firearm traumatic brain injury
Introduction
Introduction to firearm traumatic brain injury The head injury caused by gunpowder, explosives, etc., such as bullets, bullets, and various fragments, is called a firearm-type head injury. The flat-shot fashion can be seen in shotguns and shotguns. The airgun injury is strict. It is not a firearm injury, but because of the lead shot that it shoots, it can also cause injury to the skull. Therefore, it is also placed in a firearm wound. Firearm-related head injury is a serious trauma, and its incidence and mortality are both Higher. basic knowledge Proportion of disease: The incidence rate is high during the war years, and the current incidence rate is extremely low, about 0.0001% Susceptible people: no specific population Mode of infection: non-infectious Complications: shock fracture
Cause
Causes of firearm craniocerebral injury
(1) Causes of the disease
At present, according to whether the dura mater is broken, the firearm-type brain injury is simplified into two types: non-piercing and penetrating.
Non-piercing injury
There are often local soft tissue or with skull injury, but the dura mater is still intact, the traumatic local and hedging parts may have brain contusion, or form a hematoma, such as light, medium-sized injuries, a few can be heavy.
2. Wear through injury
That is, open brain injury, there are many broken bone fragments or bullets in the skull, the brain tissue of the injured area has different degrees of damage, and there are many opportunities for ballistic hematoma. It is a serious injury, and it is usually divided into:
(1) Blind tube injury: There is only an entrance without an exit. There are often broken bone fragments and foreign objects near the entrance to the skull. Metal foreign objects remain in the skull, mostly at the farthest end of the injured road, and the local brain contusion and laceration is more serious.
(2) penetrating injury: there are entrances and exits, the entrance is small, the exit is large, there are broken bone fragments near the intracranial entrance and the extracranial subcutaneous outlet, and the brain contusion and laceration is serious. If the life center is injured, the wounded will die in a short time. .
(3) tangential injury: the scalp, skull and brain are grooved lesions or defects, and the broken bone fragments are mostly intracranial or extracranial.
(4) Anti-jump injury: The shrapnel is worn inside the skull and is resisted by the skull on the opposite side of the entrance. The direction of the rebound rebounds in the brain tissue, forming a complex injury.
In addition, according to the type of projectile, it can be divided into shrapnel, gunshot wound, or classified according to the damage site to supplement the above classification.
(two) pathogenesis
The pathological changes of firearm-induced craniocerebral injury are different from those of non-firearm injuries. The brain damage caused by shrapnel or bullet wounds of high-speed light weapons has certain characteristics. The pathological changes of the injured brain are divided into three areas:
Primary wound area
Refers to a wide and narrow wound in the center of the wound, containing damaged and liquefied brain tissue fragments, blending with blood and blood clots, containing skull fragments, hair, cloth, sand and shrapnel or bullets, etc. The proximal end of the injured road is scattered, which makes the damage area of the brain increase. The shrapnel or gunshot wound is located on the far side of the injured road. The meninges and cerebral hemorrhage are easy to accumulate in the injured area to form an epidural, subdural, intracerebral Or intraventricular hematoma, the location of the hematoma in the brain injury, can be located in the proximal, middle and distal.
2. Close to the brain damage zone on Monday, for the brain contusion zone
The injury mechanism is due to the moment when the high-speed projectile penetrates into the closed cranial cavity, forming a temporary cavity in the brain, causing an overpressure phenomenon, and the shock wave is transmitted to the surrounding brain tissue, so that the brain tissue is immediately subjected to high pressure and successive negative pressure effects. Causes brain contusion and laceration, pathological signs appear as punctiform hemorrhage and cerebral edema zone, ischemic changes in nerve tissue in this area, oligodendrocytes and astrocytes swell or disintegrate, followed by microglia It becomes a lattice cell, enters the area in large quantities, and begins the tissue repair process.
3. Located around the brain contusion area as a concussion area
Brain tissue can be seen without obvious pathological changes under the naked eye or general light microscope, but temporary dysfunction can occur.
The pathological changes of the brain may vary with the type of trauma, time after injury, initial surgical treatment and post-treatment. The blood circulation and cerebrospinal fluid circulation disorder in the brain, blood and hematoma formation in the brain, acute brain edema, and concurrent infection Pathological changes can be complicated by factors such as increased intracranial pressure.
The above pathological evolution is roughly divided into the acute phase, the inflammatory reaction phase and the complication phase. If the wound is thoroughly debrided early, it can be healed without complications.
In addition, brain impact injuries may also occur, caused by high-pressure shock waves caused by bomb or bullet knock, causing spotted hemorrhage, brain contusion, brain edema, lung, liver, spleen and hollow organs. There can also be impact injuries at the same time, not to be ignored.
Prevention
Firearm injury prevention
The mortality rate of penetrating wounds was 49.3% to 60.7% at the beginning of the First World War, about 30% at the end of the World War I, and dropped to 15% during the Second World War. The mortality rate is still above 10%. The main causes of death are:
1 Damage to important areas of the brain.
2 concurrent intracranial hematoma.
3 combined injuries and shock.
4 intracranial infections.
The research on wound ballistics in China is developing rapidly. The damage effect, injury mechanism, damage characteristics, direct damage of craniocerebral firearm injuries, adjacent injuries, distant parts damage (far-reaching effect) and their effects on various projectiles The understanding of influence has gradually deepened. The theory of wound ballistics is used to guide the treatment of firearm injuries, and good results have been achieved. The mortality rate of craniocerebral firearm injuries has dropped to 9.4 to 9.6%. Shock can occur when there is a large amount of blood loss in the head wound.
When a contaminated foreign body enters the brain, an intracranial infection can be formed. When the skull is penetrated, a skull fracture may occur, and when the brain tissue is damaged, a hematoma may be complicated.
Complication
Firearm traumatic brain injury complications Complications, shock fractures
When a large amount of blood is lost in the head wound, shock may occur. When the contaminated foreign matter enters the skull, an intracranial infection may be formed. When the skull is penetrated, a skull fracture may occur, and when the brain tissue is damaged, the intracerebral hematoma may be complicated.
Symptom
Firearm craniocerebral injury symptoms Common symptoms Trauma coma increased intracranial pressure intracranial infection neck tonic high fever cerebral palsy consciousness disorder blood pressure drop shock
Consciousness disorder
Post-injury consciousness level is the most important indicator for judging the severity of firearm-induced craniocerebral injury. It is the main basis for surgical indication and prognosis estimation. However, craniocerebral penetrating injury sometimes has heavier brain damage, and there is no coma. Continuous observation should be emphasized. The process of change of consciousness, such as the middle awake period or the improvement period after the injury, or the coma at the time of injury, and then into the coma, or the progressive increase in consciousness disorder, all reflect the symptoms of acute brain compression in the injured, in the acute phase, Be alert to the hematoma adjacent to the invasive or invasive path, and the change in the chronic phase may be an abscess.
2. Changes in vital signs
Severe craniocerebral wounds, most of the wounds immediately after the injury, pulse, blood pressure changes, injury to the brain stem area important life center, early respiratory reversal, slow or intermittent breathing, pulse to slow or fine, pulse Symptoms of central failure such as irregularities and decreased blood pressure, deep and slow breathing, slow and powerful pulse, changes in blood pressure are increased intracranial pressure, brain pressure and cerebral palsy, often indicating intracranial hematoma, open injury Causes external hemorrhage, loss of a large amount of cerebrospinal fluid, can cause shock and failure, should be aware of the presence or absence of chest, abdominal trauma, large fractures and other serious combined injuries.
3. Brain damage symptoms
The wounded may have symptoms and signs due to brain contusion, hematoma, and brain swelling. Subarachnoid hemorrhage may cause meningeal irritation, and hypothalamic injury may cause central hyperthermia.
4. Increased intracranial pressure
There is a greater chance of acute intracranial hematoma in the acute phase of firearm injury, but diffuse cerebral edema is more worrying, mainly manifested as headache, nausea, vomiting and brain swelling. Chronic phase is often due to intracranial infection, cerebral edema, manifested as The brain is prominent, the consciousness is turned bad, and the optic disc is swollen. At a certain stage, it is reflected in changes in vital signs, and eventually signs of cerebral palsy.
5. Intracranial infection
The initial treatment of penetrating injury is not complete or too late, and it is easy to cause intracranial infection. The main manifestations are: high fever, neck stiffness, and meningeal irritation.
6. Examination of craniocerebral wounds
This is a particularly important examination in craniocerebral firearm injuries. The location, number, shape, bleeding, and pollution of the entrance and exit are important. The connection between the entrance and exit helps to determine whether the penetrating injury crosses important structures.
In combat, because of the large number of wounded, the inspection requirements are simple and concise, and quickly identify the nature of the brain injury and the presence of combined injuries in other parts.
To emphasize the X-ray examination of the skull: this is necessary to understand the condition of the wound, determine the nature, number, location of the intracranial foreign body, and whether it is necessary to have multiple head injuries. It also plays an important role in guiding the debridement surgery. Cerebral angiography Usually in the first and second line hospitals should not be used, in the case of acute brain compression, it is advisable to seize the opportunity to directly conduct debridement exploration.
Under field conditions, lumbar puncture examination should be done as far as possible. If there is suspected intracranial infection, lumbar puncture and cerebrospinal fluid examination can be performed. If necessary, antibiotics can be injected through the subarachnoid space as a treatment.
Complications and sequelae of firearm-induced craniocerebral injury can be selected according to the specific conditions, including CT brain scan.
Examine
Examination of firearm craniocerebral injury
1. Skull X-ray film
For craniocerebral firearm injuries, it is necessary to routinely shoot the cranial slices after removing the surface sand and other pollution. The filming can not only be clear whether it is a blind tube injury or a penetrating injury, whether there is a foreign body in the skull, and know the exact position, and it is necessary to guide the debridement operation. Important role.
2. Cerebral angiography
It is not necessary for people who arrive at the hospital quickly, but if the condition worsens or has side signs after 3-8 hours of injury, or if hematoma and cerebral edema need to be distinguished, cerebral angiography is very large without CT equipment. Value, can provide information on the location and size of the hematoma, advanced intracranial pressure, contribute to the diagnosis of brain abscess, cerebral angiography also contribute to the diagnosis of traumatic intracranial aneurysms.
3. Brain CT scan
CT scans for the diagnosis of skull fragments, shrapnel, invasive, intracranial gas, intracranial hematoma, diffuse brain edema and ventricular enlargement are both correct and rapid, and have special value for the monitoring of medical efficacy.
Diagnosis
Diagnosis and identification of firearm traumatic brain injury
According to the history of trauma and clinical manifestations, the diagnosis can generally be confirmed.
