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1、,頭部外傷,- 外傷中最致命的傷害,國外,急診室外傷求診者,外傷死亡病例,頭部外傷 10,外傷 90,頭部外傷 41,外傷 59,國內,花蓮1989年 Survey,急診室外傷求診者 (11,900例),外傷死亡病例 (350例),頭部外傷 12,外傷 88,頭部外傷 49,外傷 51,P,HEAD INJURY TRIAGE SCHEME,LEVEL OF CONSCIOUSNESS GCS 9,PUPILS UNEQUAL OR LATERALISED DEFICIT,PUPILS UNEQUAL OR LATERALISED DEFICIT,YES,NO,OPEN INJURY,NO,L
2、OC 5 MIN,diffuse axonal injury,contussion,minor injury,NO,YES,YES,NO,NEUROLOGICALLY NORMAL,YES,NO,YES,YES,NO,骨折 線狀、粉碎、開放、凹陷 腦震盪(Cerebral Concussion) 腦挫傷(Contusion) DAI (Diffuse Axonal Injury) Raccoons eyes Battles sign,耳後瘀青,兩眼周圍瘀青,頭 部 外 傷,顱內出血,硬腦膜上 硬腦膜下 腦內 腦室內 混和,Incidence of Hematoma,Extradural - 1
3、6 Intradural: Pure subdural - 22 Intracerebral subdural - 54 Extra- + Intradural - 8,Diffuse Axonal Injury(DAI),Shearing or stretching of axons Coma lasts longer than 6 hours 6-24 hours - mild Moderate or severe - over 24 hours Three forms: 1.focal lesion - corpus callosum 2.focal lesion - rostral b
4、rain stem 3.Diffuse lesion,Classification of Brain Herniation,Subfalcial herniation Uncal herniation Tonsillar herniation Downward herniation Upward herniation External herniation,Brain herniation - Landmark of Neurosurgery,Pupil Dilatation - Compression of 3rd nerve by uncal herniation (D.D:Consens
5、ual reflex) Hemiplegia - Compression of cerebral peducle (uncal herniation) Conscious change - Compression of reticular activating system of brain stem Homonymous hemianopsia - Compression of post cerebral artery (False localizing sign) Abducent nerve palsy - IICP (False localizing sign),頭部外傷治療最近重大改
6、變,Steroid 已不被使用 Hyperventilation 必須有條件的使用 SjvO2 頸靜脈氧氣飽和度漸被重視 ICP monitor 仍以腦室內效果最佳,Risk of intracranial hematoma(requiring removed)in adult attending A and E departments after head injury.,No skull # orientated 1 in 6000 No skull # not orientated 1 in 120 Skull # orientated 1 in 32 Skull # not orien
7、tated 1 in 4,後 遺 症,輕微 頭痛、頭暈、暈眩、 記憶障礙、行為障礙. 嚴重 癲癇 慢性硬腦膜下血腫,結 果,死亡 10 植物人 1-3 嚴重殘障 5-10 輕度殘障 5-10 恢復 其餘,Neurobehavioral change,30,臨床(20年) 預防(1年),病例 2000人 死亡 200人(10) 植物人 60人 ( 3) 殘障 400人(20) 恢復 1340人,挽救死亡數 800人 植物人 240人 殘障 1600人,An Epidemiological Study of TBI and The Effect of Prevention Strategies,H
8、ow to implement a prevention strategy?,1. To know the basic concept of injury prevention 2. To know the epidemiology of injury in your country 3. To perform an epidemiological study of head injury 4. To implement a prevention strategy 5. To evaluate the outcome & revise the strategy,1. To know the b
9、asic concept of injury prevention,To know the basic concept of injury prevention,Host - the individual affected Environment Physical - the location at which the injury occurs Social - societal attitudes, lawsetc. Agent - energy Vector - car, motorcycle, weapons.,The Haddon Models,The four Es of inte
10、rvention,Engineering - helmet design Economic - monetary incentives Education - reasoning & knowledge Enforcement - by laws & regulations,2. To know the epidemiology of injury in your country,International Comparison of Injury Deaths (case per 100,000),source:WHO, World Health Statistics Annual,1994
11、,The Trend of Injury Deaths in Taiwan,1990-2001,12960,Chi-Chi earthquake,The Trend of Traffic Injury Deaths in Taiwan, 1990-2001,Why ?,3. To perform an epidemiological study of head injury,Epidemiology of Head Injury - A 14 year Study,M:F=2:1,Step 1,Taipei 220/105 (Incidence) 22/105 (Mortality) 60 (
12、Traffic accident),Hualien 380/105 (Incidence) 88/105 (Mortality) 80 (Traffic accident),公元11年(4f肿瘤fbb癌症yuw3胃癌d65io肠癌.f2tr肺癌65ff) (西汉王莽新朝三年),是中国古老的实证医学萌芽。由于儒、释、道三教合流所形成的中国文化格局,“重道轻器” (45传染病q566丙肝964jo乙肝28jgsx甲肝gh)衍生出的务虚倾向,重体悟而疏实证,必然缺少逻辑推理,致使中国的实证医学成就在日后难以与西方医学同日而语。古埃及医师运用念咒、画符和草药治病,前二者就是巫医。(df高血压958心脏
13、病983u6糖尿病87fr)西医在古希腊时期就开始医巫分家,亚里士多德曾详细描述了动物的内脏和器官,古希腊医学最高成就的代表人物希波克拉底将唯物主义哲学运用于医学之中,在论圣病中说:“被人们称为神圣的疾病(指癫痫和一些精神患者),在我看来一点也不比其他病症更神、更圣,与其他任何疾病一样起源于自然的原因。只因这些病症状奇异,而人们对它们又一无所知,充满疑惑,故而将其原因和性质归之于神灵。”亚里士多德所创立的唯物主义医学体系,加快了医学科学化的进程;(df4肺炎88gdg青霉素d25f肝炎df6) (df肺25s血液f369血小板t5172红血球gdf55m白血球fd2) 非凡(45传染病q566
14、丙肝964jo乙肝28jgsx甲肝gh)的事件都集中发生在这个时期。并且是独立地发生在中国、印度和西方”。这一阶段,(df高血压958心脏病983u6糖尿病87fr)是东、西方哲学、科学、文化发展的重要时期。此时诸子蜂起,儒家、墨家、道家、法家学派林立,形成了空前绝后的学术繁荣局面,对中华文化的发展起了奠基作用;处在古典希腊文明的开创时期,(df肺25s血液f369血小板t5172红血球gdf55m白血球fd2)出现了德谟克利特、费底亚斯、阿基米德、苏格拉底等哲人和智者。在东、西方科学和文化昌明的大背景下,(4f肿瘤fbb癌症yuw3胃癌d65io肠癌.f2tr肺癌65ff) 黄帝内经和希波克
15、拉底全集代表着中、西两座医学的峰巅之作便自然而然的诞生了。内经的问世,标志着中医学已从简单的临床经验积累,升华到系统的理论总结。关于希波克拉底全集,意大利著名医史学家卡斯蒂格略尼认为:“是自然科学几乎(df高血压958心脏病983u6糖尿病87fr)没有萌芽的时代,在医术上具有先进性的最宝贵的代表文献。希波克拉底学派的医学虽然在解剖学、生理学、病理学的知识上有缺陷,虽然只是很少而粗略地研究过动物,但是它主要是建立在临床实验和哲学推理的基础上,终能使医学提高到难以超过的高度。这是历史上最有意义的现象之一,并可能是最重要的,因为(45传染病q566丙肝964jo乙肝28jgsx甲肝gh)它说明通过
16、经验,(df肺25s血液f369血小板t5172红血球gdf55m白血球fd2)实际观察和正确的推理,可以得到极有价值的宝贵材料,他的确解决了医学历史上具有决定性倾向的开端。”比较黄帝内经和希波克拉底全集,二者的理论建构有诸多相似之处:废巫存医、整体观念、调节平衡、哲学思辩、临床实践。(4f肿瘤fbb癌症yuw3胃癌d65io肠癌.f2tr肺癌65ff) 其中黄帝内经(df高血压958心脏病983u6糖尿病87fr)强调以五脏为中心的整体观,从外测内,可以不依赖解剖形态学而照样诊治疾病。其理论体系是自洽的,难以突破;希波克拉底全集虽然没有系统的解剖学和生理学等基础知识,但却强调具体的解剖结构,
17、为医学的实证开了先河。这些差异为中、西医学的日后分向而行埋下了伏笔。 (df高血压958心脏病983u6糖尿病87fr) 医学教材 东、西方文化历史背景是中、西医学形成、发展的土壤。公元2世纪东、西方的两位医学巨匠张仲景和盖伦,(df高血压958心脏病983u6糖尿病87fr)传承了不同的学术思想,创建了迥异的医学范式,发展和完善了不同的理论体系,使中、西医学各自走向了两条完全不同的发展道路。(df肺25s血液f369血小板t5172红血球gdf55m白血球fd2) 在汉代医学家张仲景所著述的伤寒杂病论之前,就有内经、难经、本草经等古典医药典籍。张仲景总结了汉代以前的医学成就,继承了内经等基本
18、理论和丰富的医药知识,结合自己的临床实践,写成了伤寒杂病论。其贡献在于确立了中医学辨证论治的理论体系,为后世中医临床医学的发展,奠定了坚实的基础。(df4肺炎88gdg青霉素d25f肝炎df6) 在西方,盖伦的一生生活在罗马帝国时安东尼父子的执政期。彼时,罗马帝国的繁荣,为盖伦的医学成就、以及西方医学的(df高血压958心脏病983u6糖尿病87fr)昌盛,提供了可靠的政治、经济(45传染病q566丙肝964jo乙肝28jgsx甲肝gh)、科技和文化保证。(4f肿瘤fbb癌症yuw3胃癌d65io肠癌.f2tr肺癌65ff) 盖伦继承希波克拉底的学术思想,著述200余部著作,现存的83部著作中
19、,内容涉及解剖、生理、病理、卫生、药物、希波克拉底文集研究、哲学、(df高血压958心脏病983u6糖尿病87fr)语言学、逻辑学、数学、历史、法律等。倡导实证医学,他的科学方法论具有重视实验、(df肺25s血液f369血小板t5172红血球gdf55m白血球fd2)疾病局部定位思想、重视形式逻辑、强调演绎法等特点,对后世西医学的发展影响深远。 (4f肿瘤fbb癌症yuw3胃癌d65io肠癌.f2tr肺癌65ff) 中、西医学在张仲景和盖伦完全相悖的医学范式引导下,开始步入了分道扬镳的历史进程。在中华文化强调(45传染病q566丙肝964jo乙肝28jgsx甲肝gh) “中和”的大背景下,学术
20、界便有了“海纳百川”的宽松气氛。出现了学术流派精彩分呈,如瘟病的寒温之争,经方时方之别等。中医学按张仲景的思维范式,(df高血压958心脏病983u6糖尿病87fr)蓬蓬勃勃的发展起来了。随着科学的进步和社会的发展特别是医疗实践的发展,最初的中医学理论已无法诠释新的科学事实,因此,医学理论必须不断创新,才能适应社会需要,这就促使中医学进入汉代以后,呈现出全面发展的阶段,这个阶段共包括四个时期:(df4肺炎88gdg青霉素d25f肝炎df6) 编辑本段魏晋隋唐时期 由于重视总结临床经验,(df高血压958心脏病983u6糖尿病87fr)并继承整理发挥(df肺25s血液f369血小板t5172红血
21、球gdf55m白血球fd2)黄帝内经、伤寒杂病论等经典医著的理论,出现了众多名医名著。如晋代王叔和的脉经和皇甫谧的针灸甲乙经、隋代巢元方的诸病源候论、唐代孙思邈的千金要方和千金翼方。(4f肿瘤fbb癌症yuw3胃癌d65io肠癌.f2tr肺癌65ff) 编辑本段宋金元时期 我国经济和科学技术日益发展,学术文化领域百家争鸣,(df高血压958心脏病983u6糖尿病87fr)特别是思想家的革新精神,为中医学理论的创新和突破性进展,提供了有利的文化背景。宋代陈无择著三因极一病证方论一书,(45传染病q566丙肝964jo乙肝28jgsx甲肝gh)提出三因学说;并产生了最具盛名四大学派,刘完素倡导火热
22、论;张从正力倡“攻邪论”;李杲提出“内伤脾胃,百病由生”的理论;朱震亨创造性地阐明了相火的演变规律。 编辑本段明清时期(df肺25s血液f369血小板t5172红血球gdf55m白血球fd2) 是中医学理论综合汇编、深化发展,临床各科辨证体系丰富、提高阶段。如明代楼英的医学纲目和王肯堂的证治准绳,清代吴谦等编著的医宗金鉴和陈梦雷主编的古今图书集成医部全录等。王清任著医林改错,注重实证研究,(df高血压958心脏病983u6糖尿病87fr)纠正了古医籍中关于解剖知识的某些错误,肯定了“脑主思维”,发展了瘀血理论。温病学说的形成和发展,标志着中医理论的创新与突破,吴有性著温疫论,叶天士著温热病篇,
23、吴鞠通著温病条辨等,在药物学研究方面,(45传染病q566丙肝964jo乙肝28jgsx甲肝gh)李时珍著的本草纲目,总结了16世纪以前我国药物学研究的成就。 而西方医学随着西罗马帝国的灭亡,逐渐进入了中世纪的千年黑暗,科学变成了神学的奴婢,牧师取代医师。(4f肿瘤fbb癌症yuw3胃癌d65io肠癌.f2tr肺癌65ff) 从13世纪开始,始渐复明,直到15世纪,冲破封建宗教藩篱,才得以迅速发展。达芬奇(df高血压958心脏病983u6糖尿病87fr)开创现代解剖学,维萨里创立解剖生理学;1731年意大利摩尔干尼创立了病理解剖学;1855年德国魏尔啸创建了细胞病理学;与此同时西方科学方法论对
24、医学发展具有指导作用。以实验为主的实证方法(观察实验和比较分析)、(df肺25s血液f369血小板t5172红血球gdf55m白血球fd2)及对医学研究中的“经院哲学”的彻底决裂、依靠各门自然科学所提供的技术手段和方法,(df4肺炎88gdg青霉素d25f肝炎df6) 培养了医学家们的科学意识,赋予了医学的自然科学属性,使其摆脱了思辩推理的玄想而成就了生物医学模式下的实验科学。至此中医学在实证医学领域已无法于西医同日而语。但中医学相对于西医学的(df高血压958心脏病983u6糖尿病87fr)优势是从宏观入手,注重整体,强调局部与局部、局部与整体之间的联系,重视辨证,主张“三因治宜”的个体化诊
25、疗方略等。 编辑本段东西方医学差异 中、西医学运用不同的思维模式诊治疾病,其基本理论各成体系并有根本差异。(45传染病q566丙肝964jo乙肝28jgsx甲肝gh)中西医学的差异不仅仅是有否实证的科学理念,最主要的是两种文化体系的差别。从理论上讲,中西医学是两种不可能统一的医学体系。“中体西用”曾成为中西医汇通派的指导思想,但由于两种医学的根基不同,硬在中医之体上套上西医之用,近一个世纪的事实证明,“汇通医学的体用判断脱离了中西医学的事实认识,(df高血压958心脏病983u6糖尿病87fr)以价值认识代替了事实认识,决定最终结果劳而无功”,因此,中、西医学应并存共荣而不必强求统一。 (df
26、4肺炎88gdg青霉素d25f肝炎df6) 尽管目前中、西医学还不可能融合成为一种统一的医学模式,但可以独立发展,并存共荣,整合互补。(45传染病q566丙肝964jo乙肝28jgsx甲肝gh)缘于现代信息论、(df肺25s血液f369血小板t5172红血球gdf55m白血球fd2)系统论和控制论的影响,西医学的发展趋势若仅仅是单纯地重视分析而忽略了整体结构和整体功能,无疑将渐行渐窄。而中医讲究“感悟”,(4f肿瘤fbb癌症yuw3胃癌d65io肠癌.f2tr肺癌65ff) 未免夹带有很多主观因素,难以客观地定量,定性。若中医的诊察疾病能参考现代医学的微观分析,将辨证与辨病相结合,实现宏观与微
27、观的统一,使中医诊断客观化,即把分析与综合相结合的方法引入中医理、法、方、药的研究,使二者有机结合,互相借鉴、补充,避免各自的片面性、局限性,这将有利于中西医学的优势互补,(df高血压958心脏病983u6糖尿病87fr) “和而不同”,多元发展。近年来,中医药在防治非典、禽流感和艾滋病方面发挥的独特作用也证实了二者的有机结合,具有肯定的临床疗效。 编辑本段东西方医学交融(df高血压958心脏病983u6糖尿病87fr) 不管是中医学还是西医学,从二者现有的思维方式的发展趋势来看,均是走向现代系统论思维,中医药学理论与现代科学体系(45传染病q566丙肝964jo乙肝28jgsx甲肝gh)之间
28、具有系统同型性,属于本质相同而描述表达方式不同的两种科学形式。可望在现代系统论思维上实现交融或统一,成为中西医在新的发展水平上实现交融或统一的支撑点,希冀籍此能给(df高血压958心脏病983u6糖尿病87fr)中医学以至生命科学带来良好的发展机遇,进而对医学理论带来新的革命。 编辑本段现代中医史(df4肺炎88gdg青霉素d25f肝炎df6)轴心时代中、西医学的峰巅之作。雅斯贝而斯曾说:“如果历史有一个轴心,那么我们就必须将这轴心作为一系列对全部人类都有意义的事件,发生于公元前800至200年间的这种精神历程似乎构成了这样一个轴心。,医学健康系列精品课件,本文档下载后可以修改编辑,欢迎下载收
29、藏。,Incidence Mortality Cause by TA I-Lan 311/105 53/ 105 60 Hualien 437/105 72/ /105 60.9 Taitung 341/ /105 83/ 105 53.5 Peng-Hu 260/ 105 84/ 105 73.8,Step 2,Incidence Cause by TA Nationwide 230/105 69.3,Step 3,Step 4 Intervention 1st stage 1994 Feb. - 1994 June 2nd stage since June, 1997,Analysis o
30、f Head Injury by Age 1989-1998,Analysis of Means of Transportation Involved in Head Injury by Age,4. To implement a prevention strategy,Priority,US & UK,Taiwan,Seat belt use,Alcohol (1/4 road users),Motorcyclists & helmet use,Major tragedies,Truck & van,Bicyclist,Public transportation,Motorcyclists
31、(Helmet use) involving over 10 million people,Seat belts & air bags - involving over 5 million people,Alcohol - 4 million people (Average 1/5 population),Pedestrian - over 5 million,Environment - over 3 million,Public transportation - over 3 million (Truck, Bus etc.),The Trend of Traffic Injury Deat
32、hs in Taiwan, 1990-2001,Intervention,Helmet Use Enforcement (Taipei) 1994.2-5 Helmet Use Law 1997.6 Drunk Driving Law 1999.6 Seat Belt Law 2001.9 Cellular Phone Prohibition 2001.9 Child Car Seat Enforcement 2001.9 Others ?,The Motorcycle Helmet Law,Intervention - step 1. Helmet Use Enforcement in Ta
33、ipei City, Feb.- May, 1994,2. Helmet Use Law,6. Child Car Seat,5. Cellular Phone,3. Drunk Driving Law,4. Seat Belt Law,0,5,10,15,20,25,30,0,1,2,3,4,5,6,7,8,9,10,11,12,1,2,3,4,1993,1994,1993-1994 Motorcycle Related Death in Taipei,Thousand people,Department of Transportation & Communication,Numbers o
34、f head injuries by month, Taipei City , Taiwan,July,1992-June,1993,July,1993-June,1994,94.2 - 94.5,Numbers of operated & non-operated head injuries by month, Taipei City ,Taiwan,operated non-operated,July,1992-June,1993,July,1993-June,1994,94.2 - 94.5,Glasgow outcome scale in head injuries by month,
35、 Taipei City ,Taiwan,death vegetative severe - disability moderate - disability good - recovery,July,1992 - June,1993,July,1993 - June,1994,94.2 - 94.5,Preliminary Facts & Extrapolation of Helmet Use Enforcement,Motorcycle - related deaths were reduced by 50,At least 1000 people could be saved per y
36、ear if 80 of motorcyclists used helmets,Taipei,Taiwan,Motorcycle - related head injury were reduced by 30,Intervention - step 2. Helmet Use Law Jun. 1, 1997,6. Child Car Seat,5. Cellular Phone,3. Drunk Driving Law,4. Seat Belt Law,Helmet Use Rate - Sep. 1997,97,99,79,89,Pre-law: June 1, 1996 May 31,
37、 1997 Post-law:June 1, 1997 May 31, 1998,No. of cases,- 1725,Motorcycle-related Head Injury pre and post helmet use law (56 Hospitals),(33),- 42,Craniectomy,( Data was collected from 56 major hospitals ),- 45,(1st year),(2nd year),-38,Traffic Injury Related Head Injury Death Rate,- 41,(1st year),(2n
38、d year),( Data was collected from 56 major hospitals ),Cause of Traffic-related Head Injury Pre and Post Helmet Use Law,-33,+0.5,+15,(cases),Traffic-related Mortalities Pre and Post Helmet Use Law,Data provided by the Department of Transportation,Traffic-related Hospitalizations Pre and Post Helmet
39、Use Law, Reduce Medical expenses a hundred million NT dollars per month at least.,Data provided by the Nation Health Insurance Bureau,Helmet Use Law,Death OR Nonuser v.s. Helmet User 1.56 If all motorcycle riders used helmet, 38 of death could have been avoided.,(Petridou E. et al., 1998),Effect of
40、Helmet Use,Reduce Head Injury Rate by 3 times Reduce Death Rate by 7 times,Intervention - step 3. Drunk Driving Law Jun. 1999,2. Helmet Use Law,6. Child Car Seat,5. Cellular Phone,4. Seat Belt Law,Drunk Driving Law,Blood alcohol was detected in 18.7 injuries. Head - 86.7 Thoracic - 67.7 Abdominal -
41、31.4,(Wong E. et al., 2002),Effect of Restriction on Drunk Driving,Alcohol-related Traffic Accident Rate : - Urban: 12 - Rural: 25 Reduce the Degree of Severity on Injury - Moderate and Severe Cases Rate Reduction - 12,(Head injury databank, Taiwan),Intervention - step 4. Seat Belt Law Sep. 1, 2001,
42、2. Helmet Use Law,6. Child Car Seat,5. Cellular Phone,3. Drunk Driving Law,4. Seat Belt Law,Seat Belt,Death OR Nonuser v.s. Seat Belt User 1.44 If all car occupants used seat belts, 27 of death could have been avoided.,(Petridou E. et al., 1998),Reduce the Degree of Severity on Injury - 60 Reduce th
43、e Death Rate - 43 Reduce the Hospitalization Rate - 3 times,Effect of Seat Belt,Intervention - step 5. Cellular Phone Prohibition in Driving Sep. 1, 2001,2. Helmet Use Law,6. Child Car Seat,3. Drunk Driving Law,4. Seat Belt Law,5. Cellular Phone,Cellular Phone,Talking more than 50 minutes per month
44、on cellular phones in a vehicle - 5.59 fold increased risk in a traffic injury.,(Violanti JM et al., 1996),Intervention - step 6. Child Car Seat Enforcement Sep. 1, 2001,2. Helmet Use Law,5. Cellular Phone,3. Drunk Driving Law,4. Seat Belt Law,6. Child Car Seat,Child Car Seat,According to a research
45、 of NHTSA in U.S.A., the reduction of the potential children car accident rate is 70 when using the child car seat correctly. Some researches in other countries indicate that the death rate is 8 times when not using child car seat.,5. To evaluate the outcome & revise the strategy,During the past 6 y
46、ear, there is a great reduction of traffic injury death - 2,000 people per year being saved. (totally 8,000),The possible causes could be: people being saved Intervention per year Helmet Use Law 900 45 Seat Belt Law 200 10 Drunk Driving Law 200 10 Child Car Seat 50 2.5 Cellular Phone Prohibition 50
47、2.5 Others 600 30,The four Es of intervention in Taiwan,Engineering - 10 (helmet design) Economic - 15 (insurance) Education - 15 (public & school) Enforcement - by laws & regulations 60,Summary,Based on a 14-year epidemiological study of head injury. Intervention through 6 stepwise approaches has been implemented in Taiwan since 1994. Totally 8,000 people have been saved during the past 6 years. (currently 2,000 people per year) Increasing the engineering, economic and educational interventions in other injury fields are recommended in the future.,Other Injury Field Need