重症頭部外傷例に対する初期診療が転帰に与える影響―特に脳神経外科医の役割について

The Influence of the Primary Management on the Outcome of Severe Traumatic Brain Injury : Role of Neurosurgeons

Ⅰ．はじめに

　交通事故や墜落事故などの高エネルギー外傷例の多くは頭部外傷を伴っており，転帰向上のためには重症頭部外傷に対する適切な治療が不可欠といえる．このため高エネルギー外傷患者を受け入れる医療機関は，初期診療（初療）を確実に遂行できる能力を有すると同時に，重症頭部外傷の診断と治療が適確に行える必要がある．このことから脳神経外科医の常駐する救命救急センターへの収容が望ましいが，実際には外傷発生地の地理的条件や地域の救急医療体制などにより，1，2次救急病院が初療を担うことが多いのも現状であろう．

　今回，高エネルギー外傷による重症頭部外傷例に対する初療の転帰に及ぼす影響を検証するため，当院高度救命救急センター（以下，当センター）に直接搬入された症例と他院から転送されてきた症例をretrospectiveに比較検討したので，初療時の脳神経外科医の役割に関する考察を加えて報告する．

　Objective　To evaluate the influence of the primary management on the outcome in severe head-injured-patients, we retrospectively studied the patients transported to our hospital directly and the those referred from other hospitals.

　Methods　The subjects include 83 patients with severe head injury with a Glasgow coma scale (GCS) score of 8 or lower at the time of arrival at the emergency room during the periods of between January, 2003 to March, 2006. Forty nine patients were transported directly (direct group) and 34 referred from other hospitals (transfer group). The patients in direct group was transported by a helicopter or an ambulance car, and the patients in transfer group were carried by an ambulance car. The variables analyzed in these 2 groups of patients were the initial GCS score, injury severity score (ISS), and the presence or absence of light reflex or shock at the time of transportation, the time periods from the injury and primary management, the time from the injury and operation in surgical patients, the type of primary managements and outcomes.

　Result　The number of patients with shock was significantly larger in the transfer group than that in the direct group. The shock was considered to be developed during the transportation. The outcomes were then significantly poorer in the transfer group than those in the direct group. There was no significant difference between the time from the injury and primary management in these 2 groups, but the primary management seemed to be more appropriate in the direct group compared to that in the transfer group. These findings suggested that outcomes of severe high-impact head injuries, such as injuries caused by a traffic accident, would be markedly affected by the primary treatment.

　Conclusion　The doctor-helicopter system, in which emergency physicians arrive at the site shortly after the occurrence of injury, and start primary examination, will influence outcomes of multiple injuries accompanying severe head injury. Severe head-injured patients by high-impact injury should be transported as early as possible to the emergency medical center, and neurosurgeons have an important role in the primary management.