小児重症頭部外傷治療アルゴリズム：Second tier therapy

出典
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1: Management of Pediatric Severe Traumatic Brain Injury: 2019 Consensus and Guidelines-Based Algorithm for First and Second Tier Therapies.
著者: Patrick M Kochanek, Robert C Tasker, Michael J Bell, P David Adelson, Nancy Carney, Monica S Vavilala, Nathan R Selden, Susan L Bratton, Gerald A Grant, Niranjan Kissoon, Karin E Reuter-Rice, Mark S Wainwright
雑誌名: Pediatr Crit Care Med. 2019 Mar;20(3):269-279. doi: 10.1097/PCC.0000000000001737.
Abstract/Text: OBJECTIVES: To produce a treatment algorithm for the ICU management of infants, children, and adolescents with severe traumatic brain injury.
DATA SOURCES: Studies included in the 2019 Guidelines for the Management of Pediatric Severe Traumatic Brain Injury (Glasgow Coma Scale score ≤ 8), consensus when evidence was insufficient to formulate a fully evidence-based approach, and selected protocols from included studies.
DATA SYNTHESIS: Baseline care germane to all pediatric patients with severe traumatic brain injury along with two tiers of therapy were formulated. An approach to emergent management of the crisis scenario of cerebral herniation was also included. The first tier of therapy focuses on three therapeutic targets, namely preventing and/or treating intracranial hypertension, optimizing cerebral perfusion pressure, and optimizing partial pressure of brain tissue oxygen (when monitored). The second tier of therapy focuses on decompressive craniectomy surgery, barbiturate infusion, late application of hypothermia, induced hyperventilation, and hyperosmolar therapies.
CONCLUSIONS: This article provides an algorithm of clinical practice for the bedside practitioner based on the available evidence, treatment protocols described in the articles included in the 2019 guidelines, and consensus that reflects a logical approach to mitigate intracranial hypertension, optimize cerebral perfusion, and improve outcomes in the setting of pediatric severe traumatic brain injury.
Pediatr Crit Care Med. 2019 Mar;20(3):269-279. doi: 10.1097/PCC.000000...

Glasgow Coma Scale（GCS）

英国のグラスゴー大学により発表された意識障害の分類。開眼（E）、言語（V）、運動（M）の3つに分けて記録し、3～15点の13段階の意識レベルで表し、点数が低いほうが意識レベルが悪くなる。
出典
imgimg
1: Severe head injuries in three countries.
著者: B Jennett, G Teasdale, S Galbraith, J Pickard, H Grant, R Braakman, C Avezaat, A Maas, J Minderhoud, C J Vecht, J Heiden, R Small, W Caton, T Kurze
雑誌名: J Neurol Neurosurg Psychiatry. 1977 Mar;40(3):291-8.
Abstract/Text: Methods for assessing early characteristics and late outcome after severe head injury have been devised and applied to 700 cases in three countries (Scotland, Netherlands, and USA). There was a close similarity between the initial features of patients in the three series; in spite of differences on organisation of care and in details of management , the mortality was exactly the same in each country. This data bank of cases (which is still being enlarged) can be used for predicting outcome in new cases, and for setting up trials of management.
J Neurol Neurosurg Psychiatry. 1977 Mar;40(3):291-8.

外傷性クモ膜下出血

クモ膜下出血の頭部CT像。シルビウス溝と脳底クモ膜下槽に血液を認める。

急性硬膜外血腫

典型的には頭蓋骨直下に両凸レンズ型の出血を認める。出血源は中硬膜動脈、ときに後硬膜動脈の断裂によるものがほとんどであるが、まれに静脈洞損傷によるものがある。
出典
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1: Traumatic brain injury.
著者: William Heegaard, Michelle Biros
雑誌名: Emerg Med Clin North Am. 2007 Aug;25(3):655-78, viii. doi: 10.1016/j.emc.2007.07.001.
Abstract/Text: Traumatic brain injury (TBI) is a significant source of morbidity and mortality throughout the world. This article discusses the epidemiology, pathophysiology, and clinical presentations of minor, moderate, and severe TBI. Controversial topics, such as hypertonic saline for increased intracranial pressure, prehospital intubation of patients who have experienced TBI, and the use of recombinant factor VIIa, are addressed.
Emerg Med Clin North Am. 2007 Aug;25(3):655-78, viii. doi: 10.1016/j.e...

急性硬膜下血腫

急性硬膜下血腫の単純CT画像。
右後頭頂部の脳と頭蓋骨の間に半月状の高吸収域を認める（白および黒の矢印）。脳実質内出血の領域（H）も認める。重症頭部外傷の12～29％を占める[1]。
 
参考文献：
  1. Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW, Servadei F, Walters BC, Wilberger JE; Surgical Management of Traumatic Brain Injury Author Group. Surgical management of acute subdural hematomas. Neurosurgery. 2006 Mar;58(3 Suppl):S16-24; discussion Si-iv. Review. PubMed PMID: 16710968.

脳実質内出血

多発性の頭蓋骨陥没骨折と脳実質内出血を伴う重度の外傷性脳損傷

びまん性軸索損傷（DAI）

A：正常頭部CT画像
B：同日MRI画像では深部大脳白質に多数の微小出血（矢印）を認める（びまん性軸索損傷）

急性硬膜外血腫

典型的には頭蓋骨直下に両凸レンズ型の出血を認める。出血源は中硬膜動脈、ときに後硬膜動脈の断裂によるものがほとんどであるが、まれに静脈洞損傷によるものがある。
出典
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1: 著者提供

外傷性クモ膜下出血、脳挫傷

右頭頂部の外傷性クモ膜下出血と左前頭部の巨大な脳挫傷、脳出血、midline shiftを認める。
出典
img
1: 著者提供

急性硬膜下血腫

典型的には頭蓋骨直下に三日月形の出血を認める。出血源は架橋静脈、上矢状静脈洞に入る上行静脈、蝶形頭頂静脈洞、横静脈洞、上錐体静脈洞などに入る下大脳静脈の損傷、脳表の挫傷や裂傷による動静脈の損傷が主である。
aでは左急性硬膜下血腫、bでは右急性硬膜下血腫とともに著明なmidline shiftを認める。
出典
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1: 著者提供

重症頭部外傷の治療アルゴリズム

重症頭部外傷患者に限らず、外傷患者では病院到着前であればJPTECに、病院到着後であればJATECに準じて診察をすすめる。
A、B、Cに重点を置きつつ、病院前では酸素化の維持とともに意識レベルの変化と瞳孔所見に特に注意する（日本では心肺停止患者以外、救命士の気管内挿管が認められていないため）。病院後では気管挿管施行のうえ、ヘルニア徴候があればETCO2を30〜35mmHgを目標に正常補助換気を行う。
 
**：実際は、過換気になり過ぎないように、ETCO2を目標に正常換気が推奨される。

小児重症頭部外傷治療アルゴリズム： First tier therapy

出典
imgimg
1: Management of Pediatric Severe Traumatic Brain Injury: 2019 Consensus and Guidelines-Based Algorithm for First and Second Tier Therapies.
著者: Patrick M Kochanek, Robert C Tasker, Michael J Bell, P David Adelson, Nancy Carney, Monica S Vavilala, Nathan R Selden, Susan L Bratton, Gerald A Grant, Niranjan Kissoon, Karin E Reuter-Rice, Mark S Wainwright
雑誌名: Pediatr Crit Care Med. 2019 Mar;20(3):269-279. doi: 10.1097/PCC.0000000000001737.
Abstract/Text: OBJECTIVES: To produce a treatment algorithm for the ICU management of infants, children, and adolescents with severe traumatic brain injury.
DATA SOURCES: Studies included in the 2019 Guidelines for the Management of Pediatric Severe Traumatic Brain Injury (Glasgow Coma Scale score ≤ 8), consensus when evidence was insufficient to formulate a fully evidence-based approach, and selected protocols from included studies.
DATA SYNTHESIS: Baseline care germane to all pediatric patients with severe traumatic brain injury along with two tiers of therapy were formulated. An approach to emergent management of the crisis scenario of cerebral herniation was also included. The first tier of therapy focuses on three therapeutic targets, namely preventing and/or treating intracranial hypertension, optimizing cerebral perfusion pressure, and optimizing partial pressure of brain tissue oxygen (when monitored). The second tier of therapy focuses on decompressive craniectomy surgery, barbiturate infusion, late application of hypothermia, induced hyperventilation, and hyperosmolar therapies.
CONCLUSIONS: This article provides an algorithm of clinical practice for the bedside practitioner based on the available evidence, treatment protocols described in the articles included in the 2019 guidelines, and consensus that reflects a logical approach to mitigate intracranial hypertension, optimize cerebral perfusion, and improve outcomes in the setting of pediatric severe traumatic brain injury.
Pediatr Crit Care Med. 2019 Mar;20(3):269-279. doi: 10.1097/PCC.000000...

小児重症頭部外傷治療アルゴリズム：Second tier therapy

出典
imgimg
1: Management of Pediatric Severe Traumatic Brain Injury: 2019 Consensus and Guidelines-Based Algorithm for First and Second Tier Therapies.
著者: Patrick M Kochanek, Robert C Tasker, Michael J Bell, P David Adelson, Nancy Carney, Monica S Vavilala, Nathan R Selden, Susan L Bratton, Gerald A Grant, Niranjan Kissoon, Karin E Reuter-Rice, Mark S Wainwright
雑誌名: Pediatr Crit Care Med. 2019 Mar;20(3):269-279. doi: 10.1097/PCC.0000000000001737.
Abstract/Text: OBJECTIVES: To produce a treatment algorithm for the ICU management of infants, children, and adolescents with severe traumatic brain injury.
DATA SOURCES: Studies included in the 2019 Guidelines for the Management of Pediatric Severe Traumatic Brain Injury (Glasgow Coma Scale score ≤ 8), consensus when evidence was insufficient to formulate a fully evidence-based approach, and selected protocols from included studies.
DATA SYNTHESIS: Baseline care germane to all pediatric patients with severe traumatic brain injury along with two tiers of therapy were formulated. An approach to emergent management of the crisis scenario of cerebral herniation was also included. The first tier of therapy focuses on three therapeutic targets, namely preventing and/or treating intracranial hypertension, optimizing cerebral perfusion pressure, and optimizing partial pressure of brain tissue oxygen (when monitored). The second tier of therapy focuses on decompressive craniectomy surgery, barbiturate infusion, late application of hypothermia, induced hyperventilation, and hyperosmolar therapies.
CONCLUSIONS: This article provides an algorithm of clinical practice for the bedside practitioner based on the available evidence, treatment protocols described in the articles included in the 2019 guidelines, and consensus that reflects a logical approach to mitigate intracranial hypertension, optimize cerebral perfusion, and improve outcomes in the setting of pediatric severe traumatic brain injury.
Pediatr Crit Care Med. 2019 Mar;20(3):269-279. doi: 10.1097/PCC.000000...

Glasgow Coma Scale（GCS）

英国のグラスゴー大学により発表された意識障害の分類。開眼（E）、言語（V）、運動（M）の3つに分けて記録し、3～15点の13段階の意識レベルで表し、点数が低いほうが意識レベルが悪くなる。
出典
imgimg
1: Severe head injuries in three countries.
著者: B Jennett, G Teasdale, S Galbraith, J Pickard, H Grant, R Braakman, C Avezaat, A Maas, J Minderhoud, C J Vecht, J Heiden, R Small, W Caton, T Kurze
雑誌名: J Neurol Neurosurg Psychiatry. 1977 Mar;40(3):291-8.
Abstract/Text: Methods for assessing early characteristics and late outcome after severe head injury have been devised and applied to 700 cases in three countries (Scotland, Netherlands, and USA). There was a close similarity between the initial features of patients in the three series; in spite of differences on organisation of care and in details of management , the mortality was exactly the same in each country. This data bank of cases (which is still being enlarged) can be used for predicting outcome in new cases, and for setting up trials of management.
J Neurol Neurosurg Psychiatry. 1977 Mar;40(3):291-8.