Debridement of penetrating craniocerebral injury

Brain penetrating injuries are almost always caused by gunshot wounds. In several wars since the Second World War, the rate of gunshot wounds has declined, accounting for 10% to 30% of firearm injuries. The automatic rifle and machine gun used in wartime are high-speed (500m / s or more) injuries, the injury energy is about 1000J, the death immediately after the injury and the death within a few hours, the majority of the patients sent to the hospital for treatment /3. Usually, the pistol injury is a low speed (less than 500m / s) injury, the injury energy is 230 ~ 400J, in addition to the high mortality rate of suicide, most can be sent to hospital for treatment. The diameter of the temporal cavitation caused by the high-speed bomb passing through the brain tissue is about 10 times larger than the diameter of the projectile, and the instantaneous cavity caused by the pistol is 2 to 3 times larger than that of the projectile. The brain stem is often damaged by pressure waves. Therefore, most of the wounds are stopped after the injury, or stopped after a few seconds and several minutes. Therefore, it is important to perform artificial respiration immediately in the first aid. The projectile wounded by the penetrating wound has already flown out of the skull, but the brain damage is heavy and wide, and the important structures such as the ventricles, basal ganglia and the main blood vessels of the brain are often damaged. The debridement surgery is complicated, and the disability rate and mortality rate are high. This is a characteristic of craniocerebral trauma. Treatment of diseases: brain trauma, open brain trauma Indication 1. The wounded are generally in good condition. Debridement should be prepared after the wound examination and skull imaging to understand the distribution of foreign bodies. 2. The wounded are in a coma, and those with intracranial hypertension and cerebral palsy should be debrided immediately. Contraindications 1. The injury is serious, manifested as deep coma, pathological respiration, blood pressure drop, pulse frequency is weak, suggesting brain stem failure, not suitable for brain debridement, supportive therapy should be performed. 2. With multiple injuries such as chest and abdomen visceral injuries, pale complexion, weak pulse, and decreased blood pressure, it is not suitable for brain debridement. Should first resist shock and treat chest and abdomen organ injury, and then go to brain debridement after the condition is stable. 3. A few days after the injury, the brain has a purulent discharge in the wound. It is not suitable for brain debridement. After the infection is controlled, the debridement is performed in the late stage. Preoperative preparation 1. Prepare the skin, first wash the head with soap and water, 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 antiserum 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 are available when conditions are available to understand the extent and extent of brain injury. There is no intracranial hematoma, its size and location. Surgical procedure Scalp incision Generally, the distance between the entrance and the exit is relatively long, and the scalp incision should be made separately. When the inlet and outlet distances are only a few centimeters, the inlet and outlet can be connected to a scalp incision. 2. Skull treatment Those who have an entrance in the face, an ankle or a forehead are craniotomy with a bone flap; those with an entrance or an exit at the front, the top, the ankle, or the occiput are craniotomy with a bone window. Small hole fractures can also be used for craniotomy. If the entrance and exit bone holes are only a few centimeters apart, you can bite the middle bone bridge and make an oblong bone window. 3. Dural incision The damaged and damaged dura mater at the entrance and exit were excised and cut open to expand the brain. If the entrance and the exit are adjacent, the middle dura mater is cut open, and the suture is passed through the dura mater and retracted outside the bone window to prepare for debridement in the brain. 4. Brain debridement The characteristic of penetrating traumatic brain injury is that there are many skull fragments and other foreign bodies scattered in the proximal segment of the brain injury. The brain injury in the distal segment is heavier, and there are more inactive brain tissue and blood clots, but generally no broken. The bone fragments, the fracture fragments of the exit have already flown out with the projectile. The order of debridement of entrance and exit depends mainly on which side has active bleeding or hematoma compression emergency, that is, debridement from the side first; if there is no emergency in both places, the brain can be removed first by the entrance. Bone piece. Entering the debridement through the entrance bone window is the same as debridement of the brain tube blind injury. Entering the debridement from the exit, pay attention to clear the inactivated brain tissue and blood clots, and carefully stop the bleeding, so that the broken bone fragments can be completely removed in the proximal part of the injured road, and the single bone piece that is difficult to reach in the deep brain does not need to be forcibly extracted, and the wound is inactivated in the distal segment. Tissue and blood clots are cleaned and hemostasis is complete. 5. Wound suture Drainage was placed in the brain injury at the entrance and exit, and wound suture was performed. complication Traumatic infection Seen in the time delay of brain debridement, or insufficient debridement, the brain still contains some broken bone fragments, inactivated brain tissue and clots. The infection should be controlled and the local treatment of the wound should be strengthened and debrided again if necessary. 2. Brain highlight More common after debridement, the 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 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.