Management dilemma in penetrating head injuries in comatose patients: Scenario in underdeveloped countries.
Management dilemma in penetrating head injuries in comatose patients: Scenario in underdeveloped countries.
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DOI：
10.4103/2152-7806.99930
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发表时间：
2012
影响因子：
--
通讯作者：
Nizami FA
中科院分区：
文献类型：
--
作者：
Wani AA;Ramzan AU;Dar TI;Malik NK;Khan AQ;Wani MA;Alam S;Nizami FA
对脑损伤最小的患者的最佳管理一直是有争议的问题，特别是当患者神经系统状况不佳时。这在神经外科服务有限和患者流动率与可用资源不成比例的地区很重要。我们的目的是确定积极管理的有效性，昏迷患者后穿透导弹脑损伤。所有枪伤或爆炸伤的患者，如果他们在最初复苏后格拉斯哥昏迷评分低于8分，并且没有其他可以解释其神经系统状况差的损伤，则纳入其中。急诊手术的指征是有肿块病变引起明显肿块效应的证据；否则，则延迟清创。不手术的患者为不可逆休克或颅内小颗粒且无明显头皮损伤的患者。格拉斯哥预后评分为1、2或3分的患者被归类为不良预后（UO），评分为4和5分的患者被归类为良好预后（FO）。手术治疗13例，保守治疗13例。预后良好的患者特点为年轻(OR = 28, P = 0；031)，血流动力学正常（OR = 18, P = 0.08），瞳孔反应（OR = 9.7, P = 0.1），损伤仅局限于一个半球（OR = 15, P = 0.07）。复苏后休克的患者全部死亡，而血液动力学状态正常的患者有25%的预后良好。在资源有限的发展中国家，在遭受穿透性导弹伤害后处于昏迷状态的患者，如果伴有双脑损伤、不可逆休克或双侧无反应瞳孔扩大，则不应进行积极治疗。这在接收许多具有相同类型损伤的患者的情况下尤其重要。
The optimal management of patients with minimal injury to brain has been a matter of controversy and this is especially intensified when the patient has a poor neurological status. This is important in the regions where neurosurgical services are limited and patient turnover is disproportionate to the available resources. We aimed to determine the effectiveness of aggressive management in coma patients after penetrating missile injuries of the brain. All the patients of gunshots or blast injuries were included if they had a Glasgow Coma Scale score of less than 8 after initial resuscitation and had no other injury that could explain their poor neurological status. The indication for emergency surgery was evidence of a mass lesion causing a significant mass effect; otherwise, debridement was done in a delayed fashion. The patients who were not operated were those with irreversible shock or having small intracranial pellets with no significant scalp wounds. The patients who had a Glasgow outcome score of 1, 2, or 3 were classified as having an unfavorable outcome (UO) and those with scores 4 and 5 were classified as having a favorable outcome (FO). We operated 13 patients and the rest 13 were managed conservatively. The characteristics of the patients having a favorable outcome were young age (OR = 28, P = 0 .031), normal hemodynamic status (OR = 18, P = 0.08), presence of pupillary reaction (OR = 9.7, P = 0.1), and injury restricted to one hemisphere only (OR = 15, P = 0.07). All of the patients who were in shock after resuscitation died while 25% of the patients with a normal hemodynamic status had a favorable outcome. In developing countries with limited resources, the patients who are in a comatose condition after sustaining penetrating missile injuries should not be managed aggressively if associated with bihemispheric damage, irreversible shock, or bilateral dilated nonreacting pupils. This is especially important in the event of receiving numerous patients with the same kind of injuries.