CRANIAL INJURY - Mechanical damage to the skull and intracranial formations - the brain, blood vessels, cranial nerves, the meninges. The main reasons are traffic accidents, falls , industrial, sports and domestic injuries. Brain damage can result from: 1) focal damage, usually causing contusion (contusion) of the cortical regions of the brain or intracranial hematoma; 2) diffuse axonal damage involving deep sections of white matter.
A contusion — a center of traumatic crush of brain tissue — is often formed in the basal regions of the frontal and anterior sections of the temporal lobes, which are closely in contact with the protruding bone relief. Diffuse axonal damage is the result of rotational or linear acceleration at the time of injury. Depending on the magnitude of the acceleration with diffuse axonal damage, a wide range of disorders is possible, from mild confusion and short-term loss of consciousness (with concussion of the brain) to coma and even death. Secondary brain damage is associated with hypoxia, ischemia, intracranial hypertension, and infection.
There is an open craniocerebral injury (TBI), in which there is a communication of the cranial cavity with the external environment, and closed.
The main clinical factors determining the severity of the injury are: the duration of loss of consciousness and amnesia, the degree of depression of consciousness at the time of hospitalization, the presence of stem neurological symptoms.
Conducting the examination of the patient with head injury, especially severe, you need to adhere to a certain plan.
1. First, you should pay attention to the airway, breathing frequency and rhythm, the state of hemodynamics.
2. It is necessary to quickly examine the chest and abdomen to exclude hemo- or pneumothorax , abdominal bleeding.
3. Assess the state of consciousness. For mild TBI, it is important to assess the orientation in place, time, self, attention, asking the patient to name the months of the year in the reverse order or sequentially subtract 40 by 3, memories, asking to remember 3 words and checking if the patient can name them after 5 minutes.
4. Inspect the head, torso, limbs, paying attention to external signs of injury (injuries, bruises , bruises, fractures).
5. It is important to identify signs of a skull base fracture: the flow of cerebrospinal fluid from the nose (unlike regular mucus CS contains glucose), the symptom of glasses (the delayed appearance of a bilateral bruise in the periorbital region bounded by the edges of the orbit), the flow of blood and CSF from the ear ( bleeding from the ear can also be due to damage to the external auditory canal or eardrum), as well as bruising behind the auricle in the mastoid process, appearing 24–48 h after in injuries.
6. When collecting anamnesis in a patient or persons accompanying him, attention should be paid to the circumstances of the injury (the injury can trigger a stroke , an epileptic seizure), the use of alcohol or drugs.
7. Finding out the duration of loss of consciousness, it is important to consider that for an external observer, consciousness returns at the moment when the patient opens his eyes, for the patient himself, consciousness returns at that moment when the ability to remember returns. The duration of the period amnesized to patients is one of the most reliable indicators of injury severity. It is determined by asking the patient about the circumstances of the injury, previous and subsequent events.
8. The appearance of meningeal symptoms indicates a subarachnoid hemorrhage or meningitis , but the stiffness of the neck muscles can be checked only when injury to the cervical region is excluded.
9. All patients with TBI undergo radiography of the skull in two projections, which can reveal depressed fractures , linear fractures in the middle cranial fossa or on the base of the skull, fluid level in the ethmoid sinus, pneumocephalus (presence of air in the cranial cavity). In a linear fracture of the cranial vault, attention should be paid to whether the fracture line does not cross the furrow in which the middle meningeal artery passes. Its damage is the most common cause of epidural hematoma.
10. Most patients (even with minimal signs of damage to the cervical spine or an abrasion on the forehead) should be given an X-ray of the cervical region (at least in lateral projection, and an image of all the cervical vertebrae should be obtained).
11. Displacement of the median structures of the brain during the development of an intracranial hematoma can be detected using echoencephaloscopy.
12. Lumbar puncture in the acute period usually does not bring additional useful information, but can be dangerous.
13. If there is confusion or depression of consciousness, focal neurological symptoms, an epileptic seizure, meningeal symptoms, signs of a skull base fracture, a comminuted or depressed fracture of the cranial vault, urgent neurosurgeon consultation is necessary. Special vigilance regarding hematoma is necessary in the elderly, patients suffering from alcoholism or taking anticoagulants.
Traumatic brain injury is a dynamic process that requires constant monitoring of the state of consciousness, neurological and mental status. During the first day, the neurological status, first of all, the state of consciousness should be assessed every hour, refraining from sedation, if possible (if the patient falls asleep, then he should be awakened periodically).
Mild TBI is characterized by short-term loss of consciousness, orientation, or other neurological functions, usually occurring immediately after injury. Score on the Glasgow coma scale during the initial examination is 13 - 15 points. After the recovery of consciousness, amnesia is detected for events that immediately preceded the injury or occurred immediately after it (the total duration of the amnesic period does not exceed 1 hour), headache , autonomic disturbances (fluctuations in blood pressure, pulse lability, vomiting , pallor, hyperhidrosis), asymmetry of reflexes, pupillary disorders and other focal symptoms, which usually spontaneously regress within a few days. Criteria for mild TBI correspond to concussion and mild brain contusion. The main feature of mild TBI is the principal reversibility of neurological disorders, however, the recovery process may take several weeks or months, during which patients will remain headache , dizziness , asthenia, impaired memory, sleep, and other symptoms (postcommutation syndrome). In automobile accidents, mild head injury is often combined with a whiplash injury resulting from sudden head movements (most often as a result of a sudden over-bending of the head, followed by rapid flexion). Whiplash injury is accompanied by sprain and neck muscles and manifests pain in the neck and occipital region and dizziness, which spontaneously disappear within a few weeks, usually leaving no consequences.
Patients with a slight injury should be hospitalized for observation for 2-3 days. The main goal of hospitalization is not to miss a more serious injury. Subsequently, the likelihood of complications (intracranial hematoma) is significantly reduced, and the patient can be allowed to go home, provided that he is watched by relatives, and if his condition worsens, he will be quickly brought to the hospital. Particular caution should be observed in children in whom intracranial hematoma may develop in the absence of an initial loss of consciousness.
Treatment is reduced only to symptomatic care. If pain is prescribed, analgesics are prescribed, in case of severe vegetative dysfunction, beta-blockers and bella-aminal are prescribed, and in case of sleep disturbances benzodiazepines are used. In mild TBI, clinically significant cerebral edema usually does not develop, therefore, diuretic administration is not advisable. Long bed rest should be avoided - it is much more beneficial for the patient to return to his usual environment earlier. But it should be borne in mind that the performance of many patients for 1–3 months is limited. Long-term uncontrolled intake of benzodiazepines, analgesics, especially those containing caffeine , codeine and barbiturates, contributes to the chronicity of post-traumatic disorders. Patients undergoing mild TBI are often prescribed nootropic drugs - piracetam (nootropil) at 1.6 - 3.6 g / day, pyritinol (encephabol) at 300-600 mg / day, cerebrolysin 5-10 ml intravenously, glycine 300 mg / day under the tongue. Patients often need not so much medicine as tactful and detailed explanation of the essence of their symptoms, the inevitability of their regression for a short time and the need to adhere to the principles of a healthy lifestyle.
If there are no direct or indirect signs of damage to the brain substance during a head injury (loss of consciousness or short-term confusion, amnesia , stunning, persistent vomiting , persistent dizziness , focal symptoms, etc.), then a bruise of the soft tissues of the head is diagnosed. Carefully ascertaining the circumstances of the injury, making a radiography of the skull and making sure that there is no bone damage, such a patient can be released home, warning of the need for immediate treatment when the condition worsens. You must first treat the wounds, if necessary, prescribe antibacterial drugs and carry out the prevention of tetanus.
Moderate and severe TBI are characterized by prolonged loss of consciousness and amnesia, persistent cognitive and focal neurological disorders. In severe TBI, the probability of an intracranial hematoma is significantly higher. The hematoma should be suspected with progressive depression of consciousness, the emergence of a new or increasing focal symptoms that already existed, the appearance of signs of penetration. The “light period” (short-term return of consciousness with subsequent deterioration), which is considered a classic sign of hematoma, is observed only in 20% of cases. The development of a long coma immediately after injury in the absence of an intracranial hematoma or massive contusion foci is a sign of diffuse axonal damage. Delayed deterioration, in addition to intracranial hematoma, may be caused by cerebral edema, fat embolism, ischemia, or infectious complications. Fat embolism occurs a few days after the injury, usually in patients with fractures of the long bones - when the fragments are biased or attempted to reposition, in most patients the respiratory function is disturbed and small hemorrhages occur under the conjunctiva. Post-traumatic meningitis develops several days after the injury, more often in patients with open TBI, especially in the presence of a skull base fracture with the appearance of a message (fistula) between the subarachnoid space and the paranasal sinuses or middle ear.
Treatment of severe TBI comes down mainly to the prevention of secondary brain damage and includes the following measures:
1) maintaining the airway (cleansing the mucus of the mouth and upper respiratory tract, the introduction of the duct). In moderate stunners in the absence of respiratory disorders, oxygen is prescribed through a mask or nasal catheter. With deeper impairment of consciousness, lung damage, and depression of the respiratory center, intubation and mechanical ventilation are necessary. To avoid aspiration, the stomach should be emptied with a nasogastric probe. Prevention of stressful gastric bleeding - a risk factor for aspiration pneumonia - involves the introduction of antacids;
2) stabilization of hemodynamics. It is necessary to correct gycevolemia, which may be associated with blood loss or vomiting, while avoiding overhydration and increased brain edema. Usually enough 1.5 - 2 l / day of saline or colloidal solutions. The introduction of glucose solutions should be avoided. With a significant increase in blood pressure prescribed antihypertensive drugs (beta-blockers, angiotensin-converting enzyme inhibitors, diuretics, clophelin). It should be borne in mind that due to impaired cerebral autoregulation
a rapid drop in blood pressure can cause brain ischemia; special care is needed in relation to elderly patients suffering from arterial hypertension for a long time. With low blood pressure, fluid is injected, corticosteroids, vasopressors;
3) for suspected hematoma, an immediate consultation with a neurosurgeon is indicated;
4) prevention and treatment of intracranial hypertension. Until a hematoma is ruled out, the introduction of mannitol and other osmotic diuretics can be dangerous, but with rapid depression of consciousness and signs of penetration (for example, when the pupil is dilated), when surgery is planned, 100 to 200 ml of a 20% solution of mannitol should be injected quickly ( pre-catheterized bladder). After 15 minutes, lasix is injected (20-40 mg intramuscularly or intravenously). This allows you to gain time for research or emergency transportation of the patient;
5) with pronounced excitation, sodium hydroxybutyrate (10 ml of 20% solution), morphine (5-10 mg intravenously), haloperidod (1-2 ml of 0.5% solution) are injected, but sedation makes it difficult to assess the state of consciousness and may be the cause of late diagnosis hematomas. In addition, excessive and unreasonable introduction of sedatives can be the cause of slow recovery of cognitive functions;
6) for epileptic seizures, Relanium is injected intravenously (2 ml of a 0.5% solution intravenously), after which antiepileptic drugs are prescribed immediately (carbamazepine, 600 mg / day);
7) nutrition of the patient (through a nasogastric tube) usually begin on the 2nd day;
8) antibiotics are prescribed for the development of meningitis or prophylactically with an open head injury (especially with CSF);
9) trauma to the facial nerve is usually associated with a fracture of the pyramid of the temporal bone and may be caused by damage to the nerve or swelling in the bone canal. In the latter case, the integrity of the nerve is not violated and corticosteroids may be useful;
10) partial or complete loss of vision may be associated with traumatic neuropathy of the optic nerve, resulting from nerve contusion, hemorrhage into it and / or spasm and occlusion of the vessel supplying it. In the event of this syndrome, administration of high doses of corticosteroids is indicated.
Chronic subdural hematoma develops several weeks and even months after a head injury, which is sometimes so insignificant that by the time hematoma symptoms appear (drowsiness, depression of consciousness, hemiparesis, aphasia , epileptic seizure), the patient has time to forget about it. Especially often chronic subdural hematoma occurs in the elderly. The cause of the increase in neurological symptoms after TBI may be normotensive hydrocephalus .