每日一题_2022.09.28

A 28-year-old man is admitted to the neurologic ICU for management of severe traumatic brain injury sustained in a motorcycle accident in which he was not wearing a helmet. On admission, vital signs are: blood pressure 158/98 mm Hg, heart rate 128 beats/min, respiratory rate 22/min (overbreathing the ventilator), temperature 37.8°C (100.4°F). Glasgow Coma Scale score is 6. An external ventricular drain (EVD) is placed for intracranial pressure (ICP) monitoring. ICP is 28 mm Hg and remains elevated for 30 minutes. The patient’s head is elevated, and he receives IV fentanyl and propofol for analgosedation.

Which of the following is the next step in this patient’s management?

A. Immediate pentobarbital coma

B. Immediate hypothermia to 33°C

C. Neurosurgical evaluation for bifrontal hemicraniectomies

D. Draining cerebrospinal fluid via EVD

E. No further intervention

答案解析：

脑外伤基金会指南鼓励通过脑室外引流 (EVD) 进行颅内压 (ICP) 监测，促进脑脊液引流以控制ICP。低温、半颅骨切除术和 ICP 监测在创伤性脑损伤 (TBI) 中的作用最近受到3项前瞻性随机对照试验的挑战。在 EuroTHERM 研究中，患者接受 IV 戊巴比妥与低温方案治疗难治性颅内高压。低温组总体远期疗效更差。该研究受到批评，因为低温患者在随机化前未接受高渗或高渗盐水，达一定程度的选择偏倚。在 DECRA 研究中，重度 TBI 患者被随机分配接受药物治疗与双额叶半颅骨切除术。手术组远期疗效更差。该研究受到批评，因为手术组患者在随机化前可能患有小脑幕切迹疝（颅神经或瞳孔反射异常）。最后，在 BEST-TRIP 研究中，南美洲重度 TBI 患者被随机分配接受 ICP 监测与临床监测方案。组间结局无差异。该研究受到批评，因为人口和医疗系统的差异，这使得很难将结果推广到更先进的医疗系统，其中院前和院后护理可能更积极。

正确答案：D