澳大利亚John Murtagh全科病案研究(四十七)——一位62岁男病人酒后头部损伤

John Murtagh

John Murtagh.澳大利亚John Murtagh全科病案研究(四十七)——一位62岁男病人酒后头部损伤[J].中国全科医学，2013，16(6)：1827-1828.[www.chinagp.net]

译者按：在病人接受医院的急症和急救服务前，全科医生可能是首先接触紧急状态病人的医生。创伤昏迷是常见的紧急状态之一，通常病人无法通过语言交流来阐述病情，医生可以通过间接的信息来源，并借助神经学检查，如格拉斯哥昏迷量表，来初步判断损伤的部位和严重程度，以便及时处理和转送病人。

1　病史

张某是一位62岁的男性病人，他的几个朋友把他送到急诊室。他喝得烂醉，可能是摔倒在人行道上受伤了。在他摔倒受伤前，他找人吵架，还跟两个年轻人打起来了。他的朋友跟你说，张某以前是一个很和蔼可亲和聪明的公务员，不过他很喜欢豪饮，特别是啤酒和烈酒。朋友们现在最担心的是，张某一反常态，思维混乱，而且不能正常地走路。在他跌倒前大约1个小时，张某还在跟朋友交谈，开始的时候谈得还算正常，可是他逐渐地变得越来越烦躁，容易生气，语无伦次，让人无所适从。

2　体检

张某看上去病得不轻。主要是表面上的擦伤，不过他浑身散发浓烈的酒气。他说话语无伦次、含糊不清、杂乱无章。他的头皮有一处撕裂，左侧面部、颈部和双臂有挫伤。

他的生命体征：脉搏64次/min，血压140/90 mm Hg(1 mm Hg=0.133 kPa)，呼吸14次/min。他当时的状况无法进行心理状态测验。他对口令不做出反应，比如让他睁开双眼。在他耳边大声问话，他嘴里嘟嘟囔囔的不知道在说什么。不过他对疼痛刺激(在眉弓上电刺激)有反应，他会睁开双眼，躲开刺激。

3　提问

3.1你怀疑这个病人有哪些问题?

3.2根据对他意识状态的客观评价〔a 根据5个意识程度的分类；b 根据格拉斯哥昏迷量表(Glasgow coma scale)〕，你的初步结论是什么？

3.3你考虑要做哪些辅助检查?

4　解答

4.1你应该考虑这个病人有颅内占位性病变，特别是硬膜外血肿或硬膜下血肿。

4.2a：简化的意识程度分类包括5个等级。(1)意识清醒：病人保持清醒的意识；(2)意识混浊：病人的思维混乱；(3)神志不清：病人对摇动和喊叫有反应；(4)轻度昏迷：病人对疼痛有反应；(5)昏迷状态：病人对任何刺激没有反应。张某属于第4级，即轻度昏迷。b：格拉斯哥昏迷量表有三个标准，最高评分15分，最低评分3分。张某得分为8分，提示应该采用脑伤图对他进行严密监测(注：也可以采用其他的昏迷评估量表)。(1)睁眼(4～1分)：张某为2分(疼痛时睁眼)；(2)语言反应(5～1分)：张某为3分(回答含糊不清)；(3)摇动反应(6～1 分)：张某为3分(对疼痛刺激有反应)。

4.3需要做的辅助检查包括：(1)CT或核磁共振扫描(如果没有这些设备，可以做X线检查)；(2)血糖和血酒精浓度检查；(3)脉搏血氧饱和度；(4)尿药物筛查。

5　进一步的临床细节

医院对张某进行严密的观察。30 min内，护士报告说他发出一些让人听不懂的声音，而且对疼痛刺激的反应很小。体检发现，左侧眼瞳孔收缩。生命体征：脉搏55次/min，血压160/100 mm Hg，呼吸9次/min。

6　进一步的提问

现在最应该采取什么行动?

7　对进一步提问的解答

很明显，张某的颅腔内有占位性病变，很可能是急性硬膜外血肿。这需要实行外科引流减压手术，以挽救他的生命。需要在受伤的头颅部位钻孔。如果你没有足够的技术和设备做这种手术，则应该立即把病人转到紧急外科中心。

·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.