样性指数差异无统计学意义;伤后3 d,致伤各组大鼠胃内菌群条带有减少趋势,乳酸杆菌组出现优势菌群变化,三组大鼠DGGE图谱相似性分别为72%、58%、62%,乳酸杆菌组胃内菌群丰富度和多样性指数显著低于肠内营养组和合生元组(P＜0.01);伤后7 d,三组大鼠胃内菌群条带较少,乳酸杆菌组数量最少,三组大鼠DGGE图谱相似性分别为61%、51%、58%,合生元组胃内菌群丰富度和多样性指数显著高于乳酸杆菌组和肠内营养组.结论乳酸杆菌对重型颅脑损伤大鼠胃内菌群失调有调整作用,且添加乳酸杆菌比合生元的效果好.

Abstract：

Objective To probe into the effect of the enteral nutrition added with lactobacillus on gastric bacteria of rats with severe brain injury. Methods Severe brain injury was made in rats that were then fed with enteral nutrition (3-9 entire nutrients), lactobacillus (3-9 entire nutrients + lactobacillus) and synbiotics (3-9 entire nutrients + lactobacillus + fiber) respectively. Gastric body and gastric antrum mucosa were collected at day 1, 3 and 7 after injury to detect the change of the gastric bacteria. Results DCCE analysis showed less bacteria in sham operation group. On the first day after severe brain injury, the flora bands were increased remarkably but the number of bacteria was decreased in three groups. The similarity of denaturing gradient gel electrophoresis ( DGGE) map patterns was 65% , 64% and 53% respectively in the enteral nutrition group, lactobacillus group and synbiotics group, with no significant difference in regard of the diversity index. On the third day after severe brain injury, the flora bands showed a tendency of decrease, with the similarity of denaturing gradient gel electrophoresis (DGGE) map patterns for 72% , 58% and 62% respectively. The richness and diversity of total bacteria in the lactobacillus group was remarkably lower than that in the enteral nutrition group and synbiotics group (P＜0.01). On the seventh day after SHI, the flora bands were decreased in three groups, with the minimum number of the bacteria. The similarity of denaturing gradient gel electrophoresis ( DGGE) map patterns was 61% , 51% and 58% respectively, with higher richness and diversity of total bacteria in the synbiotics group compared with the other groups. Conclusion Lactobacillus can help improve gastric bacteria disturbance of rats with severe brain injury. In the meantime, addition of the lactobacillus is better than addition of the synbiotics.     

重型颅脑损伤患者血清血栓调节蛋白和血管性假血友病因子动态变化及其临床意义

Objective To investigate the changes of thrombomodulin (TM) and von Willebrand factor (vWf) and their clinical significance in patients with severe brain injury. Methods The study involved 62 patients with severe brain injury who were divided into diffuse axonal injury group (28 patients) and focal brain injury group (34 patients). Then, the 62 patients were divided into young group (16-30 years old, 20 patients), middle-aged group (31-65 years old, 20 patients) and elderly group ( ＞65 years old, 22 patients). The serum levels of TM and vWf were determined at days 1 and 7 after injury respectively. ELISA method was employed to determine the serum levels of TM and vWf.Results The vWf in focal brain injury group was significantly higher than that of diffuse axonal injury group at days 1-7 after injury ( P ＜ 0.05 ). Compared with the young and middle-aged groups, the TM and vWf levels in the elderly group at day 1 after injury were significantly elevated ( P ＜ 0. 05 ). The TM levels in patients with delayed traumatic intracerebral hematoma (DTICH) were significantly higher than that in patients without DTICH (P ＜ 0. 05). Conclusions In the acute stage of severe brain injury,injury severity and activation of endothelial cells varies in patients with different types of injury and at different ages. TM is one of sensitive indicators to reflect the cerebal vascular endothelial cell injury. It is very meaningful to assess the prognosis of severe brain injury by measuring serum levels of TM and vWf and take TM as a predictive indicator for DTICH.     

骨关节型严重多发伤的救治

目的 探讨如何提高基于损伤控制外科理论的治疗在骨关节型严重多发伤中的效果.方法回顾性分析2006年1月-2009年6月应用损伤控制性手术治疗骨关节损伤为主的严重多发伤63例(平均ISS≥27分)的并发症、死亡率及骨折愈合关节功能恢复.结果61例创伤性休克中57例得到纠正,3例因失血性休克死于入院后2 h内,1例因严重颅脑外伤死于人院后11 h;1例因ARDS死于术后24 h;1例于伤后6 d因多器官功能衰竭死亡.52例骨折愈合,肢体功能恢复满意;2例行截肢术;3例轻度跛行,行走痛.结论损伤控制手术有助于骨关节型严重多发伤的救治,对临床救治严重创伤患者具很大指导意义.

Abstract：

Objective To investigate the curative effect of damage control theory in treating severe polytrauma patients combined with bone and joint injury. Methods A retrospective study was done on data including complication, death rate, fracture healing and joint function recovery of 63 patients with severe polytrauma combined with bone and joint injury( average ISS ≥27 points) admitted to our hospital from January 2006 to June 2009. Results Of all the patients, 57 shock patients were cured,three died of hemorrhagic shock within two hours after admission and one patient died of severe traumatic brain injury 11 hours after admission. One patient died of ARDS at 24 hours postoperatively and one died of multiple organ failure at day 6 after injury. Fracture healing was achieved in 52 patients, with satisfactory recovery of the limb function. Amputation was performed in two patients and three patients had mild claudication and pain walking. Conclusion Damage control strategy has great clinical significance in guidance of treatment of severe polytrauma combined with bone and joint injury.     

骨关节型严重多发伤的救治

Objective To investigate the curative effect of damage control theory in treating severe polytrauma patients combined with bone and joint injury. Methods A retrospective study was done on data including complication, death rate, fracture healing and joint function recovery of 63 patients with severe polytrauma combined with bone and joint injury( average ISS ≥27 points) admitted to our hospital from January 2006 to June 2009. Results Of all the patients, 57 shock patients were cured,three died of hemorrhagic shock within two hours after admission and one patient died of severe traumatic brain injury 11 hours after admission. One patient died of ARDS at 24 hours postoperatively and one died of multiple organ failure at day 6 after injury. Fracture healing was achieved in 52 patients, with satisfactory recovery of the limb function. Amputation was performed in two patients and three patients had mild claudication and pain walking. Conclusion Damage control strategy has great clinical significance in guidance of treatment of severe polytrauma combined with bone and joint injury.     

重型颅脑创伤后脑疝伴失血性休克救治策略

Objective To explore emergency treatment strategies for the patients with brain hernia combined with hemorrhagic shock after severe traumatic brain injury and their effect on prognosis.Methods A retrospective analysis was made on 54 patients (study group) with brain hernia combined with hemorrhagic shock treated with selective treatment strategies from May 2006 to May 2009. Another 48 patients with the same injuries treated with no selective treatment strategies from April 2003 to April 2006 were used as control group. The mortality within one week and the GOS six months after injury were compared in two groups. Results There was no statistical difference in aspects of sex, age, injury mechanism, GCS and blood loss in both groups (P＞0.05). Thirteen patients died in the study group within the first week, with mortality rate of 24.1%. While 16 patients died in the control group at the first week, with mortality rate of 33.3% (P＜0.05). GOS half year after injury in the study group was better than that in the control group (P＜0.05).Conclusion Early selective treatment strategy based on degree of shock may obtain better outcome for patients with brain hernia combined with hemorrhagic shock after severe brain injury.     

重型颅脑创伤后脑疝伴失血性休克救治策略

Objective To explore emergency treatment strategies for the patients with brain hernia combined with hemorrhagic shock after severe traumatic brain injury and their effect on prognosis.Methods A retrospective analysis was made on 54 patients (study group) with brain hernia combined with hemorrhagic shock treated with selective treatment strategies from May 2006 to May 2009. Another 48 patients with the same injuries treated with no selective treatment strategies from April 2003 to April 2006 were used as control group. The mortality within one week and the GOS six months after injury were compared in two groups. Results There was no statistical difference in aspects of sex, age, injury mechanism, GCS and blood loss in both groups (P＞0.05). Thirteen patients died in the study group within the first week, with mortality rate of 24.1%. While 16 patients died in the control group at the first week, with mortality rate of 33.3% (P＜0.05). GOS half year after injury in the study group was better than that in the control group (P＜0.05).Conclusion Early selective treatment strategy based on degree of shock may obtain better outcome for patients with brain hernia combined with hemorrhagic shock after severe brain injury.     

载脂蛋白E基因对轻、中型创伤性脑损伤急性期脑电活动的影响

Objective To investigate the influence of apolipoprotein E gene (APOE) polymorphism on the acute-phase brain electrical activity after mild/moderate traumatic brain injury. Methods The clinical data of 112 patients with mild/moderate traumatic brain injury were collected and the APOE genotypes were identified by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). The brain electrical activity in every patient was recorded twice by using electroencephalogram within one week after injury. Qualitative and quantitative methods were used to determine the variations of brain electrical activity. Chi-square test, variance analysis and logistic regression analyses via SPSS version 11.5 were performed among APOE genotypes, electroencephalogram data and clinical data. Results The distributions of APOE genetypes and alleles matched Haldy-Weinberg Law in 112 patients. Of 22 patients with APOEε4, 12 patients (55%) presented with deteriorated electroencephalogram, which was significantly higher than those (16 of 90 patients, 18%) without APOEε4 (P ＜ 0. 01). Comparison of the first and second electroencephalograms demonstrated that the slow waves were increased significantly in patients with APOEε4 ( P ＜ 0. 01 ) but decreased in patients with APOEε2 and APOEε3 (P ＜0.05). The reduction of slow waves in APOEε2 carriers was more obvious than APOEε3 carriers (P ＜0.05). Univariate and multivariate logistic regression analyses showed that APOEε4 was a risk factor to electroencephalogram aggravation after traumatic brain injury. Conclusion APOEε4 is a risk factor to electroencephalogram aggravation during acute stage after mild/moderate traumatic brain injury. However,APOEε2 seems to be beneficial for recovery of brain electrical activity.     

重型颅脑外伤术后癫痫发作58例临床分析

目的探讨重型颅脑外伤术后癫痫发作的原因,预防及治疗应注意的问题。方法对476例重型脑外伤手术后并发癫痫发作的58例患者进行分析,重点对术后的预防用药、易致癫痫发作原因及再次手术问题进行总结。结果476例颅脑外伤术后并发癫痫发作58例,占12.2%,并发癫痫病例大多药物治疗效果好,对难治性癫痫药物无法控制的5例病例经再次手术均取得满意疗效。结论对重型脑外伤手术中的正确处理以及术后恰当的预防性用药等可以降低术后癫痫的发病率、减轻癫痫发作程度。     

飞行员重症恶性疟疾伴并发症一例并文献复习

目的 探讨飞行员重症恶性疟疾的临床诊治及航空医学鉴定. 方法 结合1例飞行员重症恶性疟疾的临床诊断、抢救治疗、康复情况及健康鉴定情况,复习相关文献,对飞行员重症恶性疟疾的临床诊治及医学鉴定进行探讨. 结果 该飞行员有到非洲出访史,临床表现为发热、肝功能不全、急性肾功能衰竭、低血糖、急性溶血性贫血及溶血性尿毒综...     

民航飞行员机械瓣膜置换术后的航空医学鉴定——附病例报告一例

目的 通过分析民航飞行员1例机械瓣膜置换术后病例及文献回顾,以期加强对该病的认识,提高鉴定水平.方法 介绍1例飞行员主动脉瓣机械瓣置换术后的临床资料,分析并探讨该病的医学鉴定方法.结果 该飞行员2年前体检时发现血压脉压差大,超声心动图示左室明显增大,左房增大,主动脉瓣重度返流,左室收缩功能测量值在正常低限的52%.1个月后行主动脉机械瓣置换术.术后1年申请特许鉴定,考虑其血凝控制稳定,心功能良好,在自我认识充分、密切随访和严格的航医监控的前提下特许合格,但不担任机组必需成员,每月飞行不超过50 h.特许合格后安全飞行200 h,未见因医学原因出现的飞行事故或飞行事故征候.结论 民航飞行员机械瓣膜置换术后的航空医学评定应遵循个别评定、风险评估和谨慎的原则,若心功能良好,血凝较为稳定,且控制在可接受范围内,无出血、栓塞的高危因素,预计发生出血、栓塞、卡瓣、瓣膜功能不良等总体风险水平在可接受范围内,在飞行员自我认识充分、密切航医监控、定期专科会诊的前提条件下可给予有限制的特许合格,但仍需密切随访.     

创伤性颅脑损伤患者的长期预后研究

目的 探讨中重度创伤性颅脑损伤 （ traumatic brain injury, TBI）患者康复治疗出院后的长期预后，以及癫痫对长期预后的影响。方法 对102例康复治疗出院的中重度TBI患者进行随访研究。结果 死亡率为2．0％，不良预后发生率为16．7％，继发癫痫者占33．3％。功能独立性程度和就业状况比例失衡。继发癫痫组在GOS、残疾等级量表功能部分（DRS—F）、就业部分（DRS—E）等级和生存质量指数（QLI）评分上与无癫痫组比较，差异均有统计学意义（P〈0．05），继发癫痫者的长期预后相对更差。经Pearson相关性分析，GOS与DRS—F、DRS—E、QLI评分之间的相关性均达到显著性水平。结论　康复治疗后的中重度TBI患者远期死亡率为2．0％，再就业率低，癫痫对远期生活质量有显著影响。应规范TBI急性期和亚急性期的康复体系，为大样本长期预后研究打下基础。     

一例战斗机飞行员硬膜外血肿清除术后随访12年并文献复习

目的 探讨外伤致飞行员硬膜外血肿的诊治方案、预后评估. 方法 结合1例男性战斗机飞行员的临床资料及复习文献,对硬脑膜外血肿的发生、诊治及预后进行综合分析. 结果 原歼-6飞行员,因车祸致头部外伤后昏迷,清醒后感头痛、头昏、恶心和呕吐.头颅CT提示:左颞顶部硬膜外血肿.保守治疗3 h病情加重.复查头颅CT示:左颞顶部硬膜外血肿明显增大.全麻下急诊行左颞顶部硬膜外血肿清除术,经综合治疗,临床治愈出院.出院诊断:重型闭合性颅脑损伤,左颞顶部硬脑膜外血肿,左颞顶骨骨折,头皮血肿.后因脑外伤综合征两次住院治疗.复查头颅CT无异常发现.1年半后停飞,转业到民航,2002年在民航开始参与飞行(副驾)空客及波音系列机型至今已6年,一切正常. 结论 根据外伤史、临床症状及头颅CT检查可明确诊断飞行员硬膜外血肿.及时而合理的治疗有利于病情恢复,并可恢复飞行.     

民航飞行员先天性二叶式主动脉瓣畸形医学鉴定的探讨——附二例病例报告

目的 分析民航飞行员先天性二叶式主动脉瓣畸形的航空医学意义,探讨民用航空医学体检鉴定的政策、标准、方法和措施,提高体检鉴定水平.方法 报告2例民航飞行员先天性二叶式主动脉瓣畸形的临床资料,分析其发病特点;检索并借鉴国外航空医学的处置政策及具体方法,对我国民用航空医学的体检鉴定提出意见和建议.结果 确诊2例飞行员先天性二叶式主动脉瓣畸形,无任何临床症状,无明显血流动力学改变的临床证据,亦不具备介入和（或）手术治疗的临床指征.根据我国现行民航飞行人员体检鉴定标准,仅可按特许鉴定方案进行体检鉴定;两例飞行员特许鉴定合格后,分别恢复飞行3个月和13个月,飞行耐力良好,未见因医学原因出现的飞行事故或飞行事故征候.结论 民航飞行员先天性主动脉瓣畸形的航空医学评定应遵循个别评定、风险评估和谨慎的原则,若无症状、无血流动力学改变的临床证据、不具备介入治疗或手术治疗的指征等,总体风险水平在可接受范围内.在飞行员自我认识、密切航医监控、定期专科会诊的前提条件下可给予特许合格,或考虑授权航空体检医生进行协助特许体检鉴定.     

民航飞行员先天性二叶式主动脉瓣畸形医学鉴定的探讨——附二例病例报告

目的 分析民航飞行员先天性二叶式主动脉瓣畸形的航空医学意义,探讨民用航空医学体检鉴定的政策、标准、方法和措施,提高体检鉴定水平.方法 报告2例民航飞行员先天性二叶式主动脉瓣畸形的临床资料,分析其发病特点;检索并借鉴国外航空医学的处置政策及具体方法,对我国民用航空医学的体检鉴定提出意见和建议.结果 确诊2例飞行员先天性二叶式主动脉瓣畸形,无任何临床症状,无明显血流动力学改变的临床证据,亦不具备介入和(或)手术治疗的临床指征.根据我国现行民航飞行人员体检鉴定标准,仅可按特许鉴定方案进行体检鉴定;两例飞行员特许鉴定合格后,分别恢复飞行3个月和13个月,飞行耐力良好,未见因医学原因出现的飞行事故或飞行事故征候.结论 民航飞行员先天性主动脉瓣畸形的航空医学评定应遵循个别评定、风险评估和谨慎的原则,若无症状、无血流动力学改变的临床证据、不具备介入治疗或手术治疗的指征等,总体风险水平在可接受范围内.在飞行员自我认识、密切航医监控、定期专科会诊的前提条件下可给予特许合格,或考虑授权航空体检医生进行协助特许体检鉴定.     

Agricultural pilot safety in Australia: a survey

Agricultural flying is one of the most hazardous forms of aviation. The incidence of death and injury among agricultural pilots in Australia is over one hundred times the national average for work-related injury. As with most forms of aviation, the pilot's awareness of and attitude toward risk are important factors in accident prevention. However, it is difficult for others to monitor and regulate agricultural flying activity, and responsibility for safety tends to fall largely on the pilot. A 1988 survey of agricultural pilots in Australia, carried out on behalf of the Civil Aviation Authority, showed that: 1) over 50% regularly exceed regulated flying hours; 2) 90% fly on application when tired; 3) there is a systematic relation between accidents and exposure to risk; 4) pilots perceive the main factor contributing to accidents is the pilot. The practical challenge for aviation medicine is to improve occupational safety by assisting pilots to monitor their own capabilities and performance.     

Spinal injury after ejection in jet pilots: mechanism, diagnosis, followup, and prevention.

In order to contribute to the study of spinal injury after ejection., the author analyzed the results of 100 cases of ejections carried out by military and civil Italian jet pilots in a period of 20 years. Of this group, 47 successfully ejected from aircraft without injury; 11 ejections proved fatal. The remaining 42 pilots sutained vertebral fractures, while 27 sustained other traumatic injuries different from spinal fractures. There were 23 vertebral fractures in 15 pilots and the most frequently affected vertebrae were those of the thoraco-lumbar junction. Analysis was make of the pathology, the clinical and radiological profiles, the therapeutic treatment, and the relative aeromedico-legal aspects concerning the temporary unfitness for flying or permanent grounding of the personnel as well as the possible prevention of spinal injury after ejection     

31P NMR characterization of graded traumatic brain injury in rats

Irreversible tissue injury following central nervous system trauma is believed to result from both mechanical disruption at the time of primary insult, and more delayed "autodestructive" processes. These delayed events are associated with various biochemical changes, including alterations in phosphate energy metabolism and intracellular pH. Using 31P NMR, we have monitored the changes in phosphorus energy metabolism and intracellular pH in a single hemisphere of the rat brain over an 8-h period following graded, traumatic, fluid percussion-induced brain injury. Following trauma the ratio of phosphocreatine to inorganic phosphate (PCr/Pi) declined in each injury group. This decline was transitory with low injury (1.0 +/- 0.5 atm), biphasic with moderate (2.1 +/- 0.4 atm) and high (3.9 +/- 0.9 atm) injury, and sustained following severe injury (5.9 +/- 0.7 atm). The initial PCr/Pi decline in the moderate and high injury groups was associated with intracellular acidosis; however, the second decline occurred in the absence of any pH changes. Alterations in ATP occurred only in severely injured animals and such changes were associated with marked acidosis and 100% mortality rate. After 4h, the posttraumatic PCr/Pi ratio correlated linearly with the severity of injury. We suggest that a reduced posttraumatic PCr/Pi ratio may be indicative of altered mitochondrial energy production and may predict a reduced capacity of the cell to recover from traumatic injury.