CRANIAL-BRAIN TRAUMA

CRANIAL-BRAIN TRAUMA - mechanical damage to the skull and intracranial formations - the brain, vessels, cranial nerves, meninges. The main causes are traffic accidents, falls , industrial, sports and domestic injuries. Brain damage can be the result of: 1) focal damage, usually causing a bruise (concussion) of the cortical parts of the brain or intracranial hematoma; 2) diffuse axonal damage involving deep sections of white matter.

The bruise is the focus of traumatic crushing of the brain tissue - it is often formed in the basal parts of the frontal and anterior sections of the temporal lobes that are in close 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 in diffuse axonal damage, a wide range of disorders can arise 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, infection.

Isolate an open craniocerebral injury (CCT), in which there is a communication of the cranial cavity with the external environment, and closed.

The main clinical factors that determine the severity of injury are: the duration of loss of consciousness and amnesia, the degree of oppression of consciousness at the time of hospitalization, the presence of neurologic stem.

Carrying out an examination of a patient with CCT, especially severe, you need to follow a certain plan.

1. First you should pay attention to the patency of the airways, the frequency and rhythm of breathing, the state of hemodynamics.

2. Quickly examine the chest and abdomen to exclude hemo- or pneumothorax , abdominal bleeding.

3. Assess the state of consciousness. With a lung injury it is important to assess the orientation in place, time, self, attention, asking the patient to call the months of the year in reverse order or sequentially subtract from 40 to 3, memory, asking to memorize 3 words and checking whether the patient will be able to name them after 5 minutes.

4. Inspect the head, trunk, limbs, paying attention to the external signs of injury (injuries, bruises , bruises , fractures).

5. It is important to identify the signs of fracture of the base of the skull: the outflow of cerebrospinal fluid from the nose (unlike the usual mucus, the liquor contains glucose), the symptom of glasses (the delayed appearance of bilateral bruising in the periorbital area bounded by the edges of the orbit), the discharge of blood and cerebrospinal fluid from the ear Bleeding from the ear may be associated with damage to the external ear canal or tympanic membrane), as well as a bruise behind the auricle in the region of the mastoid process that appears 24-48 hours after the injury.

6. Collecting an anamnesis from a patient or accompanying persons, it is necessary to pay attention to the circumstances of the injury (trauma can trigger a stroke , epileptic fit), the use of alcohol or drugs.

7. When determining the duration of loss of consciousness, it is important to consider that for the external observer the consciousness returns at the moment when the patient opens his eyes, for the very patient the consciousness returns at the moment when the ability to remember is returned. The duration of the amnesized period is one of the most reliable indicators of the severity of the injury. It is determined by asking the patient about the circumstances of the injury, previous and subsequent events.

8. The appearance of meningeal symptoms indicates subarachnoid hemorrhage or meningitis, but the rigidity of the neck muscles can be checked only if the cervical injury is excluded.

9. All patients with CCT are undergoing radiography of the skull in two projections, which can reveal depressed fractures, linear fractures in the area of ​​the middle cranial fossa or on the base of the skull, the level of fluid in the treacle, pneumothsephalus (the presence of air in the cranial cavity). With a linear fracture of the cranial vault, attention should be paid to whether the fracture line crosses the furrow in which the middle meningeal artery passes. Her damage is the most common cause of epidural hematoma.

10. Most patients (even with minimal signs of damage to the cervical spine or abrasion on the forehead) should be assigned a roentgenography of the cervical spine (at least in the lateral projection, with an image of all the cervical vertebrae).

11. The displacement of the midline structures of the brain during the development of intracranial hematoma can be detected using echoencephaloscopy.

12. Lumbar puncture in an acute period usually does not bring additional useful information, but can be dangerous.

13. In the presence of confusion or oppression of consciousness, focal neurological symptoms, epileptic seizure, meningeal symptoms, signs of fracture of the base of the skull, a comminuted or depressed fracture of the cranial arch, urgent consultation of the neurosurgeon is necessary. Special caution with regard to hematoma is needed in the elderly, patients suffering from alcoholism or taking anticoagulants.

Craniocerebral trauma is a dynamic process that requires constant monitoring of the state of consciousness, neurological and mental status. During the first day of the neurological status, first of all the state of consciousness should be evaluated every hour, abstaining whenever possible from the appointment of sedatives (if the patient falls asleep, it should be periodically awakened).

Lightweight TBI is characterized by a short-term loss of consciousness, orientation or other neurological functions, usually immediately after the injury. The Glasgow Coma score is 13 to 15 for the initial examination. After the restoration of consciousness, amnesia is detected on the events that immediately preceded the trauma or occurred immediately after it (the total duration of the amnesic period does not exceed 1 hour), headache , autonomic disorders (fluctuations in blood pressure, pulse lability, vomiting , pallor, hyperhidrosis), asymmetry of reflexes, Pupillary disorders and other focal symptoms that usually spontaneously regress within a few days. The criteria of mild TBI correspond to concussion of the brain and a bruised brain contusion of mild degree. The main feature of lightweight TBI is the fundamental reversibility of neurological disorders, but the recovery process can last for several weeks or months, during which patients will have headache , dizziness , asthenia, memory impairment, sleep and other symptoms (post-comon syndrome). In car accidents, an easy CCT is often combined with a whiplash injury of the neck, which results from sudden movements of the head (most often as a result of sudden over-extension of the head followed by rapid flexion). A whiplash injury is accompanied by a sprain of the ligaments and muscles of the neck and is manifested by pain in the cervico-occipital region and dizziness that spontaneously pass for several weeks, usually leaving no consequences.

Patients with minor trauma should be hospitalized for observation on 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 released home, provided that he is followed by relatives, and if the condition worsens, he will be quickly taken to the hospital. Particular care should be taken in children who have intracranial hematoma can develop in the absence of an initial loss of consciousness.

Treatment is reduced only to symptomatic care. When pain is prescribed analgesics, with pronounced vegetative dysfunction - beta-blockers and bellataminal, with sleep disturbance - benzodiazepines. With mild TBI, there is usually no clinically significant cerebral edema, so diuretics are not advisable. Avoid prolonged bed rest - much more beneficial early return of the patient to the familiar environment. But it should be borne in mind that the performance of many patients within 1-3 months is limited. Continuous uncontrolled use of benzodiazepines, analgesics, especially those containing caffeine , codeine and barbiturates, contributes to the chronicity of post-traumatic disorders. Patients who underwent a lung injury are often prescribed nootropic drugs - piracetam (nootropil) at 1.6-3.6 g / day, pyrithinol (encephabol) at 300-600 mg / day, cerebrolysin 5-10 ml intravenously, glycine 300 mg / Day under the tongue. Patients often need not so much in medicines as in tactfully and in detail explaining 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 in the 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 finding out the circumstances of the injury, having made a radiograph of the skull and making sure that there are no bone injuries, such a patient can be released home, having warned of the need for immediate treatment if the condition worsens. Preliminarily you need to treat wounds, if necessary, prescribe antibacterial drugs and conduct tetanus prophylaxis.

The moderate and severe TBI are characterized by a prolonged loss of consciousness and amnesia, persistent cognitive and focal neurological disorders. In severe TBT, the probability of intracranial hematoma is significantly higher. Hematoma should be suspected with progressive depression of consciousness, the appearance of a new or an increase in the already existing focal symptomatology, the appearance of signs of wedging. The "light interval" (short-term return of consciousness with subsequent deterioration), considered a classic sign of a hematoma, is observed only in 20% of cases. The development of a prolonged coma immediately after trauma in the absence of intracranial hematoma or massive contusion foci is a sign of diffuse axonal injury. Delayed deterioration, in addition to intracranial hematoma, can be caused by brain edema, fat embolism, ischemia or infectious complications. Fat embolism occurs a few days after the injury, usually in patients with fractures of long tubular bones - when the fragments are displaced or attempted to reposition them, in most patients the respiratory function is disrupted and small hemorrhages develop under the conjunctiva. Posttraumatic meningitis develops a few days after the trauma, more often in patients with open TBI, especially when there is a fracture of the base of the skull with the appearance of a message (fistula) between the subarachnoid space and the paranasal sinuses or middle ear.

Treatment of severe TBT is mainly to prevent secondary brain damage and includes the following measures:

1) maintenance of patency of the respiratory tract (cleansing from the mucus of the mouth and upper respiratory tract, the introduction of airway). With moderate stunning, in the absence of breathing disorders, oxygen is prescribed through a mask or nasal catheter. With a deeper violation of consciousness, lung damage, respiratory center depression, intubation and ventilation are necessary. To avoid aspiration, the stomach should be cleaned with a nasogastric tube. Prevention of stress gastric bleeding - a risk factor for aspiration pneumonia - involves the introduction of antacids;

2) stabilization of hemodynamics. It is necessary to correct gitsovolemiyu, which can be associated with blood loss or vomiting, while avoiding hyperhydration and increased brain edema. Usually, 1.5 to 2 l / day of physiological solution or colloidal solutions is sufficient. Glucose solutions should be avoided. With a significant increase in blood pressure prescribed antihypertensives (beta-blockers, angiotensin-converting enzyme inhibitors, diuretics, clonidine). It should be borne in mind that due to a violation of autoregulation of the cerebral circulation

A rapid fall in blood pressure can cause brain ischemia; Special caution is needed in relation to elderly patients, long time suffering from hypertension. With low blood pressure, injections of liquid, corticosteroids, vasopressors;

3) if there is a suspicion of a hematoma, an immediate consultation with a neurosurgeon is indicated;

4) prevention and treatment of intracranial hypertension. While hematoma is not excluded, administration of mannitol and other osmotic diuretics can be dangerous, but with rapid inhibition of consciousness and appearance of signs of wedging (for example, with dilated pupils), when surgery is planned, 100-200 ml of a 20% solution of mannitol Pre-catheterize the bladder). After 15 minutes, enter lasix (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 oxybutyrate (10 ml of 20% solution), morphine (5-10 mg intravenously), haloperidod (1-2 ml of 0.5% solution), but sedation makes it difficult to assess the state of consciousness and may be the cause of untimely diagnosis Hematomas. In addition, excessive and unreasonable administration of sedatives can be the cause of delayed recovery of cognitive functions;

6) with epileptic seizures, Relanium is injected intravenously (2 ml of a 0.5% solution intravenously), after which immediately antiepileptic drugs are prescribed inside (carbamazepine, 600 mg / day);

7) the patient's food (through a nasogastric tube) is usually started on the 2nd day;

8) antibiotics are prescribed for the development of meningitis or prophylactically with an open craniocerebral trauma (especially with a liquor fistula);

9) trauma of the facial nerve is usually associated with a fracture of the pyramid of the temporal bone and may be due to damage to the nerve or its edema in the bone channel. In the latter case, the integrity of the nerve is not disturbed and corticosteroids may be useful;

10) partial or complete loss of vision can be associated with traumatic neuropathy of the optic nerve, which is a consequence of nerve contusion, hemorrhage into it and / or spasm and occlusion of the vessel supplying it. When this syndrome occurs, high doses of corticosteroids are indicated.

Chronic subdural hematoma develops several weeks and even months after a head injury, which is sometimes so insignificant that the patient has time to forget about it at the time of the appearance of the symptoms of hematoma (drowsiness, oppression of consciousness, hemiparesis, aphasia , epileptic seizure). Especially often chronic subdural hematoma occurs in the elderly. The cause of the increase in neurological symptoms after CCT may be normotensive hydrocephalus .