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神经外科急诊急救课件

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神经外科 急诊 急救 课件
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As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 哈医大附属四院神经外科哈医大附属四院神经外科 刘晓谦刘晓谦 教授教授 神经外科急诊急救 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 神经外科急诊急救范围 l各种类型颅脑损伤 l脊髓损伤 l出血性脑血管病 蛛网膜下腔出血 脑出血大于 毫升 脑动静脉畸形 AVM l缺血性脑血管病 急性期溶栓 小时内 l急性梗阻性脑积水 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 一 颅脑损伤一 颅脑损伤 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 颅脑损伤是常见的神经外科 急症 常见 交通事故 生产事故 自然灾害 战争等 我科进行 750余例手术其中1 5是外伤 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 颅脑损伤 头皮损伤 颅骨损伤 脑损伤 头皮血肿 头皮裂伤 头皮撕脱伤 线性骨折 凹陷性骨折 继发性脑损伤 原发性脑损伤 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 头皮撕脱伤 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 颅底骨折 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 颅骨凹陷骨折 depressed fracture of skull As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 颅骨凹陷骨折 depressed fracture of skull As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 颅骨凹陷骨折颅骨凹陷骨折 depressed fracture of skulldepressed fracture of skull As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 硬膜外血肿 epidural hematoma As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 硬膜外血肿硬膜外血肿 epidural hematomaepidural hematoma As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 硬膜外血肿钻孔引流术后 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 硬膜下血肿 subdural hematoma As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 颅脑损伤的处理 着重于脑疝的预防和早期发现 特别是颅 内血肿的早期发现和处理 以争取良好的疗效 对原发性脑损伤的处理除了病情观察以外 主要是对已产生的昏迷 高热等疾病的护理和 对症治疗 预防并发症 以避免对脑组织的进 一步损害 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 颅脑损伤的诊断程序 病史 伤情轻重 闭合性或开放性 根据体征和 CT确立诊断 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 病情观察 1 意识 2 瞳孔 3 神经系体征 5 其它 4 生命体征 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester l 昏迷评分 GCS l 根据 睁眼 语言 肢体活动 l l睁眼反应 语言反应 运动反应 l正常睁眼 4 正确回答 5 按吩咐动作 6 l呼唤睁眼 3 错误回答 4 刺痛定位 5 l刺痛睁眼 2 语无伦次 3 刺痛回缩 4 l不能睁眼 1 只能发音 2 肢体屈曲 3 l 不能言语 1 肢体过伸 2 l 无反应 1 l 正常15分 8分以下昏迷 最低3分 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 特殊监测 1 CT检查 2 颅内压监测 3 脑诱发电位 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 脑损伤分级 1 按伤情轻重分级 2 按Glasgow GCS 昏迷评分法 3 按GCS 伤后昏迷时间 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 颅脑损伤现场急救 中国有 抢救一条龙 的说法和做法 而龙头就是第一现场 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 1 对伤者的全身有个判断 查看伤者意识 清楚不清楚 会不会说话 2 查看伤者的血压 脉搏和呼吸 判断有 无休克 呼吸困难等 3 检查胳膊 腿 胸 腹部等 正确搬动 病人 4 要保证伤者的呼吸道通畅 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 呼吸道通畅极为重要 1 清除呼吸道分泌物 2 呕吐是将头转向一侧以免误吸 3 深昏迷者须抬起下颌或留置咽通气道 4 环甲膜穿刺或气管切开 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 治疗脑水肿 预防脑疝 1 甘露醇 速尿 清蛋白 甘油 2 激素 包括地塞米松 ACTH 3 过度换气 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 转运的医院需掌握两个原则 1 就近 抓紧时间 抢救脑外伤 时间 就是生命 2 医院应有急诊CT和神经外科绿色通道 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 颅脑损伤处理原则 轻型 留急诊室观 察 意识 瞳 孔等 24h 颅骨X线片 和头CT 对症处理 中型 留观或住院 观察48 72h 颅骨X线片 和头CT 对症处理 复查CT 做 好手术准备 重型 住院ICU观察 监测 复查 CT 积极对症处理 高颅压 癫痫 等 注意昏迷的护 理和治疗 保 证呼吸道通畅 及时手术 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 手术治疗 1 开放性脑损伤 2 尽早进行清创缝合术 使之成为闭 合性脑损伤 2 闭合性脑损伤 3 针对颅内血肿和重度脑挫裂伤合并 脑水肿引起的颅内压增高和脑疝 其 次为颅内血肿引起的局灶性脑损害 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 手术方式 1 开颅血肿清除术 2 去骨瓣减压术 3 钻孔探查术 4 脑室引流术 5 钻孔引流术 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 对症治疗与并发症处理 高热 躁动 蛛网膜下腔出血 外伤性癫痫 尿崩 消化道出血 急性神经源性肺水肿 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 欧洲成人重型颅脑损伤诊治指南 入院前和入院时处理 记录 恢复和稳定有效 的通气和循环 转院前 必要 时气管 插管 机械辅 助呼吸 高流 量吸 氧预 防低 氧血 症 维 持 血 压 受伤 时间 原 因和 性质 神 经 系 统 状 况 其它伤初步检查 可酌情作头颅 颈椎 骨盆和 其它部位X线检 查 有无胸腹伤 如有低血压应 在转院前处理 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 神经外科处理 病人应转到CT 24h开机 能作快速诊治的神经外科病房 1 对复苏和伤情再评估和处理 2 作排除胸腹部伤等的全面检查 3 尽快作头颅CT和定期复查头颅CT 4 颅内血肿手术 5 ICU监测 6 尽早建立营养支持 7 防止发热 高血糖及其他并发症 8 颅内压监测 积极处理颅内压增高 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 二 脊髓损伤二 脊髓损伤 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 脊髓损伤是脊柱骨折的严重 并发症 由于椎体的移位或碎骨片 突出于椎管内 使脊髓或马尾神经 产生不同程度的损伤 胸腰段损伤 使下肢的感觉与运动产生障碍 称 截瘫 而颈段脊髓损伤后 双上肢 也有神经功能障碍 为四肢瘫痪 简称 四瘫 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 脊髓损伤分类 1 脊髓震荡 2 脊髓挫伤与出血 3 脊髓断裂 4 脊髓受压 5 马尾神经损伤 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 脊髓损伤检查 1 全身检查 2 注意有无复合伤 勿因搬动病人加重 损伤 2 局部检查 局部有压痛 肿胀 畸形及棘突分离 3 神经系统检查 4 辅助检查 X线平片 CT MRI As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 脊髓损伤治疗 1 搬运和转运 脊髓损伤主要是由脊柱骨关节损伤造成的 因 此在搬动和转运中必须保持脊椎骨的原位 切 忌扭曲 故搬运中要保持脊柱固定 使病人卧 硬板床上 头颈部吊带牵引以策安全 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 脊髓损伤治疗 2 一般处理 查明有无胸腹脏器损伤 如果呼吸苦难 宜早气管切开 以便 于减少无效腔和便于吸出气管分泌物 有腹胀者留置胃管 有尿潴留者放置导尿管 辅助人工呼吸及给氧吸入 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 脊髓损伤治疗 3 脊髓损伤的治疗原则 压迫脊髓的骨片 血肿 异物 弹片 一般应 争取早期手术清除 开放性脊髓损伤 火器或白刃伤 应尽早进行 手术清创 并尽可能保存硬脊膜完整或在无感 染的情况下修补硬脊膜 对椎体移位的脊髓断裂伤 亦应进行椎体复位 固定术 以便于将来的功能训练和减轻痛苦 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 三 脑血管病三 脑血管病 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 概 述 血管源性脑部病损的总称 急性脑血管病或脑血管意外 脑卒中 中风 呈急骤发生的脑局部血液循环和神经功能障碍 临床高发病率 死亡率和致残率 颅内动脉 破裂 闭塞 脑梗塞脑出血蛛网膜下腔出血 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 流行病学调查 v中老年人最主要和常见疾病原因之一 v与心血管病 恶性肿瘤成为三大主要死因 v患病率719 10万 v发病率219 10万 年新发120 150万 v死亡率116 10万 年死亡80 100万 v近70 的存活者留有不同程度的偏瘫 失语和痴 呆 致残率高 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 基本要素血管壁 血流动力学 血液流变学三大因素 病理生理 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 脑血管病的基本病理生理改变 血管因素 血液流变学 因素 血流动力学 因素 TIA 脑梗塞 缺血 血管闭塞 出血 血管破裂 混合性中风 动脉硬化 动脉瘤 血管畸形 高血压 低血压 血液病 血粘度改变 RBC变形性 蛛网膜下 腔出血 脑出血 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 出血性脑血管病 n 脑出血 n 蛛网膜下腔出血 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 脑出血 v原发于脑实质内非创伤性出血 形成 颅内血肿 导致局灶性神经功能障碍 v临床上死亡和致残率极高 v主要病因 高血压动脉硬化 v少见病因 血管异常 肿瘤 血液病 v主要部位 基底节 内囊 脑干 小脑 脑叶内 v大脑中动脉分支 豆纹动脉 v与主干呈直角分出 承受压力较大 v供应深部脑组织的穿透支 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 临床特征 v发病年龄 50 70岁 男 女性 v起病状态 激动或活动中发病 v既往史 多有高血压病史 v进展情况 迅速 数小时达高峰 v局灶症状 明显 偏瘫等 v昏迷 颅高压症状突出 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 脑出血的治疗原则 v就地治疗 v防治并发症 v控制高血压 v控制脑水肿 降低颅内压 v手术治疗 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 一般治疗 控制高血压 v保持血压 180 100mmHg v降压不可过速 过低 v密切观察血压的变化和调整头位 床头高度 v过高抬高床头约30度 45度 v正常床头放下 v过低头位放低 v持续过低升压药 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 控制脑水肿 降低颅内压 l20 甘露醇250m1 静脉滴注 30min 每日2 4次 l甘油果糖250 500ml 静脉滴注 每日1 2次 l速尿 20 40mg 静脉注射 每8 12小时 l白蛋白 10 20g 静脉滴注 每日1次 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 手术治疗 1 小脑出血 2 颅内压增高或脑疝早期征象 3 脑叶内血肿或出血性脑梗死 血肿量和部位 1 10ml不手术 2 10 30ml暂不手术 密切观察 3 30ml手术治疗 4 濒死状态抢救治疗 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 问题 止血药物的应用 非常规使用 v对于全身其它部位的出血 特别是合并消化道 出血时 应及时使用止血药物 v对于高血压性脑出血 神经内科不常规使用止 血药物 v对于应用溶栓药物相关的脑出血 必须及时使 用止血药物 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 蛛网膜下腔出血 v临床分类 v自发性SAH v外伤性SAH 多伴发于颅脑外伤 v继发性SAH 脑实质出血破入 v主要病因 v动脉瘤 占SAH的80 前循环多见80 90 v先天性动脉瘤 90 v动脉硬化性动脉瘤 7 v感染性动脉瘤 1 v动静脉畸形 AVM 次之 额顶区多见 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 临床特征 v发病年龄 青壮年多见 35 65岁 v发病情况 起病急骤 数分钟计 v起病诱因 活动用力或激动病史 v局灶神经功能障碍少见 v脑膜刺激表现突出 v短暂意识障碍 一过性 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 临床表现 v突然发生头痛伴呕吐 v一过性意识障碍 v脑膜刺激征 颈项强直 Kernig s 征 v动眼神经麻痹 后交通动脉或小脑上动脉 v眼底检查 玻璃体下出血 v腰穿 C S F呈均匀血性 三管实验 v急诊CT示脑蛛网膜下腔积血 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester SAH的危险性 vSAH再次破裂 复发 v3 4周内易复发 死亡率成倍增长 v脑血管痉挛 引起局灶性脑缺血 v可在3天 1月许发生 与出血量相关 v脑积水 脑脊髓液吸收循环障碍 v发生较晚 1 2周后出现 或与药物相关 如抗纤容类药物 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 实验室辅助检查 vCT 早期有价值 24小时后开始转阴 v脑脊液检查 确定性诊断 但是有风险 vMRI 帮助发现AVM或伴发脑缺血 vDSA 检查病因的主要手段 vTCD 能作为检查血管痉挛手段 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester SAH治疗 治疗目标 v避免SAH再出血 v防治脑血管痉挛和其它并发症 治疗选择 v安静 绝对卧床休息 避免激动 v抗纤溶药物的使用 v脑血管痉挛治疗 v病因治疗 DSA后手术或介入治疗 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 蛛网膜下腔出血的抢救 l l 早期血管造影早期血管造影 7272小时左右小时左右 l l 择期血管造影择期血管造影 3 43 4周后周后 l l 治疗手段治疗手段 发现病因 手术治疗发现病因 手术治疗 或血管内介入治疗或血管内介入治疗 容易发生再次出血 容易发生再次出血 死亡率极高 约死亡率极高 约50 50 发现动脉瘤发现动脉瘤 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 动脉瘤术前CT As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 动脉瘤术前CTA As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 动 脉 瘤 术 前 D S A As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 动脉瘤术后CT As an intern who has just entered kindergarten the following plans have been drawn up for the new semester SAH预后 v病因 出血部位 出血量 v有无再出血 v有无其它并发症 v颅内动脉瘤 首次病死率约30 存 活者2 3要复发 复发死亡率上升 vAVM 急性期病死率约为10 复发 25 单击此处编辑母版标题样式 单击此处编辑母版副标题样式 66 缺血性脑血管病 短暂性脑缺血发作 脑梗塞 死 脑血栓形成 脑栓塞 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 短暂性脑缺血发作 TIA v好发中年以后 男 女 2 1 v短暂 局限性脑功能障碍 v突然发生 消失 数分钟 数十分钟 v24小时缓解 不遗留症状和体征 v1 4 1 5病人发展为完全性脑卒中 另外 可逆性缺血性脑损害 reversible ischemic neurologic deficit RIND As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 短暂性脑缺血发作 TIA 主要病因 主动脉 脑动脉系统的动脉粥样硬化 发病机制 l微栓子学说 栓子进入血管引起小血管闭塞 小且易于溶解 可在眼底动脉发现栓子 l盗血现象 锁骨下动脉管腔狭窄闭塞 上肢动 脉内压力 血液经对侧椎动脉 同侧椎动脉 同侧锁骨下动脉流向上肢 l其它病因 血压低 动脉痉挛 血粘度增加 血液高凝 动脉炎 颈椎病等 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 短暂性脑缺血发作 TIA 临床特征性表现 v颈内动脉系统 一侧视力丧失 单眼黑蒙 一侧肢体无力 感觉障碍 失语 v椎基动脉系统 跌到发作 眩晕 复视 视野缺损 交叉性运动 感觉障碍 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 临床考虑 完全性中风的前兆 意义重大 v检查并积极治疗 纠正 危险因素 v治疗以抗血小板聚集为主 或抗凝治疗 阿斯匹林类药物 低分子肝素 疗效不明确 v外科干预处理 外科手术治疗颈动脉病变 内膜剥离术 神经介入治疗颈动脉狭窄 扩张 支架术 搭桥术 短暂性脑缺血发作 TIA As an intern who has just entered kindergarten the following plans have been drawn up for the new semester l患者 黄 男 73岁 因阵发性视物旋 转1月入院 有高血压病史11年 脑血管 DSA检查提示右侧椎动脉闭塞 左侧椎 动脉狭窄 于左侧椎动脉狭窄处行AMG 支架 4 14mm 置入术 造影显示狭窄 解除 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester As an intern who has just entered kindergarten the following plans have been drawn up for the new semester As an intern who has just entered kindergarten the following plans have been drawn up for the new semester l蒋 男 57岁 右侧肢体麻木 疼痛伴 发作性头昏2年余 头颅MRI提示多发性 腔隙性脑梗塞 DSA检查提示 右侧颈 内动脉起始段 右侧椎动脉起始段 左 侧椎动脉均狭窄 于3处狭窄分别置入 SMART支架 造影显示狭窄消失 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester As an intern who has just entered kindergarten the following plans have been drawn up for the new semester As an intern who has just entered kindergarten the following plans have been drawn up for the new semester As an intern who has just entered kindergarten the following plans have been drawn up for the new semester l梁 男 65岁 脑梗塞患者 行脑血管 DSA检查显示左侧椎动脉狭窄达90 右颈内动脉局限性狭窄 于左椎动脉狭 窄处行球囊扩张术 造影显示狭窄明显 改善 As an intern who has just entered kindergarten the following plans have been drawn up for the new semester As an intern who has just entered kindergarten the following plans have been drawn up for the new semester As an intern who has just entered kindergarten the following plans have been drawn up for the new semester As an intern who has just entered kindergarten the following plans have been drawn up for the new semester As an intern who has just entered kindergarten the following plans have been drawn up for the new semester As an intern who has just entered kindergarten the following plans have been drawn up for the new semester As an intern who has just entered kindergarten the following plans have been drawn up for the new semester As an intern who has just entered kindergarten the following plans have been drawn up for the new semester As an intern who has just entered kindergarten the following plans have been drawn up for the new semester As an intern who has just entered kindergarten the following plans have been drawn up for the new semester 动脉粥样硬化性脑血栓形成 v发病率最高 约占全部中风的 70 80 v常见病因 v动脉粥样硬化 伴有高血压 最多见 v脑动脉炎 梅毒 钩端螺旋体 次之 v结缔组织病 真性红细胞增多症少见 v发生在颅底动脉环 基底动脉 颈动 脉分叉处 As an intern who has just entered kinderg
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