John Murtagh

John Murtagh.澳大利亞John Murtagh全科病案研究(四十七)——一位62歲男病人酒后頭部損傷[J].中國(guó)全科醫(yī)學(xué)，2013，16(6)：1827-1828.[www.chinagp.net]

譯者按：在病人接受醫(yī)院的急癥和急救服務(wù)前，全科醫(yī)生可能是首先接觸緊急狀態(tài)病人的醫(yī)生。創(chuàng)傷昏迷是常見(jiàn)的緊急狀態(tài)之一，通常病人無(wú)法通過(guò)語(yǔ)言交流來(lái)闡述病情，醫(yī)生可以通過(guò)間接的信息來(lái)源，并借助神經(jīng)學(xué)檢查，如格拉斯哥昏迷量表，來(lái)初步判斷損傷的部位和嚴(yán)重程度，以便及時(shí)處理和轉(zhuǎn)送病人。

1　病史

張某是一位62歲的男性病人，他的幾個(gè)朋友把他送到急診室。他喝得爛醉，可能是摔倒在人行道上受傷了。在他摔倒受傷前，他找人吵架，還跟兩個(gè)年輕人打起來(lái)了。他的朋友跟你說(shuō)，張某以前是一個(gè)很和藹可親和聰明的公務(wù)員，不過(guò)他很喜歡豪飲，特別是啤酒和烈酒。朋友們現(xiàn)在最擔(dān)心的是，張某一反常態(tài)，思維混亂，而且不能正常地走路。在他跌倒前大約1個(gè)小時(shí)，張某還在跟朋友交談，開(kāi)始的時(shí)候談得還算正常，可是他逐漸地變得越來(lái)越煩躁，容易生氣，語(yǔ)無(wú)倫次，讓人無(wú)所適從。

2　體檢

張某看上去病得不輕。主要是表面上的擦傷，不過(guò)他渾身散發(fā)濃烈的酒氣。他說(shuō)話語(yǔ)無(wú)倫次、含糊不清、雜亂無(wú)章。他的頭皮有一處撕裂，左側(cè)面部、頸部和雙臂有挫傷。

他的生命體征：脈搏64次/min，血壓140/90 mm Hg(1 mm Hg=0.133 kPa)，呼吸14次/min。他當(dāng)時(shí)的狀況無(wú)法進(jìn)行心理狀態(tài)測(cè)驗(yàn)。他對(duì)口令不做出反應(yīng)，比如讓他睜開(kāi)雙眼。在他耳邊大聲問(wèn)話，他嘴里嘟嘟囔囔的不知道在說(shuō)什么。不過(guò)他對(duì)疼痛刺激(在眉弓上電刺激)有反應(yīng)，他會(huì)睜開(kāi)雙眼，躲開(kāi)刺激。

3　提問(wèn)

3.1你懷疑這個(gè)病人有哪些問(wèn)題?

3.2根據(jù)對(duì)他意識(shí)狀態(tài)的客觀評(píng)價(jià)〔a 根據(jù)5個(gè)意識(shí)程度的分類；b 根據(jù)格拉斯哥昏迷量表(Glasgow coma scale)〕，你的初步結(jié)論是什么？

3.3你考慮要做哪些輔助檢查?

4　解答

4.1你應(yīng)該考慮這個(gè)病人有顱內(nèi)占位性病變，特別是硬膜外血腫或硬膜下血腫。

4.2a：簡(jiǎn)化的意識(shí)程度分類包括5個(gè)等級(jí)。(1)意識(shí)清醒：病人保持清醒的意識(shí)；(2)意識(shí)混濁：病人的思維混亂；(3)神志不清：病人對(duì)搖動(dòng)和喊叫有反應(yīng)；(4)輕度昏迷：病人對(duì)疼痛有反應(yīng)；(5)昏迷狀態(tài)：病人對(duì)任何刺激沒(méi)有反應(yīng)。張某屬于第4級(jí)，即輕度昏迷。b：格拉斯哥昏迷量表有三個(gè)標(biāo)準(zhǔn)，最高評(píng)分15分，最低評(píng)分3分。張某得分為8分，提示應(yīng)該采用腦傷圖對(duì)他進(jìn)行嚴(yán)密監(jiān)測(cè)(注：也可以采用其他的昏迷評(píng)估量表)。(1)睜眼(4～1分)：張某為2分(疼痛時(shí)睜眼)；(2)語(yǔ)言反應(yīng)(5～1分)：張某為3分(回答含糊不清)；(3)搖動(dòng)反應(yīng)(6～1 分)：張某為3分(對(duì)疼痛刺激有反應(yīng))。

4.3需要做的輔助檢查包括：(1)CT或核磁共振掃描(如果沒(méi)有這些設(shè)備，可以做X線檢查)；(2)血糖和血酒精濃度檢查；(3)脈搏血氧飽和度；(4)尿藥物篩查。

5　進(jìn)一步的臨床細(xì)節(jié)

醫(yī)院對(duì)張某進(jìn)行嚴(yán)密的觀察。30 min內(nèi)，護(hù)士報(bào)告說(shuō)他發(fā)出一些讓人聽(tīng)不懂的聲音，而且對(duì)疼痛刺激的反應(yīng)很小。體檢發(fā)現(xiàn)，左側(cè)眼瞳孔收縮。生命體征：脈搏55次/min，血壓160/100 mm Hg，呼吸9次/min。

6　進(jìn)一步的提問(wèn)

現(xiàn)在最應(yīng)該采取什么行動(dòng)?

7　對(duì)進(jìn)一步提問(wèn)的解答

很明顯，張某的顱腔內(nèi)有占位性病變，很可能是急性硬膜外血腫。這需要實(shí)行外科引流減壓手術(shù)，以挽救他的生命。需要在受傷的頭顱部位鉆孔。如果你沒(méi)有足夠的技術(shù)和設(shè)備做這種手術(shù)，則應(yīng)該立即把病人轉(zhuǎn)到緊急外科中心。

·WorldGeneralPractice/FamilyMedicine·

1　History

ZX,a 62 year old man,was brought into the emergency room by his friends because he was intoxicated from alcohol and had sustained injuries from a fall onto the footpath.Prior to this he had been argumentative and had a fight with two younger men.According to his friends he was a very pleasant and clever public servant but had a history of binge drinking of beer and spirits.Now they were most concerned about him since he had become uncharacteristically confused and unable to walk normally.About an hour previously and soon after his fall he had been conversing with them and seemed well orientated but gradually became irritable,confused and disorientated.

2　Examination

On examination he looked unwell,had superficial injuries and smelt of alcohol.His speech was incoherent as it was slurred and garbled.He had lacerations to the scalp,a bruise of the left side of the head,neck and both arms.

His vital signs were pulse 64/min regular,BP 140/90 mm Hg.Respiration 14/min.It was not possible to perform a mental state examination.He would not respond to verbal commands on request including opening his eyes.He would mumble inappropriate words in response to shouting in his ear.However in response to painful stimuli(digital pressure over the supraorbital ridge) he would open his eyes and withdraw from the pain.

3　Questions

3.1What particular conditions in this man would you be concerned about?

3.2In objective assessment of his conscious state what would be your description of a.the classification according to the 5 conscious levels；b.the Glasgow coma scale(if applicable).

3.3What investigations would you consider?

4　Answers

4.1You should be concerned about an intracranial space occupying lesion such as an extradural haematoma(in particular) or a subdural haematoma.

4.2a.The simplified classification of conscious levels is consciousness(awake),clouded consciousness(confused),stupor(responds to shake and shout),semi comatose(responds to pain) and coma(unresponsive).ZX is level 4-semi comatose.b.The Glasgow coma scale(15 to 3) has three criteria.(1)Eye opening(4 to 1)ZX scores 2(eyes open to pain).(2)Verbal response(5 to 1)ZX scores 3(inappropriate words).(3)Motor response(6 to 1)ZX scores 3(withdraws from painful stimuli).The total Glasgow coma score for ZX is 8/15 which equates to taking care and monitoring closely with a head injury chart′.

Note:Readers may use another and perhaps better coma assessment scale.

4.3Investigations to consider include:(1)imaging-CT or MRI scan(plain X ray if these unavailable).(2)blood sugar and alcohol.(3)pulse oximetry.(4)urine drug screen.

5　Further clinical details

ZX was placed under careful observation.Within 30 minutes the observing nurse reported that he was now making incomprehensible sounds and there was minimal response to painful stimuli.Examination of the eyes revealed a constricted pupil on the left side.His vital signs were pulse 55/min,BP 160/100 mm Hg.Respiration 9/min.

6　Further question

What would be the most appropriate course of action?

7　Answer of further question

ZX obviously has a space occupying mass in his skull,probably an acute extradural haematoma.It demands decompression with surgical drainage as a life saving procedure.This is achieved via a burr hole at the location of the trauma.Immediate referral to an emergency surgical centre is mandatory assuming that you do not have the necessary skills and equipment to perform this procedure.