Intracranial hematoma removal for firearm injury

Cranial firearm penetrating injury combined with intracranial hematoma is as high as 40% to 50%. In the Second World War, Schorstein (1947) counted the incidence of intracranial hematoma in the brain injury patients who were debrided 2 to 3 days later or later. Barnett and Meirowsky reported that the incidence of intracranial hematoma was closely related to the time of debridement after injury in the treatment of American brain injury in the Korean battlefield. 24 to 72 hours after injury in the posterior hospital debridement, the incidence of intracranial hematoma was 7%; 12 to 36 hours after the injury was sent to the hospital debridement, intracranial hematoma accounted for 24%; 8 hours after injury through the front specialist surgery team Inventors, intracranial hematoma accounted for 46%. It is suggested that the incidence of intracranial hematoma in craniocerebral firearm penetrating wounds is very high, and early debridement can save many wounded. The type of intracranial hematoma caused by firearm injury can be divided into subdural, subdural, intracerebral, cerebral longitudinal fissure (or paralysis) and intraventricular hematoma type 5. Treatment of diseases: firearm-induced head injury Indication Firearm wound intracranial hematoma removal is applicable to: 1. The wounded person is in a coma state, the pupil of the same side of the entrance is dilated, or the pupil of the opposite side of the entrance is dilated, suggesting that there is an intracranial hematoma on the ipsilateral or contralateral side, and an emergency craniotomy should be performed. 2, the injured have intracranial hypertension, and hemiplegia, aphasia or symptoms continue to increase, but lack of cerebral angiography and CT scan conditions, should be explored early. 3, the wounded are generally in good condition when they come to the hospital, but hematoma and broken bone fragments or metal foreign bodies are found by CT examination. Contraindications The wounded were deeply comatose, the pupils on both sides were dilated, all reactions disappeared, and the breathing stopped for several hours, and the operation was difficult to save. Preoperative preparation 1. Prepare the skin, wash the head with soap and water first, and shave the head on the eve of surgery. Fasting before surgery. One hour before the operation, 0.1 g of phenobarbital, 0.4 mg of atropine or 0.3 mg of scopolamine were intramuscularly injected. 2, tetanus anti-serum 1500U. 3. Take the positive and lateral slices of the skull to understand the number, size and location of intracranial fragments and metal foreign bodies. 4, CT scans when conditions are available to understand the extent and extent of brain injury, the size and location of intracranial hematoma. Surgical procedure 1, scalp incision Focusing on the entrance of the injection, a flap incision is often used. When the scalp has a large defect in the scalp, it is difficult to suture, and the brain is exposed, a transfer flap can be used and an incision can be designed. 2, skull treatment Hematoma surgery in the proximal part of the entrance and the brain injury is performed by a bone window craniotomy that enlarges the entrance of the skull. For the hemispheres of the contralateral cerebral hemisphere and the ipsilateral hemisphere and the hemisphere in the longitudinal fissure caused by the shrapnel or projectile, the craniotomy should be performed close to the hematoma. 3, dural incision After the craniotomy of the bone window, the epidural hematoma can be removed, and for the subdural and intracerebral hematoma, the dural rupture should be slightly trimmed and the incision should be extended to reveal the hematoma; the craniotomy of the bone flap is still needed. The dura mater is turned in the opposite direction to the bone flap to reveal subdural and intracerebral hematoma. 4, hematoma clearance In the first-line hospitals to clear ultra-acute or acute hematoma, due to various conditions, the hematoma should be removed, and the shallow bone pieces that are easy to find can be removed. Generally, the brain is not emphasized or forced to complete debridement in the brain. After the hematoma is cleared, the injury is sent to the second-line hospital, and the brain is debrided again. However, when the specialist surgery team or hospital performs intracranial hematoma surgery, the hematoma removal and bone removal should be completed in one operation. Avoid multiple operations. Intraventricular hematoma, including intraventricular hemorrhage, can be removed by treatment through the bone window. For hematoma that occurs on the contralateral hemisphere surface, in the distal part of the ipsilateral hemisphere or in the longitudinal fissure of the brain, it is removed by craniotomy of the bone flap, and the metal foreign bodies in the hematoma and adjacent to it are also removed. 5, wound suture The first-line hospital only cleared the intracranial hematoma. If the bone fragments in the brain were not removed or not completely removed, the dura mater was not sutured or repaired, and the scalp was not sutured or sutured at both ends of the incision. The specialist surgery team can repair the dura mater after removing the hematoma and foreign body in the brain, and the scalp is sutured in two layers. complication 1, traumatic infection Delayed operation time, or insufficient debridement, caused by some broken bone fragments, inactivated brain tissue and clots in the brain. The infection should be controlled and the local treatment of the wound should be strengthened and debrided again if necessary. 2, brain prominent Postoperative brain tissue bulges outward through the bone defect, due to brain swelling and edema, traumatic hematoma or local infection of the wound, etc., should be treated according to the cause. Since the brain tissue of the external process is still lifeless and should not be removed, a cotton ring should be placed around it to protect it with rubber strips. 3, meningitis Most of them are due to insufficient brain debridement, leaving a variety of foreign bodies, inactivated tissues and blood clots to cause good breeding conditions for bacteria. Sensitive to antibiotics for pathogenic bacteria, including intrathecal injection. 4, skull osteomyelitis Trauma infection affects the skull and forms marginal osteomyelitis, also seen in frontal sinus infections. The wound forms part of the chronic sinus, often with dead bone formation and with epidural abscess or granulation tissue. After the infection is controlled, the surgery extensively removes the bone damaged by the inflammation to reveal the normal dura mater, and the wound can be cured. 5, brain abscess If there are no debridement in the brain, the brain remains in the brain. Among them, about half of them have intracranial infections, mainly brain abscesses, especially in dense bones. Large shrapnel above 1cm can also cause brain abscess. CT examination can understand the location, size and film formation of the abscess, and its relationship with the bone piece or shrapnel. Treatment is based on the formation of an abscess membrane, using different surgical methods. 6, traumatic epilepsy Most epileptogenic lesions are located in the marginal zone of the meningeal brain scar. The antiepileptic drug should be taken first. If the episode is frequent and the drug control is ineffective, the epileptic foci can be found under the examination of the EEG cortical electrode, and the subdural transverse fiber is cut or the lesion is removed.