院前早期气管插管对急性重型颅脑损伤患者的临床疗效及预后分析

摘要

Objective To analyze the clinical efficacy and prognosis of prehospital and early endotracheal intubation in patients with acute severe craniocerebral injury.Methods The clinical data of 420 patients with acute severe craniocerebral injury from Jan.2008 to Dec.2014 in our hospital were retrospectively analyzed.Among them 285 were males,135 were females with an average age of 45.3(19-70) years.260 cases were injured from traffic accidents,75 were injured from high falling,64 were injured from strikes and 20 were from other injuries.According to the timing of tracheal intubation,these patients were divided into the early tracheal intubation group (within 2 hours,191 cases) and delayed tracheal intubation group (more than 2 hours,229 cases).Before intubation,1d and 3d after intubation,the changes of blood gas parameters and intracranial pressure were analyzed,and the incidence of pulmonary infection,mortality and activities of daily living (ADL) grade for six months were compared.Results Compared with before tracheal intubation,the levels of arterial oxygen pressure (PaO2),oxygen saturation (SpO2) at 1d and 3d after intubation were significantly increased(PaO2:P=0.038;SpO2:P=0.041).However,arterial carbon dioxide pressure (PaCO2),heart rate (HR),respiratory rate (RR) and intracranial pressure were significantly decreased in both groups (PaCO2:P=0.033;HR:P=0.036;RR:P=0.044).The levels of PaO2 and SpO2 in the early intubation group at 1d and 3d after intubation were higher than those in the delayed intubation group (PaO2 at 1d after intubation:P=0.027,SpO2:P=0.028;PaO2 at 3d after intubation:P=0.017,SpO2:P=0.031).However,the levels of PaCO2,HR,RR and intracranial pressure were decreased (PaCO2 at 1d after intubation:P=0.036,HR:P=0.034,RR:P=0.023;PaCO2 at 3d after intubation:P=0.022,HR:P=0.030,RR:P=0.026).Compared with the delayed intubation group,the incidence of pulmonary infection and mortality were significantly lower in the early intubation group (the incidence rate of pulmonary infection:P=0.038;mortality rate:P=0.026).The proportion of level I and Ⅱ in ADL grade was significantly higher in the early intubation group than in the delayed intubation group,but level Ⅲ,Ⅳ and Ⅴ was significantly lower (P=0.024).Conclusion Early endotracheal intubation can effectively improve the clinical efficacy and prognosis in patients with acute severe craniocerebral injury,reducing its morbidity and mortality,which has important clinical significance,worthy of clinical use and promotion.%目的 探究院前早期气管插管对急性重型颅脑损伤患者的临床疗效及预后的影响.方法 回顾性分析2008年1月~2014年12月綦江区人民医院收治的420例急性重型颅脑损伤的患者的临床资料,其中男性285例,女性135例;年龄19~70岁,平均45.3岁.致伤原因:道路交通伤260例,坠落伤75例,打击伤64例,其他伤21例.根据气管插管的时机将其分为早期插管组(指对受伤患者2h内实施的气管插管,191例,)和延迟插管组(指对受伤患者2h后或出现以下呼吸衰竭表现时给予的气管插管,229例),分析插管前、插管后1d及3d血气指标及颅内压变化,比较两组患者肺部感染发生率、死亡率及6个月神经功能即日常生活活动能力(ADL分级)情况.结果 与气管插管前比较,两组患者插管后1、3d 的动脉血氧分压(PaO2)和血氧饱和度(SpO2)明显升高(PaO2:P=0.038;SpO2:P=0.041),而动脉二氧化碳分压(PaCO2)、心率(HR)、呼吸频率(RR)及颅内压明显降低(PaCO2:P=0.033;HR:P=0.036;RR:P=0.044);早期插管组插管后1d及3d的PaO2、SpO2较对应的延迟插管组升高(插管后1d的PaO2:P=0.027,SpO2:P=0.028;插管后3d的PaO2:P=0.017,SpO2:P=0.031),而PaCO2、HR、RR及颅内压降低(插管后1d的PaCO2:P=0.036,HR:P=0.034,RR:P=0.023;插管后3d的PaCO2:P=0.022,HR:P=0.030,RR:P=0.026).早期插管组肺部感染发生率及死亡率明显低于延迟插管组(肺部感染发生率:P=0.038;死亡率:P=0.026).早期插管组ADL分级Ⅰ级和Ⅱ级比例明显高于延迟插管组,而Ⅲ级、Ⅳ级、Ⅴ级明显低于延迟插管组(P=0.024).结论 早期气管插管可有效改善急性重型颅脑损伤患者临床疗效及预后,对于降低其致残率及死亡率具有重要的临床意义,值得临床运用及推广.