First aid for a head injury. Providing first aid for a gunshot wound
Gunshot craniocerebral wounds (GMTW) are divided into three groups: tissue wounds, non-penetrating and penetrating.
Soft tissue wounds with damage to the aponeurosis should be regarded as open damage skulls, which can lead to infectious and inflammatory intracranial processes (meningitis, encephalitis, etc.). PTCM with a bone fracture without damage to the dura mater is classified as non-penetrating damage. PTCM with bone fractures, damage to the dura mater belong to penetrating damage. In case of damage to the dura mater, there is always a risk of intracranial infectious and inflammatory complications.
By the type of projectile gunshot wounds are divided into bullet and shrapnel (metal fragments, balls, arrow-shaped elements, etc.) and wounds from secondary projectiles (fragments of rocky soil, glass, brick, cement, wood, etc.).
Non-penetrating wounds of the soft tissues of the skull lead to severe craniocerebral injuries as a result of a concussion or contusion of the brain and the formation of intracranial hemorrhages.
Penetrating FMRs always cause severe concomitant brain damage, both local at the site of injury and generalized. Bullets, having high kinetic energy, cause significant damage to the brain in the circumference of the wound channel due to shock-shaking molecular destruction of the brain and surrounding tissues. The hydrophilicity of the brain contributes to the formation of large zones of its cellular destruction and concussion. The wound channel always significantly exceeds the size of the bullet.
The fragments cause the destruction of the bone and brain with the available kinetic energy and their mass. At the end or when hitting a metal helmet, they lead to concussion, brain contusion and less significant brain damage. The danger of shrapnel wounds in their significant infection and multiplicity of wounds.
By type of wound channel Distinguish wounds: through, blind, tangential, ricocheting.
Blind wounds of the skull are characterized by a wound channel that ends blindly and, as a rule, contains a foreign body.
Blind wounds are divided into simple ones (the wound channel and the foreign body are located in the same part of the brain to which the skull defect is attached) (Fig. 73, 1); radial (the foreign body reaches the falciform process and, having lost its “strength”, stops at it) (Fig. 73.2); segmental (foreign body passes 2-3 lobes of the brain and stops at inner surface bones, the wound channel in this case constitutes a segment in relation to round shape skulls) (Fig. 73.3); diametrical (foreign body passes through the medulla and stops at the inner surface of the bone opposite the inlet and bone fracture) (Fig. 73, 4).
In assessing a skull injury, it is important to take into account localization, side, singleness, multiplicity, combination with other injuries and combinations with other traumatic factors.
By area of the brain wounds are divided as follows: frontal, parietal, temporal, occipital. Parabasal wounds are divided into anterior (fronto-orbital, temporo-orbital, with damage paranasal sinuses nose, wounds of the eyeball), middle (temporomandibular, with damage to the paranasal sinuses) and posterior (posterior cranial fossa, craniospinal). Parabasal wounds are often combined.
Rice. 73.
1 - simple; 2 - radial; 3 - segmental; 4 - diametrical
Skull injuries can be single And multiple, isolated And combined.
Type of gunshot fracture The skull often determines the nature of the injury and the choice of neurosurgical tactics. Gunshot fractures include:
- incomplete - characterized by damage to one plate of the skull;
- linear (crack) - often connects two defects;
- depressed - can be impression and depression;
- crushed - characterized by the formation of small bone fragments that fill the defect of the skull or move inside the skull;
- perforated - characterized by a small defect of the skull, a deep displacement of bone fragments and foreign bodies. Perforated fractures can be blind, through and sheer. Depending on the location of the foreign body, a perforated blind fracture can be simple, radial, segmental, diametrical and comminuted (Fig. 73). With penetrating wounds of the skull and brain, the inlet is usually small, not far from it, along the wound channel, small bone fragments are located. The outlet is much larger and is characterized by a large bone damage and extracranial displacement of bone fragments. A perforated sheer fracture occurs as a result of a bone injury and with a ricocheting rebound of a wounding projectile. With this mechanism of injury, bone fragments rush intracranially and damage the medulla to a great depth. Craniograms reveal a small defect in the skull and deep-seated (according to a plumb line) bone fragments;
- comminuted - characterized by extensive bone fragmentation with the formation of large bone fragments and gaping cracks extending from the defect.
Peacetime bullet wounds are characterized by the proximity of the shot (suicidal attempt, criminogenic situation, accidental shots) with the presence of soot at the entrance of the bullet. In this case, the wound channel in the brain is often narrow through or blind, with a small area of bone damage.
Explosions of improvised weapons are characterized by a combination of injuries to the face, neck, jaws, eyes, and hands. Shot wounds are usually multiple and blind. Three zones are distinguished in a gunshot wound: the zone of the primary wound channel, the zone of contusion (primary traumatic necrosis) and the zone of molecular concussion. The wound channel is filled with fragments of dead tissue, blood clots, foreign bodies. The walls of the wound channel form a zone of contusion (primary necrosis). To the periphery of this zone are tissues that have been exposed to a shock wave, and not to the injuring projectile itself (a zone of molecular concussion). Figuratively speaking, a gunshot wound is a "cemetery nerve cells, conductors and blood clots. Under unfavorable conditions, the tissues of this zone may be partially necrotic (secondary or subsequent necrosis).
All gunshot wounds from the moment of their infliction contain a variety of microorganisms and can be considered primarily infected. With inadequate medical care, microbes can enter the wound and from the environment (secondary microbial contamination).
Bacterial contamination of a wound must be distinguished from an infected wound, when microbes that have invaded non-viable tissues have a pathogenic effect on the wound process and the body as a whole.
The acute period of a gunshot wound depends on the severity of head injury and lasts from 2 to 10 weeks. All victims with gunshot wounds are considered as the most severe, urgent, requiring specialized care. Therefore, such victims must be delivered as soon as possible to a specialized hospital, where there are necessary conditions for providing assistance in full. In the absence of the possibility of transportation and contraindications to it, surgical intervention at the stage of qualified assistance is carried out only with increasing bleeding and compression of the brain.
Emergency care for patients with gunshot wounds consists in the normalization of respiration and hemodynamics, the prevention and relief of increasing edema-swelling of the brain, infectious and inflammatory complications.
General principles of intensive care for gunshot brain injuries.
1. Ensuring adequate gas exchange (respiration). If necessary, intubation and ventilation.
2. Maintenance of optimal systemic and cerebral perfusion pressure, BCC, CVP.
3. In order to increase the resistance of the brain to possible disorders of gas exchange and blood circulation, 5 mg of verapamil is administered intravenously as a bolus, followed by its slow infusion at 2 mg/h. In addition, magnesia sulphate 10 mg/kg, lidocaine 4–5 mg/kg, sodium thiopental, GHB, diazepine preparations (Relanium, Sibazon, Seduxen, etc.), antioxidants (Vit E – 5 ml/m2 – 3 times a day).
4. Maintenance of water and electrolyte balance, avoiding hypoosmolarity (300 mosm/l), as it leads to cerebral edema, and hyperosmolarity (320 mosm/l), as it leads to dehydration, hypovolemia, hemoconcentration, decreased perfusion in the first queue of damaged structures. Maintain hematocrit at 30-35%.
5. With increased intracranial pressure (ICP) - an elevated position of the head end by 30 °, moderate hyperventilation, mannitol 20% - 0.5 - 1.0 g / kg of body weight for 10 minutes. Furosemide 0.5-1.0 mg/kg is additionally administered to enhance the action of the osmodiuretic.
6. Corticosteroids: metiped 20 mg/kg or dexamethasone 1 mg/kg, then IM every 6 hours at 0.2 mg/kg.
7. Stable acid-base state.
8. Improving metabolism (nootropics, essentiale).
9. Inhibitors of proteolytic enzymes (trasilol, contrical, gordox).
11. With convulsions - sodium thiopental, difenin, seduxen, etc.
12. With hyperthermia - lytic mixtures and physical methods of cooling.
13. Prevention of infectious and inflammatory complications, antibiotics, wound PST.
14. Ensuring nutrition of approximately 30 kcal/kg of body weight per day.
15. Control of concomitant injuries, complications.
Technique and timing of surgical treatment of gunshot wounds of the skull and brain
With a gunshot wound, there are no objective criteria for predicting the possible transition of microbial contamination to a wound infection, therefore, all gunshot wounds should be considered as infected and subjected to surgical treatment. Thus, the surgical treatment of gunshot wounds is the main therapeutic measure.
Surgical debridement contributes to the prevention of wound infection, successful wound healing and more favorable results. The quality of surgical treatment depends on the skill level of the specialist, clear knowledge topographic anatomy damaged area, good practical skills and the availability of appropriate equipment and tools.
The main types of surgical treatment of the wound:
primary - the first surgical intervention in the wounded, carried out for tissue damage. Its main task is to create unfavorable conditions for the development of wound infection;
secondary - an intervention undertaken about subsequent (secondary) changes in the wound caused by various complications;
repeated - the second operation in a row, carried out even before the development of wound complications with the inferiority of the primary treatment.
Primary surgical treatment (PSD) of head wounds is more effective the earlier it is performed. It helps to accelerate wound healing and improve treatment outcomes. The earlier and more radically surgical treatment is performed, the better results. The appearance of signs of wound suppuration does not prevent surgical intervention, which prevents more severe infectious complications. Delay in debridement, even under the protection of antibiotics, can lead to the development of infectious complications.
Depending on the timing of the PST is:
early - intervention carried out on the first day after injury, when in most cases it is possible to prevent the development of infection;
delayed - from the first to the second day (24 - 48 hours);
late - after 48 hours.
Delayed and late primary debridement requires early application antibiotics to reduce the risk of infection.
Primary and secondary surgical treatment of the wound are carried out in the same way. An exception is sometimes made by late primary and secondary surgical treatment, which can only be reduced to ensuring a free outflow of discharge from the wound with already developed infectious complications, mainly by opening purulent streaks, applying contra-openings and good drainage. Excision of dead tissues during these periods can be performed more completely, since by this time their delimitation from living tissues (demarcation) is clearly outlined.
Before surgical treatment, it is necessary to clarify the nature of the injury, determine the direction of the wound channel in case of penetrating wounds, study x-rays, perform echoencephaloscopy and outline a preliminary operation plan, taking into account the general condition of the patient and the existing neurological symptoms.
Primary surgical treatment should be carried out with strict observance of asepsis, antisepsis and with adequate anesthesia.
When choosing a method of anesthesia, an individual approach is necessary, based on taking into account the condition of the victim and the nature of the injury. Often operations are preceded and accompanied by anti-shock, infusion-transfusion and decongestant therapy.
The main elements of the surgical treatment of a gunshot wound are:
a) dissection;
b) careful excision of non-viable tissues;
c) if possible, restoration of anatomical relationships in the wound;
d) its adequate drainage.
The search and removal of foreign bodies located far from the wound channel should not be more dangerous for the wounded than the wound itself, especially for metal objects in the cranial cavity.
It should be taken into account that even a radical and early PST of a gunshot wound does not guarantee the absence of new foci of necrosis and the development of infectious complications. Therefore, PST of wounds is supplemented by various chemical and physical methods of its purification.
As already mentioned, best results gives early treatment of the wound. This makes it possible to achieve smooth wound healing, minimize infectious complications, and apply primary dura mater and skull defect plasty. The earlier the wounded in the skull is delivered to a specialized department, the earlier he is operated on, the more opportunities for an uncomplicated course of the injury.
preparation operating field start by shaving your head. Be sure to shave the entire head so as not to miss multiple small wounds, some of which may be penetrating. Treatment of the skin is carried out according to generally accepted rules in compliance with all the rules of asepsis and antisepsis. On the prepared area, the planned surgical incisions are marked.
After that, the operating field is isolated with sterile linen.
In addition to the standard set of neurosurgical instruments, it is necessary to have a magnet pin for extracting metal fragments.
Most non-penetrating skull wounds can be treated under local anesthesia with potentiation. For this purpose, before the operation, the wounded person is injected with 1-2 ml of a 2% solution of promedol, diphenhydramine, analgin. In patients with penetrating wounds, treatment is performed under general anesthesia. Local anesthesia produce a 0.5 - 1% solution of novocaine with the addition of a non-epileptogenic antibiotic.
Selecting a section view should take into account the location, direction of the vessels and nerves, as well as cosmetic considerations. Usually, a fringing or arcuate incision is made. Through wounds with a short skin bridge are excised with a single incision.
Horseshoe incisions should not be used to avoid infection of gunshot wounds.
In the projection of the fracture, soft tissues are excised immediately to the full depth to the bone in one block. The periosteum is exfoliated to the periphery for more convenient biting of the bone. Incomplete fractures of the skull in the form of superficial scratches, gouges or uzurs are treated with sharp spoons, leveling the bone defect and giving it a scaphoid shape. In the early stages of injury, the wound can be sutured tightly.
Craniotomy is not indicated in the presence of isolated cracks of the vault without gaping and visible contamination (hair, dirt, headgear particles), in the absence of signs of intracranial hematoma.
Surgical treatment of depressed fractures without significant displacement of fragments is performed according to the rules set forth in Chapter VII. When processing crushed fractures, first, small bone fragments of the outer plate are removed with a sharp spoon, then fragments of the inner plate of the skull are carefully removed with tweezers. Perforated fractures are carefully cleaned from free bone fragments and foreign bodies. Subsequently, the bone defect is successively expanded with wire cutters until an unchanged dura mater appears.
When performing trepanation of the neck, it is necessary to treat cracks extending from the defect, especially if they gape. To do this, a semi-oval excision of the edges is performed at the beginning of the outgoing crack at a distance of 0.5 - 1 cm along the latter.
Through wounds are treated starting from the inlet. With perforated through fractures of the segmental type, when there is a small bone bridge between the inlet and outlet holes (with a short chord of the wound channel), this bridge should be removed to avoid osteomyelitis. If the distance between the inlet and outlet is large, then it is advisable to keep the bone bridge and close it with soft covers. Small perforated bone defects with multiple wounds and located close to each other are combined into a common trepanation defect.
Comminuted fractures with the destruction of large areas of bone and the formation of multiple cracks and large bone fragments create great difficulties for craniotomy. Large bone fragments that go deep under the soft tissues and have not lost contact with the periosteum should not be removed. In such cases, the edges of bone fragments facing the wound are brought together. Movable bone fragments are fixed with bone forceps to avoid tearing them off the periosteum. And then their edges are refreshed.
Responsible is the decision on the need to dissect the intact DM. Indications for its dissection are set out in the section on the general principles of craniotomy.
At penetrating wound primary treatment of deep wounds is more complicated. First, bone fragments filling it (“bone plug”) are carefully removed from the dura defect. This eliminates the obstruction to outflow from the wound channel. Then the tip of the aspirator or a vinyl chloride tube is inserted into the wound channel and, gradually immersing it, the contents of the wound channel are sucked out: destroyed particles of the brain (detritus), blood clots, bone fragments, hair, pieces of headgear and other foreign bodies. At the same time, the depth of penetration of the aspirator or tube is correlated with craniography data on the depth of bone fragments and their localization. Aspiration of the contents of the wound channel is carried out better with constant washing of the wound. This allows, together with the liquid, to more effectively remove small particles of bone, blood clots, etc. Manipulations in the wound channel must be careful and delicate so as not to damage the medulla and not cause bleeding from thrombosed vessels.
In the absence of signs of swelling of the brain, a technique can be used that artificially increases intracranial pressure. Temporary compression of the jugular veins of the victim contributes to the movement of the contents of the wound channel to more superficial parts of the wound. In this case, brain detritus, blood clots and bone fragments are squeezed out of the wound channel, after which they are removed. Subsequently, the wound is carefully washed out of the rubber pear with an isotonic solution of sodium chloride, while the remnants of the contents of the wound channel are removed. The appearance of pulsation of the medulla after these measures indicates the usefulness of the treatment of the wound channel.
How to act in those cases when, with the above methods, metallurgical fragments and deeply located bone fragments do not move independently to the surface of the wound? It is necessary to carefully expand the wound channel with brain spatulas and illuminate it in order to remove the fragment under visual control with tweezers or with the help of an aspirator. It is also possible to use a special magnet.
Is it possible to conduct a digital revision of the brain wound in search of foreign bodies? Only in exceptional cases, a foreign body is felt with the tip of the little finger. For this purpose, the tip of the little finger is carefully inserted into the wound channel. Having determined the localization of the foreign body in the brain, tweezers with long jaws or nasal tweezers bent at an angle are inserted along the little finger, with which a bullet or a fragment is captured. Then the finger is removed and after it the instrument with the foreign body is very carefully removed. This procedure sometimes has to be repeated several times. Only after the removal of all bone and accessible metal foreign bodies, the brain wound is considered radically treated.
With penetrating wounds, it is necessary to perform a radical PST - removal of all non-viable tissues: detritus, blood clots, accessible foreign bodies, crush foci. Subsequent plasty of dura defects can be performed with artificial or preserved solid meninges. It is advisable to use a constant flushing system for the treatment of the wound channel. The washing liquid washes out necrotic tissues, blood clots, brain detritus, brain decay products, without causing additional brain injury. The supply drain, through which the infusion of solutions with antibiotics is carried out, is pulled up by 1-2 mm daily until it is completely removed from the wound channel, and after that the system is completely removed.
Hemostasis is carried out according to the generally accepted rules set out in Chapter VI.
How to complete the operation? Is it possible to sew up the wound tightly? In peacetime practice, deaf closure of soft tissues is generally recognized. The primary repair of an artificial DM defect with alloplastic films (polyethylene, etc.) or a lyophilized casing is widely used. In the absence of contraindications, a bone defect can be closed with fast-hardening plastics (protacryl, butacryl, norakryl, etc.). However, it is advisable to perform primary plastic surgery in specialized departments, during early operations and long-term observation of the wounded in postoperative period. A blind suture is applied to a cranial wound in cases where the neurosurgeon treats the wounded person in the skull and brain at an early stage, when the operation can be performed carefully and radically. A blind seam is applied to the covers in one row. A graduate is left between the seams for 1 - 2 days. It is mandatory to use antibiotics for prophylactic purposes, as well as systematic observation of the operating specialist.
Thus, PST of a gunshot wound of the skull and brain is reduced to solving 4 main issues: indications, timing, technique and place of primary trepanation.
PST is not carried out for the wounded with impaired vital functions and with extensive wounds that are incompatible with life. In case of shock in the pre- and postoperative period, antishock therapy. The wounded with depression of consciousness to the point of coma should be operated on only when the severity of their condition is due to increasing compression or expansion of the area of brain injury.
We agree with the opinion of many authors that only a neurosurgeon should treat craniocerebral wounds. To do this, in cases of non-transportability of the victim to the stage of qualified assistance, a neurosurgeon from the regional center for disaster medicine must be called without fail. This can significantly reduce the number of errors made by general surgeons and traumatologists, and thereby improve outcomes.
During surgical treatment non-penetrating gunshot wounds it can be limited only to the removal of bone fragments, if necessary, resection of the bone, removal of bone fragments that have shifted into the epidural space, removal of epidural hematomas, followed by the installation of a flushing system and the imposition of a blind suture. The indications for dissection of the DM and revision of the subdural space have already been discussed in previous chapters.
Basic rules of surgical treatment of gunshot wounds of the skull and brain.
1. In the absence of contraindications, the treatment of a gunshot wound should be carried out in the first 24 hours after the injury.
2. If transportation is necessary, use modern, fully equipped vehicles: helicopters, airplanes, reanimobiles.
3. Early intensive care complex at the stage of "ambulance" in order to stabilize vital functions and prepare for surgery: analgesics, intubation, cardiotonic, etc.
4. Prevention of infectious complications by early administration of antibiotics at the prehospital stage.
5. Application of a full range of diagnostics and stabilization of vital functions in the preoperative period.
6. Treatment of wounds should be performed only by a neurosurgeon and preferably in specialized institutions.
7. General anesthesia.
8. PHO should be as radical as possible.
9. A blind suture can be applied to the wound only after a radical surgical treatment in the first 24 hours in a specialized hospital.
10. Use of tidal systems.
Management of the wounded in the postoperative period
Victims with gunshot wounds require careful constant care and qualified treatment.
The patient should be laid with the head end of the bed raised so that the site of the skull injury where the operation was performed is not pressed against the pillow. An elevated position of the head by 15-30° reduces intracranial pressure by improving venous outflow.
Food should be high in calories and well digestible.
In order to avoid vomiting, it is recommended to feed the wounded 5 to 6 times a day in small portions. In case of violation of swallowing, nutrition is carried out through a probe. In those wounded in the skull and brain, the functions of urination and defecation are often impaired, which requires the necessary medical and hygienic measures.
Patients after treatment of a wound of the head and brain are drowsy, lethargic, do not ask to drink and eat, may long time to be motionless. Attentive care for them, careful feeding, monitoring the cleanliness of the bed are necessary condition in the treatment of neurosurgical wounded, contribute to the prevention of bedsores.
The principles of pathogenetic therapy in such patients after surgery are outlined in Chapter IX.
Particular attention should be paid to the management of the postoperative wound. The wound is examined the next day after the operation, the accumulated blood is removed, the drainage tubes are tightened. An infected wound is inspected every day. Often, gunshot wounds heal by secondary intention: they gape due to a significant tissue defect and the presence of necrosis with the formation of granulations, which may be accompanied by pus. With a decrease in the body's resistance, microbial contamination leads to the development of infectious complications.
After treatment of damage to only the soft tissues of the skull, it is recommended to remove the sutures on the 7th - 8th day. If the wound is penetrating, with a tendency to the formation of protrusion of the brain or postoperative liquorrhea, the sutures are removed on the 9th - 10th day. With "open management" of the wound, the frequency of its examination depends on the severity infectious processes. So, when applying an ointment dressing-tampon (such as a Mikulich bandage) and a smooth course, dressing and examination of the wound are performed no more than once a week. At infected wound with a fetid odor and purulent discharge, loose dressings moistened with hypertonic saline sodium chloride. Such dressings have to be changed daily, or even 3-4 times a day. It is advisable to use sorbents, hygroscopic gauze. Quartz irradiation of the wound, recommended 7-10 days after the wound, contributes to the rapid rejection of necrotic areas and the appearance of granulations. In the presence of liquorrhea, a dressing is shown without changing it for 10-12 days. Lumbar punctures or lumbar drainage are performed.
Particular attention should be paid to the management of the wounded with secondary brain prolapse, which develops under the influence of traumatic cerebral edema or as a result of infectious complications. During dressings, the protrusion of the brain is carefully washed with a 3% hydrogen peroxide solution or a weak antiseptic solution.
It is unacceptable to cut off the protrusion in order to avoid generalization of the encephalitic process into the depths of the brain or perforation of the brain stomach with the development of porencephaly. Depending on the state of protrusion of the brain, the type of dressing is also chosen. With "benign prolapse" (according to the terminology of N. N. Burdenko), when the protruding substance of the brain has no visible damage or is covered with granulations, the use of emulsions and ointments containing antibiotics or antiseptics is recommended.
With "malignant prolapse" of the brain, which has the appearance of a decaying and necrotic medulla, wet-drying dressings moistened with a hypertonic solution of sodium chloride are shown. If “benign” protrusions are recommended to be bandaged once every 5-6 days, then decaying (purulent-necrotic, hemorrhagic) ones need daily dressings.
The use of ultraviolet irradiation contributes to the rejection of purulent-necrotic masses and the appearance of granulations. After applying a bandage, the protrusion of the brain must be protected with a cotton-gauze "donut" fixed over the bandage. This is especially important in the restless behavior of those wounded in the head.
In the treatment of those wounded in the head, the issue of continuity is very important. What should be the minimum length of stay of the wounded in the hospital where the operation was performed? The transfer of such a patient to the next stage of medical care can be carried out only after the formation of adhesions in the area of the membranes in the craniocerebral wound and the development of a protective biological shaft in the medulla. This significantly reduces or eliminates the risk of generalization of wound infection during the evacuation of the wounded.
With non-penetrating wounds of the skull, transportation in most cases is possible after 1.5 - 2 weeks. The period of mandatory hospitalization for penetrating craniocerebral injuries is 3 weeks if the postoperative course is smooth. With the development of brain protrusion, meningoencephalitis, brain abscess, pneumonia and other complications, the hospitalization period should be increased.
The most typical errors in surgical care for those wounded in the head are:
1. Carrying out non-radical surgical treatment of a gunshot wound, leaving non-viable tissues, grains of foreign bodies, bone fragments, hematomas and poor-quality hemostasis.
2. Treatment of penetrating craniocerebral wounds not in specialized institutions by general surgeons.
3. Excision of damaged skin in the form of "pyataks" with multiple superficial wounds with small fragments.
4. Unreasonable expansion of indications for emergency surgical interventions at the stage of qualified medical care for those wounded in the head, surgical intervention for the wounded in a state of shock with violations of vital functions without appropriate anti-shock infusion-transfusion and intensive therapy.
All this leads to an increase in the number of adverse outcomes in the treatment of head wounds.
Compliance with the basic rules of surgery and pathogenetic treatment of victims with gunshot wounds to the head, outlined in this chapter, will improve the quality of medical care and increase the survival rate.
Combat injuries of the skull and brain are gunshot injuries(bullet, shrapnel wounds, MVR, blast injuries), non-gunshot injuries(open and closed mechanical injuries, non-gunshot wounds) and their various combinations.
The operation of craniotomy was known back in Ancient Egypt. Surgical treatment of craniocerebral wounds was performed by many famous surgeons of the past: J.L. Petit, D.J. Larrey, H.W. Cushing and others. Nevertheless, military neurosurgery as a branch of military field surgery was formed only during the years of the Great Patriotic War when the system of specialized medical (including neurosurgical) care was first born and field surgical hospitals were created for the wounded in the head, neck and spine ( N.N. Burdenko, A.L. Polenov, I.S. Babchin, V.N. Shamov). Experience in the treatment of combat injuries of the skull and brain in local wars and armed conflicts of recent decades has made it possible to supplement modern military neurosurgery with a number of new provisions and to formulate the concept of early specialized neurosurgical care ( B.A. Samotokin, V.A. Khilko, B.V. Gaidar, V.E. Parfenov).
14.1 GUN SHOT INJURIES TO THE SKULL AND BRAIN
14.1.1. Terminology, classification
According to the period of the Great Patriotic War, gunshot injuries of the skull and brain accounted for 6-7% of all gunshot injuries, in the armed conflicts of recent decades in the North Caucasus, their frequency has increased to 20%.
There are isolated, multiple and combined injuries (wounds) of the skull and brain. isolated is called an injury (wound), in which there is one damage. Simultaneous damage to the skull and brain by one or more MS
called in several places multiple trauma (wound) of the skull and brain . Simultaneous damage to the skull and brain, as well as the organ of vision, ENT organs or MFR is called multiple trauma (wound) of the head . Simultaneous damage to the skull and brain with other anatomical areas of the body (neck, chest, abdomen, pelvis, spine, limbs) is called combined traumatic brain injury (wound) .
The classification of gunshot wounds of the skull and brain is based on their division into 3 large groups, proposed by N.N. Petrov in 1917: soft tissue injuries, components 50%; non-penetrating wounds of the skull, constituting 20%; penetrating wounds of the skull and brain, accounting for 30% of all gunshot wounds of the skull and brain.
Soft tissue injuries of the skull characterized by damage to the skin, aponeurosis, muscles or periosteum. With gunshot wounds of soft tissues, there are no fractures of the skull bones, but the brain can be damaged in the form of concussion, bruising, and even compression (hematoma) due to the energy of the lateral impact of the RS.
Non-penetrating wounds of the skull characterized by damage to soft tissues and bones while maintaining the integrity of the dura mater. This type of damage is always accompanied by brain contusion, subarachnoid hemorrhage, rarely - compression of the brain (bone fragments, epi- or subdural hematoma). Despite skull fractures and microbial contamination of the wound, the dura mater in most cases prevents the spread of infection to the brain tissue(Fig. 14.1).
Penetrating wounds of the skull and brain are characterized by damage to the integument, bone, membranes and substance of the brain, are distinguished by the severity of the course and high mortality (up to 53%, according to the period of the Great Patriotic War, 30% - in local wars). The severity of penetrating injuries is determined by the structures through which the MS passes (cortex, subcortex, ventricles of the brain, basal ganglia or brain stem) and the degree of their damage (Fig. 14.2).
The injuries of the stem and deep parts of the brain are especially severe. With penetrating wounds, severe AI most often develops - meningitis, meningoencephalitis and brain abscess, the frequency of which reached 70% during the Great Patriotic War and 30% in modern wars.
However, these data are not enough to make a complete diagnosis of a craniocerebral injury. For this purpose, it is applied nosological classification of gunshot wounds of the skull and brain(Table 14.1).
Rice. 14.1. Non-penetrating wound of the skull with bone fracture
Rice. 14.2. Tangential penetrating wound of the skull and brain
Table 14.1. Classification of gunshot wounds of the skull and brain
Gunshot wounds of the skull and brain are divided according to a number of features. According to etiology, they are bullet, shrapnel wounds and MVR - they differ in the volume and nature of the damage, because bullets have greater kinetic energy than fragments, and MVRs are distinguished by combined and combined damage patterns.
Penetrating wounds of the skull can be through and blind , and according to the location of the wound channel they are divided into tangent, segmental and diametrical (O.M. Kholbek, 1911).
The injury is called tangent(tangential), when a bullet or a fragment passes superficially and damages the bone, dura mater and superficial parts of the brain (Fig. 14.2). It should be noted that in case of tangential wounds, despite the superficial location of the wound channel and the insignificant extent of destruction of the medulla formed during MS, morphological and functional disorders often spread to neighboring areas of the brain. This is due to the fact that the substance of the brain is a medium containing a large amount of fluid and located in a closed space, limited by dense shells and bones of the skull.
The wounds are called segmental when MS passes through the cranial cavity along one of the chord within one or two lobes of the brain, and the wound channel is located at some depth from the surface of the brain; at the same time, it has a rather significant length (Fig. 14.3).
Rice. 14.3. Segmental penetrating wound of the skull and brain
With all segmental wounds, small fragments of bone, hair, and sometimes fragments of a headgear are brought into the depth of the wound channel. Destruction of the medulla, as with any gunshot wound, are not limited to the zone of passage of the projectile, but spread to the sides and are expressed in the formation of hemorrhages and foci of bruising of the brain tissue at a considerable distance from the wound channel.
At diametrical In wounds, the wound channel lies deeper than with segmental ones, passing along the large chord (diameter) of the circumference of the skull (Fig. 14.4).
Diametral wounds are the most severe, because. the wound channel in these cases passes at a great depth, damaging the ventricular system, the brain stem and other deep-lying vital important formations. Therefore, diametrical wounds accompanied by high mortality, and deaths occur in the early stages as a result of direct damage to the vital centers of the brain.
A variety of diametrical wounds are diagonal, in which the wound channel also runs along the diameter of the skull, but in a different plane, located closer to the sagittal one. With these injuries, the inlet of the wound channel is usually located in facial areas, jaws, neck, and the output - on the convexital (convex) surface of the skull. This location of the wound channel is accompanied by primary damage to the brain stem and defines these injuries as deadly.
Rice. 14.4. Diametric penetrating wound of the skull and brain
Blind skull wounds have one inlet and a wound channel of various lengths, at the end of which lies a bullet or fragment. By analogy with penetrating wounds, blind wounds are divided into simple, radial, segmental and diametric (Fig. 14.5).
The severity of the blind wound is determined depth of the wound channel and its dimensions. Among the most severe are blind wounds passing through the base of the brain.
Among the penetrating gunshot wounds of the skull, the so-called ricocheting injuries (according to R. Payr, 1916), characterized in that in the presence of one wound hole (inlet), only bone fragments of the skull are found in the depth of the wound channel, and the RS is absent - it, having hit a convex
Rice. 14.5. Scheme of blind penetrating wounds of the skull and brain: 1 - simple; 2 - radial; 3 - segmental; 4 - diametrical
the surface of the skull, inflicts damage and abruptly changes the flight path (ricochets), moving away from the skull ( external ricochet). At internal ricochet RS changes its trajectory upon contact with the concave surface of the skull on the opposite side of the inlet of the wound channel.
Since the determination of the severity of brain damage and the diagnosis of life-threatening consequences of gunshot injuries of the skull and brain is based on the identification of a number of clinical symptoms and syndromes, they are presented separately in section 14.1.3.
14.1.2. Clinic and diagnosis of gunshot wounds of the skull and brain
In field conditions, at the advanced stages of medical evacuation (MPP, medr, omedb), the possibilities and time for a full-fledged neurological examination of a wounded person with a gunshot injury of the skull and brain are extremely limited. The sorting of the wounded and the diagnosis is carried out by military doctors and general surgeons. Therefore, their tasks are 1) identification of the life-threatening consequences of injury for the timely provision of emergency medical care and 2) formulation of the diagnosis of injury according to the algorithm proposed in the textbook to make the correct sorting decision.
At the advanced stages of medical evacuation, the diagnosis of gunshot trauma to the skull and brain is based on the identification of common and local symptoms gunshot injury, symptoms of acute impairment of vital functions, cerebral and focal symptoms of brain damage.
The examination of any casualty at the marshalling yard begins with an assessment of the severity of his condition and the active detection of an acute impairment of vital functions. Symptoms that are not related to brain damage are referred to in this chapter as common symptoms. Identifying and assessing them is important because 60% of injuries to the skull and brain are combined with injuries to other areas of the body: neck, chest, abdomen, pelvis, spine, or extremities. Damage to the skull and brain is not always the leading one, and in some cases a severe craniocerebral injury is combined with severe damage to another area: often the limbs, less often the chest, abdomen, and pelvis. Therefore, when sorting the wounded, it is important not to randomly identify general symptoms, but targeted identification of the four major syndromes .
It manifests itself cyanosis of the skin and lips, restless behavior of the wounded, frequent and noisy breathing . The main reasons for the development of this syndrome are asphyxia or severe chest injuries with ARF.
It manifests itself pallor of the skin and lips, lethargy of the wounded, frequent and weak pulse, low SBP - less than 100 mm Hg. The main reason for the development of this syndrome is acute blood loss. Most often it is caused by severe concomitant injuries of the abdomen, chest or pelvis, less often - limbs.
Traumatic Coma Syndrome. It manifests itself lack of consciousness, speech contact, limb movements, motor response to pain. With a deep coma, respiratory and circulatory disorders of central origin are possible (with the exclusion of damage to the chest and sources of bleeding). The cause of this syndrome is severe brain damage.
terminal state syndrome. It manifests itself gray (earthy) color of the skin and lips, severe lethargy of the wounded up to stupor, frequent (heart rate more than 140 per minute) and weak pulse only on the carotid arteries, blood pressure is not determined, breathing is rare, fading. The causes of the terminal state can be: an extremely severe injury of any localization, but most often a severe MVR, severe injuries to several areas of the body, severe injuries to the abdomen or pelvis with acute massive blood loss, gunshot wounds to the skull with extremely severe brain damage.
After evaluating general symptoms examination of wounds and other injuries- there may be several on the head and in other areas of the body. When examining a craniocerebral wound, its localization, depth, area, nature of damaged tissues are determined, that is, local symptoms. At the same time, superficial gunshot wounds are easily detected, with bleeding, its sources are specified. Important information can be obtained when, when examining a wound, bone fragments of the skull, the outflow of cerebrospinal fluid or destroyed brain matter (cerebral detritus) are visible - they indicate the penetrating nature of the injury (Fig. 14.6).
Deep wounds of the skull in a serious condition of the wounded should not be specially examined, because the harm from this can be greater than the benefit, when, for example, bleeding or liquorrhea resumes when a blood clot is accidentally removed.
Rice. 14.6. Outflow of cerebral detritus from a wound with a blind penetrating wound of the skull in the left temporal region
In general, of the local symptoms for making a sorting decision, the following are of the greatest importance: external bleeding and the outflow of cerebrospinal fluid or cerebral detritus from the wound, the rest, if possible, clarify the diagnosis. That's why important rule staged treatment of the wounded in the head is the following: at the advanced stages of medical evacuation, the bandage previously applied to the head wound, which lies well on it, is not removed for the diagnosis of the wound. It is removed only in case of heavy contamination with earth, RV or HVTS. With intensive wetting of the bandage with blood: on the MPP (medr) - it is bandaged, in the omedb - it is removed in the operating room, where the wounded is delivered to stop external bleeding.
The basis for the diagnosis and prognosis of gunshot TBI is the determination of the severity of brain damage and its life-threatening consequences.
Diagnosis of the severity of brain damage is based on the active detection of cerebral and focal symptoms, and symptoms of impaired vital functions.
Cerebral symptoms V most characterize the severity of brain damage and are available for determination
in the advanced stages of medical evacuation. Minimal brain damage is indicated loss of consciousness at the time of injury and amnesia events before or after the injury. Less informative symptoms of brain damage are headache, dizziness, tinnitus, nausea, vomiting, lethargy or motor agitation.
The most informative symptom of brain damage is impaired consciousness. . At the same time, the more pronounced the degree of impairment of consciousness, the more severe the damage to the brain. Therefore, it is necessary to know well the degree of impairment of consciousness in order to make a diagnosis of gunshot TBI and make a triage decision. There are many subjective and objective methods and scales of impaired consciousness (the Glasgow coma scale, the Shakhnovich scale, etc.), but for the advanced stages of medical evacuation, the domestic descriptive technique with the allocation of six degrees of impaired consciousness is by far the most convenient.
1. Moderate stun- wounded in consciousness, answers questions, but is inhibited or excited, disoriented in space and time.
2. Stun Deep- wounded in a state of sleep, but with strong impact at him (shout, slaps on the cheeks) answers questions in monosyllables and languidly.
3. Sopor- consciousness is absent, speech contact is impossible, tendon reflexes, motor protective reactions to pain, eye opening are preserved.
4. Coma moderate- consciousness is absent, speech contact is absent, tendon reflexes and motor protective reactions to pain are absent; spontaneous breathing, swallowing, pupillary and corneal reflexes were preserved.
5. Coma deep- consciousness is absent, speech contact is absent, tendon reflexes and motor protective reactions to pain are absent; pupillary and corneal reflexes are absent, swallowing is impaired; relatively stable hemodynamics, spontaneous breathing is inefficient, but rhythmic.
6. Coma beyond- to symptoms deep coma added: instability of hemodynamics of central origin [decrease in SBP less than 90 mm Hg, tachycardia (HR more than 140 per minute), less often bradycardia (HR less than 60 per minute)] and pathological respiratory rhythms, bilateral mydriasis.
Focal symptoms to a lesser extent characterize the severity of brain damage. However, they have great importance in the diagnosis of brain compression - a life-threatening consequence of a craniocerebral injury - and in determining the localization of the injury. At the stages of providing first medical and qualified medical care, it is possible to determine only bright focal symptoms.
Anisocoria- often a manifestation of a volumetric process in the cranial cavity (intracranial hematoma, hydroma, local cerebral edema in the region of the brain wound) on the side of the dilated pupil.
Fixation of the eyeballs and head to the side(to the right or to the left) often indicates a volumetric process in the cranial cavity on the side of fixation (“the fixed gaze of the patient shows the surgeon which side to do the trepanation”).
crooked mouth; a cheek that takes the form of a “sail” when breathing; smoothness of the nasolabial fold, non-closure of the eyelid are signs of damage. facial nerve Is that on this side.
Localized leg cramps it is often a manifestation of a volumetric process in the cranial cavity on the opposite side.
Paralysis of the limbs it indicates damage to the motor areas of the brain or a volumetric process in the cranial cavity on the opposite side.
Symptoms such as speech, hearing and vision disorders- especially in one ear, eye.
Symptoms of acute impairment of vital functions indicate either an extremely severe brain injury, or the development of cerebral edema and its infringement in the opening of the cerebellar plaque or in the large occipital foramen of the base of the skull (dislocation). Violation of vital functions occurs as a result of primary or secondary (due to infringement) damage to the brain stem, in which the nuclei of the vasomotor and respiratory centers are located. They are manifested by severe hemodynamic disorders: persistent arterial hypertension(SBP over 150 mm Hg) , or arterial hypotension(SBP less than 90 mm Hg), tachycardia(heart rate over 140 per minute) or bradycardia(HR less than 60 in 1 min). Most characteristic manifestation violations of vital functions is violation of the rhythm of breathing requiring the use of ventilators.
14.1.3. Determination of the severity of brain damage, diagnosis of life-threatening consequences of gunshot injuries of the skull and brain
At the stages of providing first medical and qualified medical care, the diagnosis of the severity of brain damage is carried out by military doctors and general surgeons, so it should be based on simple and accessible symptoms.
From these positions, three degrees of severity of brain damage are distinguished: mild, heavy and extremely heavy. It should be clearly understood that such a division of gunshot injuries of the skull and brain is used only at the advanced stages of medical evacuation (MPp, medr, omedb), where the sorting of the wounded is carried out without removing bandages, without undressing and, of course, without a full neurological examination. The main task of sorting the wounded at these stages of evacuation is not making an accurate diagnosis, but isolating 4 triage groups:
those who need to eliminate the life-threatening consequences of injury, that is, in emergency measures;
to be evacuated in the 1st stage;
to be evacuated in the 2nd stage;
agonizing.
The formulation of the final diagnosis and assessment of the severity of a craniocerebral injury is carried out only in a specialized neurosurgical hospital. Therefore, the criteria for assessing the severity of brain damage at the advanced stages of medical evacuation are the stability of the condition of the wounded and the absence of violations of vital functions for the triage period, and not the neurological deficit that will remain in the wounded after the final cure.
Minor brain damage. In pathogenetic and morphological terms, mild injuries are characterized by damage to only superficial cortical structures on the convexital (convex) surface of the brain. Subcortical formations and the trunk are intact. Non-severe brain injuries often occur when the soft tissues of the skull are injured and with non-penetrating wounds of the skull, rarely with penetrating blind (superficial) and tangential wounds.
The main clinical criterion for non-severe brain damage is the preserved consciousness: clear, moderate stun or deep stun. Focal symptoms with mild brain damage may be absent, and may be presented very clearly, for example, with a penetrating blind wound of the left temporal lobe (speech disorders, etc.), anterior central gyrus (motor disorders). Functional disorders vital important organs can not be. In prognostic terms, this is the most favorable group of the wounded, therefore, with non-penetrating and especially penetrating injuries of the skull, they should be quickly taken to a specialized hospital before the development of life-threatening complications.
Triage conclusion at the advanced stages of medical evacuation - evacuation in the 2nd stage in VPNhG.
Severe brain damage. In pathogenetic and morphological terms, severe injuries are characterized by damage to the cortical structures of the brain on its basal surface and subcortical formations. The brain stem can be involved in the pathological process with edema and dislocation, that is, it can be infringed in the openings of the skull. Severe brain injuries are more common with penetrating blind (deep) and penetrating segmental wounds.
The main criterion for severe brain damage is the lack of consciousness - its disturbance in the form of stupor and moderate coma. Focal symptoms in severe brain damage are mild, because they are masked by the absence of reflex activity and bright cerebral symptoms (extrapyramidal syndrome, diencephalic catabolic syndrome). Usually it is manifested only by pupillary and oculomotor disorders. Violations of vital functions are manifested only in the circulatory system: persistent arterial hypertension (BP over 150 mm Hg), tachycardia (heart rate over 120 per minute). In terms of prognosis, this group is characterized by high (about 50%) mortality, a high incidence of complications and long-term consequences. Most of the wounded with severe brain damage with penetrating wounds of the skull do not return to duty.
Triage conclusion at the advanced stages of medical evacuation - evacuation in the 1st stage in VPNhG.
Extremely severe brain damage. In pathogenetic and morphological terms, extremely severe injuries are characterized by primary damage to the brain stem. As a rule, they occur with penetrating diametrical and diagonal wounds.
The main criteria for extremely severe brain damage are: a pronounced impairment of consciousness in the form of a deep or transcendental coma and a violation of vital functions. Focal symptoms are absent due to deep coma, i.e. total absence reflex activity. Violations of vital functions are manifested by persistent hypotension (systolic blood pressure less than 90 mm Hg), tachycardia (heart rate more than 140 per minute) or bradycardia (heart rate less than 60 per minute) and respiratory rhythm disturbance requiring mechanical ventilation. In prognostic terms, the wounded with extremely severe brain damage are unpromising for survival, mortality approaches 100%. Therefore, starting from the stage of providing qualified medical care, they belong to the sorting category of “agonizing”.
Life-threatening consequences of gunshot trauma to the skull and brain- pathological processes that develop immediately after injury due to damage to vital organs and tissues. A distinctive feature of life-threatening consequences is the failure of the body's defense mechanisms to eliminate them on their own. Therefore, in the absence of emergency medical care, the life-threatening consequences of injuries lead to death. Therefore, at all advanced stages of medical evacuation, urgent medical care is performed not for injuries or injuries, but for their life-threatening consequences. In case of gunshot injuries of the skull and brain, three types of life-threatening consequences can occur: external bleeding, cerebral compression and asphyxia.
external bleeding is a life-threatening consequence of a gunshot injury to the skull and brain in cases where it does not stop on its own or under a conventional aseptic dressing. The frequency of its occurrence, according to recent armed conflicts, is low and amounts to 4%. Sources of severe external bleeding are:
Arterial vessels of the integumentary tissues of the skull and the main one - a. temporalis superficialis with its branches;
Arteries of the dura mater, primarily branches a. menin-gea media; sinuses of the dura mater;
Vessels of the brain located in the brain wound. Brain compression- a pathological process, stretched in dynamics from several hours to several days and often leading to death if it is not eliminated. Most often, compression of the brain in gunshot wounds is due to intracranial hematomas (Fig. 14.7., 14.8.), Less often - local cerebral edema in the wound area or depressed skull fracture (Fig. 14.9.).
With gunshot craniocerebral wounds, compression of the brain is relatively rare - in 3% of cases.
For a long time there were incorrect judgments about the mechanism of development of intracranial hematomas, which was reflected in the treatment tactics. It was believed that an intracranial hematoma is formed by a pumping mechanism, increasing with each portion of blood and squeezing the brain after the volume of the hematoma exceeds the size of the reserve intrathecal spaces: 80 ml for the epidural
Rice. 14.7. Compression of the brain by an epidural hematoma in the right fronto-parietal-temporal region (computed tomogram)
Rice. 14.8. Subdural hematoma in the left temporal region (intraoperative photograph)
Rice. 14.9. Depressed by a fracture of the left parietal region (intraoperative photograph)
and 180 ml for the subdural space. In accordance with this, unreasonable calls for immediate trepanation at any stage of treatment and simplified ideas about the technique for eliminating compression were practiced: craniotomy - removal of a hematoma - ligation of a bleeding vessel - recovery. In practice, such situations turned out to be rare in case of non-gunshot head injury; they never occur with gunshot wounds.
Special studies of employees of the Leningrad Research Institute of Neurosurgery. A.L. Polenov under the direction of Yu.V. Zotov showed that the main volume of intracranial hematoma is formed during the first 3-6 hours, at the same time a blood clot is formed, which subsequently interacts with the damaged area of the brain, causing its local edema, a decrease in the reserve intrathecal space and - brain compression syndrome. The smaller the volume of brain damage and the greater the reserve volume of the hypothecal space (for example, with hematomas resulting from damage to the meningeal vessels by fragments of the skull bones), the slower the compression of the brain is formed: from 1 day to 2 or more weeks. In gunshot wounds, when brain damage is extensive, the main role in the formation of brain compression belongs not so much to the hematoma as to the reactions of the damaged brain.
The classic neurological picture of head compression
Rice. 14.10. Typical hemilateral syndrome with cerebral compression (Yu.V. Zotov, V.V. Shchedrenok)
brain in the form of dilated pupil on the side of compression and central hemiplegia on the opposite side is described in many textbooks - and it should always be remembered when examining a wounded person with a craniocerebral wound (Fig. 14.10).
In the conditions of staged treatment, when sorting the wounded in the head, it is necessary to actively identify all the most informative symptoms of brain compression.
"Lucid interval"- the length of time between loss of consciousness at the time of TBI (injury) and repeated loss of consciousness by the time of examination; during this period of time, the wounded is conscious (usually this is specified by the attendants). This symptom is typical for mild brain damage, against which compression develops. With severe brain damage, consciousness disorders progress, more often from stupor to coma. The diagnostic reliability of this symptom is very high.
Fixation of the head and gaze towards the compression of the brain. A very reliable, but not often occurring symptom of brain compression. It is determined when examining the wounded at the sorting yard, when the doctor sets the head of the wounded to the middle position, and the wounded reflexively turns it with effort to its previous position. Similarly to the position of the head, the eyeballs are also fixed.
Local cramps of the limbs on the side opposite to the compression of the brain, are also easily identified at the sorting yard. It is impossible not to notice them, because they are unstoppable - you have to administer anticonvulsants (which, by the way, is ineffective). The diagnostic value of a symptom increases significantly if the arm or leg of the same name is subject to convulsions (hemilateral convulsive syndrome).
Anisocoria - a symptom that is easily determined by a careful examination of the wounded, but its diagnostic value in relation to compression of the brain and, moreover, the side of the pathological process, is relatively small and amounts to 60%.
Bradycardia - Heart rate below 60 in 1 min. An important symptom indicating the likelihood of brain compression, but its specificity is low - it is also a manifestation of damage to the brain stem and a number of extracranial injuries (heart contusion, contusion of the adrenal glands). Its diagnostic value greatly increases when it is combined with one of the above symptoms. Important
remember that with combined craniocerebral injuries (traumas) accompanied by acute blood loss, for example, with simultaneous injuries of the abdomen or pelvis, a heart rate below 100 in 1 min should be regarded as relative bradycardia.
Hemiplegia, monoplegia, less often - paresis of the limbs on the side opposite to the compression of the brain, are important but non-specific symptoms of cerebral compression as they are often neurological manifestation gunshot wound. On the sorting yard, where special neurological techniques are not used, only gross motor disorders are detected in the form of a lack of limb movements. This increases their diagnostic value, especially in combination with other symptoms.
The diagnostic significance of these symptoms for detecting cerebral compression increases significantly when they are combined: the more symptoms there are, the greater the likelihood of cerebral compression.
Asphyxia- sharp developing disorder breathing (suffocation) as a result of impaired patency of the upper respiratory tract - with gunshot injuries of the skull and brain is rare - up to 1% of cases. More often, asphyxia occurs with multiple head injuries, when skull injuries are combined with injuries to the face and jaws. In these cases, the cause of asphyxia is the flow of blood from the wounds of the MFR into the oropharynx and larynx against the background of a violation of the innervation of the epiglottis or a decrease in the cough reflex. In severe isolated craniocerebral injuries, the aspiration mechanism of asphyxia is realized due to the ingress of vomit into the respiratory tract. With extremely severe injuries of the skull and brain, dislocation asphyxia develops due to retraction of the tongue: as a result of damage to the trunk, the activity of the glossopharyngeal and hypoglossal nerves is disrupted, the tongue loses muscle tone and sinks into the oropharynx, blocking the airways.
All life-threatening consequences of injuries should be actively identified. The wounded with external bleeding and asphyxia should be given emergency care at all stages of medical evacuation, and the wounded with brain compression should be urgently (by helicopter) evacuated to a specialized neurosurgical hospital - only in this hospital they can receive full-fledged emergency care.
Examples of diagnoses of gunshot wounds of the skull:
1. Multiple fragmentation blind wound soft tissues of the right half of the head.
2. Bullet tangential non-penetrating wound of the skull in the left parietotemporal region with mild brain damage, with an incomplete fracture of the right parietal bone.
3. Shrapnel blind penetrating wound of the skull in the right parietal region with severe brain damage, with a perforated fracture of the parietal bone. Traumatic coma(Fig. 14.11 color illustration)).
4. Bullet through segmental penetrating wound of the skull in the left fronto-temporal region with severe brain damage, with multi-comminuted fractures of the frontal and temporal bones. Brain compression. Traumatic coma.
5. Bullet penetrating diametrical bihemispheric penetrating wound of the skull in the temporal regions with extremely severe brain damage, with comminuted fractures of the temporal bones. Continued external bleeding. terminal state.
6. Severe mine-explosive wound. Combined mechanothermic combined trauma of the head, chest, limbs.
Multiple gunshot trauma to the head. Shrapnel blind penetrating left-sided fronto-orbital wound of the skull with severe brain damage, multiple fractures of the walls of the orbit and destruction of the left eyeball.
Closed chest injury with multiple rib fractures on the right and lung injury. Right-sided tension pneumothorax.
Detachment of the left lower leg at the level of the middle third with extensive destruction of soft tissues and skin detachment up to lower third hips. Continued external bleeding.
Flame burn of the lower extremities
Acute massive blood loss. terminal state.
14.2. NON-FIRE SHOT INJURIES OF THE SKULL
AND THE BRAIN
14.2.1. Terminology and classification
According to the etiology, non-gunshot injuries of the skull and brain are divided into mechanical (closed and open) TBI and non-gunshot wounds. In combat conditions, mechanical head injury occurs
quite often, accounting for 10-15% of the entire combat pathology of this localization.
TO closed TBI include such damage to the skull and brain, in which the integrity of the skin as a natural biological barrier is preserved. TBI with skin injury are open ; They may be non-penetrating And penetrating depending on the integrity of the dura mater . Fractures of the base of the skull with external otitis or nasoliquorrhea are considered as open penetrating TBI, since at the base of the skull the dura mater is tightly fused with the bone and is necessarily damaged along with it in fractures.
Non-gunshot wounds of the skull and brain (stab wounds, stab wounds, dowel wounds from a construction pistol, etc.) are rare in combat conditions, do not constitute a big problem and are described in neurotraumatology manuals.
As with gunshot trauma to the skull and brain, in non-gunshot trauma, there are combinations of injuries to various parts of the head and anatomical regions of the body. The combination of brain damage with damage to the eyes, ENT organs, face and jaws refers to multiple head injuries, and the combination of TBI with damage to other areas of the body - to combined TBI.
In 1773 a French surgeon J.L. Petit proposed to distinguish 3 types of TBI: concussion, bruise and compression of the brain. In most textbooks, such a division of TBI with varying degrees of detail for each type has been preserved to this day. One circumstance was incomprehensible: why can compression develop with any type and severity of brain damage? The answer to this question was found by military field surgeons, when in the 1990s. new principles for the classification of combat injuries were formed, an objective assessment of the severity of injuries and a new method for formulating a diagnosis in the system of staged treatment of the wounded were introduced.
From these positions, brain compression does not characterize the type and severity of TBI (injury), but is its life-threatening consequence. Brain compression develops when large vessels, cerebrospinal fluid, large bone fragments of the skull get into the morphological substrate of damage.
Thus, the basis classification of non-gunshot TBI is divided into the following types:
Brain concussion;
mild brain injury;
brain contusion medium degree gravity;
Severe brain injury.
This classification reflects not only the type, but also the severity of TBI, both in terms of clinical and morphological manifestations. At the same time, the deepening of the severity of TBI occurs from the surface of the brain to the depth: from a concussion (functional disorders at the cortical level, clear consciousness) to a severe bruise (damage to the brain stem, deep or transcendental coma).
For the correct formulation of the diagnosis of a non-gunshot injury of the skull and brain, nosological classification(Table 14.2.)
As can be seen from the classification, one of the sections in the formulation of the diagnosis is the state of the subshell spaces. It should be borne in mind that their significance increases in the late periods of traumatic disease, in the process of specialized treatment. They are not detected at the advanced stages of medical evacuation. It is important to know that epidural and subdural hemorrhages are diagnosed only in peacetime by CT or MRI, or by forensic autopsy. They are fundamentally different from epidural and subdural hematomas by their small volume, cloak-like flat character, and, most importantly, by the fact that they do not cause compression of the brain.
Cranial fractures may also not be detected in the advanced stages of medical evacuation - and this is not strictly necessary. Fractures of the bones of the base of the skull are detected by indirect signs. “Symptom of glasses” (periocular hematomas) or nasal liquorrhea (liquor leakage from the nose) indicate fractures of the bones of the base of the skull in the anterior cranial fossa. Symptoms of damage to the facial (twisted mouth, the cheek "sails", the eyelid does not close, tearing or dry eyes) or auditory (unpleasant tinnitus) nerves are signs of a fracture of the pyramid of the temporal bone.
The life-threatening consequences of non-gunshot injuries of the skull and brain are manifested by the same symptoms as with a gunshot injury.
Table 14.2. Classification of non-gunshot injuries of the skull and brain
Examples of non-gunshot TBI diagnoses:
1. Open traumatic brain injury. Brain concussion. A torn-bruised wound of the right parietal-temporal region.
2. Closed craniocerebral injury. Mild brain injury. Subarachnoid hemorrhage.
3. Open penetrating traumatic brain injury. Moderate brain injury. Subarachnoid hemorrhage. Fracture of the left temporal bone with the transition to the base of the skull. Rupture-bruised wound of the left temporal region. Left-sided otohematoliquorrhea.
4. Open traumatic brain injury. Severe brain injury. Subarachnoid hemorrhage. fracture frontal bone on right. A torn-bruised wound of the frontal region on the right. Traumatic coma.
5. Closed craniocerebral injury. Severe brain injury. Subarachnoid hemorrhage. Fracture of the bones of the cranial vault. Compression of the brain by an intracranial hematoma in the left fronto-parietal-temporal region. Traumatic coma.
6. Severe concomitant trauma to the head, abdomen, limbs. Open penetrating traumatic brain injury. Severe brain injury. Intraventricular hemorrhage. Fractures of the bones of the vault and base of the skull.
Closed trauma of the abdomen with damage to internal organs. Continued intra-abdominal bleeding.
Closed multiple injury of the extremities. Closed fracture right femur in the middle third. Closed fracture of both bones of the left leg in the lower third.
Acute massive blood loss. Traumatic coma.
14.2.2. Clinic and diagnosis of non-gunshot traumatic brain injury
In field conditions, the possibilities and time for a full-fledged examination of the wounded with non-gunshot injuries of the skull and brain are extremely limited. That's why remember the main symptoms of TBI and focus on them in the process of medical sorting of the wounded. Usually wounded with non-severe TBI independently move around the divisions of the sorting and evacuation department, complain of headache, tinnitus, disorientation - they need to be laid down, calmed down, examined, performed medical assistance and sent on a stretcher to the evacuation room
tent. Wounded from severe TBI delivered on a stretcher, often unconscious, which creates significant difficulties in diagnosis.
Examination of a casualty with a non-gunshot TBI begins with active detection (see section 14.1.2.) 4 main syndromes of acute impairment of vital functions. Based on their presence and severity, an assessment of the general condition of the wounded is formed. Like gunshot wounds, non-gunshot head injuries in 60% of cases are combined with damage to other areas of the body.
Syndrome of acute respiratory distress indicates asphyxia (often as a result of aspiration of vomit, cerebrospinal fluid, less often - dislocation of the tongue) or severe concomitant damage to the chest.
Syndrome of acute circulatory disorders(in the form of traumatic shock) develops with acute massive blood loss as a result of collateral damage abdomen, pelvis, limbs.
Traumatic Coma Syndrome clearly indicates severe brain damage, and terminal state syndrome- about an extremely severe brain injury or a severe concomitant injury.
With closed non-gunshot TBI local symptoms poorly expressed. More often than others, subcutaneous hematomas of the scalp, periorbital hematomas are detected, less often - liquorrhea from the nose and ears. Since the liquor flowing from the ears and nose is often mixed with blood, they use symptom of "double spot". CSF poured onto a white sheet or towel with blood forms a double-circuit round spot: inside - pink, outside - white, yellow. With open non-gunshot TBI, local symptoms are also localization, nature and depth of the wound of the integumentary tissues of the skull.
Cerebral and focal symptoms brain injuries in non-gunshot head injuries are of primary importance for determining the severity of brain damage, and identification syndrome of acute disorders of vital functions central origin - important predictive value. They allow the triage doctor to make the correct triage decision. The characteristics of these symptoms, methods of detection are similar to those used in the examination of the wounded with gunshot trauma to the skull and brain (see section 14.1.2).
From the nosological classification of non-gunshot TBI, it can be seen that for the diagnosis individual forms TBI (such as brain contusion
mild and moderate severity) of great importance are the condition of the intrathecal cerebrospinal fluid spaces, the presence and nature of fractures of the skull bones. To identify the first, it is necessary to perform a lumbar puncture, which is a general medical manipulation and can easily be performed by a surgeon or an anesthesiologist at the stage of CCP. This determines the CSF pressure (normally it is 80-180 mm of water for the prone position) and the presence of blood in the CSF - subarachnoid hemorrhage. Diagnosis of fractures of the bones of the skull is also possible in the omedb when performing x-rays of the skull in frontal and lateral projections.
At the same time, the determination of the state of the CSF spaces and the X-ray detection of skull fractures are not of fundamental importance for making a sorting decision. In addition, lumbar puncture itself can be accompanied by the development of brain dislocation (wedging of the brain stem into the foramen magnum of the skull): due to the jet exit of the cerebrospinal fluid from the needle, a sharp decrease in the cerebrospinal fluid pressure in the basal cistern, a sudden cessation of breathing occurs on the dressing table and death. You should remember the rule: lumbar puncture is contraindicated at the slightest suspicion of brain compression!
Non-severe TBI. In pathogenetic and morphological terms, they are characterized either only by functional disorders of the central nervous system, or by damage to blood vessels. arachnoid, or foci of hemorrhage, destruction of the cortical structures of the brain. Subcortical formations and the trunk are intact.
The main clinical criterion for non-severe TBI is the preserved consciousness: clear, moderate stunning, deep stunning. From these positions, the group of non-severe TBI includes: brain concussion, bruises of mild and moderate severity.
Brain concussion- the mildest form of TBI, in which morphological changes in the brain and its membranes are absent, and pathogenetic and clinical manifestations are due to functional changes in the central nervous system. The main clinical symptoms are: short-term (several minutes) loss of consciousness at the time of injury and retrograde amnesia. Such wounded usually move independently (clear consciousness), but complain of headache, nausea, dizziness, and sometimes vomiting. They belong to the category of lightly wounded and are evacuated in the 2nd place by any transport to the VPGLR, where there is
a specialized neurological department for the treatment of this category of the wounded.
Mild brain injury- this is also a mild form of TBI, in which, unlike concussion, there are not only functional changes CNS, but morphological in the form of damage to the vessels of the arachnoid. The latter are detected during lumbar puncture as an admixture of blood in the cerebrospinal fluid. - subarachnoid hemorrhage. Basically, the clinical manifestations are the same as with a concussion, but are found: moderate stunning in terms of consciousness, headache and nausea are more pronounced, and vomiting occurs more often. Under staged treatment lumbar puncture for differential diagnosis is not performed, therefore, in practice, these wounded also belong to the lightly wounded and are sent to the VPGLR.
Moderate brain injury eat. This form of brain injury lives up to its name - it occupies an intermediate position between mild and severe forms of TBI. However, since there is no “moderately severe” triage group in military field surgery, wounded with moderate brain contusions are classified as “non-severe TBI” triage group. This is both prognostic and theoretically justified: there are no lethal outcomes, complications are rare, the treatment period does not exceed 60 days, and treatment is usually conservative. At the same time, with this form of TBI, there are often fractures of both the vault and the base of the skull, and the morphological substrate of injury is small foci of contusion (hemorrhage, subpial destruction), located only in the cortical structures of the brain. Therefore, the second (after skull fractures) pathognomonic symptom of brain contusions of moderate severity are focal symptoms brain damage. Most often, in the conditions of staged treatment, oculomotor disorders (paresis of the oculomotor, abducens cranial nerves), innervation disorders (paresis, paralysis) of the facial or auditory nerve, less often there are violations of speech, vision, paresis of the limbs. These wounded are delivered, as a rule, on a stretcher, the state of consciousness is stunning (moderate or deep), vital functions are within normal limits, stable. The wounded with moderate brain bruises are also evacuated in the 2nd place by any transport, but not to the VPGLR, but to the VPNH or VPNhG, since focal symptoms can still be a sign of slowly developing cerebral compression.
Severe TBI. In pathogenetic and morphological terms, they are characterized not only by damage to the cortical structures of the brain, but also to subcortical formations, the upper parts of the brain stem.
The main clinical criterion for severe TBI is the lack of consciousness - there are disturbances of consciousness in the form of stupor and moderate coma.
Since damage to these structures has a characteristic clinical picture, extrapyramidal and diencephalic forms of severe brain contusion are distinguished according to the level of damage.
Extrapyramidal form of severe brain injury. As a result of damage to the subcortical formations in this form of severe contusion, the clinical picture is clearly dominated by hypokinetic rigid or hyperkinetic syndrome. The first syndrome is manifested by waxy rigidity of all muscle groups of the wounded, a mask-like face with no facial expressions, the second, on the contrary, by constant athetoid (worm-like) movements of the limbs (especially the upper ones). Consciousness - stupor, focal symptoms - not expressed (rarely - anisocoria, oculomotor disorders), vital functions are stable. The prognosis for life is favorable (mortality rate is less than 20%), the social prognosis is often favorable.
Diencephalic form of severe brain injury. With this form of severe bruising as a result of damage to the interstitial brain, where the main autonomic centers are located, the clinical picture manifests itself brightly. diencephalic catabolic syndrome. It is characterized : arterial hypertension, tachycardia, muscular hypertension, hyperthermia, tachypnea. Consciousness - moderate coma. The pupils are usually evenly constricted, the eyeballs are fixed in the center. Focal symptoms are practically absent. Vital functions at the level of subcompensation (see Appendix 1, scales "VPH-SP", "VPH-SG"), that is, their stability is relative, sometimes correction is required during evacuation in the form of mechanical ventilation. The prognosis for life is relatively favorable, because. lethality reaches 50%; the social prognosis is often unfavorable, since most of the wounded become disabled after receiving a severe TBI.
The wounded with severe TBI, despite the relative stability of vital functions, do not linger at the stages of providing qualified assistance for intensive corrective therapy. After the normalization of external respiration, either by setting up an air duct, or by intubating the trachea with mechanical ventilation, they are urgently evacuated to the upper respiratory tract in the 1st place.
Extremely severe TBI. In pathogenetic and morphological terms, they are characterized by damage to the brain stem. The main clinical criterion for extremely severe TBI is the lack of consciousness - its disturbance in the form of a deep or transcendental coma. Damage to the brain stem has a characteristic clinical picture in the form of mesencephalo-bulbar syndrome. Therefore, these forms of TBI are called mesencephalo-bulbar form of severe brain contusion. First of all, this form is manifested by severe violations of vital functions: persistent arterial hypotension refractory to infusion therapy, uncontrolled tachycardia (bradycardia) and arrhythmia, pronounced tachy-or bradypnea or abnormal respiratory rhythms requiring IVL. The eyeballs are fixed in the center, the pupils are wide, there is no reaction to light. It should be remembered that in extremely severe TBI
Absolutely unfavorable prognostic signs are bilateral paralytic mydriasis and Magendie's sign. (unequal position of the eyeballs in relation to the horizontal axis: one is higher, the other is lower). Without intensive correction of vital functions death comes within a few hours. Even in the conditions of specialized centers, the mortality rate for this type of TBI approaches 100%. Therefore, the wounded with extremely severe TBI at the advanced stages of medical evacuation are classified as agonizing.
Life-threatening consequences with non-gunshot TBI develop in 5-8% of cases. Relatively rare are external bleeding from the sinuses of the dura mater with multiple open fractures of the bones of the cranial vault - up to 0.5% and asphyxia (aspiration of cerebrospinal fluid, blood, vomit, dislocation of the tongue) - up to 1.5%. In other cases, the life-threatening consequences of TBI are represented by compression of the brain by intracranial (meningeal, intracerebral) hematomas, hydromas, and depressed fractures of the cranial vault. The clinical picture and symptoms of life-threatening consequences in non-gunshot trauma are similar to those in gunshot injuries.
14.3. ASSISTANCE AT MEDICAL EVACUATION STAGES
The main principle of the staged treatment of those wounded in the head is the fastest possible delivery to the VPNkhG, bypassing even the stage of providing qualified surgical care.
First aid. applied to the head wound aseptic dressing. To prevent aspiration of blood and vomit during vomiting and nosebleeds, the upper respiratory tract is cleaned. When the tongue is retracted, the nurse opens the wounded mouth with a mouth expander, the tongue is removed with the help of a tongue holder, the mouth cavity and pharynx are cleaned of vomit with a napkin, and an air duct (TD-10 breathing tube) is introduced. The wounded, who are unconscious, are taken out in a position on their side or on their stomach (a folded overcoat, duffel bag, etc. is placed under the chest).
In case of severe wounds, promedol from a syringe tube is not injected into the head due to the threat of respiratory depression.
First aid carried out by a paramedic, who controls the correctness of the previously carried out activities and corrects their shortcomings. Elimination of asphyxia is carried out in the same ways as in the provision of first aid. If breathing is disturbed, mechanical ventilation is performed using a manual breathing apparatus, oxygen inhalation. If the bandage gets wet with blood, it is bandaged tightly.
First aid. During armed conflict first medical aid is provided as a pre-evacuation preparation for aeromedical evacuation of the wounded with severe and extremely severe injuries - directly to the 1st echelon MVG to provide early specialized surgical care.
IN large scale war wounded in the head after first aid is evacuated to the omedb (omedo).
In medical triage There are 4 groups of the wounded with gunshot or non-gunshot injuries of the skull and brain.
1. Those in need of urgent first aid measures in the dressing room - wounded with ongoing external bleeding from head wounds and wounded with asphyxia.
2. The wounded, who can be given first medical aid at the sorting yard with subsequent evacuation in the 1st turn, - wounded with signs of brain compression and wounded with severe brain damage.
3. The wounded, who can be given first medical aid at the sorting yard with subsequent evacuation in the 2nd stage, - wounded with minor brain damage.
4. agonizing- the wounded with extremely severe brain damage - are sent to a sorting tent in a specially equipped place (is fenced off with sheets from the rest of the wounded). It should be remembered that a group of those agonizing at the stage of rendering first medical aid is singled out only when there is a massive influx of the wounded. Under normal circumstances, any casualty with detectable blood pressure should be evacuated. .
In the dressing room, the unconscious wounded are cleared of the upper respiratory tract. To prevent retraction of the tongue, an air duct is introduced. In case of ineffective spontaneous breathing, the anesthesiologist-resuscitator performs tracheal intubation, mechanical ventilation. If tracheal intubation is not possible, a conicotomy or tracheostomy is performed.
With abundant soaking of the bandage with blood, it is tightly bandaged. Continued bleeding from the soft tissue arteries visible in the wound is stopped by bandaging them or applying a pressure bandage with the introduction of napkins moistened with a 3% hydrogen peroxide solution into the wound.
The rest of the wounded in the head are assisted in the sorting and evacuation department. They are given antibiotics and tetanus toxoid, according to indications they are used cardiovascular agents. Narcotic analgesics are not administered for penetrating craniocerebral injuries, tk. they depress the respiratory center. The overflowing bladder in the wounded with impaired consciousness is emptied by a catheter.
After providing first aid, the wounded are sent to the evacuation room, from where they are evacuated in accordance with the sorting conclusion. One should strive to evacuate the wounded in the head by helicopter immediately to the VPNhG.
Qualified medical care. The basic principle of providing CCP to the wounded with severe wounds and head injuries is do not delay them at this stage of the evacuation .
In progress triage there are 5 groups of wounded with gunshot and non-gunshot injuries of the skull and brain.
1. Those in need of urgent qualified surgical care: wounded with asphyxia are sent to the dressing room for the seriously wounded, where a special dentist's table is set up for them; wounded with heavy external bleeding are sent to the operating room. After rendering assistance - evacuation to VPNhG in the 1st stage.
2. Stretcher wounded with no consciousness, but stable vitals important functions (with severe brain damage, brain compression) - need to be prepared for evacuation in the intensive care unit, less often - evacuation ( only restoration and maintenance of breathing, up to intubation and ventilation ), after which evacuation is carried out to the VPNhG in the 1st stage.
3. Stretcher wounded with preserved consciousness ( with mild brain damage) - are sent to the evacuation tents for evacuation to the VPNhG in the 2nd stage.
4. Walking wounded in the head- are sent to the sorting tent for the lightly wounded, where they are preparing for evacuation to the VPGLR in the 2nd stage.
5. agonizing- wounded with extremely severe brain damage with fading vital functions and signs of a fatal wound (diagonal, diametrical with the expiration of brain detritus) - are sent to the ward symptomatic therapy allocated specifically in the hospital department.
The wounded are sent to the operating room with ongoing external bleeding, which cannot be stopped by tightly bandaging the bandage. Surgical interventions performed for ongoing external bleeding should only include measures to stop bleeding. When hemostasis is achieved, the surgical intervention should be stopped, the wound covered with a bandage, and the wounded person is sent to the VPNkhG, where an exhaustive surgical treatment of the craniocerebral wound will be performed by a specialist.
Surgery for ongoing external bleeding is performed under general anesthesia and can consist of 3 elements: stop bleeding from a soft tissue wound; trepanation
bones in the fracture area (with continued bleeding from under the bone); stop bleeding from the dura mater, sinuses and (or) brain wounds.
The first stage of the operation is the incision of the soft tissue wound. In this case, bleeding from soft tissues is stopped by diathermocoagulation or ligation and stitching of the bleeding vessel. Then the bone wound is examined, and if bleeding continues from under the bone, the bone wound expands with bone forceps-nippers (Fig. 14.12.).
The size of the burr hole can be different, but most often - up to the border of the intact dura mater. Bleeding from the vessels of the dura mater is stopped by diathermocoagulation or stitching.
To stop bleeding from the sinus of the dura mater, the following methods are used. With complete or almost complete breaks, sinus ligation. It can be done
Rice. 14.12. Expansion of the bone wound
be only with a sufficient size of the bone defect by incisions in the dura mater on the sides of the sinus, after which a silk thread is passed around the sinus with a round needle, which is tied (Fig. 14.13, 14.14).
It is impossible to ligate the sinus behind the Roland sulcus, and especially at the confluence of the sinuses, because. this may result in death.
Rice. 14.13. Ligation of the superior sagittal sinus. The needle is brought under the sinus
Rice. 14.14. The needle is passed through the crescent of the brain ( falx cerebri)
The simplest and most commonly used method - sinus tamponade, which can be done with a piece of muscle or gauze turundas (Fig. 14.15).
Sinus wall closure succeeds only with small linear wounds. The imposition of the lateral ligature possible, but only with minor damage. In a very serious condition of the wounded, clamps can be applied to the sinus wound and left for the period of evacuation. At the same time, one should strive to preserve the lumen of the sinus.
If bleeding continues from under the dura mater, it is dissected with thin scissors through the wound. Visible bone fragments are removed from the wound channel with thin tweezers. To stop bleeding from the vessels of the brain, diathermocoagulation, tamponing with turundas with hydrogen peroxide is used. The new method proposed Yu. A. Sh u l e you m, is to stop bleeding from a deep brain wound with a fibrin-thrombin mixture, which is prepared immediately before injection into the wound and fills the wound channel in the form of a cast, stopping bleeding. Human fibrinogen in the amount of 1 g, diluted in 20.0 ml of a 0.9% solution sodium chloride and 200 activity units (EA) thrombin in 5 ml of the same solution through an elastic plastic tube connected to a tee, two syringes are simultaneously injected into the wound, the cavity of which is filled with the resulting mixture (Fig. 14.16).
After the bleeding has stopped, the wound is loosely packed with napkins, not sutured, and the wounded is evacuated to the VPNhG for final surgical treatment.
With asphyxia in the dressing room, the upper respiratory tract is sanitized, removing vomit, mucus and blood clots from them, an air duct is inserted or the trachea is intubated. With simultaneous injury to the maxillofacial area or neck, an atypical or typical tracheostomy may be indicated.
Tracheostomy technique next: the position of the wounded on his back with his head thrown back, a roller is placed under the shoulder blades. Under local anesthesia with a 0.5% solution of novocaine, a longitudinal incision of the skin, subcutaneous tissue and fascia of the neck is made along the midline of the neck from the thyroid cartilage to a point immediately above the notch above the sternum. Leather, subcutaneous tissue and the muscles are bluntly bred with a clamp in the lateral direction. The exposed isthmus of the thyroid gland is retracted upward, if not possible, it is crossed and tied up. Then the pretracheal fascia is opened and the anterior wall of the trachea is exposed. Trachea
Rice. 14.15. Stopping bleeding in wounds of the superior sagittal sinus with tight tamponade
Rice. 14.16. Scheme of filling the wound channel with fibrin-thrombin mixture
Rice. 14.17. Stages of performing a longitudinal tracheostomy: a - incision line; b - muscle breeding; c - capture of the trachea with a single-toothed hook; g - section of the trachea; e - view after insertion of a tracheostomy tube into the trachea
is grasped with a sharp hook, lifted, and then dissected. The trachea is opened with a T-shaped incision: between the 2nd and 3rd rings transversely (cut length up to 1.0 cm), then in the longitudinal direction - through the 3rd and 4th rings up to 1.5-2.0 cm long see After the incision of the trachea is made, a tracheodilator is inserted into it, the hole expands, and then a previously prepared tracheostomy tube is inserted into it (Fig. 14.17).
The wound should be sutured without tension to prevent subcutaneous emphysema. Only skin sutures are used. The tracheostomy cannula is held in place by tying it around the neck with gauze.
With signs of severe acute respiratory failure IVL is performed.
To all the rest wounded in the head medical assistance (binding bandages, injection of non-narcotic analgesics for pain, repeated administration of antibiotics according to indications, etc.) is carried out in the sorting and evacuation department in the scope of first medical aid.
Wounded in the head after preparing for evacuation must be evacuated to GB immediately in the presence of transport, since neurosurgical operations at the stages of providing qualified medical care are not performed. All stretcher wounded are evacuated to VPNhG, walking - to VPGLR.
Specialized surgical care with gunshot and non-gunshot injuries of the skull and brain is based on two basic principles: 1) rendering as soon as possible after injury; 2) full, exhaustive and complete nature of surgical interventions(Fig. 14.18.) .
All stretcher wounded with gunshot and non-gunshot brain injuries receive specialized neurosurgical care at the VPNkhG.
Rice. 14.18. Tidal drainage after PST surgery of a craniocerebral wound
Walking wounded with gunshot and non-gunshot head injuries, who have no focal symptoms of brain damage and the penetrating nature of the injury are excluded, are sent for treatment to the VPGLR, where there is a specialized neurological department for them.
Control questions:
1. Name the signs of a penetrating wound of the skull and brain.
2. What criteria underlie the selection of open craniocerebral injuries and penetrating wounds of the skull? List the possible complications of penetrating head injuries.
3. What is different clinical picture brain injury from a concussion?
4. What is the difference between the clinical picture of moderate brain contusion and light bruise degrees?
5. Name the main clinical difference between severe craniocerebral injuries and non-severe ones.
6. What degrees of impaired consciousness are typical for severe brain contusions and how do they differ?
7. Name the main reasons for the development of cerebral compression.
8. What clinical picture is typical for the development of cerebral compression?
Even with a minor wound. The safest are the wounds on the front of the skull, although they look terrifying. It should be remembered that small wound on the back of the head is much more dangerous than the huge ragged surface in the cheek area.
For head injuries first aid, which can be provided to the victim, is very small, since in such situations qualified medical assistance is needed. That's why main help for a victim with a head wound, in fact, it is his speedy delivery to a medical facility and stopping the bleeding.
First aid algorithms for head injuries differ in two factors - the presence or absence of a foreign object in the wound. Let's consider both algorithms separately.
First aid algorithm for a victim with a foreign object in a head wound
1. Estimate the likely speed of the ambulance's arrival. If the ambulance can arrive within half an hour, then you should call it immediately and then begin first aid to the victim. If the ambulance does not arrive within 20-30 minutes, then you should start providing first aid, after which you should organize the delivery of the victim to the hospital on your own (by your own car, by passing transport, calling friends, acquaintances, etc.);
2.
3.
If a person is unconscious, his head should be thrown back and turned to one side, since it is in this position that air can freely pass into the lungs, and the vomit will be removed outside without threatening to clog the airways;
4.
If any foreign object sticks out of the head (knife, rebar, chisel, nail, ax, sickle, shell fragment, mines, etc.), do not touch or move it. Do not try to pull the object out of the wound, as any movement can increase the amount of damaged tissue, worsen the condition of the person and increase the risk of death;
5.
First of all, inspect the head for bleeding. If there is, it should be stopped. To do this, it is necessary to apply a pressure bandage as follows: put a piece of clean tissue or gauze folded in 8-10 layers on the bleeding site. On top of the gauze or cloth, put some hard object that will put pressure on the vessel, stopping the bleeding. Any small, solid object with a flat surface can be used, such as a jewelry box, TV remote control, a bar of soap, a comb, etc. The object is tied to the head with a tight bandage from any available material - a bandage, gauze, a piece of cloth, torn clothes, etc .;
6.
If it is impossible to apply a pressure bandage, then you should try to stop the bleeding by pressing the vessels with your fingers to the bones of the skull near the site of the injury. In this case, the finger should be held on the vessel until the blood stops oozing from the wound;
7.
An object sticking out in the wound should simply be fixed so that it does not move or move during the transportation of the victim. To do this, a long ribbon (at least 2 meters) is made from any dressing material at hand (gauze, bandages, fabric, pieces of clothing, etc.), tying several short pieces into one. The tape is thrown over the object exactly in the middle so that two long ends are formed. Then these ends are tightly wrapped around a protruding object and tied into a tight knot;
8.
After fixing the foreign object in the wound and stopping the bleeding, if any, you should apply cold as close as possible to it, for example, an ice pack or a heating pad with water;
9.
The victim is wrapped in blankets and transported in a horizontal position with a raised foot end.
First aid algorithm for head injuries without a foreign object in the wound
1.
Estimate the likely speed of the ambulance's arrival. If the ambulance can arrive within half an hour, then you should call it immediately and then begin first aid to the victim. If the ambulance does not arrive within 20-30 minutes, then you should start providing first aid, after which you should organize the delivery of the victim to the hospital on your own (by your own car, by passing transport, calling friends, acquaintances, etc.); 2.
Lay the person in a horizontal position on a flat surface, such as the floor, earth, bench, table, etc. Place a roller of any material under your feet so that the lower part of the body is raised by 30 - 40 o;
3.
If a person is unconscious, his head should be thrown back and turned to one side, since it is in this position that air can freely pass into the lungs, and the vomit will be removed outside without threatening to clog the airways;
4.
If there is an open wound on the head, do not try to wash it, feel it, or fill the fallen tissue back into the cranial cavity. If there is an open wound, you should simply put a clean napkin on top of it and wrap it loosely around your head. All other dressings should be applied without affecting this area;
5.
Then inspect the surface of the head for bleeding. If there is bleeding, then it must be stopped by applying a pressure bandage. To do this, directly on the place from which blood flows, it is necessary to put a piece of clean cloth or gauze folded in 8-10 layers. On top of the gauze or cloth, put some hard object that will put pressure on the vessel, stopping the bleeding. Any small, solid object with a flat surface can be used, such as a jewelry box, TV remote control, a bar of soap, a comb, etc. The object is tied to the head with a tight bandage from any available material - a bandage, gauze, a piece of cloth, torn clothes, etc .;
6.
If a pressure bandage cannot be applied, then the head is simply wrapped tightly with any dressing material (bandages, gauze, pieces of cloth or clothing), covering the place from which blood oozes;
7.
If there are no materials for applying a bandage, then bleeding should be stopped by firmly pressing the damaged vessel with your fingers to the bones of the skull. The vessel should be pressed against the bones of the skull 2-3 cm above the wound. Hold the vessel clamped until the blood stops oozing from the wound;
8.
After stopping the bleeding and isolating the open wound with a napkin, it is necessary to give the victim a supine position with raised legs and wrap him in blankets. Then you have to wait ambulance"or independently transport a person to the hospital. Transportation is carried out in the same position - lying with legs raised.
Gunshot wounds of the skull are severe, especially if there is also a brain wound at the same time.
In peacetime, these wounds are quite rare, and bullet wounds to the head predominate. The bullet in the vast majority of cases gives through or tangential wounds. Blind bullet wounds are rare. Most blind wounds are caused by shrapnel and can occur during various blasting operations. When injured, fragments carry with them particles of a headdress, hair, etc. to the brain. Foreign bodies carried away by fragments serve as a source of infections.
In the first hours after injury, traumatic edema develops in the brain. The amount of cerebrospinal fluid in the ventricles and subarachnoid space increases, thereby increasing intracranial pressure, which contributes to the protrusion of the brain from the wound. In the future, traumatic edema disappears and is replaced by edema from inflammation. Brain prolapse after injury can also occur due to purely mechanical reasons.
In the fallen part of the brain, blood circulation is disturbed, which leads first to edema, and later to its necrosis.
All gunshot wounds of the skull and brain are divided into non-penetrating and penetrating. TO non-penetrating wounds include injuries to the brain tissues and bones of the skull without damage to the dura mater. Gunshot wounds are also divided depending on the angle at which bullets or shell fragments strike the surface of the head. Distinguish: 1) tangent, 2) diametrical (longitudinal), diagonal (transverse), 3) segmental and 4) blind wounds.
According to the shape of the wound, or rather, the defect, tangential wounds are called striated.
Tangential (tangential) include such wounds in which the injuring projectile passes tangentially to the surface of the skull. With tangential wounds, either only soft tissues can be damaged, or bone can also be damaged.
Damage to the bone can be different - from scratches, shallow furrows to fractures with the formation of cracks and fragments in the bone. Due to ruptures of the spongy substance of the cranial bones, hemorrhages are observed. Ruptures of the vessels of the dura and pia mater above the dura and under the dura cause the formation of hematomas (suprathecal and intrathecal). They lead to brain damage.
With diametrical wounds, the wound channel passes along one of the diameters of the skull. These wounds are characterized by the presence of an inlet and outlet (smaller inlet and larger outlet). Wounds at close range are characterized by tremendous destruction of the skull and brain, since a bullet at close range, as mentioned, has a bursting effect. Segmental wounds (or segmental) occupy a middle position between tangential and diametrical. The bullet channel with these wounds runs along the chord of the circle. A characteristic feature of these wounds is the presence of a crack running from the inlet to the outlet. In the brain, the same damage is observed as with tangential and diametrical wounds.
Blind wounds occur as a result of being wounded by fragments of various sizes, etc. Blind wounds can also be caused by bullets at the end. Non-penetrating blind wounds are caused by bullets and shrapnel with low force. With these injuries, fractures with depression are observed.
Symptoms. The symptoms of gunshot wounds to the brain are diverse and vary depending on the location, extent and severity of the injury and circulatory disorders. In mild cases, phenomena of concussion and brain contusion are observed. In cases of moderate severity, the symptoms of bruising and concussion are more intense and may be accompanied by phenomena of brain compression by bone fragments, bullets, or hemorrhage. Compression of the brain, depending on the zone, is accompanied by focal symptoms (excitation, nystagmus, contractures, paralysis). Immediately after the injury, dumbness, deafness can be observed; in severe cases, the symptoms are expressed in the appearance of hemiplegia. All seriously wounded in the skull clearly expressed shock. The temperature often rises to 40°. In very severe cases, the wounded fall into a coma. Breathing is hardly noticeable, the pulse is weak, the skin is cold; the wounded involuntarily excretes urine and feces. Death comes very quickly.
Of the individual symptoms, attention is drawn to themselves:
1) loss of consciousness; prolonged loss of consciousness occurs in most severe penetrating wounds;
2) strong excitement or numbness, which can turn into a collapse;
3) vomiting, which is observed more often with injuries near the fourth ventricle and the medulla oblongata;
4) changes in heart rate; frequent and small pulse in the first time after injury (up to 130 beats per minute) indicates shock; more rapid pulse in the future it happens with a developing infection; tense rare pulse is observed with increased cranial pressure or irritation of the vagus nerve, acceleration of the pulse - with increased pressure due to cerebral edema or hemorrhage:
5) rapid breathing in shock; with loss of consciousness, it is irregular and often bubbling; in severe cases, Cheyne-Stokes respiration is observed;
6) the temperature is initially elevated; an increase in temperature further indicates an infection; it can be observed after dressings, unnecessary movements, etc.;
7) congestive nipples are noted from the side of the eyes; dilated and uneven nipples indicate an increase in intracranial pressure;
8) immediately after the injury, dumbness and deafness can be observed;
9) focal symptoms: irritation, paresis and paralysis with injuries, compression and contusions of the brain.
Treatment . Surgical care should be provided to the wounded in the skull in a timely manner and as soon as possible, which is very important to prevent infections. Should be considered general state the wounded, the state of the wound and nervous phenomena. The wounded are subjected to surgical intervention in the first hours after the injury. If it is impossible to perform the operation during the first hours, the primary wound treatment can be performed after 24-48 hours or even longer (delayed primary treatment). The lengthening of the wound treatment period became possible due to the use of sulfanilamide preparations (into the wound and inside) and especially penicillin (powdering the wound, infiltration of the skin edges, wound irrigation and intramuscular injection). Currently, the use of penicillin together with streptomycin is recommended.
The operation consists in excising the edges of the wound, biting the edges of the bone defect, removing fragments and foreign bodies, blood clots, destroyed brain matter, and stopping bleeding. The soft integument wound is not sutured, the brain wound is not plugged. A bandage is applied to the wound with sterile petroleum jelly, some non-irritating antiseptic solution and sprinkled with penicillin powder.
Thank you
A gunshot wound is a wound received as a result of fragments of shells, bullets or shots entering the human body. Therefore, if a person was injured by any factor related to a firearm, then such an injury should be regarded as a firearm and first aid provide accordingly. First aid to a victim with a gunshot wound is provided according to the same rules, regardless of what kind of damaging factor was the wound (a bullet, shrapnel or shot). In addition, the rules for rendering assistance are the same for gunshot wounds to various parts of the body.
Rules for calling an ambulance in case of a gunshot wound
The first step in providing first aid to a victim of a gunshot wound is to assess the situation and examine him for any external bleeding. If a person has visible heavy bleeding, where blood flows from wounds jet, then, first of all, it must be stopped and only after that call an ambulance. If the bleeding does not look like a jet, then first call the ambulance team. After calling an ambulance, you should begin to perform all the other stages of first aid to the victim of a gunshot wound. If the ambulance does not arrive at the scene within 30 minutes, then you should independently deliver the victim to the nearest hospital. To do this, you can use any means - own car, passing transport, etc.
Algorithm for providing first aid to a victim with a gunshot wound to any part of the body except the head
1. Call the victim to determine if he is conscious or fainting. If a person is unconscious, then do not try to bring him to his senses, since this is not necessary for first aid;2. If a person is unconscious, his head should be thrown back and turned to one side, since it is in this position that air can freely pass into the lungs, and the vomit will be removed outside without threatening to clog the airways;
3. Try to minimize the amount of movement of the victim, as he needs rest. Do not try to move the victim to a more comfortable place or position, in your opinion. Give first aid to a person in the position in which he is. If in the process of providing assistance you need to get to some parts of the body, move around the victim yourself, and move him minimally;
4.
5. Do not clean the wound of blood, dead tissue and blood clots, as this can lead to very rapid infection and deterioration of the wounded person;
6. If prolapsed organs are visible from the wound on the abdomen, do not reposition them!
7. First of all, you should assess the presence of bleeding and determine its type:
- Arterial- scarlet blood, flows out of the wound in a jet under pressure (creates the impression of a fountain), pulsates;
- Venous- blood is dark red or burgundy in color, flows out of the wound in a weak stream without pressure, does not pulsate;
- capillary- blood of any color flows from the wound in drops.
If it is dark outside, then the type of bleeding is determined by tactile sensations. To do this, a finger or palm is placed under the flowing blood. If the blood "beats" the finger and there is a clear pulsation, then the bleeding is arterial. If the blood flows in a constant stream without pressure and pulsation, and the finger feels only gradual moistening and warmth, then the bleeding is venous. If there is no clear sensation of flowing blood, and the person providing assistance feels only sticky moisture on his hands, then the bleeding is capillary.
In case of a gunshot wound, the whole body is examined for bleeding, since it can be in the area of the inlet and outlet.
8. If the bleeding is arterial, then it should be stopped immediately, since every second in such a situation can be decisive. Seeing a gushing stream of blood, you do not need to try to look for materials for a tourniquet and remember how to properly apply it. You just need to stick the fingers of one hand directly into the wound from which blood is pouring, and plug the damaged vessel with them. If, after inserting the fingers into the wound, the blood does not stop, then you should move them around the perimeter, looking for a position that will block the damaged vessel and, thereby, stop the bleeding. At the same time, when putting your fingers in, do not be afraid to expand the wound and tear part of the tissue, since this is not critical for the survival of the victim. Having found the position of the fingers at which the blood stops flowing, fix them in it and keep them until the tourniquet is applied or the wound is packed.
To pack a wound you need to find pieces of clean tissue or sterile dressings (bandages, gauze). Before the start of packing the wound, the fingers pressing the vessel must not be removed! Therefore, if you are one on one with the victim, you will have to tear him or your clean clothes with one hand, and squeeze the damaged vessel with the other, preventing blood from flowing out. If there is someone else nearby, ask them to bring the cleanest clothes or sterile bandages. Tear things into long strips no more than 10 cm wide. To pack the wound, take one end of the tissue with your free hand and stick it deep into the wound, with the other hand still holding the vessel clamped. Then push a few centimeters of tissue tightly into the wound, tamping it down to form a kind of "plug" in the wound channel. When you feel that the tissue is above the level of the damaged vessel, remove your fingers pressing it. Then quickly continue to push the tissue into the wound, tamping it down, until the channel is filled to the very surface of the skin (see Figure 1). From this point on, the bleeding is considered to be stopped.
Figure 1 - Packing the wound to stop bleeding
Wound tamponade can be performed when it is located on any part of the body - limbs, neck, torso, abdomen, back, chest, etc.
If there is arterial bleeding on the arm or leg, then after pinching the vessel with your fingers, you can apply a tourniquet. Any long object that can be wrapped around the limb 2-3 times and tied tightly, for example, a belt, tie, wire, etc., is suitable as a tourniquet. A tourniquet is applied above the site of bleeding. A tight bandage is applied directly under the tourniquet or clothing is left (see Figure 2). The tourniquet is twisted very tightly around the limb, compressing the tissues as much as possible. After making 2 - 3 turns, the ends of the tourniquet are tightly tied and a note is placed under it with the exact time of its application. The tourniquet can be left for 1.5 - 2 hours in summer and 1 hour in winter. However, doctors do not recommend trying to apply a tourniquet to people who have never done this before, at least on a mannequin, since the manipulation is quite complicated, and therefore more often harmful than good. Therefore, the best way to stop arterial bleeding is clamping the vessel with fingers in the wound + subsequent tamponade.
Figure 2 - Applying a tourniquet
Important! If it is impossible to apply a tamponade or a tourniquet, then you will have to compress the vessel until the ambulance arrives or the victim is taken to the hospital.
9. If venous bleeding, then to stop it, you need to strongly compress the skin with the underlying tissues, thereby squeezing the damaged vessel. It must be remembered that if the wound is above the heart, then the vessel is clamped above the point of damage. If the wound is below the heart, then the vessel is clamped below the point of injury. Keeping the vessel compressed, it is necessary to pack the wound (see point 5) or apply a pressure bandage. Wound tamponade is the best way, because it is highly effective and does not require any special skills, and therefore can be used by anyone in a critical situation. Tamponade can be performed on any part of the body, and a pressure bandage is applied only to the limbs - arms or legs.
To apply a pressure bandage it is necessary to find a clean piece of tissue or a sterile bandage that completely covers the wound in size, and any dense object with a flat surface (for example, a jewelry box, a control panel, a spectacle case, a bar of soap, a soap dish, etc.) that will put pressure on the vessel . A dressing tape is also needed, such as a bandage, gauze, pieces of clothing or any clean cloth. First, put a piece of clean cloth on the wound and wrap it with 1-2 turns of a bandage or dressing tape made from improvised materials (torn clothes, pieces of cloth, etc.). Then put a dense object on the wound and tightly wrap it around the limb, literally pressing it into the soft tissues (see Figure 3).
Figure 3 - Applying a pressure bandage
Important! If it is impossible to either tamponade the wound or apply a pressure bandage, then you will have to squeeze the vessel with your fingers until the ambulance arrives or the victim is taken to the hospital.
10. If capillary bleeding, then just press it with your fingers and wait 3 to 10 minutes until it stops. In principle, capillary bleeding can be ignored by bandaging the wound without stopping it.
11. If possible, one ampule of Dicinon should be injected into the tissues near the wound to stop bleeding and Novocaine, Lidocaine or any other pain medication;
12. cutting or tearing clothing around the wound;
13. If the internal organs fell out of the wound on the abdomen, then they are simply carefully collected in a bag or a clean cloth and glued to the skin with adhesive tape or adhesive tape;
14.
If there is any antiseptic solution, for example, Furacilin, potassium permanganate, hydrogen peroxide, Chlorhexidine, alcohol, vodka, cognac, beer, wine or any alcoholic drink, you should gently wash the skin around the wound with it. In this case, you can not pour antiseptic into the wound! It is only necessary to treat the skin around the wound. If there is no antiseptic, then you can simply use clean water (spring, well, mineral water from bottles, etc.). The simplest and most effective way of such skin treatment is the following: pour an antiseptic onto a small area of the skin and quickly wipe it with a clean piece of cloth in the direction from the wound to the periphery. Then pour over another area of skin and wipe it either with a new clean piece of cloth, or with a clean piece of cloth that has already been used once. Treat all the skin around the wound in this way;
15. If it is impossible to treat the wound, then this should not be done;
16. After treating the wound, if possible, lubricate the skin around it with brilliant green or iodine. Neither iodine nor brilliant green can be poured into the wound!
17. If there is Streptocid powder, then you can pour it into the wound;
18. After stopping the bleeding and treating the wound (if possible), a bandage should be applied to it. To do this, the wound is covered with a sterile bandage, gauze or just a piece of clean cloth. A layer of cotton wool or a small twist of fabric is applied on top. If the wound is located on the chest, then instead of cotton wool, a piece of any oilcloth is applied (for example, a bag). Then all this is tied to the body with any dressing material (bandages, gauze, pieces of cloth or clothing). If there is nothing to attach the bandage to the body, then it can simply be glued with adhesive tape, adhesive plaster or medical glue;
19. If there are prolapsed organs on the abdomen, then before applying the bandage, they are covered with rolls of fabric and bandages. After that, the bandage is applied over the rollers, without squeezing the organs. Such a bandage on the abdomen with fallen internal organs should be constantly watered to keep it moist;
20. After applying a bandage, you can put an ice pack on the wound area to reduce pain. If there is no ice, then nothing needs to be put on the wound;
21. Place the victim on a flat surface (floor, bench, table, etc.). If the wound is below the heart, then raise the victim's legs. If the wound is chest, then give the victim a semi-sitting position with legs bent at the knees;
22. Wrap the casualty in blankets or existing clothing. If the victim is not wounded in the stomach, give him a sweet warm drink(if possible).
23. If blood has soaked into the tamponade or dressing and is oozing out, it does not need to be removed and changed. In this case, another one is simply applied over the bandage soaked in blood;
24. If possible, take some kind of antibiotic a wide range actions (Ciprofloxacin, Amoxicillin, Tienam, Imipinem, etc.);
25. In the process of waiting for an ambulance or transporting the victim to the hospital by any other means of transport, it is necessary to maintain verbal contact with him if the person is conscious.
Important! When wounded in the stomach, you should not give a person food and drink. Also, do not give him any medications by mouth.
Algorithm for providing first aid to a victim with a gunshot wound to the head
1.
See if the victim is conscious. If the person is fainting, do not bring him back to consciousness, as it is not necessary; 2. If a person is unconscious, tilt his head back and at the same time turn slightly to one side, since it is in this position that air can freely pass into the lungs, and vomit will be removed outside without threatening to clog the airways;
3. Move the casualty as little as possible to keep him calm. A person with a gunshot wound is shown how to move as little as possible. Therefore, do not try to move the victim to a more comfortable, in your opinion, place or position. Give first aid to a person in the position in which he is. If in the process of rendering assistance you need to get to some parts of the body, move around the victim yourself, trying not to move him;
4. If a bullet remains in the wound, then do not try to get it, leave any foreign object inside the wound channel. Trying to pull the bullet out can cause more bleeding;
5. Do not attempt to clean the wound of dirt, dead tissue, or blood clots, as this is dangerous;
6. On the wound hole in the skull, simply place a sterile napkin and wrap it loosely around the head. All other dressings, if necessary, should be applied without affecting this area;
7. Examine the victim's head for bleeding. If there is one, it must be stopped by pinching the vessel with your fingers or by applying a pressure or simple bandage. A simple dressing consists in tightly wrapping the head with any dressing material at hand, for example, bandages, gauze, fabrics, or torn clothing. A pressure bandage is applied as follows: a piece of clean cloth or gauze folded in 8-10 layers is placed on the area with bleeding, then it is tied to the head in 1-2 rounds. After that, any dense object with a flat surface (remote control, bar of soap, soap dish, spectacle case, etc.) is placed over the bandage at the bleeding site and tightly wrapped, carefully pressing down on soft tissues;
8. After stopping the bleeding and isolating the open wound with a napkin, it is necessary to give the victim a supine position with raised legs and wrap him in blankets. Then you should wait for an ambulance or transport the person to the hospital yourself. Transportation is carried out in the same position - lying down with legs raised. Before use, you should consult with a specialist.
