创伤性颅脑损伤常规

进入二线治疗 Tier 1 completed within 120 minutes, if ICP ≥ 20 mmHg/27.2 cm H20 mmHg proceed to Tier 2.
二线治疗 TIER 2
⑴渗透性治疗 HyperOsmolar Therapy ①甘露醇：间断0.25 - 1 gm/kg o Mannitol: intermittent boluses of Mannitol (0.25 - 1 gm/kg body weight). 维持血容量正常（等容） ，低血容量，停止使用甘露醇，每6小时监测 血钠和渗透压，如渗透压大于320，或渗透间隙小于20，停止甘露醇。 Must maintain a euvolemic state. Mannitol may be held if there is evidence of hypovolemia. Must check serum Na and Osmolality every 6 hr and hold additional doses IF serum Osmolality exceeds 320 mOsm/L or Osmolar gap < 20..
glucose is 80-180 mg/dl 。
8. 预防性抗癫痫治疗
Antiseizure prophylGlucocorticoids should not be administered.
10.静脉H2阻滞剂、质子泵抑制剂、硫糖铝预防应激性溃疡
Stress Ulcer Prophylaxis with intravenous H2 blocker, PPI （proton-pump inhibitors）, or sucralfate
压指导脑灌注压的治疗。 ICP monitoring should be highly considered in all patients undergoing emergent surgical procedures (orthopedic repair, etc) in whom a moderate to severe brain injury is suspected (GCS 3-12) to guide appropriate intraoperative Cerebral Perfusion Pressure (CPP) management. 脑室外引流 EVD Management 当ICP>20mmHg5分钟，打开EVD。
intensively avoided
4. 容量复苏—目标 CVP=5-7mmHg(等容）
Volume resuscitation- Target CVP is 5-7 mm Hg (Euvolemia target) TBI 病人推荐监测 CVP，避免高容量增加 ARDS 发生率。 不能因担心脑水肿而限制容量复苏。早期体液复苏用生理盐水，高渗 盐水为二线 渗透性降颅内压的药物。
5. 贫血—目标血红蛋白 ≥ 8 g/dL，Hgb < 8 输血。
Anemia- Target Hemoglobin concentration is ≥ 8 g/dL. Blood transfusion if Hgb < 8
6.凝血病—目标 INR ≤ 1.4，血小板≥ 75 X 103 / mm3 CoagulopathyTarget INR is ≤ 1.4 and platelets of ≥ 75 X 103 / mm3 血小板 < 75 x 103 / mm3， 输血小板； 使用新鲜冰冻血浆（ FFP） ， Vitk, VII因子，精氨酸加压素，凝血酶原复合物等纠正凝血病。 7.代谢监测—目标 Na = 135-145 mmol/L，高渗盐水治疗Na+ ： 145-160 mmol/L. 血糖 80-180 mg/dl ，Q6h测血糖。 Metabolic monitoring: Goal Na = 135-145 mmol/L; HTS therapy Na+ Range 145-160. Target glucose is 80-180 mg/dl 。 Target
②高渗盐水： bolus 3% NaCl 钠，血钠>160 mEq/L. 停用。
250 cc ，30分钟。 每6小时监测血
o Hypertonic saline: boluses of 3% NaCl (250 cc over ½ hour) or other concentrations (e.g. 23.4% - 30 cc) may be used. Must check Serum Na and Osmolality every 6 hr and hold additional doses if the serum sodium exceeds 160 mEq/L. ⑵目标PCO2 30 - 35 mmHg, PCO2 goal 30 - 35 mmHg, as long as brain hypoxia is not encountered ⑶肌松药： Neuromuscular paralysis: pharmacologic paralysis with a continuous infusion of a neuromuscular blocking agent should be employed if the above measures fail to adequately lower the ICP and restore CPP. Titrate infusion to maintain at least two twitches (out of a train of four) using a peripheral nerve stimulator. Adequate sedation must be utilized if
TBI ）治疗常规 创伤性颅脑损伤（ 创伤性颅脑损伤（TBI TBI）治疗常规
Management Guidelines for TBI
1.气管插管：
GCS ≤ 8 需气管内插管，丙泊酚镇静 Intubate for GCS ≤ 8. Propofol is strongly preferred for sedation.
monitoring and drainage is to leave the ICP device to the transducer for continuous monitoring and to drain only for elevations above the threshold (20 mm/Hg). When ICP is ≥ 20, the drain should be opened and allowed to drain to 10 cmH2O, then returned to the transducer. ⑷甘露醇— 0.25-1.0g/kg; IV Mannitol – 0.25-1.0g/kg; IV bolus x 1 dose. 一线治疗在120分钟内完成，如ICP≥ 20 mmHg/27.2 cm H20 mmHg，
11. 深静脉血栓预防：<72小时内。
DVT Prophylaxis.
12. 需呼吸机治疗的病人及早气管切开。
Early Tracheostomy is recommended in ventilator dependent
patients.
13.营养：72小时肠内营养。
Nutrition. Start w/in 72 hours via gastric or enteral route .
2. 氧合/通气—目标：
PaO2 ≥ 100mmHg a; O2 Sat ≥ 90%; Goal PCO2=35-45 mm Hg 持续给氧，插管病人监测：ETCO2。 非插管病人监测SPO2 早期避免过度通气，禁止预防性过度通气。 治疗性过度通气只用于对于急性脑疝及难治性高颅内压引起神经症 状恶化时 Oxygenation/Ventilation – TARGET PaO2 ≥ 100mmHg and O2 Sat ≥ 90%; Goal PCO2=35-45 mm Hg ，Use Continuous O2 , End-tidal CO2 (ETCO2) for intubated and pulse oximetry for un-intubated patients. Avoid hyperventilation during initial resuscitation. Prophylactic hyperventilation is prohibited. Therapeutic hyperventilation only for acute neurological deterioration due to brain herniation or for refractory↑ ICP . 3.血压—目标血压
颅内高压的治疗 一线治疗 TIER 1
⑴头部抬高30度 Head of patient’s bed to be placed at ≥ 30 degrees. ⑵ 镇静与止痛：丙泊酚、芬太尼 Sedation and analgesia using recommended agents (propofol, fentanyl, and versed) in intubated patients. Pain relief and sedation are appropriate initial modalities for treatment of intracranial hypertension. ⑶脑室外引流- ICP监测装置连接传感器持续监测ICP，当ICP ≥ 20 mmHg 持续 ≥ 5min. 引流10 cmH2O。 Ventriculostomy - EVD drain; drain to 10 cmH2O for ICP ≥ 20 mmHg sustained for ≥ 5min. The preferred method for ICP
收缩压 100-180mmHg . MAP≧80mmHg,CPP ≥ 60 mm Hg. 生理盐水输注达目标血压,必须避免 SBP<90mmHg Blood Pressure- Target Systolic Blood Pressure (SBP) is 100-180 mm Hg, MAP ≥ 80 mm Hg, CPP ≥ 60 mm Hg. Normal Saline is preferred to achieve target SBP . SBP < 90 mmHg should be
高颅内压治疗
Management of Increased Intracranial Pressure
颅内压监测指征： 1.有颅内高压症状和体征或GCS ≤ 8 的病人需脑室监测颅 内压。 All patients with signs and symptoms of increased intracranial pressure (ICP) and/or GCS ≤ 8 should receive a ventriculostomy for ICP monitoring. 2.尽管CT结果正常，但有下列两项或以上者： � 年龄大于40 � 体态异常-单侧或双侧。 � 收缩压小于100 mmHg ICP monitoring should additionally be considered for those patients with a normal admission CT scan of the brain if two or more of the following criteria are met: •age over 40 years •unilateral or bilateral motor posturing •systolic blood pressure < 100 mmHg 3.对可疑 TBI（GCS 3-12 ）病人做急诊手术（骨折等） ，应监测颅内
CVP monitoring is recommended in all patients with severe TBI requiring EVD or intubation. •Avoid hypervolemia due to increased incidence of ARDS. •Do not withhold volume resuscitation for concerns of cerebral edema. •Initial resuscitation fluid should be NS. Hypertonic saline is only a secondary osmotic agent for ICP control.