CHMT surgery. Higher professional education

Under head injury understand damage to the skull and intracranial contents (brain, meninges, blood vessels, cranial nerves) by mechanical energy.

Traumatic brain injury (TBI) is one of the most common types of injuries in peacetime, accounting for about 40% of all types of injuries. TBI belongs to the category of severe damage to the human body, accompanied by high mortality: from 5 to 70%. In wartime, the frequency of injuries to the skull and brain is constantly increasing: the Great Patriotic War - 11.9%; Vietnam - 15.7%; Afghanistan - 14.4%; Chechnya - 22.7%.

Mechanism of injury

direct and indirect.

Pathogenesis.

In the pathogenesis of TBI, two main factors of a mechanical nature are of particular importance: 1) temporary changes in the configuration of the skull according to the type of its general or local deformation with the occurrence in some cases of a skull fracture; 2) displacement of the brain in the cranial cavity (in relation to the internal walls of the cavity and intracranial fibrous septa) - linear and rotational displacement, change in velocity in a linear direction, linear acceleration and deceleration.

Types and classification of skull injuries.

Injuries to the skull and brain are divided into closed and open (wounds) . Distinguish firearms and non-firearms wounds. Closed TBI includes injuries in which there are no violations of the integrity of the head cover. An open TBI is called with the presence of a wound of the soft tissues of the skull (aponeurosis), as well as a fracture of the base of the skull, accompanied by bleeding or liquorrhea from the ear or nose. With the integrity of the dura mater, open craniocerebral injuries are classified as non-penetrating , and in case of violation of its integrity - to penetrating .

Classification.

1. I. Closed head injuries: Brain concussion; 2. Brain contusion: - mild; - moderate severity; - severe degree. 3. Compression of the brain on the background of a bruise and without a bruise: - hematoma: acute, subacute, chronic (epidural, subdural, intracerebral, intraventricular); - hydrowash; - bone fragments; - edema-swelling; - pneumocephalus. 4. State of the subshell spaces: - subarachnoid hemorrhage; CSF pressure: normotension, hypotension, hypertension. 5. Condition of the skull: - without damage to the bones; type and location of the fracture. 6. Condition of the integument of the skull: - bruises; - abrasions. 7. Associated injuries and diseases. 8. According to its severity, a closed craniocerebral injury is divided into three degrees: - mild (concussion and mild brain contusion), moderate (medium brain contusion) and severe (severe brain contusion with compression).
2. II . Gunshot wounds of the skull and brain: By type of wounding projectile: - bullet, - fragmentation. 2. By the nature of the wound: - soft tissues, - non-penetrating with bone damage, - penetrating. 3. According to the type of wound channel: - blind, - tangent, - through, - ricocheting. 4. By localization: - temporal, - occipital, other areas. 5. According to the type of fracture of the skull bones: - linear, - depressed, - crushed, - perforated, - comminuted. 6. By the number of wounds: - single, - multiple. 7. According to the influence of combinations of various factors: - mechanical, - radiation, - thermal, - chemical. 8. According to the nature of brain damage: - concussion, - bruise, - crush, - compression. 9. According to the severity of the injury: - light, - moderate, - severe. 10. According to the severity of the condition of the wounded: - satisfactory, - moderate, - severe, - terminal. 11. Blind wounds: - simple, - radial, - segmental, - diametrical, - rebounding, - tangential. 12. Through wounds: - segmental, - diametrical, - tangential.

During TBI, it is customary to distinguish the following periods:

1) acute period - from the moment of injury to stabilization at various levels of functions impaired due to injury (from 2 to 10 weeks, depending on the clinical form and severity of TBI);

2) intermediate period - from the moment of stabilization of functions to their full or partial recovery or stable compensation (with mild TBI - up to two months, with moderate TBI - up to four months, with severe TBI - up to six months);

3) long-term period - clinical recovery or the maximum possible restoration of impaired functions or the emergence and (or) progression of new pathological conditions caused by TBI (up to two years or more). A detailed diagnosis, including all the elements of this classification, can only be made in a specialized hospital.

The clinical picture of damage to the skull and brain consists of cerebral and local (focal) neurological symptoms. Cerebral symptoms include headache, nausea, vomiting, dizziness, etc. Local (focal) symptoms depend on the location of the focus of brain damage and can manifest as hemiparesis, hemiplegia, speech and visual disorders.

Clinic of closed TBI.

1. Closed brain injury with concussion symptoms is a functionally reversible form of brain injury. It is characterized by short-term loss of consciousness from a few seconds to several minutes, retro- and anterograde amnesia, vomiting, headache, dizziness, and other autonomic disorders. In the neurological status, as a rule, only cerebral neurological symptoms are noted. There are no injuries to the bones of the skull, the pressure of the cerebrospinal fluid and its composition are without deviations from the norm. The condition of patients, as a rule, improves within the first or second week.
2. Closed brain injury, accompanied by symptoms of brain contusion (degrees - easy, medium, heavy). brain contusion mild degree It is characterized by turning off consciousness from several minutes to one hour. Then there is a headache, dizziness, nausea, vomiting, retro- and anterograde amnesia. Vital functions are usually not impaired, a moderate increase in heart rate, respiration, and an increase in blood pressure are possible. Focal symptoms are mild (nystagmus, pyramidal insufficiency) and disappear after 2-3 weeks. Unlike concussion, subarachnoid hemorrhages and skull fractures are possible. brain contusion medium degree It is characterized by a loss of consciousness after an injury lasting from several minutes to several hours. Expressed retrograde and anterograde amnesia and other cerebral symptoms. Complaints of severe headache, repeated vomiting, transient disturbances of vital functions in the form of bradycardia, tachycardia are possible). Nested symptoms are clearly manifested, determined by the localization of the brain contusion - hemiparesis, speech disorders, visual disorders, etc. With a lumbar puncture, blood-colored cerebrospinal fluid is usually detected, flowing under high pressure. Craniograms often show skull fractures. brain contusion severe accompanied by a loss of consciousness from several hours to several weeks. Severe violations of vital functions are observed: bradycardia or tachycardia, often with arrhythmia, arterial hypertension, respiratory distress. In the neurological status, stem symptoms come to the fore: floating movements of the eyeballs, paresis of accommodation, tonic nystagmus, swallowing disorders, decerebrate rigidity (generalized or focal seizures). As a rule, a brain contusion is accompanied by fractures of the bones of the vault or base of the skull, massive subarachnoid hemorrhages.
3. Closed trauma of the brain, accompanied by symptoms of increasing compression of the brain (against the background of bruises or without bruises of the brain). The brain compression syndrome is characterized by a life-threatening increase at various intervals after the injury (the so-called "light period") of cerebral, focal and stem symptoms. Depending on the background (concussion, brain contusion), on which traumatic compression of the brain develops, the latent period may be pronounced, erased, or absent altogether. Clinically, in this case, pupil dilation appears on the side of compression, and hemiplegia on the opposite side. The appearance of bradycardia is characteristic.

Clinical brain injury.

At the suggestion of E.I. Smirnov (1946) it is customary to divide the course of pathological processes in brain injury into five periods.

They are called periods of traumatic brain disease:

- initial period - "chaotic" according to N.N. Burdenko, lasting about three days. It is characterized by a predominance of cerebral symptoms over local ones, impaired consciousness, respiration, cardiovascular activity, and the act of swallowing;

II - the period of early reactions and complications - (infection and discirculation), lasting up to three weeks - 1 month is characterized by an increase in edema-swelling of the brain, its protrusion (benign prolapse). The wounded regain consciousness, focal symptoms are detected, the course is complicated by the development of meningitis, meningoencephalitis, suppuration of the wound channel. As a result of the development of infection, malignant protrusions (secondary prolapses) occur;

III - the period of elimination of early complications and a tendency to limit the infectious focus, begins on the 2nd month after the injury and lasts about 3-4 months (depending on the severity of the injury). With a smooth course, the wound heals and recovery occurs.

I V - period of late complications , begins 3-4 months after the injury and lasts 2-3 years, is characterized by the formation of late brain abscesses, outbreaks of meningitis, meningoencephalitis;

V - period of long-term consequences associated with the presence of a meningeal scar. May last for many years after injury.

Diagnosis of TBI:

1. Identification of an anamnesis of trauma.

2. Clinical assessment of the severity of the condition.

3. The state of vital functions.

4. The condition of the skin - color, moisture, bruising, the presence of soft tissue damage.

5. Examination of internal organs, skeletal system, concomitant diseases.

6. Neurological examination: the state of cranial innervation, the reflex-motor sphere, the presence of sensory and coordinating disorders, the state of the autonomic nervous system.

7. Shell symptoms: stiff neck, symptoms of Kernig, - Brudzinsky.

8. Echoencephaloscopy.

9. X-ray of the skull in two projections.

10. Computed or magnetic resonance imaging of the skull.

11. Ophthalmological examination of the condition of the fundus.

12. Lumbar puncture - in the acute period, it is indicated for almost all victims with TBI (with the exception of patients with signs of brain compression) with the measurement of cerebrospinal fluid pressure and the removal of no more than 2-3 ml of cerebrospinal fluid, followed by laboratory testing.

Providing assistance at the stages of medical evacuation.

First aid

is reduced to the imposition of an aseptic dressing on the wound, the careful removal of the wounded. The wounded, who are unconscious, are taken out on their side (in order to prevent aspiration of vomit), they need to unfasten the collar, loosen the belt. In case of retraction of the tongue and signs of asphyxia, introduce an air duct (S-shaped tube, breathing tube TD-1). Do not inject drugs (respiratory depression).

First aid

– Bandaging of the bandage, ventilation of the lungs with the help of the DP-10, DP-11 breathing apparatus, oxygen inhalation with the KI-4 apparatus, maintenance of cardiovascular and respiratory activity (intramuscular injection of 2 ml of cordiamine, 1 ml of caffeine). Evacuation of the wounded in the first place on a stretcher.

First aid

- fight against asphyxia, artificial ventilation of the lungs with the DP-9, DP-10 apparatus, oxygen inhalation with the KI-4 apparatus, maintenance of cardiovascular and respiratory activity (introduction of 2 ml of cordiamine, 1 ml of caffeine, 1 ml of 5% ephedrine).

If necessary, the bandage is corrected, a prophylactic dose of antibiotics is administered (500,000 units of streptomycin, 500,000 units of penicillin), tetanus seroprophylaxis is carried out by subcutaneous injection of 0.5 ml of tetanus toxoid.

The wounded are directed to the dressing MPP in the skull with ongoing bleeding from soft tissue wounds to implement hemostasis with a pressure bandage, applying a clamp to the bleeding vessel. The wounded are not detained at this stage, they are evacuated first of all with ongoing intracranial bleeding and liquorrhea, and secondarily those wounded in the soft tissues of the skull. Before transportation, according to indications, cardiovascular and respiratory means, an air duct are introduced.

It is necessary to transport the wounded to the skull in the prone position and it is better to immediately go to the SMP stage, bypassing the intermediate stages of medical evacuation.

Qualified medical care .

The wounded deserve special attention, who, as a result of medical triage, are subject to surgical treatment at this stage for health reasons (refusal to operate can lead to death).

Urgent surgical interventions are performed for the following wounds and injuries: wounds and injuries of the head and neck, accompanied by: - ​​asphyxia (tracheal intubation or tracheostomy); - external bleeding (stopping external bleeding by ligation of the vessels of the integumentary tissues or tight tamponade of the wound); - trepanation of the skull and PST of a brain wound at the stage of rendering qualified assistance (including with compression of the brain).

Sorting of the wounded in the skull on OMedB and OMO in case of mass admission will often have to be carried out without removing the bandage.

Determination of transportability is made on the basis of an assessment of the general condition, preservation of the reaction of the pupils and corneal reflexes, the state of the pulse, respiration, dressing, etc.

When evacuating, provide for: - wounded with damage to the soft tissues of the skull without focal neurological symptoms - in the GLR; - wounded with concussion - in VPNG. All other wounded with open skull injuries are sent to a specialized neurosurgical hospital.

Specialized assistance .

The hospital provides comprehensive specialized surgical care to the wounded who have not received qualified surgical care.

1. Questions for self-control.
2. Mechanism of traumatic brain injury.
3. Classification of gunshot injuries of the skull and brain.
4. Classification of non-gunshot injuries of the skull and brain.
5. Clinical picture of concussion.
6. Clinical picture of brain injury.
7. Clinical picture of brain compression.
8. Diagnosis of combat trauma of the skull and brain.
9. The volume of medical care at the stages of medical evacuation.
10. Possible complications in traumatic brain injury and their prevention.

Neurosurgical correction in the acute period of TBI is subject to wounds of soft tissues of the head, depressed fractures of the bones of the cranial vault, intracranial hematomas and hydromas, some forms of brain contusion, gunshot wounds of the skull and brain.

Soft tissue wounds of the head

Wounds of the soft tissues of the head are divided into:

1. Depending on the type of injuring agent: bruised, cut, stabbed, chopped, torn, crushed, bitten and gunshot.

2. By type: linear, stellate, scalped.

3. Distribution depth: skin, skin-aponeurotic, penetrating to the bone and deeper.

Wounds of the soft tissues of the head, except for superficial, skin wounds (their edges do not gape, they quickly stick together, and the bleeding stops on its own), are subject to surgical treatment. Depending on the timing of surgical treatment of wounds after injury, there are:

– primary surgical treatment (PSD) of the wound, performed during the first 6 hours;

- early surgical treatment of the wound, performed in the first 3 days;

- delayed surgical treatment, performed on the 4-6th day;

- late surgical treatment, performed after 6 - 7 days.

It is most optimal to perform PST in the acute period, which contributes to the healing of wounds by primary intention and the transfer of an open TBI into a closed one. However, gross vital disorders and shock may prevent the treatment of wounds in the first 6 hours.

The basic rules for the surgical treatment of head wounds are described in the section on the general principles of craniotomy. In addition to the general rules, attention should be paid to the essential details of the treatment of wounds on the head, such as the complete removal of foreign bodies from the wound. In torn-bruised and crushed wounds, only obviously non-viable parts of the edges should be removed. Careful hemostasis and a complete revision of the wound are important. Particularly relevant is a thorough instrumental or digital revision of the bottom of the wounds under the known condition of the impossibility to perform an overview craniography in the near future. If the surgeon is convinced that the bottom of the wound is an intact bone, there are no deep "pockets" or a significant detachment of soft tissues, he has the right to apply a primary blind suture. If there is a suspicion of a high probability of the development of suppuration, then the wound is drained for 1 to 2 days and, in the absence of complications of an infectious nature, secondary early sutures are applied. In cases where the wounds still suppurate, after the disappearance of the purulent discharge and the formation of good granulation tissue, late secondary sutures can be applied. In this case, it is advisable to economically “refresh” the edges of the granulating wound.

What to do if the ambulance personnel delivered to the hospital together with the victim a completely torn off extensive flap of herep soft tissues? In this case, after a full treatment of the wound on the head, the flap is freed from the aponeurosis and subcutaneous fatty tissue. Then perforating wounds of about 1 cm in size are applied on it in a checkerboard pattern and placed on an intact periosteum. If the bottom of the wound is a completely exposed bone, then its cortical layer is removed and a skin flap is placed on the “platform” prepared in this way.

Surgical treatment of depressed fractures of the bones of the cranial vault

In cases where a digital examination of the bottom of the wound or craniography revealed an open depressed fracture, the soft tissue wound should be dissected, taking into account the course of blood vessels, nerves and cosmetic considerations. The size of the wound must comply with the requirements for a possible craniotomy (Fig. 49). Access planning for closed depressed fractures should follow the requirements outlined in Chapter VI. Surgical treatment of depressed fractures of the bones of the cranial vault is indicated for the impression or depression of bone fragments to a depth greater than the thickness of the bone. In this case, the surgeon aims to provide decompression of the brain, exclude and, if necessary, remove the underlying hematoma, and prevent long-term consequences of TBI due to irritation of the underlying brain by an unremoved bone fragment. Removal or elevation of bone fragments pressed into the cranial cavity, as a rule, is carried out from a burr hole placed next to the depressed fracture (Fig. 50). It is impossible to immediately begin the removal of bone fragments from the center of the impression, since in this case there is a high probability of additional injury to the underlying brain.

Rice. 49. Excision of non-viable wound edges of the soft tissues of the head (according to A. P. Romodanov et al., 1986)

The cutter hole is expanded until an intact DM appears (Fig. 51). Small bone fragments (up to 2-3 cm) must be removed. Extracted free-lying uninfected bone fragments of a larger size are not thrown away, but kept sterile until the wound is closed, when they can be placed in the region of the skull defect between the dura mater and soft tissues. Large fragments connected by the periosteum should be raised. Reduced fragments, if they are not sufficiently immobilized, are subject to suturing. The edges of the formed bone defect are aligned to prepare them for subsequent plasty. Particular attention should be paid to the need for a thorough revision of the epidural space along the circumference of the formed bone defect. Very often fragments of the lamina vitrea are embedded under the edge of the bone and may go unnoticed and not removed, which increases the risk of developing osteomyelitis in the postoperative period. To avoid this, a Volkmann spoon or a narrow spatula carefully revise the epidural space along the edge of the bone defect and remove all free-lying, often small, bone fragments, blood clots.

Rice. fifty.

Rice. 51.

Is it possible to initially reposition bone from

– be used in children in cases where the impression of bone fragments is relatively small and all bone fragments are connected through the periosteum. In adults, such manipulation is fraught with danger, since it is possible to “miss” intracranial hematomas and bleeding located under the fracture.

It is forbidden to perform such manipulation in the area of ​​the projection course of large venous sinuses.

If an intracranial hematoma, brain crush or a massive contusion focus is detected, a decompressive (patchwork or, more often, resection) craniotomy is performed. For small depressed, perforated, gunshot fractures, it is advisable to cut out a bone flap with a damaged zone in the center (according to the De Martel principle). After an adequate revision of the wound and processing of the bone flap, the latter is laid in its original place.

Of particular difficulty are cases where the depression zone is located above the large venous sinuses. In such cases, surgical treatment is performed according to the principle from the periphery to the center.

Initially, a free flap should be prepared, cut from soft tissues (aponeurosis, muscle). It is flattened with scissors branches and stitched in at least 4 places with ligatures. Such a flap may be needed for plastic closure of the damaged area of ​​the sinus. Therefore, it must be prepared in advance.

Several burr holes are placed on both sides of the sinus and bone resection is performed from them. With bordering biting of the bone, undamaged adjacent sections of the sinus are exposed. Then proceed to the careful removal of bone fragments. It is more expedient to remove them in one block, carefully exfoliating the DM. If bleeding occurs from the sinus, it is immediately stopped by finger pressure.

How can you conclusively stop bleeding from a damaged sinus? There are several ways.

Rice. 52. Suturing the sinus wound with interrupted sutures (according to A.P. Romodanov et al., 1986)

1. Compression of the sinus on the sides of the wound by introducing tampons into the epidural space. However, this results in compression of the underlying brain, impaired blood flow through the sinus. Stopping bleeding in this way is not only ineffective, traumatic, but also does not guarantee the exclusion of re-bleeding after the removal of tampons.

2. Direct suturing of the sinus wound by applying interrupted or continuous sutures (Fig. 52). The disadvantages of this method include the difficulty of suturing in conditions of massive bleeding and poor visibility of the sinus wound edges, the possibility of cutting sutures. In addition, suturing in this way can be performed only with linear wounds of the sinuses, which is rare, and with localization of damage on the upper wall of the sinus.

3. Sinus wound plasty with an outer sheet of DM according to Bryuning-Burdenko. In conditions of intensive bleeding, such an operation is difficult to perform. In addition, the outer (conditionally infected) sheet of the dura mater, facing the lumen of the sinus, can contribute to the development of septic complications (Fig. 53).

4. The most simple, effective and reliable way can be considered sinus wound plasty with a free flap, pre-prepared, as mentioned above (Fig. 54). The surgeon, after raising his finger, which blocked the bleeding from the wound of the sinus, quickly applies a piece of the flap to the damaged area and again presses it with his finger. Then, gradual suturing of the edges of the flap along the periphery to the DM with moderate tension is performed. In most cases, this method allows you to reliably stop bleeding from a damaged sinus.

5. In those cases where there are gaping lesions of two or three walls of the sinus and the bleeding does not stop in any other way, the surgeon is forced to make a decision to ligate the sinus. With a large round needle with a strong ligature, the sinus is stitched on both sides of the wound (Fig. 55). If the bleeding continues, then it is necessary to coagulate or ligate the ascending veins of the brain, which flow into the sinus in this area.

Rice. 53. Stages of plastic closure of the sinus wound according to Bruening - Burdenko (a, b) (according to A.P. Romodanov et al., 1986)

Rice. 54.

Rice. 55.

The anatomical features of the structure of the venous system of the brain make it relatively harmless for the victim to produce ligation of the sagittal sinus in the anterior third. Ligation of the sinus in the middle and especially in its posterior third leads to a violation of the venous outflow, the rapid development of cerebral edema and, ultimately, to death.

Of particular note is the need to form a trepanation window of sufficient size if a sinus injury is suspected. It must be at least 5 x 6 x 6 cm.

When injured by bone fragments of the dura mater of the brain the latter is often dissected by radial incisions. Before this, careful hemostasis is necessary. The sheath vessels coagulate and stitch the arterial trunks of the dura mater. In the parasagittal region, incisions should be made in such a way that it is possible to discard one of the flaps with the base to the sinus.

Rice. 56. Horseshoe-shaped dissection of the dura mater with the base towards the sinus and removal of bone fragments embedded in the brain (according to A.P. Romodanov et al., 1986)

Bone fragments that have penetrated the brain, foreign bodies, crushed areas of the brain tissue are removed with tweezers, washing and suction (Fig. 56).

Bleeding from the brain tissue is stopped by coagulation, the application of cotton pads moistened with hydrogen peroxide, a hemostatic sponge, and the application of clips.

Subsequently, the dura mater is sutured. If this is not possible due to a significant protrusion of the brain into the defect, plastic closure of the dural defects is performed with the creation of a certain reserve in the form of a "sail".

In children under the age of 1 year, depressed fractures without bone fragments can be lifted with an elevator from a burr hole placed next to the fracture. For "old" depressed fractures in children, the technique of inversion of the bone flap is used. At the same time, several milling holes are superimposed along the perimeter of the depression, which are connected by cuts. If the surgeon has the appropriate equipment, preference should be given to a free flap. The formed flap is turned over with an outward impression and fixed to the main bone.

In older children, when closed, non-penetrating, depressed fractures are accompanied by the formation of bone fragments and there is a need to remove them, it is advisable not to throw away the bone fragments. After a complete treatment of the wound, the fragments are crushed with wire cutters and the formed bone “crumbs” are laid in a uniform layer on the DM. In the future - layer-by-layer suturing of the wound.

Surgical treatment of depressed fractures of fronto-basal localization

Fractures of the outer wall of the frontal sinus with an impression, but without damage to the posterior wall, do not require surgical intervention in most cases. Often, fronto-basal injury is accompanied by the formation of multi-comminuted depressed fractures in the region of the frontal sinuses and orbits. In this case, damage to the lattice labyrinth, opener, and orbital contents often occurs. Taking into account cosmetic considerations, we suggest surgical treatment of such injuries from the Zutter approach, the soft tissue incision is made approximately 1 cm posterior to the hairline. The skin-aponeurotic flap is separated with its base to the superciliary arches, exposing the zone of depression. Existing wounds are subject to economical marginal excision only in case of their obvious crushing and non-viability. With this access, a wide approach and a good overview are provided. There is no need for additional soft tissue incisions. Quite often, novice neurosurgeons, motivating their actions by the fact that there is already a wound, expand it and thereby increase the cosmetic defect.

Following the general rules for the treatment of depressed fractures, it is still necessary to remove bone tissue as sparingly as possible. Free-lying small fragments are to be removed, large fragments are carefully lifted to the level of the main bone and fixed to each other with sutures. Particular care should be taken to revise the fatty tissue of the orbit, the base of the skull. Small fragments can go unnoticed here, which damage the dura mater, optic nerve, eye muscles. After removing all the fragments to be removed, proceed to the "clean" stage of the operation.

The gloves of the operating team are processed, the towels delimiting the operating field are changed, and the area of ​​intervention is delimited with padded jackets. If there is a dural wound, it is expanded and the pole(s) of the frontal lobe(s) are inspected. Existing brain debris is washed and aspirated. Hemostasis according to generally accepted rules. The DM must be carefully sutured to avoid the formation of nasal liquorrhea in the postoperative period. After suturing the dura wound, you need to make sure that there is no damage to the membrane in other places. If any are found, be sure to take them in. The mucosa of the frontal sinus is carefully scraped out with a Volkmann spoon. Tamponade of the frontal sinuses with muscles, protacryl and other means is not advisable. Preference can be given to tamponade with a hemostatic sponge with gentamicin. After that, a layer of glue of the MK series is applied along the inner perimeter and a semi-permeable membrane OB-20 is glued. It is possible to block the mouth of the fronto-nasal passage with a small piece of crushed muscle.

Rice. 57.

1 - frontal sinus; 2 - pole of the frontal lobe; 3 - periosteal apron is fixed to the DM (according to Yu. V. Kushel, V. E. Semin, 1998)

We agree with the opinion of many authors about the need to delimit the opened frontal sinuses from the DM. To do this, a horseshoe-shaped "apron" is cut out from the skin-aponeurotic flap in the area of ​​the opened sinus with the base to the superciliary arches. It is stretched over the area of ​​the damaged sinus and sutured to the DM as close to the base as possible (Fig. 57).

Rice. 58. Frontal sinus plasty with periosteum (according to Yu. V. Kushel, V. E. Semin, 1998). The arrow shows the duplication of the periosteum

There is an opinion that cerebrospinal fluid may leak from the holes formed at the puncture sites of the DM when the aponeurotic “apron” is sutured, which leads to liquorrhea. To avoid such a complication, another method of isolating the frontal sinuses can be used. Paired holes should be drilled in the back wall of the sinus to pass the threads at a distance of about 7-8 mm from each other. The aponeurotic flap or periosteum, cut out in the same way as above, is sutured to the posterior wall of the sinus, as shown in Fig. 58. It is obligatory to form a duplicate.

Surgery for intracranial hematomas

At the stage of qualified medical care, the issue of surgical treatment of intracranial hematomas should be decided unambiguously. It should be done as soon as the diagnosis is made. In hospitals that have the possibility of CT or MRI monitoring, the tactics of treating intracranial hematomas, especially "small" ones, can be decided in each case individually and does not exclude conservative management.

The intervention is planned and carried out taking into account the severity of the condition and age of the victim, the volume of the hematoma, the presence and severity of concomitant brain contusion, dislocation syndrome, extracranial chronic and traumatic pathology. Access should be adequate (at least 7 x 7 x x 8 cm), from which it is possible to remove a hematoma, a contusion focus, to carry out a full hemostasis without additional trauma to the brain. As already noted, preference should be given to patchwork craniotomy, however, the resection method of trepanation also has a right to exist and is fully justified in the conditions of CRH.

Rice. 59. Scheme of the most common variants of epidural hematomas with branches of the middle meningeal artery. The lines indicate the Kronlein scheme. The circles indicate the places where the trefination holes overlap.

Rice. 60.

Rice. 61. Examination of the brain with a spatula after a slight expansion of the burr hole with bone cutters (according to V. M. Ugryumov, 1969)

Skull trefination technique

The imposition of a diagnostic burr hole is both the last stage of the diagnostic complex and the first stage of surgical treatment. The dissection of soft tissues is performed in the projection of the point of the highest frequency of localization of intracranial hematomas, about 5 cm long (Fig. 59).

The bone is skeletonized with a raspator. A milling hole is superimposed with a rotator (Fig. 60).

The DM is dissected with a small cruciform incision, its edges are either sutured or picked up with special tweezers with small teeth (commonly referred to as dural). A narrow cerebral spatula is carefully introduced into the subdural space (Fig. 61).

When a hematoma is detected, either the expansion of the trefination hole is performed by a resection method, or a patchwork craniotomy is performed.

Features of removal of epidural hematomas

After performing the bone stage of the operation, black blood clots are presented in the wound. They are removed gradually by aspiration and washing out with isotonic sodium chloride solution (Fig. 62). Detected sources of bleeding, which in most cases are branches of the sheath artery, are subject to coagulation, clipping or stitching and ligation. However, not always after washing the clots, the surgeon can detect a bleeding vessel. Some of the clots remain on the DM, intimately soldered to it. There is an opinion that these clots should not be removed, since they already perform a hemostatic role. We consider this tactic to be erroneous.

Rice. 62. Removal of an epidural hematoma with an electroaspirator (according to A.P. Romodanov et al., 1986)

In the immediate postoperative period, lysis of the clot that covered the damaged branch a. meningea media, resumption of bleeding, the formation of a new epidural hematoma, which necessitates re-intervention.

In our opinion, the surgeon is obliged to detect the source of hemorrhage during the first intervention and ensure conclusive and reliable hemostasis. To do this, blood clots that have “stuck” to the DM must be carefully removed by scraping with a spatula or spoon. The visualized source of bleeding is then processed according to generally accepted rules.

Particular attention should be paid to those cases when blood comes from the base of the skull and it is difficult to localize the source of bleeding, then the scales of the temporal bone are bitten as close as possible to the base of the skull, the DM is pushed back with spatulas and the sheath artery is coagulated at its base. If coagulation does not give the desired effect, flashing is technically impossible, since the artery is damaged in the area of ​​​​its exit from the spinous foramen, then bleeding can be stopped as follows: a pin is formed from an ordinary match treated with 96 ° alcohol, which is embedded in f. spinosum until the bleeding stops completely. A similar stop of bleeding is possible with a bone pin.

Additional hemostasis can be carried out with a 3% hydrogen peroxide solution, small crushed pieces of muscle, and a hemostatic sponge. We consider it necessary to suture the DM along the perimeter of the bone defect to the aponeurosis, periosteum. This reduces the epidural space in the area of ​​the removed hematoma, improves hemostasis and reduces the risk of re-accumulation of blood in this area.

Indications for dissection of the dura after removal of an epidural hematoma are described in the section on the general principles of craniotomy.

Features of removal of subdural hematomas

The technique for removing subdural hematomas depends on the timing of their formation, the age and severity of the condition of the victims. It is different in acute and chronic variants of the course. Preference should be given to osteoplastic access. After trepanation in the area of ​​localization of the hematoma, a sharply tense and cyanotic DM is always visualized, which does not transmit the pulsation of the underlying brain. Some authors believe that before dissection of the dura mater, it is advisable to perform a lumbar puncture with the removal of 20–25 ml of CSF. At the same time, a substantiation is given for a decrease in intracranial pressure and the appearance of brain pulsation.

We believe that it is not only inappropriate, but even dangerous, to perform a lumbar puncture, since when such a large amount of cerebrospinal fluid is removed, a rapid development of brain dislocation can occur. It will be better for the patient to eliminate the compression factor as soon as possible, which is also located in most cases in an accessible place.

After the obligatory coagulation of the vessels of the dura mater, the latter is dissected by one of the methods indicated in chapter VI (Fig. 63). With a pronounced tension of the dura mater, it is possible to apply at first a dotted incision for a "slow" evacuation of blood and gradual decompression of the brain. Rapid emptying of the hematoma leads to sharp changes in systemic hemodynamics. After isolating the liquid part of the hematoma, an incision is made in the dura mater, connecting the dotted incisions. Clots are evacuated by aspiration and washing out with a jet of isotonic solutions (0.9% sodium chloride, furatsilina) (Fig. 64).

After washing out the visible part of the hematoma, a false impression of its total removal may be formed. This is far from true. As a rule, in such situations, approximately half of the volume of the subdural hematoma remains unremoved. This part is located under the DM along the periphery of the trepanation window, and the surgeon does not see it. The brain is covered with cotton pads and the rest of the hematoma is methodically removed using spatulas, an aspirator and washing out.

Rice. 63.

Rice. 64. Washout and aspiration of the visible part of the subdural hematoma (according to V. M. Ugryumov, 1969)

It should be remembered that the spatulas must be carefully introduced into the subdural space. The medulla should be squeezed out gently, the pressure of the jet of the washing liquid should be moderate. The spatula can be removed only after the almost complete outflow of the lavage fluid from the subdural space.

You should not revise the subdural space with your finger, as this can damage the ascending parasinus veins and cause additional bleeding.

The complete removal of the hematoma is evidenced by the absence of clots when washing the subdural space, the retraction of the brain, the appearance of its pulsation, respiratory oscillations.

The surgeon must ensure that hemostasis is adequate. To do this, observe the wound for several minutes. After the compression factor is eliminated, the brain straightens out. At the same time, slightly bleeding veins are pressed against the inner sheet of the DM. This process contributes to the implementation of hemostasis. If, nevertheless, bleeding continues, it should be localized, the trepanation window should be expanded, the source of bleeding should be visualized, and final hemostasis should be performed by coagulation.

In most cases, subdural hematomas extend to a significant part of the convexital surface of the hemisphere, and only a small part of them can be reviewed. What to do if, after removal of the central part of the hematoma, the brain protrudes into the bone defect and does not allow adequate washing of the subdural space without additional trauma? In this case, it is necessary to make sure that there is no intracerebral hematoma. With fingers moistened with furacilin, careful palpation of the brain is performed in order to identify fluctuating zones. When such zones are identified, a brain puncture is performed, an intracerebral hematoma is verified, and it is removed. And only after that, when the tension of the brain decreases, the final removal of the subdural hematoma is performed.

If an intracerebral hematoma is not detected and the protrusion of the brain into the defect is significant, there is no pulsation, then one can think of the presence of an intracranial hematoma on the opposite side. Therefore, it is necessary to apply a search cutter hole on the opposite side.

In case of subdural hematomas extending to the base of the skull, the trepanation window should be expanded as close to the base as possible, additionally dissect the dura and completely remove blood clots located basally.

What to do in those cases when, after the complete removal of the subdural hematoma, the brain does not straighten out and a significant residual cavity remains? Such situations are possible in subacute hematomas and in elderly patients (age-related increase in reserve spaces). Relapse (retraction) of the brain is accompanied by cerebrospinal fluid hypotension, a decrease in central venous pressure. Clinically, the victims may have a deep depression of consciousness, hyperthermia, deepening of focal symptoms, respiratory disorders, arterial hypotension, bradycardia. After final hemostasis, the residual cavity should be filled with isotonic saline. Drainage is brought to the base of the skull in the projection of the middle cranial fossa and the dura mater is sutured to drainage. In the postoperative period, intravenous infusions of a 1% solution of calcium chloride, polyglucin, reopoliglyukin are carried out.

Issues of drainage, wound closure with a bone flap and features of soft tissue suturing are described in Chapter VI.

Removal of intracerebral hematomas

Intracerebral hematomas resulting from trauma are removed by patch craniotomy or by resection. Having localized by palpation the zone of the greatest fluctuation or elastic compaction, a place for puncture of the brain is chosen. Such a point should, if possible, be located in a functionally insignificant area and at the top of the gyrus. In this case, the choice of a relatively avascular zone is desirable.

Rice. 65.

Rice. 66. Encephalotomy with spatulas and aspiration of intracerebral hematoma (according to V. M. Ugryumov, 1969)

It is unacceptable to choose a puncture site in the depth of the furrow, since the vessels passing there may be damaged. This can lead to the development of ischemia and regional cerebral infarction. After point coagulation of the cortex, the brain is punctured with a special cannula with divisions. Often there is a failure in the hematoma cavity. Aspirate the liquid part of the hematoma and then proceed to the dissection of the cortex (encephalotomy), without removing the cannula. Before this, coagulation of the vessels is carried out along the line of the planned dissection of the cortex (Fig. 65).

Along the cannula, the medulla is carefully spread with spatulas until a hematoma cavity is found (Fig. 66). Often, intracerebral hematomas are “born”. The remaining liquid part and clots are washed out and aspirated from its cavity. If necessary, an economical removal of the brain substance crushed in the perifocal zone is performed. The source of bleeding, as a rule, is rarely visualized at the time of removal of the hematoma. If there is one, then the bleeding is stopped by coagulation, tamponade with cotton pads moistened with a 3% hydrogen peroxide solution, and a hemostatic sponge. Hemostasis control is carried out by assessing the purity of the washing fluid and the absence of "smoking" vessels in the cavity of the removed hematoma. It is recommended to observe the brain wound for 3-5 minutes with systolic blood pressure of at least 100 mm Hg. Art. The surgical wound is closed, as in other types of operations for TBI.

Removal of chronic subdural hematomas

Chronic subdural hematomas are removed in most cases by performing an osteoplastic craniotomy. After access and opening of the DM, a gray-green or brown capsule is found. The capsule is opened and its contents are aspirated. Then, gradually capturing the capsule with fenestrated tweezers (Fig. 67), the capsule is disconnected from the dura mater and the underlying brain. At the present stage, it is believed that the removal of the capsule can be omitted. In this regard, one should not be afraid that small, tightly fixed parts of the capsule remain. The cavity formed after removal of the hematoma is filled with saline. In the subdural space for 1 day. silicone tube drainage is placed. The dura mater is sutured tightly.

Rice. 67.

Rice. 68. Removal of a chronic subdural hematoma by washing out through trefination holes (according to A.P. Romodanov et al., 1986)

In patients in extremely serious condition, in elderly victims, emptying and washing out of the hematoma from 2–3 trefination holes without removing the capsule is legal (Fig. 68).

Removal of intraventricular hematomas

With massive intraventricular hemorrhage, lavage of the ventricular system through external ventricular drains is indicated. To do this, external drainage of the lateral ventricle is performed on the side of greater hemorrhage intensity and lavage is performed with saline warmed to body temperature. Puncture drainage is performed by placing burr holes at typical points and introducing silicone tubes into the lumen of the lateral ventricles. More often, drainage of the posterior horns of the lateral ventricles is performed.

Technique of puncture of the posterior horns of the lateral ventricles. The position of the patient lying on his stomach face down. It is important to ensure that the head is laid correctly. It is necessary to position the head so that the line of the zygomatic process is strictly vertical, and the line of the sagittal suture is strictly in the median plane. The head is treated with antiseptics according to the accepted rules for preparing the surgical field. Then the marking is made with a stick moistened with a 1% solution of brilliant green. The projection course of the sagittal sinus, the greater occipital protuberance, the puncture point of the posterior horn, and the line of the proposed incision are noted. This requires special pedantry and care to ensure that the burr hole strictly corresponds to the puncture point of the posterior horn. There are two options for puncture. In the first variant, the puncture point of the posterior horn (Dandy's point) is 4 cm above the greater occiput and 3 cm outward from the midline (Fig. 69).

Rice. 69.

Rice. 70.

After the imposition of a burr hole and point coagulation of the dura mater and the underlying cortex, ventricular puncture is performed. A metal mandrel is inserted into a silicone tube with a diameter of about 2 mm, which acts as a conductor. It is very important that the tip of the drain tube is completely smooth and free of burrs. At a distance of 4 - 5 mm from the tip of the tube, it is necessary to form 2 - 3 holes with scissors. The direction of the ventricular drainage should be along the line connecting this point with the outer-superior angle of the orbit on the same side. To do this, the surgeon palpation determines the indicated angle of the orbit with the index finger of the left hand and introduces drainage in a given direction. In this case, the drainage enters the widest part of the ventricle at its junction with the lower horn. The puncture depth is usually 5-6 cm. After the mandrin is removed, liquor enters the tube. With severe intraventricular hypertension, it is important to prevent a sharp discharge of cerebrospinal fluid and to remove it in an amount of up to 20-30 ml gradually, pinching the distal end of the drainage with a clamp. Drainage is removed through the counter-opening, fixed to the skin. The wound is sutured tightly. After washing the ventricle, the distal end of the drainage is lengthened with a sterile adapter tube, which is immersed in a closed vessel or connected to a special manometer.

In the second variant, the burr hole is applied at a point located 6 cm above the external occipital protuberance and 2.5 cm outward from the midline. The direction of advancement of the cannula should be along the line connecting this point with the center of the frontal tubercle of the same side. In this case, the end of the drainage tube enters the ventricular triangle.

Puncture technique of the anterior horns of the lateral ventricles. The patient lies on his back face up. The puncture point of the anterior horn (Kocher's point) is 2 cm anterior and 2 cm outward from the intersection of the sagittal and coronal sutures. The marking of the point is carried out at the intersection of the lines of the sagittal suture and the perpendicular from the middle of the zygomatic arch. The burr hole overlay technique is typical. The direction of advancement of the cannula is parallel to the median plane to a mentally drawn line connecting both external auditory canals. The cavity of the anterior horn of the lateral ventricle is located approximately at a depth of 4.5 - 5.5 cm (Fig. 70). Intraventricular hematomas are removed both from independent accesses to the lateral ventricles and through the zone of breakthrough of intracerebral hematoma. After evacuation of the intracerebral hematoma, they penetrate into the ventricle and remove all clots. Ventricular drainage is brought out through the main wound.

We consider it expedient to use an inflow-outflow system for draining wounds when removing intracerebral and intraventricular hematomas. Such a system creates conditions for washing out of the wound the decay products of tissues, biologically active substances, and prevents the accumulation of blood.

Removal of subdural hydromas

Subdural hydromas develop against the background of primary traumatic injuries of the brain of varying severity and are often combined with compression of its intracranial hematoma. The choice of the method of surgical intervention in the syndrome of cerebral compression by subdural hydroma depends on the presence of comorbidity in the form of foci of brain contusion, intracranial hematomas, and traumatic cerebral edema. Removal of an isolated subdural hydroma can be made from one or two burr holes. However, the presence of the above-mentioned concomitant components of brain injury requires an expansion of the scope of intervention and the use of various methods of decompressive trepanation (resection or patchwork).

The choice of the method of operation and indications for it are determined by the form and severity of brain damage. The method of choice when combining hydromas with mild contusion is the operation of evacuating hydromas from the milling holes.

With a combination of hydroma with a bruise of moderate severity and the presence of distinct focal symptoms, indicating the presence of contusion foci, a different tactic is required. The evacuation of the hydroma must be combined with a thorough revision of the brain. In such cases, the operation begins with the imposition of diagnostic milling holes. After emptying the hydroma, a wide osteoplastic trepanation is performed. In the absence of pronounced cerebral edema, the operation can be completed as a classic osteoplastic one. With significant changes in the brain, its edema, prolapse into the wound, a wide decompression is necessary. The bone flap is removed and preserved in weak formalin solutions.

If hydroma is combined with severe brain contusion, then in most cases decompressive trepanation is required. In the presence of proper conditions, it is preferable to perform a flap craniotomy. This allows a complete revision of significant areas of the hemisphere, the removal of a contusion focus, and then the use of a preserved autograft to repair a defect in the cranial vault. If there are no necessary conditions, resection trepanation of the skull can be performed.

Quite often subdural hydromas are combined with intracranial hematomas. In such cases, removal of the hematoma through decompressive trepanation is indicated and, in rare cases, the absence of gross morphological damage to the cerebral hemispheres and dislocation - osteoplastic trepanation.

It should be remembered that hydroma can be localized on the opposite side of the hematoma. At the slightest suspicion of a two-sided volumetric process, it is necessary to apply milling holes on both sides.

Technique for emptying isolated subdural hydroma from burr holes. The burr hole is most expedient to impose in the area of ​​​​the junction of the frontal, parietal, temporal lobes, since in this zone the subdural hydroma is usually the thickest. In our opinion, the burr hole should be somewhat expanded, up to a diameter of 3–4 cm. Emptying can be carried out after a cruciform dissection of the DM. The dura mater is usually tense, but does not have the bluish tint that occurs with subdural hematomas. After dissection of the dura mater, cerebrospinal fluid, often stained with blood, is usually poured out in a fountain. Subsequently, a revision of the subdural space is performed, since a combination of hydroma with small blood clots is possible, and the latter are removed. Then it is necessary to carefully excise a part of the arachnoid membrane with an area of ​​approximately 5x5 mm. Thus, conditions will be created that eliminate the functioning of the valve. The dura mater is sutured tightly leaving drainage in the subdural space for 1 day. The wound is sutured according to generally accepted rules.

Often practitioners have a question: how to measure the volume of hydroma? It should be measured before dissection of the dura by the following method. The brain cannula with a 20 ml syringe is used to puncture the DM, and the cannula is inserted into the subdural space. Liquor is removed with a syringe, and its volume is determined.

Surgery of foci of crushing of the cerebral hemispheres

In the complex treatment of patients with foci of crushing of the brain, the leading link is timely and adequate surgical intervention. To substantiate the tactics of surgical treatment of this form of TBI, it is necessary to specify the often identified concepts of "contusion focus" and "crush focus".

Crush focus is a macroscopically visible area of ​​destruction-necrosis of the medulla imbibed with blood. As a result of trauma and disorders of regional cerebral blood flow, hypoxia and dysgemic disorders increase at the site of injury, which leads to a deepening of necrotic processes in the area of ​​the crush focus and an increase in the necrosis zone. The crush focus contributes to the further development of local and general disorders of cerebral circulation and metabolism. This leads to an increase in intracranial hypertension and the development of brain dislocation. In connection with this development of the clinical picture, the presence of a crush lesion serves as the basis for its removal.

With contusion foci, unlike foci of crushing, areas of hemorrhagic softening or imbibition with blood can be macroscopically detected. Violation of the integrity of the arachnoid and pia mater is not detected, the configuration of the furrows and convolutions is preserved. Surgical treatment should be carried out only in patients with foci of crushing of the brain.

To determine the differentiated surgical tactics, knowledge is necessary main anatomical variants of surgical forms of brain crush injuries.

1. Gross destruction of tissue with rupture of the pia mater: cerebral detritus soaked in blood and sometimes containing small blood clots. Such foci in most cases are combined with large sheath hematomas.

2. The same focus of crushing of the medulla, but combined with minor blood clots (20 - 30 ml), which are formed from the cortical vessels and cover the damaged surface with a thin layer.

Table 6

Indications for surgery and the timing of its implementation, depending on the morphology of the crush injuries and the types of Klinige tegenia (according to Yu. V. Zotov et al., 1996)

3. The focus of crushing of the cortical and subcortical substance without combination with intracerebral hematoma and blood clots.

4. A focus of hemorrhagic softening in the white matter of the cerebral hemispheres, which may surround an accumulation of blood clots and liquid blood (a zone of damage around an intracerebral hematoma) or be a massive focus of cerebral detritus soaked in blood.

5. A limited, shallow focus of rupture of the medulla, located under a depressed or linear fracture of the cranial vault.

The indications for surgical intervention and the timing of its implementation are determined by the anatomical variant of the surgical forms of crush foci and the type of their clinical course (Table 6).

Contraindications for the removal of brain crushing tumor are:

1) a progressive type of clinical course of the process with IV degree hypertension-dislocation syndrome (transcendental coma with impaired vital functions);

2) severe somatic diseases over the age of 70 years.

Patients of this age category with an intraherbal hematoma are subject to surgical intervention aimed at its removal.

The operation of choice in the treatment of brain crush foci is osteoplastic decompressive craniotomy. The advantages of this type of intervention are:

– wide access;

– the possibility of an adequate revision of the brain;

– favorable conditions for the complete removal of intracranial hematomas and crush foci;

– Possibility of thorough hemostasis;

– closure of the postoperative defect with a preserved autograft.

In case of severe brain contusion, decompressive craniotomy should be performed, regardless of whether there is a prolapse of the brain into a bone defect or not.

With the pressure of multiple crush injuries of the fronto-temporal localization of one hemisphere one-sided extended lateral access should be used (Fig. 71).

The main requirement for this type of access is that the lower edge of the burr window should be as close as possible to the base of the skull. Only if this condition is met, adequate visualization of crush foci, usually localized in the anterobasal regions of the frontal and temporal lobes, is possible.

Rice. 71.

Rice. 72. Scheme of anterolateral unilateral extended access to the temporal and frontal lobes of the brain (according to Yu. V. Zotov et al., 1996)

With the impact of crush injuries in one of the temporal and both frontal lobes of the brain used developed at the Russian Neurosurgical Institute. prof. A. L. Polenova anterolateral access (Fig. 72) (R. D. Kasumov).

The patient lies on his back, his head is turned in the opposite direction from the alleged foci of crushing. The soft tissue incision begins 2 cm anterior to the auricle perpendicular to the zygomatic arch towards the intersection point of the coronary suture and the temporal line of the frontal bone. Then it continues along the border of the hairy part of the frontal region, going beyond the midline by 5 - 6 cm. On the opposite side, the incision should be extended until it starts to go down. The osteoplastic flap is sawn out of 7 or 8 burr holes. The periosteum is dissected at the places where the burr holes overlap with a 2–3 cm long incision and exfoliates from the bone only to the width of the intended hole. After applying the hole with a Volkmann spoon, the remains of lamina vitrea are removed and the dura mater is carefully peeled off from the inner surface of the bone in the direction of future cuts. A conductor for a wire saw is introduced. The guide's advancement should be delicate, without significant effort. Sometimes, in places of dense increment of the dura mater to the bone, it is damaged and the conductor is introduced into the subdural space. How to act in such situations?

First, multiple attempts should not be made to retrace the conductor from a given burr hole. You can try to pass the conductor from the opposite hole. If this option is unsuccessful, then you can impose an additional milling hole in the middle of the distance between the previous two holes and draw a conductor from it. It is also possible to bite through the "path" connecting the two holes with Dahlgren's nippers.

Before sawing the bone between the milling holes along the line of the proposed cut, the periosteum is dissected. This avoids its “grinding” with a saw and facilitates subsequent stitching.

Should the bone at the base of the flap be filed? We consider this undesirable. Conductor in this area may damage a. meningea media or its branches, which leads to additional blood loss. It is better to bite the bone on both sides at the base from both cutter holes with Dahlgren's nippers. In this case, the base of the bone flap breaks quite easily. Raising the bone flap with a raspator, the adhesions between the dura mater and the inner surface of the bone are carefully separated. If there are none, then the flap easily turns to the base on the pedicle of the temporal muscle. The dura mater should be dissected parallel to the base of the skull, then arcuately, retreating 1–1.5 cm from the edge of the bone towards the sagittal sinus.

Having established the presence of a crush site and significant prolapse of the brain tissue into the bone defect, we consider it appropriate to perform a puncture of the anterior or lower horn of the lateral ventricle. This manipulation reduces the tension of the brain, its swelling and creates more favorable conditions for subsequent surgery on the crush site. However, one should not at all costs seek to obtain cerebrospinal fluid from the ventricle. There are frequent situations when the horn of the lateral ventricle is compressed and displaced in the opposite direction. Repeated attempts to puncture him only exacerbate the situation.

In this case, you should immediately start elongation of brain crush injury.

Ogen it is important to radically remove the brain crush zone together with the transition zone. After partial removal of the crush lesion, intracranial hypertension not only remains, but continues to increase. Removal is performed first by subpial aspiration, then by economical resection of obviously non-viable cortical areas with careful coagulation and clipping of vessels. It is important during the operation to determine the boundaries of the crush site to be removed, i.e., the destruction zone and the transition zone. The destruction zone is detritus, and there are no particular difficulties here. Detritus is easily washed off with a jet of liquid from a rubber pear. The transitional zone is not rejected, but imbibed with blood, the medulla of a flabby consistency, easily removed by an aspirator at a rarefaction of 0.6 - 0.8 atm. Maintaining this vacuum allows for differentiated aspiration. In this case, the intact medulla is much more difficult to aspirate.

Currently, the ultrasonic aspirator is widely used in neurosurgery, which can be used for microsurgical operations and allows tissue fragmentation in a small radius from the tip without damaging blood vessels.

In the area of ​​brain damage - the area of ​​the crush focus, treated with the use of an ultrasonic aspirator - the formation of a delicate glial scar over the entire surface of the damage site is noted in the future. There is no inflammatory response in this area. The minimum amount of damage to the medulla after resection with an ultrasonic aspirator is due to the ability of the instrument to differentiate normal and damaged tissue in terms of structure and water content, which contributes to the removal of only damaged tissue at the border with “healthy” without injuring the latter.

The use of ultrasonic aspiration in the surgery of brain crush lesions is currently, of course, the preferred option. The domestic industry today produces the Ultrasonic Surgical Aspirator UZKh-M-21 M, which fully meets the requirements of modern neurosurgery.

After a radical removal of the crush site, it is advisable to bring inflow-outflow drainage into the area of ​​\u200b\u200bits bed. If indicated, it is possible to perform a dissection of the falciform process ( falxotomy).

Absolute indications for falxotomy:

- dislocation of the hemisphere under the falciform process;

– axial transtentorial dislocation;

- severe intracranial hypertension and brain prolapse into the trepanation window, regardless of the presence and localization of crush foci.

Relative indications for falxotomy:

- Foci of crushing in one or both frontal lobes without dislocation of the brain;

- the presence of a contusion focus of the temporal lobe with a slightly pronounced temporo-tentorial dislocation;

- vital disorders that develop more often with diffuse brain contusion.

When performing a falxotomy, the sagittal sinus is mobilized at its base near the cockscomb, stitched, tied in two places approximately 1 cm apart, and transected. Then the falciform process is dissected. In this case, it is very important to spare the ascending venous vessels as much as possible. After careful hemostasis, the DM is not sutured, but is repaired with a preserved allograft. The operation ends with decompression of the skull. The bone flap is preserved by one of the accepted methods. The wound is sutured in layers leaving for 1 day. under the skin active drainage.

Documentary reflection of the actions of the surgeon in the protocol of the operation. The protocol of surgical intervention must necessarily reflect:

– type of operational access;

- the condition of the bones before intervention on them (size, shape of the fracture, etc.);

- the size of the trepanation window;

- the state of the dura mater before its dissection;

- description of the appearance of the cerebral cortex (gyrus, furrows, their color);

- the source of bleeding, if any;

- the approximate volume of the removed hematoma, hydroma;

– the state of the brain after the evacuation of clots, removal of the crush site;

- whether the dura was sutured, the method of its plastics;

- the reasons that caused the need for external decompression;

– method of draining the ventricular system of the brain, if applicable;

- a method of external drainage of the wound.

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Traumatic brain injury

Skull injuries are divided into two main groups:

Closed TBI: when the integrity of the head covering is not broken or there are wounds of the soft tissues of the head without damage to the aponeurosis and bones.

Open TBI: there are fractures of the skull bones with injury to adjacent tissues, or a fracture of the base of the skull, accompanied by bleeding or liquorrhea (from the nose or ear).

Open TBI can be: penetrating - in violation of the integrity of the dura mater and non-penetrating: without violating its integrity.

Pathogenesis of traumatic brain injury

The leading role in the pathogenesis of traumatic brain injury is played by disturbances in the main neurodynamic processes in the central nervous system, which cause vascular liquorodynamic and endocrine-humoral disorders. Reactions of the vascular system of the brain are manifested by widespread vasospasm, followed by hyperemia of the brain and venous congestion. CSF circulation disorders are associated with disruption of the normal functioning of the choroid plexuses of the lateral ventricles, with the development of CSF hypo- and hypertension, and impaired permeability of the blood-brain barrier. The weakening of the regulatory functions of the diencephalic-pituitary system leads to hormonal imbalance in the body, circulatory disorders with the development of brain hypoxia and edema-swelling of the brain tissue.

The acute period of traumatic brain injury proceeds with severe cerebral symptoms, among which the leading place is occupied by disorders of consciousness. A decrease in cerebrospinal fluid pressure is usually observed with open penetrating brain injuries. Traumatic brain injuries are often accompanied by the development of subarachnoid hemorrhages. In the acute period of traumatic brain injury, the course and outcome of the disease depend on the severity of local brain damage, hemolytic circulation disorders, and concomitant phenomena of increasing cerebral edema, which can lead to life-threatening disorders of vital body functions. After the passage of the acute period, the further course of the disease is determined by the possibility of developing concomitant complications.

Clinical classification of TBI:

1. 
   Traumatic injury to the skull
2. 
   skull fractures
3. 
   Brain concussion
4. 
   Brain contusion (mild, moderate, severe)
5. 
   Brain compression.

Skull fractures. They are observed in both open and closed craniocerebral trauma. There are skull fractures, perforated, comminuted and depressed fractures. According to localization, fractures of the arch, base and parabasal are divided.

Brain injury. It differs from concussion by the presence of areas of local damage to the substance of the brain. The nature of the damage can be different: from small focal hemorrhages to extensive softening of the medulla, subarachnoid hemorrhages, and in some cases fractures of the bones of the vault and base of the skull.

• 
  Mild contusion: loss of consciousness from several minutes to 1 hour. After regaining consciousness, complaints of headache, dizziness, etc. Focal symptoms are usually manifested by nystagmus, asymmetry of tendon reflexes. There may be bradycardia or tachycardia, sometimes an increase in blood pressure.
• 
  Moderate bruising: loss of consciousness from several tens of minutes to 4-6 hours. Severe focal neurological disorders are characteristic in the form of hemi- and monoparesis, aphasia, visual, hearing or sensitivity disorders, amnesia, and sometimes mental disorders. Possible repeated vomiting, transient violations of vital functions. They usually disappear after 3-5 weeks.
• 
  Severe contusion: loss of consciousness from several hours to several weeks. Threatening violations of vital functions with respiratory disorders, cardiovascular activity, fever. Stem symptoms appear. Focal symptoms are expressed. Sometimes seizures. Cerebral and especially focal symptoms regress slowly, often there are residual motor disorders, changes in the mental sphere.

• 
  In the compensated phase, the brain function does not suffer due to the compensated extrusion of CSF into the spinal canal (corresponding to the light gap).
• 
  In the second phase, compression of the veins occurs with the development of congestive hyperemia of the brain, leading to an increase in its volume. Patients note an increase in headache, excitement appears, focal symptoms are determined on the side opposite to the damage.
• 
  In the third phase of compression, anemia of the brain occurs, mainly of its hemispheres, cerebral edema may develop. Consciousness turns off, cerebral, focal and stem symptoms are roughly expressed.
• 
  In the fourth - terminal phase of compression, the brainstem develops herniation with respiratory and cardiac disorders, death occurs.

Epidural hematomas - accumulation of blood between the outer surface of the dura mater and the skull bone

Subdural hematomas - are formed as a result of the accumulation of blood under the dura mater.

Intracerebral hematomas - develop as a result of diapedesis in the area of ​​the contusion focus.

Intraventricular hematomas - are formed as a result of a breakthrough of an intracerebral hematoma through the damaged wall of the ventricle, however, they are also primarily ventricular.

TBI diagnostics

• 
  Cerebral symptoms reflect the general reaction of the brain to injury. Characterized by various kinds of disturbances of consciousness (stupor, stupor, coma), headache, vomiting, nausea, meningeal syndrome, dizziness.
• 
  Focal symptoms are due to the direct influence of the pathological process on the structures of the brain. These include local headache as a result of irritation of sensitive cranial nerves. There are focal symptoms of irritation - a consequence of the irritation of certain brain structures and focal symptoms of prolapse - the result of the destruction of the corresponding areas of the brain.

Diagnostic methods include primarily puncture methods. Studies of the cerebrospinal fluid system allow you to measure pressure and examine the cerebrospinal fluid in various parts of the cerebrospinal fluid system. A lumbar puncture is used to examine the cerebrospinal fluid. For the study of cerebrospinal fluid from a large tank or with descending myelography, a suboccipital puncture is used. Puncture of the ventricles of the brain is used to unload the ventricular system in case of occlusion of the CSF pathways.

Of the special research methods at the present stage, the main role is given to X-ray, ultrasound and radioisotope methods. Echoencephalography is based on ultrasound determination of the displacement of the median structures of the brain, which makes it possible to determine the displacement of the brain tissue during compression - compression syndrome. X-ray of the skull allows you to determine the integrity of the bones of the vault, base and parabasal regions of the skull. X-ray contrast methods make it possible to obtain an image of the CSF spaces of the brain by introducing X-ray positive contrast agents into the vascular or CSF bed. These methods include angiography, ventriculography, cisternography. Computed tomography makes it possible to layer-by-layer display of the X-ray picture of the brain, skull bones and pathological formations, which in turn allows for accurate topical diagnosis and determination of the density of the intracranial formation.

Radionuclide encephalography (scintigraphy) is based on the ability of radioactive compounds to accumulate in the focus of hemorrhage or necrosis. The radiopharmaceutical is administered intravenously, after which its distribution in the brain is studied using scanning.

Basic principles of TBI treatment

Syndromic treatment:

• 
  with cerebral edema - dehydration (drip IV mannitol at the rate of 1-1.5 g of 15% solution per 1 kg of body weight per day
• 
  with traumatic psychosis mixture: 2.5% 2-3 ml chlorpromazine + 1% 2 ml diphenhydramine + 1-2 ml cordiamine + 25% 5-8 ml magnesium sulfate intramuscularly 2-3 times a day
• 
  with the development of epileptic status 2 g of global hydrate in an enema, in the absence of effect 10 ml of 2% sodium thiopental or anesthesia with nitrous oxide, phenobarbital 0.1-0.2 x 3 times a day

• 
  with irrepressible vomiting 1 ml of 0.1% atropine and 1-2 ml of 2.5% chlorpromazine
• 
  for pain syndrome 1ml 2% promedol subcutaneously
• 
  to stop bleeding in intracranial hematomas Aminocaproic acid IV 100ml
• 
  in order to increase the resistance of the brain to damaging factors - nootropic substances (Piracetam 2 ml / m)
• 
  patients are limited in fluid intake
• 
  strict bed rest

Surgical treatment of TBI is carried out mainly with compression of the brain.

One of the medical and diagnostic measures for traumatic brain injury is the imposition of diagnostic burr holes. This intervention allows you to determine the localization of intracranial hematoma, and in many cases drain the cranial cavity and thereby prevent the increase in symptoms of compression of vital structures and cerebral edema.

In order to eliminate compression of the brain by an intracranial hematoma, as well as fragments of the bones of the skull, decompressive trepanation of the skull is performed. Often, an intracranial hematoma is accompanied by a fracture of not only the vault, but also the base of the skull with bleeding or liquorrhea from the nose and ears. Surgical assistance to such victims consists in osteoplastic frontal trepanation with suturing of the dura mater. With persistent ear liquorrhea, plastic closure of the cerebrospinal fluid fistula is performed.

Chest injuries are often observed and quite often lead to death - up to 20% of the total number of deaths from trauma. Distinguish between closed and open chest injuries.

Closed injuries of the chest and organs of the chest cavity are those in which the integrity of the skin is not violated. Such injuries are divided into concussion, compression and contusion. Any damage to the chest is accompanied by a violation of the most important physiological act of the body - breathing.

Concussion of the chest occurs when a person is exposed to a blast wave (during bombing, earthquakes, blasting, etc.). The condition of patients is characterized by a high degree of severity, since in this case there is a violation of the function of the cardiovascular, respiratory and nervous systems. Clinically, this injury is manifested by a picture of a developing shock - blood pressure drops, the pulse slows down, breathing becomes superficial and rapid, the skin is pale, covered with cold sticky sweat, the patient loses consciousness. Some patients experience vomiting and hemoptysis. The last symptom is due to damage to lung tissue. The described phenomena are explained by a sharp irritation of the vagus and sympathetic nerves.

Compression of the chest occurs when two solid bodies act on it in opposite directions. The most severe consequence of this injury is congestive hemorrhage, which is expressed in the appearance of petechial hemorrhages (ecchymosis) on the skin of the head, neck, upper chest. This is due to traumatic asphyxia. The same hemorrhages are found on the mucous membranes of the oral cavity, sclera. Sometimes there is swelling of the head and neck. The cause of these manifestations is a sudden increase in intrathoracic pressure and the release of blood from the vessels of the pleural cavity into the superior vena cava and the vessels of the head and neck. If with this type of injury there are no complications from the lungs and heart, then these phenomena pass without a trace. When lung tissue is damaged, symptoms characteristic of pneumo- and hemothorax appear.

Bruising of the chest is the result of exposure to a heavy, fast-acting agent, often accompanied by a fracture of the ribs and damage to the organs of the chest cavity.

With isolated wounds of the soft tissues of the chest, the victims are usually in a satisfactory condition.

Damage to the skeleton of the chest aggravates the condition of patients. Fractures of the ribs and sternum occur when exposed to direct trauma of great force. Distinguish between complicated and uncomplicated rib fractures. In uncomplicated fractures, the lungs and pleura are not damaged. Signs of a rib fracture are local pain, crepitation of fragments, difficulty breathing. Multiple rib fractures can cause significant respiratory distress. With complicated fractures of the ribs, the pain syndrome is pronounced when the chest moves during inhalation, exhalation, and also when coughing. There is a lag of the damaged half of the chest during breathing. Such symptoms are observed due to damage to the parietal pleura and lung tissue by bone fragments. A special place is occupied by "fenestrated" fractures of the ribs, when the line of fractures runs on both sides of the sternum, resembling the contour of a butterfly with outstretched wings. The condition of such patients is especially severe, there is severe respiratory failure. This is due to the development in patients of extensive hemorrhages under the visceral and parietal pleura, hemorrhages in the parenchyma of the lung and defoliation of its tissue. Quite often a contusion of the heart and organs of the mediastinum is found. This is accompanied by a violation of automatism, excitability and conduction, the development of atrial fibrillation, extrasystole, sinus tachycardia.

Isolated fractures of the sternum occur, as a rule, due to a direct blow or pressure on the sternum in the anteroposterior direction. Accompanied by a sharp pain, aggravated by inhalation and palpation, shortness of breath. The most characteristic is the anteroposterior displacement of fragments, which is determined in the first minutes during palpation.

The most dangerous in case of bruising of the chest is damage to the tissue of the lung and pleura, resulting in pneumothorax, hemothorax and subcutaneous emphysema.

Pneumothorax is the accumulation of air in the pleural cavity. There are open, closed and valvular pneumothorax.

The accumulation of air in the pleura, which communicates with atmospheric air through a wound in the chest wall or through a large bronchus, is called an open pneumothorax. With a closed pneumothorax, the air accumulated in the pleural cavity does not communicate with the atmosphere. It is more often observed with complicated fractures of the ribs. The small size of the wound of the lung tissue is characteristic, which contributes to its rapid spontaneous closure. As a result, the amount of air in the pleural cavity remains unchanged in both phases of respiration, and the displacement and fluctuations of the mediastinum are insignificant. Valvular pneumothorax develops when a lung ruptures in the form of a flap, with a simultaneous rupture of a large bronchus, when air enters the pleura during inhalation, and cannot exit the pleural cavity during exhalation, since the lung flap closes the damaged bronchus and does not allow air to pass through. Thus, with valvular pneumothorax, the amount of air in the pleura increases with each breath and its pressure rises. Stagnation develops in the pulmonary circulation, blood oxygen saturation is sharply disturbed. Increasing respiratory failure. Above the wound in the projection of the chest, the sounds of air entering the pleural cavity are heard only on inspiration. The veins of the neck swell sharply, subcutaneous emphysema quickly spreads to the neck, face, torso. Therefore, valvular pneumothorax is also called tension and is the most life-threatening type of pneumothorax for the patient, leading to a rapid increase in the phenomena of respiratory and heart failure.

Pneumothorax can be limited - when air compresses the lung by 1/3 of its volume; medium - when the lung is compressed by 1/2 of its volume and total - when the lung is completely collapsed.

The accumulation of air in the pleura in a small amount usually does not cause respiratory and cardiac disorders, and if its further supply stops, then it resolves. More often this is characteristic of a closed pneumothorax, when there is little damage to lung tissue. A significant accumulation of air, especially under pressure (valvular pneumothorax), leads to compression of the lung, mediastinal displacement, respiratory failure and cardiac activity.

Hemothorax - accumulation of blood in the pleural cavity due to damage to the vessels of the tissue of the lung or chest wall. Distinguish unilateral and bilateral hemothorax. In the latter case, there is a threat of death of the victim from asphyxia. Local and general clinical manifestations of hemothorax depend on the amount of blood that has poured into the pleural cavity. Local signs - the presence of blood in the pleural cavity - can be detected only when more than 300 cm 3 of blood enters it. Then, percussion reveals dullness of the percussion sound. Unilateral small hemothorax does not cause severe disorders and after a few days the blood resolves. A significant accumulation of blood in the pleura is accompanied by the development of acute anemia due to blood loss, respiratory failure (compression of the lung) and cardiac activity due to displacement of the heart. Distinguish a small hemothorax when the volume of the poured out blood does not exceed 500 ml. (liquid level below the angle of the blade). Medium - blood volume up to 1000 ml. (liquid level reaches the angle of the scapula). Large - the amount of blood over 1000 ml. (fluid occupies the entire or almost the entire pleural cavity).

Depending on the presence of infection in the pleural cavity, they speak of an infected hemothorax. If the blood has clotted, the hemothorax is called clotted.

Subcutaneous emphysema in chest trauma is an external expression of a closed lung injury. The air in the pleural cavity penetrates through the damaged pleural sheet into the subcutaneous tissue and spreads through it to the chest, neck, stomach and face. The characteristic swelling is clearly visible, on palpation a characteristic crunch is felt, caused by the movement of air bubbles, on percussion - a high tympanic sound. Emphysema does not require special therapeutic measures, since after the elimination of pneumothorax, the air in the subcutaneous tissue is absorbed.

Open injuries of the chest are divided into penetrating and non-penetrating.

Non-penetrating wounds of the chest are classified as mild injuries, however, in some cases, severe complications may occur associated with the addition of a secondary infection or in the case of open fractures of the ribs.

Penetrating chest wounds are one of the most common chest injuries. The concept of "penetrating" defines the injury of the parietal pleura. Such injuries are dangerous due to apparent well-being and insignificance of clinical manifestations. Among the penetrating wounds of the chest, there are:

no open pneumothorax

with open pneumothorax

with valvular pneumothorax

With penetrating wounds, the heart, lungs, blood vessels, and esophagus can be damaged. With these injuries, hemopneumothorax is more often observed. The danger of open pneumothorax is that when breathing, air enters and exits the pleura, which infects the pleura and leads to balloting of the mediastinum, irritation of the nerve endings, which can cause cardiopulmonary shock. Open pneumothorax is complicated by shock in more than 60% of patients.

Allocate local signs of a penetrating wound: in the area of ​​the wound, flapping, whistling sounds are heard that occur both during inhalation and exhalation. On exhalation from the wound, bleeding intensifies, the blood is foamy. In the circumference of the edges of the wound, subcutaneous emphysema is determined.

Often, in patients with chest injuries, a clinic of cardiac tamponade can be observed, which indicates his injury. At the same time, venous congestion (cyanosis, tension of peripheral veins) increases, the pulse quickens, heart sounds become muffled, with percussion there is a sharp shift in the boundaries of the heart. The ECG shows a change in the T wave and a shift in the S-T interval.

Diagnosis of chest injuries

Examination allows you to identify the nature of breathing, its frequency, the symmetry of participation in breathing of the chest, flotation of the chest wall, the presence of wounds, etc.

Palpation of the chest wall makes it possible in some cases to establish or clarify the cause of the pain syndrome, to identify or confirm the presence of subcutaneous emphysema, and to determine the intensity of voice trembling. Palpation of the rib fracture area gives local pain, sometimes it is possible to determine the fracture site in the form of a “ledge” and bone crepitus here.

With percussion, the shortening of the sound indicates the presence of fluid in the pleural cavity, lung atelectasis, massive infiltrative processes in the lungs. Tympanitis is characteristic of pneumothorax.

Auscultation noted the absence or weakening of breathing. Inflammatory and infiltrative processes in the lung tissue are manifested during auscultation by various wheezing, pleural friction noise, etc.

X-ray examination is one of the main methods for diagnosing chest injuries. The study must begin with a survey radiography, which is performed in direct and lateral projections, with the patient standing, lying on his back or on his side. The main radiographic symptoms of lung damage are subcutaneous and intermuscular emphysema (light stripes of gas in the soft tissues of the chest), hemo- and pneumothorax, and various changes in the broncho-pulmonary structure. With hemothorax, there is a darkening of the pulmonary pattern corresponding to the side of the lesion. With a large hemothorax, mediastinal displacement is detected. With pneumothorax, gas is determined in the pleural cavity, pressing the lung to the root. With a large or tense pneumothorax, the shadow of the mediastinum is shifted in the opposite direction. When examining a patient in a vertical position in cases of hemopneumothorax, the horizontal level of the liquid is determined.

Puncture of the pleural cavity is the main therapeutic and diagnostic measure in patients with suspected hemo- and pneumothorax. Pleural puncture for pneumothorax is performed in the second intercostal space along the midclavicular line with the patient sitting or lying down. Puncture for hydrothorax (hemothorax) is performed in the seventh intercostal space along the posterior axillary line in the patient's sitting position. Pleural puncture is performed along the upper edge of the underlying rib in order to exclude damage to the intercostal vessels and nerve.

You can judge the cessation of bleeding in the pleural cavity using the Ruvelua-Grogoire test: if the blood obtained during puncture coagulates in a syringe or test tube, bleeding continues; if the blood does not clot, then the bleeding has stopped, or continues very slowly.

Pericardial puncture is performed if cardiac tamponade is suspected. The safest place for a pericardial puncture is the Mordan point - directly above the top of the xiphoid process. You can puncture the pericardium according to Larrey - a needle is inserted between the cartilage of the seventh rib and the base of the xiphoid process.

Thoracoscopy is indicated for closed injuries complicated by traumatic pneumothorax, cardiac tamponade. to clarify the nature of the damage and the choice of rational treatment tactics.

PLAN OF THEORETICAL LESSON

Date: according to the calendar-thematic plan

Number of hours: 4

Topic: VI/VII-3 CLOSED CRANIO-BRAIN INJURY. FRACTURE OF THE CAPITAL AND BASE OF THE SKULL

Lesson type: lesson learning new educational material

Type of training session: lecture, conversation, story

The goals of training, development and education:

Formation: knowledge on a given topic.

Questions:

- Anatomical and physiological features of the head.

TBI. The reasons. Classification, general symptoms.

- Closed TBI: concussion, bruise, compression of the brain; clinic, principles of diagnosis, provision of PHC at the prehospital stage, principles of treatment, care. Organization of the nursing process.

- Bruising of the soft tissues of the head. Fracture and dislocation of the lower jaw. Fractures of the bones of the vault and base of the skull. Causes, clinic, principles of diagnosis, provision of PHC at the prehospital stage, principles of treatment, care. Organization of the nursing process.

Development: consciousness, thinking, memory, speech, emotions, will, attention, abilities, creativity.

Upbringing: feelings and personality traits (ideological, mental, aesthetic, labor).

As a result of mastering the educational material, students should: gain theoretical knowledge on a given topic.

Logistics support of the training session: presentation, tables 118-123

Interdisciplinary and intradisciplinary links: anatomy, physiology, traumatology, pharmacology.

Update the following concepts and definitions: Traumatic brain injury. Brain concussion. Intracranial hematoma. craniotomy.

STUDY PROCESS

1. Organizational and educational moment: checking attendance for classes, appearance, protective equipment, clothing, familiarization with the lesson plan - 5 minutes .

2. Survey of students - 10 minutes .

3. Familiarization with the topic, questions, setting educational goals and objectives - 5 minutes:

4. Presentation of new material (conversation) - 50 minutes

5. Fixing the material - 5 minutes :

6. Reflection - 10 minutes.

7. Homework - 5 minutes . Total: 90 minutes.

Homework:, pp. 19-22; , pp. 517-523; ,

Literature:

1. L.I. Kolb et al. Textbook: "Private Surgery".

5. I.R. Gritsuk "Surgery"

2. L.I. Kolb et al. Textbook: "Nursing in surgery".

4. Workshop: "Surgery in tests and tasks"

6. Website: www.site

7. Teacher's personal website: www.moy-vrach.ru

VI/VII-3 CRANIO-BRAIN INJURY

ANATOMICAL AND PHYSIOLOGICAL FEATURES OF THE SKULL STRUCTURE

The main anatomical feature of the skull is a closed cavity with rigid walls. Because of this, the usual reaction to damage to soft tissues - swelling leads to compression of the brain, which requires urgent surgical intervention.

I. Cerebral skull

1. Foundation The skull on the inside is represented by 3 cranial fossae:

Anterior cranial fossa

Middle cranial fossa (the following openings open: optic canal, inferior orbital fissure, round, oval and spinous openings. Through these openings, the cranial cavity communicates with the environment.)

Posterior cranial fossa (cerebellum, medulla oblongata)

If the brain is damaged, as a result of edema, the medulla oblongata can be wedged into the foramen magnum, which can lead to death, because all the vital centers are in the medulla oblongata.

2. The upper jaw, sphenoid bone, frontal bone, ethmoid bone contain air sinuses, lined with a mucous membrane. If the air sinuses are damaged through a hole in the base of the skull, infection of the meninges, medulla with subsequent development of meningitis or brain abscesses is possible.

3. In the brain, the dura mater forms the venous cerebral sinuses (the most important is the cavernous sinus and sagittal sinus)

4. The presence in the brain of the meninges (hard, arachnoid, soft, which are involved in metabolism and are part of the blood-brain barrier - a complex immunological protection of the brain from toxic substances, bacteria and viruses.

5. The presence of an aponeurotic helmet on the skull, which leads to the possibility of scalping wounds.

6. Rich innervation and blood supply to the head lead to a discrepancy between the appearance of the wound and the patient's condition.

7. The presence of facial muscles leads to gaping wounds on the face.

8. The presence of anastomoses of the venous bed of the face and brain can lead to thrombosis of the cerebral sinuses and death.

Base of the skull, inside view:

1. Anterior cranial fossa

23. Middle cranial fossa

20. Posterior cranial fossa

18. Foramen magnum

11. Pyramid of the temporal bone

II. facial skull- a container for the senses: vision, smell, the initial section of the digestive and respiratory systems.

Educated unpaired bones:

Lower jaw

Vomer (bone part of the nasal septum)

Hyoid bone

Paired:

upper jaw

palatine bone

Inferior turbinate

nasal bone

lacrimal bone

Cheekbone

The main anatomical feature of the brain, affecting the occurrence, course and outcome of his injury, the nature of the provision of medical care, as well as its consequences, is that the brain is located in a rigid (bone) cranium, which does not allow its volume to change during edema due to injury.

CAUSES OF CRANIO-BRAIN INJURY

Such reasons are obvious. This is a blow with a heavy blunt object on the brain (mostly) or on the facial (less often) skull. Origin: Accident, fall from a height onto a hard surface, aggression.
CLASSIFICATION

According to the condition of the skin:

Closed TBI

Open TBI

According to the state of the meninges:

Penetrating

Non penetrating

Closed TBI - concussion, bruise, compression. This is damage to the head without violating the integrity of the skin or damage to the soft tissues of the head without damaging the aponeurosis.

Open TBI - concussion, contusion, compression, soft tissue wounds, fracture of the cranial vault, fracture of the base of the skull. This is damage to the soft tissues of the head, aponeurosis, fracture of the base of the skull, accompanied by damage to the airways.

With open, especially penetrating TBI, there are conditions for infection of the brain and its membranes.
Open TBI:

1. non-penetrating - without damaging the dura mater.

2. penetrating - with damage to the dura mater.
Clinical forms of TBI:

1. Concussion

2. Brain injury

3. Compression of the brain
Classification according to the severity of TBI:

Mild head injury: concussion, mild contusion

Moderate TBI: moderate brain contusion, chronic and subacute cerebral compression

Severe TBI: severe brain contusion, acute compression of the brain due to intracranial hematoma.

General view of a patient with TBI

CLINICAL SYMPTOMS

Shake brain - traumatic brain injury without obvious anatomical damage.

Refers to mild TBI. It is believed that during a concussion there is no damage to the anatomical structures of the brain, but only functional disorders of the brain. But this is only about anatomical damage. There are damages at the cellular and molecular level. This indicates the relativity of such a division. Characterized cerebral symptoms, the main ones that make it possible to establish a diagnosis are:
1. short-term loss of consciousness from a few seconds to 20 minutes;
2. retrograde amnesia - loss of consciousness due to events preceding the moment of injury;
3. nausea, single vomiting;
In addition, headache, dizziness, tinnitus, drowsiness, pain when moving the eyeballs, from vegetative reactions - sweating, nystagmus is possible.

Diagnostics:

1. Clinical examination + examination by an oculist (fundus) and a neuropathologist (topical neurological diagnostics)

2. Additional examination methods:

X-ray of the skull in 2 projections

Echoencephalography (to rule out brain compression)

Treatment:

Although a concussion is a mild head injury, it is necessary to hospitalize the patient, because sometimes under the guise of a concussion, compression of the brain occurs. Further behavior and condition of the patient is simply unpredictable. A mild TBI may well become severe over time. Treatment is carried out in the neurosurgical or in the department of pure surgery.

Appointments:

Strict bed rest

Non-narcotic analgesics intravenously

Antihistamines

Dehydration therapy

B vitamins

If necessary, sedatives (sedatives)

Injury

A brain contusion is a traumatic injury to the brain substance from minor (small hemorrhages, swelling) to severe (contusion, crushing of tissues) already accompanied by anatomical changes in the brain tissue. Hence - focal neurological symptoms.

There are 3 degrees of severity:

- easy: loss of consciousness up to 1 hour, moderately pronounced cerebral symptoms (amnesia, nausea, vomiting, headache, dizziness). Focal symptoms appear: impaired movement, sensitivity). Characteristic disorder of speech, vision, paresis of facial muscles, language, nystagmus, anisocoria. The pressure of the cerebrospinal fluid increases.

- average degree: loss of consciousness up to several hours, headache, repeated vomiting, mental disorder, bradycardia, increased blood pressure, subfebrile body temperature, tachypnea, focal symptoms - nystagmus, anisocoria, oculomotor disorders, limb paresis, sensitivity disorder, increased pressure of cerebrospinal fluid. Moderate bruises are often accompanied by fractures of the base and calvaria, as well as subarachnoid hemorrhage.

- severe degree: loss of consciousness from several hours to several weeks, focal symptoms are pronounced (nystagmus, anisocoria, paresis, oculomotor disorders), stem symptoms are pronounced - hyperthermia, floating eyeballs, tonic large-scale nystagmus, respiratory rhythm disorders, bradycardia, increased blood pressure, impaired pupillary response to light, absence or decrease in the swallowing reflex. Significantly increases the pressure of the cerebrospinal fluid flowing out (instead of a frequency of 1 drop per second) during lumbar puncture, a general state of extreme severity, convulsions, involuntary urination, involuntary defecation are possible, a fatal outcome is possible.

Diagnostics:

1. Clinical examination

2. Additional diagnostic methods:

Lumbar puncture

Echoencephalography

X-ray of the skull in 3 projections (especially when there is a suspicion of a fracture of the base of the skull)

3. examination by an oculist (fundus), a neuropathologist (topical neurological diagnostics)

Treatment:

Mild degree (see treatment of concussion) + drugs that improve microcirculation and cerebral circulation (trental, caventon, aminofillin). Dehydration therapy (20% glucose - 400 ml, magnesium sulfate 25% - 5 ml, insulin 24 units _- all administered intravenously).

For moderate to severe brain injury:

1. the introduction of drugs that improve the rheological properties of blood (rheopolyglucin, chimes, ascorbic acid, heparin).

2. antihypoxic drugs (sodium oxybutyrate, seduxen)

3. antispasmodics (papaverine 2%, nosh-pa 2%)

4. drugs that improve cerebral circulation (caventon, trental, aminofillin).

5. protease inhibitors (kontrykal)

6. nootropic drugs (nootropil, aminalon)

7. prophylactic antibiotics (ceftriaxone, thienam)

8. lytic mixtures (diphenhydramine + pipalfen + chlorpromazine)

9. dehydration therapy (40% glucose 40-60 ml, 30% urea 100 ml, 20% mannitol 30-40 ml, lasix)

10. cardiac glycosides (strophanthin and corglicon not more than 1 ml per 5% glucose with ascorbic acid and insulin).

Fracture of the base of the skull

When present, there is almost always a brain injury. If the fracture line passes through one of the air sinuses, then such a fracture is considered open.

Open fractures are the most dangerous, because it is possible to infect the brain and meninges through a hole in the middle cranial fossa.

Clinic of fracture of the base of the skull (photo):

Outflow of cerebrospinal fluid with an admixture of blood from the nose or ear canal (rhinorrhea - outflow of cerebrospinal fluid from the nose, otorrhea - from the ear).

To determine liquorrhea, a DOUBLE SPOT TEST is performed (in the center of the gauze napkin is a yellow spot of cerebrospinal fluid, and along the periphery of the gauze napkin is a brown halo of expired blood).

In case of a fracture of the pyramid of the temporal bone or the body of the bone, hidden liquorrhea is possible: the flow of cerebrospinal fluid into the nasopharynx and swallowing it, a symptom of glasses (paraorbital hematomas), a symptom of Bethel (hemorrhage in the mastoid process) - occurs when the body of the main bone or pyramid of the temporal bone is fractured.

Spectacle sign and Bell's sign do not appear immediately, but often 6-24 hours from the moment of injury.

Injury to the cranial nerves - most often damaged auditory, facial, glossopharyngeal nerves.

Diagnosis of a fracture of the base of the skull:

1. Clinical examination

2. Additional examination methods:

Radiography in 3 projections

Echoencephalography

CT scan

Nuclear magnetic resonance imaging (NMRI)

Treatment depends on whether the injury is mild or severe.

compression

Compression of the brain - traumatic damage to the medulla with gross anatomical changes in it, combined with its compression (hypertension).
P reasons:

Depressed skull fractures

Foci of crushing of the brain with bruises of the brain and, as a result, inflammatory edema in these foci;
- intracerebral hematomas

Subdural hydromas (accumulation of CSF under the dura mater)

Pneumoencephaly

Tumors, abscesses of the brain.

Acute compression of the brain - no more than 24 hours passed from the moment of injury to the examination.

Subacute compression - no more than 14 days passed from the moment of injury to the examination.

The most common causes of compression aresevere TBI and intracerebral hematoma

Triad of symptoms characteristic of intracranial hematomas:

1. The presence of a light interval (after 1 loss of consciousness, there is a period of time before a second loss of consciousness, and this interval can last from several hours to 14 days, more often 2 days.

2.Homolateral hemiparesis is the expansion of the pupil on the side of compression.

3. Contralateral hemiparesis is a paresis of a limb on the side opposite to the focus of compression.

Other symptoms of brain compression:

psychomotor agitation

repeated vomiting

Large-scale nystagmus

Psychomotor agitation is gradually replaced by lethargy, drowsiness, coma

Stem disorders: bradycardia, hypertension, convulsions, respiratory rhythm disturbance, sometimes blood pressure decreases.

Treatment brain compression:

See treatment of severe brain contusions + surgical craniotomy.

characteristic a feature of the clinical course of brain injury in childhood often the absence of pronounced neurological symptoms at the time of examination is already a few hours after a mild brain injury. In clinical manifestation, traumatic brain injury in children has a number of significant differences from those in adults. They are primarily due to the anatomical and physiological characteristics of childhood, such as:

The incompleteness of the process of ossification of the skull,

Immaturity of brain tissue

Lability of the vascular system.

All of these facts affect the clinical picture of trauma in children, which is manifested in the following:

The relative value of anamnestic information,

Loss of consciousness at the time of injury is very rare in young children, and in older children it occurs in 57% of cases,

Indistinctness and therefore subjectivism in the interpretation of the neurological picture,

Rapidity of neurological symptoms

The predominance of cerebral symptoms over focal,

Absence of meningeal symptoms in young children with subarachnoid hemorrhage,

The relative rarity of intracranial hematomas,

More often than in adults there is cerebral edema,

Good regression of neurological symptoms.

At the suggestion of M.M. It is expedient for Sumerkina to divide children into three age groups, in each of which the symptoms and course of the injury are more or less similar. The first - from 0 to 3 years old, the second - 4-6 years old, in the third are children of school age.

EXAMINATION METHODS

Clinical Methods studies in TBI:

1. Anamnesis (if the victim is unconscious, then the anamnesis is collected from a medical worker, eyewitnesses, police officers).

2. Determination of the state of vital functions (airway patency, level of consciousness, the state of the respiratory system, skin, cardiovascular activity, temperature)

3. Inspection, palpation (when examining the head, we pay attention to the integrity of the skin, the presence of deformities, paraorbital hematomas in the mastoid process. On palpation, the presence of local pain, crepitus of bone fragments, subcutaneous crepitus in the upper eyelid and forehead).

4. Assessment of neurological status:

Assessment of consciousness according to the Glasgow scale, the study of the functions of 12 pairs of cranial nerves.

Determination of the volume of active and passive movements in the limbs.

Determination of strength and muscle tone of the limbs.

Presence of nystagmus and anisocoria.

5. Consultation of an oculist (fundus) and a neuropathologist (topical neurological diagnostics)

Additional Methods research:

X-ray of the skull bones in 2 projections, with a suspected fracture of the base of the skull in 3 projections.

Lumbar (spinal tap) with laboratory examination of cerebrospinal fluid

Echoencephalography - to determine the absence or presence of displacement of the median structures of the brain

Electroencephalography helps to determine the level of brain viability.

Rheoencephalography - determination of the function of cerebral vessels.

CT scan of the brain - determination of crush injuries and the presence of hematomas.

NMRI - more accurate localization of hematomas, abscesses, crush injuries.

To assess the condition of a patient with TBI, it is necessary to know some neurological concepts:

1. Amnesia - loss of memory.

Retrograde - loss of memory for previous trauma events.

Antegrade - loss of memory for trauma and the events following it.

2. Cerebral symptoms:

Memory loss

Loss of consciousness

Dizziness

Nausea

Vomit

Photophobia

Pain in the area of ​​the eyeballs

3. Meningeal symptoms:

Neck stiffness

Kernig's sign- a symptom that is one of the important and early signs of irritation of the meninges with meningitis, hemorrhages under the membranes and some other conditions.This symptom is checked as follows: the leg of the patient lying on his back is passively flexed at an angle of 90 ° in the hip and knee joints (the first phase of the study), after which the examiner makes an attempt to straighten this leg in the knee joint (second phase). If a patient has meningeal syndrome, it is impossible to straighten his leg in the knee joint due to a reflex increase in the tone of the leg flexor muscles; in meningitis this symptom is equally positive on both sides. At the same time, it must be borne in mind that if a patient has hemiparesis on the side of paresis due to a change in muscle tone, Kernig's symptom may be negative.

Brudzinsky's symptoms- a group of symptoms that occur due to irritation of the meninges. They are one of the meningeal symptoms and can occur with a number of diseases.

Allocate:

Upper Brudzinsky's symptom - involuntary bending of the legs and pulling them to the stomach when trying to passively bend the head. First described in 1909.

Average(pubic) symptom of Brudzinsky - with pressure on the pubis, the legs bend at the hip and knee joints. Described in 1916.

Lower Brudzinski's symptom - when checking on one side of Kernig's symptom, the other leg, bending at the knee and hip joints, is pulled up to the stomach. Described in 1908.

buccal Brudzinsky's symptom - when pressing on the cheek below the zygomatic arch, the shoulders reflexively rise and the patient's arms bend at the elbow joints.

Increased sensitivity to visual and auditory stimuli.

GLASGOW SCALE

Sum of points:

15 - clear consciousness

13-14 - stupor (stun)

9-12 - stupor (cloudiness)

Less than 9 - coma (lack of consciousness)

stem symptoms:

Floating eyeballs, multiple tonic nystagmus, impaired breathing, swallowing, thermoregulation.

Focal symptoms:

Paresis, paralysis, impaired sensitivity, loss of vision, hearing, motor and sensory aphasia.

An epidural hematoma is a collection of blood between the bones of the skull and the dura mater.

A subdural hematoma is an accumulation of blood under the dura mater.

Subarachnoid hematoma is an accumulation of blood between the arachnoid and pia maters, due to damage to the pia mater and brain substance.

DIFFERENTIAL DIAGNOSISof various types of TBI is extremely important for determining the timing of inpatient and outpatient treatment, the time of disability, predicting the outcomes of each specific injury, preventing late consequences of TBI, and identifying a group of patients in need of surgical treatment.

Taking into account the fact that the vast majority of traumatic hematomas are formed against the background of a brain contusion, the main rule for the differential diagnosis of various types of TBI should be the following: every time when diagnosing a concussion of the brain, it is necessary to exclude its contusion, and every time when diagnosing a brain contusion, it is necessary rule out intracranial hematoma.

The diagnosis of cerebral contusion in the absence of focal symptoms of cortical damage should be made whenever the loss of consciousness was prolonged, the cerebral symptoms are significantly pronounced and prolonged, there is repeated vomiting, amnesia, meningeal symptoms, a fracture of the calvarium is visible on the x-ray, with a lumbar puncture in the cerebrospinal fluid blood. Blood in the cerebrospinal fluid and the presence of a skull fracture are undoubted symptoms of a brain contusion. That is why an x-ray of the skull in two projections must be done for each patient and a lumbar puncture must be done at the slightest suspicion of a brain injury.

It is very important in each case of brain contusion to exclude the possibility of compression of the brain by an intracranial hematoma. A hematoma is characterized by a "light gap" (two-stage loss of consciousness), increasing bradycardia, pupil dilation on the side of the hematoma, increased pressure and blood in the cerebrospinal fluid, congestion in the fundus. It should be noted that the "light gap", slowing of the pulse and pupil dilation on the side of the hematoma (classic Cushing's triad of intracranial hematoma) occur collectively in only 15% of patients with intracranial hematomas. Therefore, even if there is at least one of these symptoms, then it is necessary to carefully examine the patient, resorting to special methods to exclude the possibility of brain compression. But even if there are none of these three classic symptoms of a hematoma, there are no focal symptoms of cortical damage, but there is evidence for a brain contusion, then in each such case it is still necessary to assume the possibility of an intracranial hematoma. Therefore, when a patient is hospitalized with a brain contusion, after formulating the diagnosis of a contusion, it is necessary to write the words from a new line: “There are currently no data for intracranial hematoma.” And by all means, in the appointments you should write: "Hourly measurement of the pulse, registration of consciousness." The nurse on duty of the department where the patient is hospitalized should know that the deterioration or disappearance of consciousness (“light gap”) and increasing bradycardia are characteristic symptoms of brain compression by a hematoma. She should paste a separate sheet of observation of the pulse and the safety of consciousness into the medical history and note every hour or every two hours on this sheet the safety of consciousness and the pulse rate. With a deterioration in consciousness and a decrease in the pulse, she should call the doctor on duty to the patient, without waiting for the morning round.

And of course, in large hospitals where there is computed tomography, every patient with a brain contusion needs to have echolocation of the brain (every district hospital now has echolocators) and computed tomography.

Osteoplastic trepanation of the skull (photo of the surgical wound)

BASIC PRINCIPLES OF TREATMENT OF CRANIO-BRAIN INJURY

The first measures in providing first aid to patients with traumatic brain injury at the accident site should be aimed at normalizing breathing and preventing aspiration of vomit and blood, which usually occurs in patients who are unconscious. To do this, put the victim on his side or linden down.

The task of the ambulance service is to clear the airways of mucus, blood, vomit, if necessary, intubate, and in case of respiratory failure, ensure adequate ventilation of the lungs. At the same time, measures are taken to stop bleeding (if any) and maintain cardiovascular activity.

Traumatic brain injury in children ranks first among injuries requiring hospitalization.

In infancy, the most common cause of trauma to the skull and brain is a fall from a small height (from a bed, sofa, table, from a stroller; there are frequent cases of children falling from the hands of adults). A small child, deprived of targeted reflex-coordination movements, falls with a relatively heavy head down and receives a head injury.

For children of preschool and primary school age, a typical cause of injury is a fall from a height (from a window, from a balcony, a tree, etc.), sometimes significant (3-5th floor); in children of middle and senior school age, injuries received during outdoor games, as well as in traffic accidents, predominate.

The severity of the general condition and clinical course of traumatic brain injury in children depends not only on the mechanism and strength of the impact, the location and nature of damage to the brain and skull bones, concomitant injuries and premorbid status, but also on age-related anatomical and physiological features: temporary disproportion in brain development and skull, the severity of the reserve spaces of the cranial cavity; the presence of fontanelles and weak connection of the bones of the cranial vault with sutures in infants; elasticity of bones and blood vessels; relative functional and morphological immaturity of the brain; the presence of a relatively large subarachnoid space, a tight connection of the dura mater with the bone; abundance of vascular anastomoses; high hydrophilicity of brain tissue, etc.

Rapidly reacting to an injury, even a mild one, children quickly get out of a difficult state. Neurological symptoms often persist for only a few hours with a predominance of cerebral phenomena over focal symptoms, and the younger the child, the weaker the local neurological symptoms.

Classification

In 1773 J.L. Petit (Petit) for the first time divided a closed craniocerebral injury into three main forms: concussion, bruise and compression of the brain. At present, for a clear solution to the problems of diagnosing and treating injuries of the skull and brain, the following working classification, which develops the Petit schemes, seems to be the most rational (Likhterman L.B., Khitrin L. Kh., 1973).

I. Closed trauma of the skull and brain.

A. Without damage to the bones of the skull.

a) mild degree;

b) medium degree;

3. Compression of the brain (causes and forms):

a) hematoma - acute, subacute, chronic: epidural,

subdural, intracerebral, intraventricular, multiple;

d) cerebral edema;

e) pneumocephalus.

4. Combined trauma with extracranial injuries

B. With damage to the bones of the skull.

a) mild degree;

b) medium degree;

c) severe degree, incl. diffuse axonal brain damage.

2. Compression of the brain (causes and forms):

a) hematoma - acute, subacute, chronic: epidural, subdural, intracerebral, intraventricular, multiple;

b) subdural hydroma: acute, subacute, chronic;

c) subarachnoid hemorrhage;

d) cerebral edema;

e) pneumocephalus;

e) depressed fracture.

3. Combination with extracranial injuries

II. Open trauma of the skull and brain.

1. Non-penetrating, i.e. no damage to the dura mater

2. Penetrating, i.e. with damage to the dura mater

3. Gunshot wounds.

Closed craniocerebral injury

Closed injuries include those craniocerebral injuries in which there are no violations of the integrity of the soft integument of the head; if they are present, their location does not coincide with the projection of the skull fracture.

Brain compression

Among the post-traumatic causes of cerebral compression, the leading role belongs to intracranial hematomas and increasing cerebral edema. Depending on the localization of hematomas in relation to the membranes and substance of the brain, epidural, subdural, intracerebral, intraventricular and subarachnoid bleeding are distinguished.

Depending on the rate of development, all types of intracranial hematomas have the following forms of flow:

Acute, manifested in the first 3 days after the injury;

Subacute, clinically manifested on the 4-14th day from the moment of injury;

Chronic, clinically manifested in the period from 2 weeks to several years after the injury.

Such a somewhat conditional gradation is necessary from the point of view of surgical tactics. The compression syndrome is usually combined with an acute concussion, brain contusion or skull fracture, but, unlike the latter, it manifests itself after a certain period from the moment of injury - several minutes, hours or days, depending on the caliber and nature of the damaged vessel, moreover, progressively growing, threatening death. The most important diagnostic moment in the clinic of brain compression - repeated loss of consciousness after a "lucid interval" with an increase in cerebral and focal neurological symptoms - makes it necessary to closely monitor the course of closed brain injuries in children, especially in the first hours and days. However, in children, especially at an early age, there is often no “light gap”, since the developing reactive cerebral edema in combination with intracranial hematoma deepens the primary loss of consciousness.