CPR后昏迷患者脑功能预后评估--苏州VIP免费

2015/4/121心肺复苏后脑功能预后的评估江苏省人民医院急诊中心张劲松•PrognosticationofNeurologicalOutcomeinComatoseCardiacArrestSurvivors•心脏骤停后昏迷患者脑功能预后评估•AAN2006•美国神经病学会2006年发布的心肺复苏后昏迷患者预后判断指南•ERC&ESICM2014•欧洲复苏协会和危重病协会联合发布的心脏骤停后昏迷患者脑功能预后的评估Introduction•Thegoalofpost-cardiacarrestmanagementistoreturnpatientstotheirprearrestfunctionallevel.•心肺复苏后转归：–清醒–死亡–Comatosesurvivors•Earlyprognosticationofneurologicaloutcomeisanessentialcomponentofpost-cardiacarrestcare.Introduction•Whendecisionstolimitorwithdrawlife-sustainingcarearebeingconsidered,toolsusedtoprognosticatepooroutcomemustbeaccurateandreliablewithafalse-positiverate(FPR)approaching0%.•不良预后的定义(AAN)：–死亡–1个月后无意识–6个月后严重残疾、生活不能自理•对心肺复苏后昏迷患者脑功能预后判断，具有重要的临床和经济学意义。2015/4/122评估手段评估手段NeurologicalexaminationGCS评分•GCSscore＜5at72hoursafterCA(FPR0%,95%CI0%to6%)arelessreliableforpredictingpooroutcome.[AHA2010]•主观评分，受气管插管/切开、颜面部水肿、镇静、TH治疗等因素影响。GCS评分•Motorresponsetopain[ERC2014]–Anabsentorextensormotorresponsetopain,correspondingtoamotorscore1or2oftheGCS(M≤2)at72hfromROSC,hasahigh[74(68-79)%]sensitivityforpredictionofpooroutcome,buttheFPRisalsohigh[27(12-48)%].–受镇静或肌松药物影响GCS评分•评价103名CA后接受HT治疗患者脑功能预后，分为预后良好组（36例）和预后不良组（67例）。•Inthefirst7daystheGCSgraduallyimprovedinbothgroups.•InthepooroutcomegrouptheproportionofpatientswithamotorscoreofM1orM2wassignificantlyhighercomparedtothefavourableoutcomegroup(94.0%versus80.6%,p=0.031).L.L.A.Bisschopsetal.Resuscitation,2011,82:696-701.2015/4/123GCS评分•因其敏感性较高，可与其他监测手段联合使用。•[ERC2014]脑干反射判别患者昏迷层面（皮层、间脑、中脑、桥脑、延脑）和脑死亡•睫状脊髓反射------------间脑平面•额眼轮肌反射-----------间脑-中脑•垂直性前庭反射--------间脑-中脑平面•瞳孔对光反射-----------中脑平面•角膜反射------------------脑桥平面•嚼肌反射------------------脑桥平面•水平性前庭眼反射------脑桥下部•眼心反射-------------------延髓平面•掌颏反射-------------------皮质-皮质下•角膜下颌反射-------------间脑-中脑脑干反射•pupillarylightreflexes–瞳孔对光反射——反射消失，中脑平面受损•cornealreflexes–角膜反射——反射消失，脑桥平面受损•vestibulo-ocularreflexes–前庭眼球反射——反射消失，脑桥下部平面受损脑干反射•BilateralabsenceofpupillarylightrefleximmediatelyafterROSChasaverylimitedvalueinpredictingpooroutcome[FPRis8(1-25)%].•At72hfromROSC,itpredictspooroutcomewith0%FPR,bothinTH-treatedandinnon-THtreatedpatients(95%CIs0-2and0-8,respectively);however,itssensitivityislow(24and18%respectively).•Abilaterallyabsentcornealreflexisslightlylessspecificthanthepupillaryreflexforpredictionofpooroutcome.•原因之一为受镇静或肌松药物影响。脑干反射•AmongadultpatientswhoarecomatoseandhavenotbeentreatedwithHT,•theabsenceofbothpupillarylightandcornealreflexesat72hoursafterCApredictedpooroutcomewithhighreliability.•Theabsenceofvestibulo-ocularreflexesat24hours(FPR0%,95%CI0-14%)arelessreliable.[AHA2010]脑干反射•不论是否接受TH治疗，ROSC后72h双侧瞳孔对光反射及角膜反射消失可判断预后不良。•考虑到镇静剂残留及患者瘫痪可能，神经学评估应延长超过72h，以减少FPR。•[ERC2014]2015/4/124Seizuresormyoclonusstatusepilepticus•癫痫/肌阵挛性癫痫持续状态•Seiz...