Debridement of craniocerebral tangent wound

Cranial tangential injury accounts for about 20% of craniocerebral penetrating penetrating injuries in the statistics of war wound treatment, and the actual injury rate is higher than that on the fire line. The reason is that the death of the wound immediately or within a few hours is very high. Less, almost all the wounded can be sent to the treatment unit. This type of injury is characterized by the linearity of the projectile passing through the wounded head and causing the scalp soft tissue, skull, dura mater and brain tissue to be damaged, and there are more skull fragments in the sulcus wound of the brain. Dispersed, because the wound is farther from the brain stem, the effect of pressure waves on the brain stem has been weakened, so the changes in vital signs are not serious. However, the scope of cerebral cortex injury is wide, sports and linguistic areas are often involved, and the incidence of epilepsy is high. However, the deep structural damage of the brain is less, and the debridement is not complicated. Treatment of diseases: craniocerebral injury, firearm traumatic brain injury 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 have been debridement in the first-line hospital. After the hospital, the cranial bone film proves that there are many broken bone fragments or large shrapnel above 1cm in the brain, and should be prepared for reoperation. 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. 4. After the brain debridement, the wound has healed. After imaging examination, it shows that there is still a single bone piece or a <1cm shrapnel in the deep brain. Without signs of infection, there is no need to debride again. 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 scalp is wounded longer, and some scalp injuries are two close entrances and exits. After the wound edge is removed, an arc-shaped incision is made centering on this. 2. Skull and dura treatment The skull has a sulcus fracture, which is removed from the fracture margin by a rongeur and is exposed to the normal dura mater 1 cm or more around the dura mater to form an oblong bone window. A narrow strip is removed from the dura mater. 3. Brain debridement In the open sulcus brain injury, a large number of skull fragments are distributed, and the brain tissue mixed with shattered and discolored, such as clots, hair, hat fragments and other foreign matter, needs to be removed. The broken bone pieces are distributed shallowly, and the brain plate is opened to open the wound to find the requirements for thorough debridement. The fascia or aponeurosis is used to repair the dural defect, and the artificial meninges are generally not used. 4. Wound suture The scalp wounds were detached under the aponeurosis on both sides of the scalp. 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.