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andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies硬膜外血肿清除术andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies1.概念及结构解剖013.物品准备032.适应症及体位024.手术配合及注意事项04andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies颅内血肿颅脑损伤导致颅内出血，使血液在颅腔内聚集达到一定体积，成为颅内血肿。一般幕上血肿量在20ML以上，幕下血肿在10ML以上即可引起急性脑受压症状。按出血来源和发生部位可分为：硬膜外血肿、硬膜下血肿和脑内血肿。andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergenciesandHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergenciesandHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies头颅分为颅顶部和颅底部•颅顶部为眉间、眶上缘、颧弓、外耳孔、乳头基部、上项线和枕外粗隆连线以上部分。额顶枕区软组织由皮肤、皮下组织、帽状腱膜、腱膜下层和颅骨骨膜。皮下脂肪层被许多腱膜纤维分隔，其将皮肤和帽状腱膜紧密的连接起来。andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergenciesandHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies•头皮的主要动静脉和神经穿行于此层。这三层不易分开，术中常被同时切开。帽状腱膜前连额肌，后连枕肌，均为皮肤肌，是形成头皮软组织张力的主要组织，缝合创口时必须要缝合此层。帽状腱膜下层为疏松组织，术中分离软组织与颅骨时即由此层分开。颅骨骨膜与颅骨外面间除骨缝外，链接额较松，术中可由颅骨上分离。andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergenciesandHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies•颅底部由不规则的软骨化骨组成，颅底内表面由前向后为阶梯型的颅前窝、颅中窝、颅后窝，前高后低。前大部半部被面部骨覆盖，后半部枕外粗隆、上项线以下部分称枕下区，是手术通向颅后窝的途径。andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies硬脑膜：内层反折处形成静脉窦，静脉窦壁厚缺乏弹性，破裂时止血困难。蛛网膜：位于硬脑膜下，两者间为硬脑膜下腔。软脑膜：紧贴脑表面，深入脑的所有凹陷和裂沟，在一定部位形成皱襞，与室管膜愈合形成脉络膜组织，进入脑室形成脉络丛脑膜：脑组织外有3层脑膜覆盖，即硬脑膜、蛛网膜和软脑膜andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies1231.伤后有明显的中间清醒期，有骨折线经过血管沟，并有明显脑受压症状或出现颞叶沟回疝综合症者2.CT发现在硬膜下有一较大的梭形血肿，使中线移位者。3.经钻孔证实为硬膜下血肿者。硬膜外血肿手术适应症andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies手术的麻醉方式•全身麻醉，气管内插管andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies•根据手术部位，采取适合的体位。一般为仰卧位.手术体位andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies手术用物准备•洗手护士：器械包：颅脑包（如为脑内血肿备上显微器械）持物钳，大碗敷料包：包底，颅脑敷料，手术衣，2至3包无菌纱布。andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies大碗内用物：手套（多打2副）、吸引器管、单极电刀、双机电凝镊、骨蜡、明胶海绵、1、4、7#慕斯线、4-0#、2-0#的可吸收线、20ML、60ML注射器、头皮夹、脑棉片、11#刀片、腔镜套、线锯、骨钻头、输液线、脑棉A备用物品：止血纱布、颅骨锁、生物胶原蛋白海绵、16#或18#引流管、弹力头网。BandHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies巡回护士：01根据体位备头架或头圈、两组静脉通道（必要时麻醉师深静脉置管）、眼贴膜、双耳塞棉球、调节好室温、正确黏贴负极板。02andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies手术步骤及配合•1手术野皮肤常规消毒，铺单:先递一中单从中间对折，铺与头颈下方，顺序递横折1/3朝自己，横折1/3朝助手，竖折1/3朝助手的治疗巾3块铺盖于手术切口周围，巡回护士放托盘于托盘架上压住治疗巾，洗手护士于穿好手术衣的医生铺颅脑大单，铺好后协助医生贴C-P护皮膜，托盘铺大包皮递艾利斯2把固定于托盘下方与切口之间的布单上，形成器械袋。放置好双极、电刀、吸引管、输液线，准备头皮夹。andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergenciesLOREMIPSUMDOLORLOREM•2.切开皮肤，皮下及帽状腱膜沿切口线两侧铺干纱布，递手术刀切开皮肤及帽状腱膜层，每切一段，递头皮夹钳钳夹头皮止血，出血部位递双极止血，andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergenciesandHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies•3.翻开皮瓣：翻转皮瓣：递大圆针7#线悬吊，递直钳橡皮圈固定托盘上，双极止血，湿纱布覆盖保护，准备套好颅脑电钻。andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergenciesandHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies•4.骨瓣成形递骨膜剥离器剥离骨膜，电钻钻孔，递线锯导板、线锯、线锯拉钩锯开颅骨，（或铣刀直接切开骨瓣）用剥离子分离硬脑膜与颅骨，掀开骨瓣用湿纱布包好待用，递咬骨钳咬平骨窗边缘，骨蜡止血。andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies•5.清除血肿，彻底止血：递神经剥离子或脑压板，轻轻将血肿从硬脑膜游离下来，也可以用吸引器吸除，遇活动性出血，递双极止血或丝线贯穿结扎。andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies•6.悬吊硬脑膜清除死腔：递小圆针1#丝线沿骨窗周围每隔2-3CM作硬脑膜与骨膜的悬吊缝合，如仍有渗血处，递明胶海绵或止血纱布放置于硬脑膜与颅骨内板之间。andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies•7.缝合颅骨骨瓣：清点器械和脑棉片，放回骨瓣，用颅骨锁固定骨瓣。andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies•8.缝合帽状腱膜及皮肤递大圆针7#丝线或2-0#可吸收缝合帽状腱膜，递消毒棉球消毒切口皮肤，递皮针4#线缝合皮肤，切口再次用消毒棉球消毒。andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies•9.包扎伤口：递敷料覆盖伤口，并用弹力头网包扎。手术完毕洗手护士整理器械，巡回护士送病人回监护室与监护室护士认真交接