标准大骨瓣减压术治疗重型颅脑损伤合并脑疝

探讨标准大骨瓣减压术在重型颅脑损伤合并脑疝治疗中的应用价值。标准组选择重型颅脑损伤合并脑疝56例,采用标准大骨瓣减压术;常规组选择前期重型颅脑损伤合并脑疝75例,采用常规颞顶部去骨瓣减压术。两组间疗效评分采用伤后半年时GOS评定。结果表明,标准大骨瓣减压术治疗重型颅脑损伤合并脑疝,可改善患者预后,降低死亡率。     

标准大骨瓣开颅减压治疗重型颅脑损伤80例临床分析

目的:探讨标准大骨瓣减压手术治疗重型颅脑损伤的疗效。方法:回顾性分析80例行标准大骨瓣开颅减压治疗的重型颅脑损伤患者的临床资料。结果:术后6~18个月,采用格拉斯哥预后标准(GCS)评估:良好36例(45%),中残10例(12.5%),重残6例(7.5%),植物生存2例(2.5%),死亡26例(31.25%)。结论:标准大骨瓣术式清除血肿彻底,减压充分,可改善重型颅脑损伤患者的预后。     

改良去大骨瓣减压术治疗重型颅脑损伤52例临床分析

目的：探讨改良去大骨瓣减压术在临床上治疗重型颅脑损伤的疗效．方法：回顾性分析我科自2010年7月~2012年10月以来52例重型颅脑损伤患者采用单侧改良去大骨瓣减压术的预后及其并发症．结果：术后恢复良好者19例,中残11例,重残5例,植物人生存4例,死亡13例,总预后不良率42．31％．结论：改良去大骨瓣减压术具有骨窗范围大。脑挫裂伤灶显露好,更有利于清除颅内血肿及损伤的大脑半球、侧裂血管的减压,能有效降低颅内压、解除脑疝,从而达到改善预后、减少并发症、提高病人生存质量的目的．在临床急重型颅脑损伤患者的治疗中应用广泛,疗效确切．     

去骨瓣减压术在重度颅脑损伤中的应用

目的：评估去骨瓣减压术对重度颅脑损伤患者的治疗作用。方法：回顾性地研究了接受去骨瓣减压术的52名患者在去骨瓣减压前后颅内压、CT表现（中线移位,脑室的大小,基底池受压）和预后的变化。结果：38名患者（73.1%）在伤后5.1±3.2个小时进行了迅速外科减压;14名患者（26.9%）在伤后49.2±50.1个小时延迟外科减压,去骨瓣减压明显降低了颅内压,减少了中线移位,改善了基底池的受压,进行迅速外科减压的患者比延迟外科减压的患者预后更好。结论：去骨瓣减压术使重度颅脑损伤患者颅内压降低,中线移位和基底池受压明显改善,死亡率下降,对改善患者的预后有利。     

额颞大骨瓣开颅治疗重型颅脑损伤48例分析

目的:评估大骨瓣减压对重型颅脑损伤患者的疗效.方法:采用额颞顶部去大骨瓣加压手术,术后均给与脱水降颅压,营养脑神经,预防感染,营养支持,维持水电解质及酸碱平衡,高压氧等治疗措施.结果:去大骨瓣组存活38例(79.2%),其中恢复良好22例(45.8%),中度残疾9例(18.8),重度残疾5例(10.4%),植物生存2例(4.2%),死亡10例(20.8%)(其中3~5分11例中死亡6例,6~8分37例中死亡4例).结论:对于急性重型颅脑损伤患者实施去大骨瓣减压,能减少死亡率和致残率,提高救治成功率和患者的生存质量.     

颅脑损伤187例死因分析

颅脑损伤在创伤外科中占有重要地位,其死亡率居于首位。我院1972年1月～1987年12月间共收治重型、特重型颅脑损伤516例,死亡187例。死亡率为36.26％。本文着重对其死亡原因及经验教训分析讨论如下:     

老年重型及特重型颅脑损伤33例死因分析

我院近八年来共收治重型及特重型颅脑损伤患者(GCS8分以下)655例,60岁以上老年患者80例,占总数12.2％,死亡33例,占老年患者的41.3％。而衡量治疗效果要综合分析,死亡率高低,仍不失为评价疗效的重要指标之一。现就其死亡原因进行分析讨论。     

去骨瓣减压术治疗脑梗塞所致脑疝

目的探讨大面积脑梗塞所致脑疝的手术指征及手术方法。方法对大面积脑梗塞所致早期天幕疝5例采用额、颞、顶去骨瓣减压术,同时剪开硬脑膜。结果 5例全部存活,随访3-6个月,患肢肌力Ⅱ-Ⅲ级2例,Ⅳ-Ⅴ级3例,不全运动性失语1例,无1例发生癫痫。结论大面积脑梗塞经积极内科治疗后发生早期天幕疝者应积极手术治疗。去骨瓣减压术是救治本病的有效方法。     

脑梗死所致脑疝的外科治疗

目的:探讨大面积脑梗死所致脑疝的手术指征及手术方法.方法:对大面积脑梗死所致早期天幕疝16例采用额、颞、顶去骨瓣减压术,同时剪开硬脑膜.结果:16例全部存活,随访3～6个月,患肢肌力Ⅱ～Ⅲ级5例,Ⅳ～Ⅴ级10例,不全运动性失语1例,无1例发生癫痫.结论:大面积脑梗死经积极内科治疗后发生早期天幕疝者应积极手术治疗.去骨瓣减压术是救治本病的有效方法.     

高龄颅脑外伤病人心电图分析

颅脑损伤后,常引起原来没有或只骨很轻器质性心脏病者心血管系统严重的异常表现即心脑综合症,对处于心血管疾病高危人群的老年人,尤其应重视其颅脑损伤后的心血管系统     

Cerebral infarct in head injury: relationship to child abuse

BACKGROUND: To determine whether CT-detected cerebral infarct in young children is associated more often with abuse or unintentional head injury. METHODS: Retrospective case-control study of injured children under age 6 who had abnormal initial head CT scans and who were admitted to the only Level I pediatric trauma center in Washington State for closed head injury (CHI) from January 1, 1992 to December 31, 1998. RESULTS: Fifteen children developed cerebral infarct after CHI during the 7 year period. These cases were compared to 53 controls (those who did not develop infarct). After adjusting for the presence of SDH and for severity of injury, patients with infarcts were six times more likely to have been abused than patients without infarcts (OR 6.1; 95% CI, 1.02-36.0). CONCLUSIONS: Cerebral infarct after CHI appears to result more frequently from abuse than unintentional injury in young children.     

Estimating the probability of abusive head trauma after abuse evaluation

BackgroundEvidence-based, patient-specific estimates of abusive head trauma probability can inform physicians’ decisions to evaluate, confirm, exclude, and/or report suspected child abuse.ObjectiveTo derive a clinical prediction rule for pediatric abusive head trauma that incorporates the (positive or negative) predictive contributions of patients’ completed skeletal surveys and retinal exams.Participants and Setting500 acutely head-injured children under three years of age hospitalized for intensive care at one of 18 sites between 2010 and 2013.MethodsSecondary analysis of an existing, cross-sectional, prospective dataset, including (1) multivariable logistic regression to impute the results of abuse evaluations never ordered or completed, (2) regularized logistic regression to derive a novel clinical prediction rule that incorporates the results of completed abuse evaluations, and (3) application of the new prediction rule to calculate patient-specific estimates of abusive head trauma probability for observed combinations of its predictor variables.ResultsApplying a mean probability threshold of >0.5 to classify patients as abused, the 7-variable clinical prediction rule derived in this study demonstrated sensitivity 0.73 (95% CI: 0.66-0.79) and specificity 0.87 (95% CI: 0.82-0.90). The area under the receiver operating characteristics curve was 0.88 (95% CI: 0.85-0.92). Patient-specific estimates of abusive head trauma probability for 72 observed combinations of its seven predictor variables ranged from 0.04 (95% CI: 0.02-0.08) to 0.98 (95% CI: 0.96-0.99).ConclusionsSeven variables facilitate patient-specific estimation of abusive head trauma probability after abuse evaluation in intensive care settings.     

Abusive head trauma in young children: characteristics and medical charges in a hospitalized population

OBJECTIVE: To describe the presenting characteristics, hospital course, and hospital charges associated with hospital admissions for head trauma in young children at a regional pediatric trauma center, and to examine whether these factors differ among abused and non-abused subjects. METHOD: Comparative case series study involving a retrospective medical record review of children less than 3 years of age admitted to Children's Hospital of Pittsburgh from January 1, 1995 to December 31, 1999. Subjects (n=377) were identified on the basis of ICD-9-CM codes for head injury. Subjects were classified as abused or non-abused based on standard criteria using information about the type of injuries, the history provided by the caretaker, and physical and radiographic findings. RESULTS: Eighty nine (23.6%) subjects were classified as abused and 288 (76.4%) were classified as non-abused. Abused subjects were more likely then non-abused subjects to be <1 year of age (vs. >1 year of age) (OR: 9.8; 95% CI: 5.0, 19.2), covered by Medicaid (vs. commercial insurance) (OR: 2.8; 95% CI: 1.7, 4.8), and admitted to the ICU (OR: 3.5; 95% CI: 2.1, 5.8; p<.001). The caretakers of abused subjects were more likely to give a history of no trauma or minor trauma compared to the caretakers of non-abused subjects (97% vs. 54%, p<.001). Length of stay was significantly greater for abused subjects versus non-abused subjects (mean: 9.25 days vs. 3.03 days, p<.001). Hospital charges (1999 dollars) were significantly higher for abused (mean+/-SD: 40,082 dollars +/- 58,004 dollars) versus non-abused (mean +/- SD: 15,671 dollars +/- 41,777 dollars) subjects. CONCLUSIONS: These results highlight the differences in the demographics, presenting characteristics and economic impact of abusive head injuries compared to non-abusive head injuries.     

Association of perpetrator relationship to abusive head trauma clinical outcomes

The diagnosis of abusive head trauma (AHT) remains a significant public health problem with limited prevention success. Providing protection from further harm is often challenged by the difficulty in identifying the alleged perpetrator (AP) responsible for this pediatric trauma. The objective of this study was to evaluate demographic and clinical characteristics of children with AHT and the relationship between APs and their victims in a large, multi-site sample. Understanding the AHT risks from various caregivers may help to inform current prevention strategies. A retrospective review of all cases of AHT diagnosed by child protection teams (CPT) from 1/1/04 to 6/30/09 at four children's hospitals was conducted. Clinical characteristics of children with AHT injured by non-parental perpetrators (NPP) were compared to parental perpetrators (PP). There were 459 children with AHT; 313 (68%) had an identified AP. The majority of the 313 children were <1 year of age (76%), Caucasian (63%), male (58%), receiving public assistance (80%), and presented without a history of trauma (62%); mortality was 19%. Overall, APs were: father (53%), parent partner (22%), mother (8%), babysitter (8%), other adult caregiver (5%); NPP accounted for 39% of APs. NPPs were more likely to cause AHT in children ≥1 year (77% vs. 23%, p < 0.001) compared to PP. Independent associations to NPP included: older child, absence of a history of trauma, retinal hemorrhages, and male perpetrator gender. While fathers were the most common AP in AHT victims, there is a significant association for increased risk of AHT by NPPs in the older child, who presents with retinal hemorrhages, in the hands of a male AP. Further enhancement of current prevention strategies to address AHT risks of non-parental adults who provide care to children, especially in the post-infancy age seems warranted.     

Inflicted skeletal trauma: the relationship of perpetrators to their victims

OBJECTIVE: Although inflicted skeletal trauma is a very common presentation of child abuse, little is known about the perpetrators of inflicted skeletal injuries. Studies exist describing perpetrators of inflicted traumatic brain injury, but no study has examined characteristics of perpetrators of inflicted skeletal trauma. METHODS: All cases of suspected child physical abuse evaluated by the child abuse evaluation teams at Vanderbilt University Medical Center (January 1996 to August 2000) and at the Children's Hospital at Denver (January 1996 to December 1999) were reviewed for the presence of fractures. All children with inflicted fractures were entered into the study, and demographic data, investigative data, and identity of perpetrators were collected. RESULTS: There were a total of 630 fractures for 194 patients. The median number of fractures per patient was 2, and the maximum was 31. Sixty-three percent of children presented with at least one additional abusive injury other than the fracture(s). Perpetrators were identified in 79% of the cases. Nearly 68% of the perpetrators were male; 45% were the biological fathers. The median age of the children abused by males (4.5 months) significantly differed from the median age of those abused by females (10 months) (p=.003). CONCLUSION: In the cases where a perpetrator of inflicted fractures could be identified, the majority were men, most commonly the biological fathers. Children injured by men were younger than those injured by women.     

股部外伤致肠系膜下动脉栓塞1例

目的:分析股部刺伤与肠系膜动脉栓塞的关系,为防止临床上今后发生类似误诊提供参考;方法:结合临床误诊病例,联系基础医学理论进行分析并行开腹探查;结果:开腹探查证实该例股部刺伤患者急性腹痛乃因肠系膜下动脉的分支———乙状结肠动脉栓塞、乙状结肠坏死所致;结论:股部外伤,尤其是严重刺伤导致大血管破裂并脂肪组织严重损伤时可能引起其他器官脂肪栓塞。     

Assessment of factors resulting in abuse evaluations in young children with minor head trauma

OBJECTIVE: The primary objective was to determine which of the examined factors prompted physicians to initiate a further abuse evaluation in young children with minor head injury. The recording of important historical elements in the charts of these patients was also evaluated. METHODS: Charts of 349 children less than 3 years of age with minor head injury were retrospectively reviewed. Age, race, sex, insurance status, findings on head CT, mechanism of injury, witnessing of event and delay in seeking care were analyzed for association with performance of skeletal survey and referral to Child Protective Services (CPS). RESULTS: Increased odds of CPS referral and increased odds of obtaining a skeletal survey were associated with positive findings on head CT, delay in seeking care, and unknown mechanism of injury. Despite a known association of age/ambulatory status with abuse, the age of the child was not associated with increased odds of abuse evaluation, and younger age was not associated with increased odds of documenting whether the injury was witnessed or when the injury occurred. Documentation of timing of injury was lacking in 29.2% of the charts. Witnessing of the event was undocumented in 48.7% of cases. CONCLUSION: Clinicians may not be using readily available, important information when considering the initiation of an abuse evaluation in young children. Clinicians seeing acutely injured children may need further education regarding developmental status and its effect on mechanisms of injury and the importance of detailed documentation in cases where abuse is a possible cause of injury. PRACTICE IMPLICATIONS: Historical factors associated with injuries in young children continue to be poorly documented. Increased pediatric training for emergency medicine physicians, clinical protocols for evaluation and documentation of injured children, and regular continuing medical education on child development and its implications on mechanisms of injury for clinicians practicing in acute care settings are needed changes that may bring about improvements.     

Primary prevention of pediatric abusive head trauma: A cost audit and cost-utility analysis

ObjectivesTo obtain comprehensive, reliable data on the direct cost of pediatric abusive head trauma in New Zealand, and to use this data to evaluate the possible cost–benefit of a national primary prevention program.MethodsA 5 year cohort of infants with abusive head trauma admitted to hospital in Auckland, New Zealand was reviewed. We determined the direct costs of hospital care (from hospital and Ministry of Health financial records), community rehabilitation (from the Accident Compensation Corporation), special education (from the Ministry of Education), investigation and child protection (from the Police and Child Protective Services), criminal trials (from the Police, prosecution and defence), punishment of offenders (from the Department of Corrections) and life-time care for moderate or severe disability (from the Accident Compensation Corporation). Analysis of the possible cost-utility of a national primary prevention program was undertaken, using the costs established in our cohort, recent New Zealand national data on the incidence of pediatric abusive head trauma, international data on quality of life after head trauma, and published international literature on prevention programs.ResultsThere were 52 cases of abusive head trauma in the sample. Hospital costs totaled $NZ2,433,340, child protection $NZ1,560,123, police investigation $NZ1,842,237, criminal trials $NZ3,214,020, punishment of offenders $NZ4,411,852 and community rehabilitation $NZ2,895,848. Projected education costs for disabled survivors were $NZ2,452,148, and the cost of projected lifetime care was $NZ33,624,297. Total costs were $NZ52,433,864, averaging $NZ1,008,344 per child. Cost-utility analysis resulted in a strongly positive economic argument for primary prevention, with expected case scenarios showing lowered net costs with improved health outcomes.ConclusionsPediatric abusive head trauma is very expensive, and on a conservative estimate the costs of acute hospitalization represent no more than 4% of lifetime direct costs. If shaken baby prevention programs are effective, there is likely to be a strong economic argument for their implementation. This study also provides robust data for future cost–benefit analysis in the field of abusive head trauma prevention.