The effects of hygiene interventions on the cerebrovascular status of severe closed head injured persons

The cerebrovascular status of 19 severe closed head injured patients was assessed during oral, body, and indwelling catheter care. Heart rates, mean arterial blood pressures, mean intracranial pressures, and cerebral perfusion pressures were recorded at baseline, peak nursing intervention, and 1-minute recovery times. Significant increases (p less than or equal to .05) in the dependent variables were noted at peak intervention; by recovery time these elevated values had returned to baseline levels. Physiologic responses that did not prove clinically significant are discussed to account for the observed changes. Since cerebral perfusion pressures never fell below 50 mm Hg, the three hygiene interventions are procedures considered safe and beneficial to the patient with closed head injury.     

Prevention of secondary brain injury: targeting technology

Use of technology in the management of the severely brain-injured patient has increased over the past decade and can be confusing and overwhelming to the critical care nurse clinicians who are new to the field of neurology. This article will describe normal physiology and cerebral dynamics and potential abnormal physiology encountered after brain injury. The technology reviewed will include intracranial pressure monitoring, cerebral blood flow monitoring and autoregulation, cerebral oxygen consumption and tissue oxygen monitoring, metabolism, sedation, and temperature monitoring. Integration of appropriate technology into patient management will be discussed using a case study to explore the utility of information at the bedside. Recognizing the difficult task of trying to control secondary injury in our patients is the first step to better outcomes. Implementing the use of technology to mitigate the situation must be done with careful consideration and a team approach to achieve the greatest benefit for the patient.     

Dural tear following traumatic spinal cord injury. A delayed complication.

Dural tears with leakage of cerebral spinal fluid into surrounding soft tissues can occur after traumatic spinal cord injury. An unusual case presented in a patient with traumatic paraplegia where the onset was delayed and clinical features were suggestive of autonomic dysfunction. The clinical features, pathophysiology and treatment of this interesting complication following traumatic spinal cord injury are discussed.     

Traumatic bilateral carotid dissection

Traumatic dissection of the carotid artery is an infrequent but serious complication of blunt cranial-cervical injury. The typical patient presents with deficits attributable to cerebral ischemia in the distribution of the affected vascular supply. Key considerations in the clinical picture are a delay in symptom presentation, normal initial computed tomography scans, and potential for concomitant cerebral or visceral injury. Because the initial clinical and diagnostic picture may be normal, it is crucial for emergency physicians to aggressively search for this injury in the presence of blunt cranial trauma. We present an unusual case of bilateral high extracranial carotid dissection secondary to blunt trauma. The pathophysiology of carotid artery trauma, treatment options, and key acute care issues are discussed.     

Head trauma in the child

Head injury, either alone or in combination with multiple injuries, is common in children. Its pattern is different in children compared to adults, with diffuse cerebral swelling rather than localized hematoma being most common. The pathophysiology of pediatric head trauma is not yet clearly elucidated, but may be closely related to changes in the regulation of cerebral blood flow. The initial management and subsequent care of the child with severe brain injury are discussed from a multisystem viewpoint. The prognosis for children with severe head injury seems brighter than for adults, but there are not yet enough data to allow prediction of outcome in any individual case. Efforts to prevent, rather than treat, head injury in childhood are more likely to be beneficial.     

Serum pancreatic enzymes in patients with coma due to head injury or acute stroke

Serum amylase and lipase were measured in 32 patients with cerebral ischemia, 19 with spontaneous cerebral hemorrhage, 15 with head injury and intracranial bleeding, and 22 with head injury without intracranial bleeding; 20 healthy subjects were also studied as controls. Serum pancreatic isoamylase concentrations were assayed in hyperamylasemic sera. The overall incidence of hyperamylasemia was 14% (12 of 88 patients: 4 with cerebral ischemia, 4 with spontaneous cerebral hemorrhage, 1 with head injury and intracranial bleeding, and 3 with head injury without intracranial bleeding). In 4 of the 12 patients the hyperamylasemia was of pancreatic origin: 1 patient with cerebral ischemia, 1 patient with spontaneous cerebral hemorrhage, 1 patient with head injury and intracranial bleeding, and 1 patient with head injury without intracranial bleeding. The incidence of hyperlipasemia was 7% (6 of the 88 patients: 1 patient with cerebral ischemia, 2 with spontaneous cerebral hemorrhage, and 3 with head injury without intracranial bleeding). We conclude that hyperamylasemia is more frequent than hyperlipasemia in patients with an altered state of consciousness due to head injury or stroke and is usually of non-pancreatic origin. This knowledge may save these patients from invasive and costly examinations.     

Traumatic asphyxia complicated by unwitnessed cardiac arrest

We report a case of traumatic asphyxia complicated by unwitnessed cardiac arrest in which the patient has made a good, functional recovery. Traumatic asphyxia is an uncommon clinical syndrome usually occurring after chest compression. Associated physical findings include subconjunctival hemorrhage and purple-blue neck and face discoloration. These facial changes can mimic those seen with massive closed head injury; however, cerebral injury after traumatic asphyxia usually occurs due to cerebral hypoxia. When such features are observed, the diagnosis of traumatic asphyxia should be considered. Prompt treatment with attention to the reestablishment of oxygenation and perfusion may result in good outcomes.     

Pharmacologic considerations in the management of the asphyxiated newborn

The causes of hypoxia and ischemia in the newborn are presented and the possible mechanisms of hypoxic- ischemic cerebral injury discussed in conjunction with the current therapeutic agents used in attempt to minimize neurological sequelae. More recent, non-invasive methods for measuring cerebral injury may allow more accurate assessment of cerebral injury and permit detailed evaluation of various therapies.     

Demyelination and cortical reorganization: functional MRI data from a case of subacute combined degeneration

Although it is accepted that functional changes of the cortex can occur in patients with white matter diseases of the brain and might have an adaptive role in limiting the clinical consequences of subcortical injury, the pathological substrates able to elicit such cortical changes are still unknown. This multiparametric magnetic resonance study of a patient with an early diagnosis of subacute combined degeneration suggests that demyelination alone does not necessarily induce adaptive functional changes of the cerebral cortex.     

颅内压增高患者短时轻度过度通气的观察与护理

目的探讨重型颅脑损伤后的患者使用短时轻度过度通气（HV）的观察与护理。方法2004年5月-2005年12月复旦大学附属华山医院神经外科急救中心收治的重型颅脑外伤的患者31例，使用短期轻度的过度通气治疗，严密观察治疗前后的呼吸指标（PaCO2、PaO2）、颅内压（intracranial pressure，ICP）、平均动脉压（MAP）、脑灌注压（CPP）、意识和瞳孔等动态变化。结果30例患者在使用过度通气1h后，ICP降至20mmHg以下；1例患者出现颅内压反跳性增高，行去骨瓣减压术控制颅内压。31例患者脑灌注压均〉60mmHg。结论 使用短时轻度过度通气可使患者的颅内压下降，通过对呼吸指标、颅内压、脑灌注压的全面仔细观察及护理，有助于保证过度通气的治疗效果，减少因使用过度通气而发生脑缺血加重的并发症。     

颅脑损伤急性期患者血糖监测及护理

目的 探讨颅脑损伤急性期患血糖监测及护理对预防并发症的重要意义。方法 对45例颅脑损伤急性期患血糖增高的原因及不良后果进行分析,并与血糖正常组40例进行比较。结果 血糖增高组患的并发症、死亡率明显高于血糖正常组（P＜0．05）。结论 颅脑损伤急性期患血糖增高提示了病情重、并发症多、预后差、死亡率高,故加强血糖监测及预见性的护理对防止并发症降低死亡率有重要意义。     

Traumatic injuries to the head and spine 2: nursing considerations

Trauma to the central nervous system can have devastating consequences for both the person who sustained the injury and his/her family/loved ones. This article first discusses pathophysiology in relation to altered cerebral haemodynamics and changes that occur after spinal injury. Following on from the underpinning theoretical perspectives, the article reviews the nursing care and management strategies required by patients who have sustained either a traumatic head injury or acute spinal injury, with the aim of controlling secondary injury, which is preventable. This ensures the patient will have the best possible prognosis and outcome.     

Cerebral oxygenation in the traumatically brain-injured patient: are ICP and CPP enough?

Secondary brain injury results in increased morbidity and mortality in the traumatically brain-injured (TBI) patient. Research has shown that prevention of secondary brain injury, as characterized by cerebral ischemia and edema, can improve neurologic outcomes. The standard of care in many facilities is to monitor intracranial pressure and cerebral perfusion pressure as indirect measures of cerebral oxygenation and perfusion and to therefore manage secondary brain injury via these parameters. Yet these may not be the most accurate or reliable measures of cerebral oxygenation. Scientifically, brain tissue oxygenation can be directly measured via the partial pressure of oxygen in brain tissue (PbO2) probe. This provides a rapid, potentially more accurate indicator of cerebral oxygenation, thereby allowing for earlier intervention into the prevention of secondary brain injury.     

高血压脑出血血肿冲洗液去甲肾上腺素动态变化的研究

目的　动态观察高血压脑出血血肿冲洗液去甲肾上腺素 (NE)的变化及其意义。方法　行微创颅内血肿清除术的中、重度 (出血量 >30ml)高血压脑出血患者 6 0例 ,连续监测血肿冲洗液中NE的动态变化。结果　高血压脑出血发病 6小时血肿冲洗液中即已检测出NE ,并于 4 8～ 72小时达高峰值 ,此后逐渐降低。结论　高血压脑出血后出血灶及周边脑组织去甲肾上腺素含量增加 ,并参与其后的病理过程 ,其水平的变化与脑出血的转归有关     

磁共振波谱对创伤性脑损伤后活体脑组织神经生化代谢的即时、动态及客观分析

背景磁共振波谱分析(magnetic resonance spectroscopy,MRS)为脑活体组织代谢物质无创检测技术,可实施长期动态监测,其实验与临床研究结果预示了其良好的应用前景.目的回顾关于磁共振波谱分析原理及对创伤性脑损伤后磁共振波谱分析的实验和临床研究结果,明确创伤性脑损伤后脑组织继发性病理生理改变的神经生化机制.资料来源应用计算机检索Medline1981-01/2003-10的相关文章,检索词"magnetic resonance spectroscopy;braininjury;brain metabolism",并限定文章语言种类为English.同时手工检索<中国临床康复>杂志2003-01/2004-03期间的相关文章,限定文章语言种类为中文,检索词"磁共振波谱".资料选择符合本条件的RCT基础与临床研究文章共33篇.选择关于磁共振波谱分析及创伤性脑损伤与磁共振波谱分析的文献,但不排除是否为盲法论证的文章.资料提炼磁共振波谱分析可反映创伤性脑损伤后活体脑组织代谢物质的动态变化.脑白质代谢物质的变化可反映轴索损伤的情况,脑灰质代谢物质的变化可反映脑挫裂伤损伤的情况.伤后早期脑代谢物质变化主要表现为一致性降低,其降低程度与伤情严重性一致;伤后晚期或恢复期,脑代谢物质浓度逐渐升高,反映了脑组织的修复情况.检测到乳酸往往提示预后不良.局灶性脑损伤与弥漫性轴索损伤伤后pH变化不同.资料综合MRS可超早期发现脑损伤情况,可反映创伤性脑损伤的伤情、伤后脑组织的恢复情况,鉴别可逆性与不可逆性损伤.MRS不仅可检测脑组织的代谢变化,且可检测脑细胞内pH及镁离子的变化,可较全面的反映单位容积内脑组织的代谢变化,且可根据MR影像情况任意选择检测部位.结论磁共振波谱分析技术能够即时、动态及客观的反映创伤性脑损伤后脑内神经生化代谢情况.     

HBOC-201 use in traumatic brain injury: case report and review of literature

BACKGROUND: The first use of HBOC-201 in severe traumatic brain injury (TBI) is presented. The use of noninvasive cerebral oximetric devices to follow clinical progress in a patient infused with HBOC-201 is reported and the literature of hemoglobin-based oxygen carriers (HBOCs) in brain injury is reported.
CASE REPORT: A 21-year-old Jehovah's Witness who was hit and dragged by a motor vehicle was admitted to the University of New Mexico Hospital Level 1 Trauma Center Trauma Surgical Intensive Care Unit with severe TBI and extensive soft tissue loss resulting in profound anemia. The patient received infusion of HBOC-201 with regional and global oximetric monitoring.
RESULTS: Chart abstraction was performed to identify clinically relevant physiologic markers of patient progress. We observed a marked increase in brain tissue oxygen saturations, central venous oxygen saturation, and hemodynamic variables after administration of HBOC-201. The patient subsequently suffered massive cerebral edema and died.
CONCLUSIONS: Major HBOC trials to date have excluded severe TBI. We report the first use of an HBOC in severe TBI to correct profound anemia. The HBOC-201 rapidly corrected cerebral venous and central venous oxygen saturations. The patient's death may have been due to massive reperfusion injury from delayed repayment of cerebral oxygen debt in a severely ischemic brain.     

脑缺血的CT、MRI表现及其理解

缺血性脑损伤是一个很有远见的临床课题,在临床很多种情况下因为多种原因均可以导致脑不同程度的缺血性损伤.以往人们大多关注于CT及MRI有无脑的梗死,或是主攻脑早期梗死的影像学表现,而恰恰忽略了脑缺血的预测性诊断与病变转归以及医疗过程中预防脑缺血性损伤方面的研究.作者以另一种视角研究和讨论多种原因导致的脑缺血性损伤,其目的是引起大家对宏观上的脑缺血性损伤的认识.缺血性脑损伤是一个系统性的病理过程,很多因果关系还不是十分清楚,既有矛盾性,又有统一性,其某些MRI表现与炎性病变、水肿等有很大的相近性或相似性.脑缺血的病理过程是一个进动中的过程,其中枢神经系统的变化也随着这种动态变化而演化.脑梗死仅是脑缺血的一种结局形式,而脑缺血则是脑梗死的前奏.临床工作中遇到很多原因导致的不同程度的缺血性脑损伤,而这种没有以梗死形式表现的脑缺血往往未被临床医师重视和理解.作者拟以常见病症的病例形式,介绍一下脑缺血的多种病因与其各自的MRI表现,并讨论如何对图像进行正确的理解,从而借助影像学的微细变化与征象来预测病变的发生发展,力求将脑缺血的诊断时间窗和治疗时间窗前移,提高患者预后生活质量.     

Delayed carotid shunt occlusion detected by electroencephalographic monitoring

Little has been recorded in the anesthesia literature concerning the changes in the electroencephalogram (EEG) that may occur during carotid endarterectomy many minutes after shunt placement and restoration of flow and that may be attributed to delayed shunt occlusion or cerebral emboli. We describe a patient in whom EEG changes indicative of cerebral ischemia occurred at the time of carotid clamping. The changes resolved promptly after placement of a carotid shunt but recurred 11 minutes later. Because of the EEG changes, the carotid shunt was evaluated and found to have become occluded. EEG monitoring was crucial to the detection of shunt occlusion in the absence of other systemic changes or surgical difficulties. The rapidity and magnitude of the changes in the EEG suggest that, if the occlusion had not been discovered and the patency of the shunt restored, the patient would have been at increased risk for neurologic injury.     

环孢素A对大鼠脑缺血再灌注损伤的保护作用

目的 :探讨环孢素A对脑缺血再灌注损伤的保护作用。方法 :将 10 8只大鼠分为假手术组、对照组和环孢素A组 ,参照Zealonga线栓法制备局灶性脑缺血再灌注损伤模型 ,大鼠脑缺血 2h再灌注 2 2和 70h后 ,分别对各组各时间点大鼠进行行为学评分、脑组织含水量、脑TTC染色和脑超微结构观察 ,并对结果进行统计处理。结果 :各时间点环孢素A组与对照组比较 ,行为学评分优于对照组 (P <0 .0 5 ) ;脑梗死灶体积和脑组织含水量均比对照组明显减轻 (P <0 .0 5 ) ;脑超微结构的异常改变轻于对照组 ;假手术组各项观察指标则无明显异常改变。结论 :免疫因素参与脑缺血再灌注损伤 ;环孢素A对大鼠脑缺血再灌注损伤具有一定的保护作用。