1.2.3. Injuries: bruises, sprains, dislocations. For any injuries, the following algorithm of actions is optimal: 1. Applying a bandage (stopping bleeding, if any).2. Creation of rest (immobilization).3. Pain relief (local cooling if possible).4. Giving

1.2.4. Bone fractures: closed and open. Limbs, spine, pelvis, ribs, collarbone. Fractures are one of the most severe types of blunt trauma. There are: complete (the bone is completely broken) and incomplete - there is a break or injury, open and closed. Symptoms

Have you ever wondered what it's like to feel a gunshot wound? What happens to the body when a bullet pierces the skin, tears muscles, crushes bones? A gunshot wound is significantly different from any other type of wound. The entrance hole is immediately surrounded by a zone of necrosis, and tissue restoration is no longer possible. And, unfortunately, from year to year the chances of getting shot by a bullet increase even for an ordinary person...

In most cases, the bullet does not go all the way through the victim's body. When it encounters a bone on the way, it begins to ricochet, causing even more damage.

Women's share

Women who are seriously injured survive 14% more often than men. Scientists believe this may be due to negative impact male sex hormones on the injured immune system.

Life or death

The likelihood of surviving a gunshot wound depends on several factors. The location of the wound, the level of blood loss and how quickly the victim is taken to the hospital matter. Overall, over the past quarter century, 40% more people are surviving gunshot wounds than before.

Headshot

When shot in the head, the bullet flies through the brain so quickly that the tissues do not tear, but seem to be pushed to the sides. However, the result is still the same.

Body side

The side of the body when wounded also has great importance. A shot to the left side causes significant bleeding, while a wound right side bleeds less. There's just lower pressure here.

Bleeding

Most often, the death of a wounded person occurs as a result of bleeding, and not as a result of the wound itself. That is, if doctors were on time at the scene of an accident in 100% of cases, then most deaths could be prevented.

Infections

The worst thing would be a wound in the stomach. Doctors will have to try very hard to save the victim and then reliably stop the consequences. A damaged stomach or intestines begins to spread infection instantly.

Trajectory

A shot from behind in the back of the head really leaves a person with a chance to survive. At the same time, a shot to the head from the side is guaranteed to be lethal. This is because a bullet traveling in a straight path usually destroys only one hemisphere of the brain, but a shot from the side will destroy both.

Shock wave

In contact with the body, the bullet generates a shock wave propagating at a speed of 1565 m/s. The kinetic energy of the projectile is then transferred to the tissues, causing long-lasting vibrations that destroy the tissues.

Caliber and wounds

A wound from a 7.62x39mm caliber bullet from an AKM will be less dangerous than a wound from a 5.45x39 caliber - a bullet from an AK74 will begin to tumble as it enters the tissue and will cause much greater damage.

Combat injuries to the skull and brain account for 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 traumatic brain injuries was performed by many famous surgeons of the past: J.L. Petit, D.J. Larrey, H.W. Cushing etc. However, military neurosurgery as a branch of military field surgery was formed only during the Great Patriotic War, when a system of specialized medical (including neurosurgical) care was first born and field surgical hospitals were created for those wounded in the head and neck and spine ( N.N. Burdenko, A.L. Polenov, I.S. Babchin, V.N. Shamov). The experience of treating combat trauma to 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 formulate the concept of early specialized neurosurgical care ( B.A. Samotokin, V.A. Khilko, B.V. Gaidar, V.E. Parfenov).

14.1 GUNSHOT INJURIES OF THE SKULL AND BRAIN

14.1.1. Terminology, classification

According to data from the period of the Great Patriotic War, gunshot injuries to 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 increased to 20%.

There are isolated, multiple and combined injuries (wounds) of the skull and brain. Isolated called a trauma (wound) in which there is one damage. Simultaneous damage to one or more MS of the skull and brain

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 maxillofacial area is called multiple head trauma (wound) . 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 basis for the classification of gunshot wounds of the skull and brain is their division into 3 large groups, proposed by N.N. Petrov in 1917: soft tissue injuries, constituting 50%; non-penetrating skull wounds, making up 20%; penetrating injuries 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 a concussion, bruise and even compression (hematoma) due to the energy of the lateral impact of the MS.

Non-penetrating skull wounds characterized by damage to soft tissues and bones while maintaining the integrity of the dura mater. This type of injury is always accompanied by a brain contusion, subarachnoid hemorrhage, and rarely by 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 injuries to the skull and brain characterized by damage to the integument, bones, membranes and substance of the brain, characterized by severity and high mortality (up to 53%, according to the period of the Great Patriotic War, 30% in local wars). The severity of penetrating wounds is determined by the formations through which the MS passes (cortex, subcortex, ventricles of the brain, basal ganglia or brain stem) and the degree of damage (Fig. 14.2).

Injuries to the stem and deep parts of the brain are particularly severe. With penetrating wounds, severe IOs most often develop - meningitis, meningoencephalitis and brain abscess, the frequency of development of which reached 70% during the Great Patriotic War and 30% in modern wars.

However, this information is not enough to make a complete diagnosis of a traumatic brain injury. For this purpose it is used nosological classification of gunshot wounds of the skull and brain(Table 14.1).

Rice. 14.1. Non-penetrating skull injury with bone fracture

Rice. 14.2. Tangent penetrating injury to 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 characteristics. According to etiology there 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 the combined nature of damage.

Penetrating injuries to 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 wound is called tangent(tangential), when a bullet or 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 scale of destruction of the medulla formed along the course of the MS, the morphological and functional disorders often spread to neighboring areas of the brain. This is explained by the fact that the substance of the brain is a medium containing a large amount of fluid and is located in a closed space limited by the dense membranes and bones of the skull.

The wounds are called segmental, when MS passes through the cranial cavity along one of chords 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 fairly significant extent (Fig. 14.3).

Rice. 14.3. Segmental penetrating injury of the skull and brain

With all segmental wounds, small fragments of bone, hair, and sometimes pieces of headgear are carried into the depths of the wound channel. Destruction of the brain matter, as with any gunshot wound, is not limited to the area of ​​passage of the projectile, but spreads to the sides and is expressed in the formation of hemorrhages and foci of contusion of brain tissue at a considerable distance from the wound canal.

At diametrical In wounds, the wound channel lies deeper than in segmental wounds, passing along the large chord (diameter) of the circumference of the skull (Fig. 14.4).

Diametrical wounds are the most severe, because the wound channel in these cases runs at great depth, damaging the ventricular system, the brainstem and other deep-lying vital important formations. Therefore, diametrical wounds are accompanied by high mortality, and deaths occur in the early stages as a result of direct damage to vital centers of the brain.

A type 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. With these wounds, the entrance opening of the wound channel is usually located in the area of ​​the face, jaws, neck, and the exit opening is 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 fatal.

Rice. 14.4. Diametric penetrating wound of the skull and brain

Blind Skull wounds have one entrance hole and a wound channel of varying length, at the end of which lies a bullet or fragment. By analogy with through wounds, blind wounds are divided into simple, radial, segmental and diametrical (Fig. 14.5).

The severity of the blind wound is determined depth of the wound channel and its size. The most severe are blind wounds running along the base of the brain.

Among penetrating gunshot wounds of the skull, sometimes there are so-called ricocheting wounds (according to R. Payr, 1916), characterized by the fact that in the presence of one wound hole (entrance) in the depths of the wound channel, only bone fragments of the skull are found, and the RS is absent - it hit the convex

Rice. 14.5. Scheme of blind penetrating wounds of the skull and brain: 1 - simple; 2 - radial; 3 - segmental; 4 - diametrical

surface of the skull, causes damage and sharply changes the flight path (ricochets), moving away from the skull ( external rebound). At internal rebound The RS changes its trajectory upon contact with the concave surface of the skull on the opposite side from the entrance opening of the wound canal.

Since determining the severity of brain damage and diagnosing the life-threatening consequences of gunshot injuries to the skull and brain are based on identifying 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 the field at the cutting edge medical evacuation(MPP, MedB, Omedb) there are extremely limited opportunities and time for a full neurological examination of a wounded person with a gunshot injury to the skull and brain. Sorting of the wounded and making a diagnosis is carried out by military doctors and general surgeons. Therefore they objectives are: 1) identification of life-threatening consequences of injury for the timely provision of emergency medical care and 2) formulation of a diagnosis of injury according to the algorithm proposed in the textbook for making the correct triage decision.

At the advanced stages of medical evacuation, the diagnosis of gunshot trauma to the skull and brain is based on identifying general and local symptoms of gunshot injury, symptoms of acute impairment of vital functions, general cerebral and focal symptoms of brain damage.

The examination of any casualty at the triage area begins with an assessment of the severity of his condition and the active identification of acute impairment of vital functions. Symptoms not associated with brain damage are referred to in this chapter as general 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 to the limbs, less often to the chest, abdomen, and pelvis. Therefore, when triaging the wounded, it is important not to randomly determine general symptoms, but targeted identification of four main syndromes .

It manifests itself bluishness 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, rapid 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 to the abdomen, chest or pelvis, and less commonly to the extremities.

Traumatic coma syndrome. It manifests itself lack of consciousness, speech contact, limb movements, motor response to pain. In deep coma, respiratory and circulatory disorders of central origin are possible (with the exception of chest damage and sources of bleeding). This syndrome is caused by severe brain damage.

Terminal syndrome. It manifests itself gray (sallow) color of the skin and lips, pronounced lethargy of the wounded person up to stupor, frequent (heart rate more than 140 per minute) and weak pulse only in the carotid arteries, blood pressure is not determined, breathing is rare and fading. The causes of the terminal condition can be: extremely severe trauma of any location, but most often - severe MVR, severe injuries to several areas of the body, severe injuries to the abdomen or pelvis with acute massive blood loss, gunshot wounds of the skull with extremely severe brain damage.

After assessing general symptoms wounds and other injuries are examined- there may be several of them on the head and in other areas of the body. When examining a cranial wound, its location, depth, area, and the nature of the damaged tissue are determined, that is, the local symptoms. In this case, superficial gunshot wounds are easily identified, and in case of bleeding, its sources are clarified. Important information can be obtained when, upon examination of the wound, bone fragments of the skull, leakage of cerebrospinal fluid or destroyed brain matter (cerebral detritus) are visible - they indicate the penetrating nature of the wound (Fig. 14.6).

Deep wounds of the skull in serious condition the wounded person should not be specifically examined, because the harm from this may be greater than the benefit when, for example, bleeding or liquorrhea resumes when a blood clot is accidentally removed.

Rice. 14.6. Excess of cerebral detritus from a wound in a blind penetrating wound of the skull in the left temporal region

In general, of the local symptoms for making a triage decision, the following are most important: external bleeding and leakage of cerebrospinal fluid or cerebral detritus from the wound; the rest, if possible, clarify the diagnosis. That's why important rule staged treatment 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 to diagnose the wound. It is removed only in case of heavy contamination with earth, radioactive substances or HTV. If the bandage is intensively soaked with blood: in the medical unit (med) it is bandaged, in the medical hospital it is removed in the operating room, where the wounded person is taken 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 active identification of the wounded person cerebral and focal symptoms, and symptoms of vital impairment important functions.

General cerebral symptoms V to the greatest extent characterize the severity of brain damage and are accessible to determination

at the advanced stages of medical evacuation. Indicates minimal brain damage loss of consciousness at the time of injury and amnesia to events preceding or after 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 . Moreover, the more pronounced the degree of impairment of consciousness, the more severe the brain damage. Therefore, it is necessary to have a good knowledge of the degree of impairment of consciousness to make a diagnosis of gunshot TBI and make a triage decision. There are many subjective and objective methods and scales for impairment of consciousness (Glasgow coma scale, Shakhnovich scale, etc.), but for the advanced stages of medical evacuation, today the most convenient is the domestic descriptive methodology, distinguishing six degrees of impairment of consciousness.

1. Moderate stun- the wounded person is conscious, answers questions, but is inhibited or agitated, disoriented in space and time.

2. The stun is deep- the wounded person is in a state of sleep, but when there is a strong impact on him (a shout, slaps on the cheeks), he answers questions in monosyllables and sluggishly.

3. Sopor- consciousness is absent, speech contact is impossible, tendon reflexes, motor defensive reactions to pain, and 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; hemodynamics are relatively stable, spontaneous breathing is ineffective, but rhythmic.

6. Coma beyond measure- to the symptoms of deep coma are added: instability of hemodynamics of central origin [decrease in sBP less than 90 mm Hg, tachycardia (heart rate more than 140 per 1 min), less often - bradycardia (heart rate less than 60 per 1 min)] and pathological respiratory rhythms, bilateral mydriasis

Focal symptoms to a lesser extent characterize the severity of brain damage. However, they are of great importance in diagnosing brain compression - a life-threatening consequence of a traumatic brain injury - and in determining the location of the injury. At the stages of providing first medical and qualified medical care, it is possible to identify only bright focal symptoms.

Anisocoria- is often a manifestation of a space-occupying process in the cranial cavity (intracranial hematoma, hydroma, local cerebral edema in the area of ​​the brain wound) on the side of the dilated pupil.

Fixing the eyeballs and head to the side(right or left) often indicates a volumetric process in the cranial cavity on the side of fixation (“the patient’s fixed gaze shows the surgeon on which side to perform the trepanation”).

Crooked mouth; cheek, which takes the shape 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.

Local limb cramps it is often a manifestation of a space-occupying process in the cranial cavity on the opposite side.

Limb paralysis it indicates damage to the motor areas of the brain or a space-occupying process in the cranial cavity on the opposite side.

Symptoms such as: speech, hearing and vision impairments- especially on one ear, eye.

Symptoms of acute impairment of vital functions indicate either extremely severe brain damage, or the development of cerebral edema and its infringement in the foramen of the cerebellar tentorium or in the foramen magnum of the skull base (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 manifest themselves as pronounced hemodynamic disorders: persistent arterial hypertension(SBP more than 150 mmHg) , or arterial hypotension(SBP less than 90 mmHg), tachycardia(heart rate more than 140 per minute) or bradycardia(heart rate less than 60 per minute). Most characteristic manifestation violations of vital functions is breathing rhythm disorder requiring the use of mechanical ventilation.

14.1.3. Determining the severity of brain damage, diagnosing life-threatening consequences of gunshot injuries to the skull and brain

At the stages of providing first medical and qualified medical care, 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 this perspective, there are three degrees of severity of brain damage: light, heavy and extremely heavy. It should be clearly understood that this division of gunshot injuries to the skull and brain is used only at the advanced stages of medical evacuation (medical evacuation, first aid, medical hospital), where the sorting of the wounded is carried out without removing the bandages, without undressing and, naturally, without a full neurological examination. The main task of triaging the wounded at these stages of evacuation is not making an accurate diagnosis, but identifying 4 triage groups:

those in need of elimination of life-threatening consequences of injury, that is, emergency care measures;

subject to evacuation in 1st priority;

subject to evacuation in the 2nd stage;

agonizing.

Formulation of the final diagnosis and assessment of the severity of the traumatic brain 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: stability of the wounded person’s condition and absence of disturbances in vital functions for the triage period, and not the neurological deficit that will remain in the wounded person after final recovery.

Minor brain damage. In pathogenetic and morphological terms, mild injuries are characterized by damage only to superficial cortical structures on the convexital (convex) surface of the brain. Subcortical formations and trunk are intact. Mild brain injuries often occur with injuries to the soft tissues of the skull 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 preserved consciousness: clear, moderate stupor or deep stupor. Focal symptoms in mild brain injuries may be absent, or they can be very vivid, for example, with a penetrating blind wound to the left temporal lobe(speech disorders, etc.), anterior central gyrus ( movement disorders). There are no dysfunctions of vital organs. In prognostic terms, this is the most favorable group of wounded, therefore, in case of non-penetrating and especially penetrating wounds of the skull, they should be quickly taken to a specialized hospital before non-life-threatening complications develop.

Triage conclusion at the advanced stages of medical evacuation - evacuation in the 2nd stage to 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 during swelling and dislocation, that is, it can be pinched in the openings of the skull. Severe brain injuries are more common with penetrating blind (deep) and through segmental wounds.

The main criterion for severe brain damage is the absence of consciousness - its disturbances in the form of stupor and moderate coma. Focal symptoms in severe brain damage are poorly expressed, since they are masked by the absence reflex activity and pronounced general cerebral symptoms (extrapyramidal syndrome, diencephalic-catabolic syndrome). It usually manifests itself only as pupillary and oculomotor disturbances. Violations of vital functions manifest themselves only in the circulatory system: persistent arterial hypertension (blood pressure more than 150 mm Hg), tachycardia (heart rate more than 120 per minute). In prognostic terms, 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 due to penetrating wounds of the skull do not return to duty.

Triage conclusion at the advanced stages of medical evacuation - evacuation to 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 diametric and diagonal wounds.

The main criteria for extremely severe brain damage are: severe impairment of consciousness in the form of deep or extreme coma and impairment of vital functions. There are no focal symptoms due to deep coma, that is, complete absence reflex activity. Violations of vital functions are manifested by persistent hypotension (SBP 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 disturbances requiring mechanical ventilation. In terms of prognosis, wounded people with extremely severe brain damage have no prospects for survival, with mortality approaching 100%. Therefore, starting from the stage of providing qualified medical care, they belong to the triage category of “agoning”.

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 inability of the body’s defense mechanisms to eliminate them independently. Consequently, in the absence of emergency medical care, the life-threatening consequences of injuries lead to death. Therefore, at all advanced stages of medical evacuation, emergency medical care is carried out not for wounds or injuries, but for their life-threatening consequences. Gunshot injuries to the skull and brain can result in three types of life-threatening consequences: external bleeding, compression of the brain 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;

Cerebral vessels located in a brain wound. Brain compression- a pathological process that lasts from several hours to several days and often leads to death if it is not eliminated. Most often, compression of the brain in gunshot wounds is caused by intracranial hematomas (Fig. 14.7., 14.8.), less often by local cerebral edema in the wound area or a depressed fracture of the skull bones (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 opinions about the mechanism of development of intracranial hematomas, which affected therapeutic tactics. It was believed that an intracranial hematoma is formed by a pumping mechanism, increasing with each portion of blood and compressing the brain after the volume of the hematoma exceeds the size of the reserve intrathecal spaces: 80 ml for epidural

Rice. 14.7. Compression of the brain by an epidural hematoma in the right fronto-parietal-temporal region (computer 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, unfounded calls for immediate trephination at any stage of treatment and simplified ideas about the technique of eliminating compression were practiced: craniotomy - removal of the hematoma - ligation of the bleeding vessel - recovery. In practice, such situations turned out to be rare with non-gunshot TBI; with gunshot wounds they never occur.

Special studies by employees of the Leningrad Research Institute of Neurosurgery named after. A.L. Polenov under the leadership of Yu.V. Zotov showed that the main volume of intracranial hematoma is formed during the first 3-6 hours; at the same time, blood clot, which subsequently interacts with the damaged area of ​​the brain, causing local swelling, a decrease in the reserve intrathecal space and - cerebral compression syndrome. The smaller the volume of brain damage and the greater the reserve volume of the subthecal space (for example, with hematomas formed as a result of 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 case of gunshot wounds, when the 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.

Classic neurological picture of compression of the head

Rice. 14.10. Typical hemilateral syndrome due to compression of the brain (Yu.V. Zotov, V.V. Shchedrenok)

brain in the form of pupil dilation on the compression side 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 injury (Fig. 14.10).

In conditions of staged treatment, when triaging head wounds, 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 at the time of examination; During this period of time, the wounded person is conscious (usually this is clarified with those accompanying him). This symptom is characteristic of mild brain damage, against the background of which compression develops. With severe brain damage, disorders of consciousness progress, often from stupor to coma. The diagnostic reliability of this symptom is very high.

Fixation of the head and gaze in the direction of compression of the brain. A very reliable, but not often encountered symptom of brain compression. It is determined when examining a wounded person at the triage area, when the doctor places the wounded person’s head in the middle position, and the wounded person reflexively turns it with effort to its previous position. Similar to the position of the head, the eyeballs are also fixed.

Local limb cramps on the side opposite to the compression of the brain, are also easily identified at the triage site. It is impossible not to notice them, since they are uncontrollable - you have to administer anticonvulsants (which, by the way, is ineffective). The diagnostic value of the symptom increases significantly if the arm or leg of the same name is affected by 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, especially, aspects of the pathological process is relatively small and amounts to 60%.

Bradycardia - Heart rate below 60 per minute. Important symptom, indicating the likelihood of compression of the brain, but its specificity is low - it is also a manifestation of damage to the brain stem and a number of extracranial injuries (cardiac contusion, adrenal contusion). Its diagnostic value increases significantly 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 to the abdomen or pelvis, a heart rate below 100 per minute should be regarded as relative bradycardia.

Hemiplegia, monoplegia, less often - paresis of the limbs on the side opposite to the compression of the brain, - these are important, but nonspecific symptoms compression of the brain, as they are often neurological manifestation gunshot wound. At the sorting site, where special neurological techniques are not used, only gross motor disorders in the form of lack of limb movements are detected. This increases their diagnostic value, especially in combination with other symptoms.

The diagnostic significance of the listed symptoms for identifying compression of the brain increases significantly when they are combined: the more symptoms there are, the more more likely compression of the brain.

Asphyxia- acutely developing respiratory distress (suffocation) as a result of obstruction of the upper respiratory tract - with gunshot injuries of the skull and brain it is rare - up to 1% of cases. More often, asphyxia occurs with multiple head injuries, when injuries to the skull 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 maxillofacial area into the oropharynx and larynx against the background of impaired innervation of the epiglottis or a decrease in the cough-left reflex. In severe isolated craniocerebral injuries, the aspiration mechanism of asphyxia is realized due to the entry of vomit into the respiratory tract. With extremely severe injuries to the skull and brain, dislocation asphyxia develops as a result of 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 must be actively identified. The wounded with external bleeding and asphyxia should be provided with emergency care at all stages of medical evacuation, and the wounded with compression of the brain should be urgently evacuated (by helicopter) to a specialized neurosurgical hospital - only there they can be provided with full emergency care.

Examples of diagnoses of gunshot wounds of the skull:

1. Multiple fragmentation blind wound of soft tissues of the right half of the head.

2. Bullet tangential non-penetrating wound of the skull in the left parietal-temporal 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 frontotemporal region with severe brain damage, with comminuted fractures of the frontal and temporal bones. Compression of the brain. Traumatic coma.

5. Bullet through-diametric bihemispheric penetrating wound of the skull in the temporal regions with extremely severe brain damage, with splintered fractures of the temporal bones. Continued external bleeding. Terminal state.

6. Severe mine blast wound. Combined mechanothermal combined trauma of the head, chest, extremities.

Multiple gunshot head injury. Shrapnel blind penetrating left-sided fronto-orbital wound of the skull with severe brain damage, multiple fractures of the orbital walls and destruction of the left eyeball.

Closed chest injury with multiple rib fractures on the right and lung damage. Right-sided tension pneumothorax.

Avulsion of the left tibia at the level of the middle third with extensive destruction of soft tissue and skin detachment to the lower third of the thigh. Continued external bleeding.

Flame burn of lower extremities

Acute massive blood loss. Terminal state.

14.2. NON-GUNSHOT SKULL INJURIES

AND BRAIN

14.2.1. Terminology and classification

Based on etiology, non-gunshot injuries to the skull and brain are divided into mechanical (closed and open) TBI and non-gunshot wounds. In combat conditions, mechanical TBIs occur

quite often, accounting for 10-15% of the total combat pathology of this localization.

TO closed TBI These include injuries to the skull and brain in which the integrity of the skin as a natural biological barrier is preserved. TBIs with skin damage 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 oto or nasolorrhea are considered as an open penetrating TBI, since at the base of the skull the dura mater is tightly fused with the bone and during fractures is necessarily damaged along with it.

Non-gunshot wounds of the skull and brain (stab wounds, stab wounds, dowel wounds from a construction pistol, etc.) are rare in combat conditions and do not amount to big problem and are described in neurotraumatology manuals.

As with gunshot trauma to the skull and brain, with non-gunshot TBI there are combinations of injuries various departments head and anatomical areas 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, this division of TBI with varying degrees of detail for each type has been preserved to this day. One circumstance was unclear: 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 damage were formed, Objective assessment severity of injuries and a new technique for formulating a diagnosis in the system of staged treatment of the wounded.

From this point of view, compression of the brain does not characterize the type or severity of TBI (injury), but is its life-threatening consequence. Compression of the brain develops when damage enters the morphological substrate large vessels, liquor ducts, large bone fragments of the skull.

Thus, the basis classification of non-gunshot TBI They are divided into the following types:

Brain concussion;

Mild brain contusion;

Moderate brain contusion;

Severe brain contusion.

This classification reflects not only the type, but also the severity of TBI, both in clinical and morphological manifestations. In this case, the severity of TBI increases from the surface of the brain in depth: from a concussion (functional impairment at the cortical level, clear consciousness) to a severe injury (damage to the brain stem, deep or extreme coma).

To correctly formulate the diagnosis of non-gunshot trauma to the skull and brain, it is used nosological classification(Table 14.2.)

As can be seen from the classification, one of the sections in formulating a diagnosis is the condition of the intrathecal spaces. It should be borne in mind that their significance increases in the later periods of a traumatic illness, in the process 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 with CT or MRI or when forensic autopsy. They are fundamentally different from epidural and subdural hematomas in their small volume, cape-like flat nature and, most importantly, in that they do not cause compression of the brain.

Calvarial fractures may also not be detected during 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” (periorbital hematomas) or nasal liquorrhea (leakage of cerebrospinal fluid 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 (distorted mouth, parous cheek, eyelid does not close, lacrimation or dry eye) or auditory (unpleasant tinnitus) nerves are signs of a fracture of the temporal bone pyramid.

The life-threatening consequences of non-gunshot injuries to 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 diagnoses of non-gunshot TBI:

1. Open traumatic brain injury. Brain concussion. Lacerated and bruised wound of the right parietotemporal region.

2. Closed craniocerebral injury. Mild brain contusion. Subarachnoid hemorrhage.

3. Open penetrating traumatic brain injury. Moderate brain contusion. Subarachnoid hemorrhage. Fracture of the left temporal bone with transition to the base of the skull. Lacerated and bruised wound of the left temporal region. Left-sided otohematoliquorrhea.

4. Open traumatic brain injury. Severe brain contusion. Subarachnoid hemorrhage. Fracture of the frontal bone on the right. Lacerated and bruised wound of the frontal region on the right. Traumatic coma.

5. Closed craniocerebral injury. Severe brain contusion. Subarachnoid hemorrhage. Fracture of the bones of the cranial vault. Compression of the brain by intracranial hematoma in the left fronto-parietal-temporal region. Traumatic coma.

6. Severe combined trauma of the head, abdomen, and limbs. Open penetrating traumatic brain injury. Severe brain contusion. Intraventricular hemorrhage. Fractures of the bones of the vault and base of the skull.

Closed abdominal injury with damage to internal organs. Continuing intra-abdominal bleeding.

Closed multiple limb injury. 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, opportunities and time for a full examination of wounded people with non-gunshot injuries to the skull and brain are extremely limited. That's why you should remember the main symptoms of TBI and focus on them in the process of medical triage of the wounded. Usually wounded with non-severe TBI move independently around the units of the triage and evacuation department, complain of headache, tinnitus, disorientation - they need to be laid down, calmed down, examined, carried out medical care measures and sent on a stretcher to the evacuation room

tent. Wounded from severe TBI are delivered on a stretcher, often unconscious, which creates significant difficulties in diagnosis.

Examination of a wounded person with non-gunshot TBI begins with active identification (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 TBI in 60% of cases is combined with damage to other areas of the body.

Acute respiratory distress syndrome 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.

Acute circulatory disorder syndrome(in the form of traumatic shock) develops with acute massive blood loss as a result of concomitant damage to the abdomen, pelvis, and limbs.

Traumatic coma syndrome clearly indicates severe brain damage, and terminal illness syndrome- about extremely severe brain damage or severe combined injury.

For closed non-gunshot TBI local symptoms poorly expressed. More often than others, subcutaneous hematomas of the scalp, periorbital hematomas are detected, and less often - liquorrhea from the nose and ears. Since the cerebrospinal fluid flowing from the ears and nose is often mixed with blood, they use "double spot" symptom. Liquor with blood spilled onto a white sheet or towel forms a double-circuit round spot: inner part- pink, outer - white, yellow. In case of open non-gunshot TBI, local symptoms are also the location, nature and depth of the wound in the integumentary tissues of the skull.

General cerebral and focal symptoms brain damage in non-gunshot TBI is of primary importance in determining the severity of brain damage, and identification syndrome of acute disturbances of vital functions central origin - important prognostic value. They allow the triage physician to make the correct triage decision. The characteristics of these symptoms and identification methods are similar to those used when examining wounded people with gunshot trauma to the skull and brain (see section 14.1.2).

From the nosological classification of non-gunshot TBI it is clear that for diagnosis separate forms TBI (such as brain contusion

mild and moderate severity) the condition of the intrathecal liquor spaces, the presence and nature of fractures of the skull bones are of great importance. To identify the first, it is necessary to perform a lumbar puncture, which is a general medical procedure and can easily be performed by a surgeon or anesthesiologist at the stage of providing CCP. In this case, the cerebrospinal fluid pressure is determined (normally it is 80-180 mm water column for a lying position) and the presence of blood in the cerebrospinal fluid - subarachnoid hemorrhage. Diagnosis of skull fractures is also possible in the medical hospital by performing radiography of the skull in frontal and lateral projections.

At the same time, determining the state of the cerebrospinal fluid spaces and x-ray detection of skull fractures are not of fundamental importance for making a triage decision. In addition, lumbar puncture itself may be accompanied by the development of brain dislocation (the wedging of the brain stem into the foramen magnum of the skull): due to the jet release of cerebrospinal fluid from the needle, sharp decline liquor pressure in the basal cistern - sudden cessation of breathing occurs on the dressing table and death. The rule to remember is: Lumbar puncture is contraindicated at the slightest suspicion of cerebral compression!

Non-severe TBI. In pathogenetic and morphological terms, they are characterized either only functional disorders activity of the central nervous system, or vascular damage arachnoid, or foci of hemorrhage, destruction of cortical structures of the brain. Subcortical formations and trunk are intact.

The main clinical criterion for non-severe TBI is preserved consciousness: clear, moderate stupor, deep stun. From this point of view, the group of non-severe TBI includes: concussion, bruises of mild and moderate severity.

Brain concussion- most light form TBI, in which morphological changes are absent in the brain and its membranes, and pathogenetic and clinical manifestations caused by 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 people usually move independently (consciousness is clear), but complain of headache, nausea, dizziness, and sometimes vomiting. They belong to the category of lightly wounded and are evacuated in the 2nd turn by any transport to the VPGLR, where there is

a specialized neurological department for the treatment of this category of wounded.

Mild brain contusion- this is also a mild form of TBI, in which, unlike a concussion, there are not only functional changes CNS, but also morphological in the form of damage to the vessels of the arachnoid membrane. The latter are detected during lumbar puncture in the form of blood in the cerebrospinal fluid - subarachnoid hemorrhage. Basically, the clinical manifestations are the same as for a concussion, but the following are found: moderate stupor in terms of level of consciousness, headache and nausea are more pronounced, and vomiting occurs more often. In conditions of staged treatment lumbar puncture for differential diagnosis not carried out, therefore, in practice, these wounded are also classified as lightly wounded and are sent to the VPGLR.

Moderate brain contusion 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 people with moderate brain contusions belong to the “non-severe TBI” triage group. This is both prognostic and theoretically justified: there are no deaths, 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, Fractures of both the vault and base of the skull, and the morphological substrate of the 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 moderate brain contusions is 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 nerves are detected; speech, vision, and paresis of the limbs are less common. These wounded are delivered, as a rule, on a stretcher, the state of consciousness is stunned (moderate or deep), vital functions are within normal limits, stable. The wounded with moderate brain contusions are also evacuated in the second place by any transport, but not to the VPGLR, but to the VPNH or to the VPNhG, since focal symptoms may still be a sign of slowly developing compression of the brain.

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 and the upper parts of the brain stem.

The main clinical criterion for severe TBI is the absence 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, according to the level of damage, extrapyramidal and diencephalic forms of severe brain contusion are distinguished.

Extrapyramidal form of severe brain contusion. 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 person, a mask-like face with an absence of 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 less than 20%), the social prognosis is often favorable.

Diencephalic form of severe brain contusion. With this form of severe contusion as a result of damage to the interstitial brain, where the main autonomic centers are located, the clinical picture appears bright diencephalic-catabolic syndrome. It is characterized by : arterial hypertension, tachycardia, muscle 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 are 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 mortality reaches 50%; the social prognosis is often unfavorable, since most wounded people become disabled after receiving a severe TBI.

The wounded with severe TBI, despite the relative stability of vital functions, do not delay at the stages of provision qualified assistance for intensive corrective therapy. After normalization of external respiration either by installing an air duct or tracheal intubation with mechanical ventilation, they are urgently evacuated to the VPNhG 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 absence of consciousness - its disturbance in the form of a deep or extreme coma. Damage to the brain stem has a characteristic clinical picture in the form of mesencephalobulbar syndrome. Therefore, such forms of TBI are called mesencephalobulbar form of severe brain contusion. First of all, this form is manifested by pronounced disturbances of vital functions: persistent refractory to infusion therapy arterial hypotension, uncontrolled tachycardia (bradycardia) and arrhythmia, severe tachycardia or bradypnea or pathological breathing rhythms requiring mechanical ventilation. The eyeballs are fixed in the center, the pupils are wide, there is no reaction to light. It should be remembered that with extremely severe TBI

absolutely unfavorable prognostic signs are paralytic bilateral mydriasis and Magendie's symptom (unequal position of the eyeballs relative to the horizontal axis: one is higher, the other is lower). Without intensive correction of vital functions, death occurs within a few hours. Even in specialized centers, the mortality rate for this type of TBI is close to 100%. Therefore, the wounded with extremely severe TBI at the advanced stages of medical evacuation are classified as dying.

Life-threatening consequences with non-gunshot TBIs develop in 5-8% of cases. External bleeding from the sinuses of the dura mater with multiple open fractures of the bones of the calvarium is relatively rare - 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 calvarial bones. The clinical picture and symptoms of life-threatening consequences in non-gunshot TBI are similar to those in gunshot injuries.

14.3. ASSISTANCE AT THE STAGES OF MEDICAL EVACUATION

The main principle of staged treatment of head wounded patients is the fastest possible delivery to the VPNhG, bypassing even the stage of providing qualified surgical care.

First aid. Apply to the head wound aseptic dressing. To prevent aspiration of blood and vomit during vomiting and nosebleeds, the upper respiratory tract is cleaned. If the tongue is retracted, the orderly opens the wounded man’s mouth with a mouth dilator, the tongue is removed using a tongue holder, the oral cavity and pharynx are cleaned of vomit from the mouth and pharynx with a napkin, and an air duct (breathing tube TD-10) is inserted. The wounded, who are unconscious, are carried out in a position on their side or stomach (a folded overcoat, duffel bag, etc. is placed under the chest).

In case of severe wounds to the head, promedol from a syringe tube is not administered due to the threat of respiratory depression.

First aid carried out by a paramedic who monitors the correctness of previously carried out measures and corrects their shortcomings. Elimination of asphyxia is carried out using the same methods as when providing first aid. If breathing is impaired, mechanical ventilation is performed using a manual breathing apparatus and oxygen inhalation. If the bandage gets wet with blood, it is bandaged tightly.

First medical aid. During armed conflict first medical aid is provided as pre-evacuation preparation for aeromedical evacuation of 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 medical care evacuated to Omedb (omedo).

During medical triage There are 4 groups of wounded with gunshot or non-gunshot injuries to the skull and brain.

1. Those in need urgent measures first aid in the dressing room - wounded with ongoing external bleeding from head wounds and wounded with asphyxia.

2. The wounded, for whom first medical aid can be provided at the triage area with subsequent evacuation to the 1st stage, - wounded with signs of brain compression and wounded with severe brain damage.

3. The wounded, for whom first medical aid can be provided at the sorting site with subsequent evacuation to the 2nd stage, - wounded with mild brain damage.

4. Agonizing- wounded with extremely severe brain damage - are sent to a triage tent in a specially equipped place (fenced off with sheets from the rest of the wounded). It should be remembered that the group of those in agony at the stage of providing first medical aid is identified only when there is a massive influx of wounded. Under normal conditions, any casualty with detectable blood pressure should be evacuated .

In the dressing room, the upper respiratory tract is cleared for unconscious wounded people. An air duct is inserted to prevent tongue retraction. In case of ineffective spontaneous breathing, the anesthesiologist-resuscitator performs tracheal intubation and mechanical ventilation. If it is impossible to intubate the trachea, a conicotomy or tracheostomy is performed.

When the bandage becomes heavily saturated with blood, it becomes tightly bandaged. Continuing bleeding from the soft tissue arteries visible in the wound is stopped by ligating them or applying a pressure bandage with the introduction of napkins moistened with a 3% solution of hydrogen peroxide into the wound.

The rest of those wounded in the head receive assistance in the triage and evacuation department. They are given antibiotics and tetanus toxoid, and are used according to indications. cardiovascular drugs. Narcotic analgesics are not administered for penetrating craniocerebral injuries, because they depress the respiratory center. Crowded bladder in the wounded with impaired consciousness, it is emptied with a catheter.

After first medical aid is provided, the wounded are sent to the evacuation room, from where they are evacuated in accordance with the triage conclusion. We should strive to evacuate those 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 evacuation .

In progress medical triage There are 5 groups of wounded with gunshot and non-gunshot injuries to 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 deployed for them; wounded with intense external bleeding are sent to the operating room. After assistance is provided, evacuation to VPNhG is the first priority.

2. Stretch wounded with lack of consciousness, but stable vital functions ( with severe brain damage, cerebral compression) - need preparation for evacuation in an intensive care ward, less often - evacuation ( only restoration and maintenance of breathing, up to intubation and mechanical ventilation ), after which evacuation is carried out to VPNhG in the 1st place.

3. Stretch wounded with preserved consciousness ( with mild brain damage) - are sent to evacuation tents for evacuation to VPNhG in the 2nd turn.

4. Walking head wounded- are sent to the triage tent for the lightly wounded, where they prepare for evacuation to the VPGLR in the 2nd line.

5. Agonizing- wounded with extremely severe brain damage with fading vital functions and signs of a fatal injury (diagonal, diametrical with the outflow of cerebral detritus) - are sent to the symptomatic therapy ward, 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 include only measures to stop the bleeding. When hemostasis is achieved, the surgical intervention should be stopped, the wound covered with a bandage, and the wounded person sent to the VPNhG, where a specialist will perform exhaustive surgical treatment of the cranial wound.

Surgery for ongoing external bleeding is carried out under general anesthesia and can consist of 3 elements: stopping bleeding from a soft tissue wound; trephination

bones in the area of ​​the fracture (if bleeding continues from under the bone); stopping bleeding from the dura mater, sinuses and (or) brain wounds.

The first stage of the operation is dissection of the soft tissue wound. In this case, bleeding from soft tissues is stopped by diathermocoagulation or ligation and suturing of the bleeding vessel. Then the bone wound is examined, and if bleeding continues from under the bone, the bone wound is expanded with bone forceps-nippers (Fig. 14.12.).

The dimensions of the burr hole can vary, 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 suturing.

The following methods are used to stop bleeding from the dural sinus. During complete or almost complete breaks, sinus ligation. It can be done

Rice. 14.12. Expansion of bone wound

be only if the bone defect is of sufficient size by making 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 and tied (Fig. 14.13, 14.14).

It is impossible to ligate the sinus behind the Rolandic groove and especially at the confluence of the sinuses, because this may cause death.

Rice. 14.13. Ligation of the superior sagittal sinus. The needle is placed under the sinus

Rice. 14.14. The needle is passed through the falx 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).

Suturing the sinus wall succeeds only with small linear wounds. Application of a side ligature possible, but only with minor damage. If the condition of the wounded person is very serious, you can apply clamps to the sinus wound and leave them for the period of evacuation. In this case, one should strive to preserve the lumen of the sinus.

If bleeding continues from under the dura mater, it is cut through the wound with thin scissors. Visible bone fragments are removed from the wound canal using thin tweezers. To stop bleeding from the vessels of the brain, diathermocoagulation and tamponing with turundas with hydrogen peroxide are used. The new method proposed Yu. A. Shulevym, 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 canal in the form of an impression, stopping the bleeding. Human fibrinogen in an amount of 1 g, diluted in 20.0 ml of 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 stopping the bleeding, the wound is loosely packed with napkins, not sutured, and the wounded person is evacuated to the VPNhG for final surgical treatment.

For asphyxia in the dressing room, the upper respiratory tract is sanitized, removing vomit, mucus and blood clots, an air duct is inserted or the trachea is intubated. If there is simultaneous injury to the maxillofacial area or neck, an atypical or typical tracheostomy may be indicated.

Technique for performing tracheostomy the following: the position of the wounded person on his back with his head thrown back, a cushion placed under the shoulder blades. Under local anesthesia with a 0.5% solution of novocaine, a longitudinal incision is made in the skin, subcutaneous tissue and fascia of the neck along the midline of the neck from the thyroid cartilage to a point immediately above the notch above the sternum. The skin, subcutaneous tissue and muscles are bluntly pulled apart with a clamp in the lateral direction. The exposed isthmus of the thyroid gland is retracted upward, if impossible, it is crossed and bandaged. The pretracheal fascia is then 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 longitudinal tracheostomy: a - incision line; b - muscle dilution; c - capture of the trachea with a single-pronged hook; d - section of the trachea; d - view after insertion of a tracheostomy tube into the trachea

It is grabbed with a sharp hook, lifted, and then cut. The trachea is opened with a T-shaped incision: between the 2nd and 3rd rings transversely (cut length up to 1.0 cm), then longitudinally - through the 3rd and 4th rings up to 1.5-2.0 cm long cm. After the trachea incision is made, a tracheal dilator is inserted into it, the hole is widened, and then a previously prepared tracheostomy tube is inserted into it (Fig. 14.17).

The wound should be sutured without tension to prevent the occurrence of subcutaneous emphysema. Only skin sutures are used. The tracheostomy cannula is held in place by tying it around the neck with gauze.

If there are signs of severe acute respiratory failure, mechanical ventilation is performed.

Everyone else wounded in the head medical care (bandaging, injection of non-narcotic analgesics for pain, reintroduction antibiotics according to indications, etc.) is carried out in the triage 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 are not performed at the stages of providing qualified medical care. All stretcher wounded are evacuated to VPNhG, walking ones - to VPGLR.

Specialized surgical care for gunshot and non-gunshot injuries of the skull and brain is based on two basic principles: 1) assistance as soon as possible after injury; 2) full, comprehensive 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 VPNhG.

Rice. 14.18. Tidal drainage after PSO surgery of a craniocerebral wound

Walking wounded with gunshot and non-gunshot head injuries, in whom the medical hospital has not identified focal symptoms of brain damage and the penetrating nature of the injury has been excluded, are sent for treatment to the VPGLR, where there is a specialized neurological department for them.

Control questions:

1. Name the signs of penetrating injury to the skull and brain.

2. What criteria underlie the distinction between open craniocerebral injuries and penetrating injuries of the skull? Name the possible complications of penetrating head wounds.

3. How does the clinical picture of a brain contusion differ from a concussion?

4. What is the difference between the clinical picture of a moderate brain injury and a mild injury?

5. Name the main clinical difference between severe and non-severe traumatic brain injuries.

6. What degrees of impairment of consciousness are characteristic of severe brain contusions and how do they differ?

7. Name the main reasons for the development of cerebral compression.

8. What clinical picture is characteristic of the development of cerebral compression?

Gunshot traumatic brain injuries (GCI) are divided into three groups: tissue wounds, non-penetrating and penetrating.

Soft tissue injuries with damage to the aponeurosis should be regarded as open damage skull, which can lead to infectious and inflammatory intracranial processes (meningitis, encephalitis, etc.). OCMR with a bone fracture without damage to the dura mater are classified as non-penetrating damage. OCMR with bone fractures, damage to the dura mater are classified as penetrating damage. In case of damage to the dura mater, there is always a risk of intracranial infectious and inflammatory complications.

By type of wounding projectile gunshot wounds are divided into bullet and fragmentation wounds (metal fragments, balls, arrow-shaped elements, etc.) and wounds from secondary projectiles (fragments of rock, glass, brick, cement, wood, etc.).

Non-penetrating injuries of the soft tissues of the skull lead to severe craniocerebral injuries as a result of concussion or contusion of the brain and the formation of intracranial hemorrhages.

Penetrating NMR always causes severe concomitant brain damage, both local at the site of injury and generalized. Bullets, having high kinetic energy, cause significant destruction of the brain in the circumference of the wound channel due to shock-concussive 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 destruction of the bone and brain with the available kinetic energy and their mass. When exhausted or when hitting a metal helmet, they lead to concussion, brain contusion and less significant brain damage. The danger of shrapnel wounds is their significant infection and multiplicity of wounds.

According to the type of wound channel wounds are distinguished: 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 canal and the foreign body are located in the same part of the brain to which the skull defect is adjacent) (Fig. 73, 1); radial (the foreign body reaches the falciform process and, having lost its “strength”, stops at it) (Fig. 73.2); segmental (the foreign body passes 2 - 3 lobes of the brain and stops at the inner surface of the bone, the wound channel in this case forms a segment in relation to the round shape of the skull) (Fig. 73.3); diametric (a foreign body passes through the medulla and stops at the inner surface of the bone opposite the entrance hole and bone fracture) (Fig. 73, 4).

When assessing a skull injury, it is important to take into account the location, side, singleness, multiplicity, combination with other injuries and combinations with other traumatic factors.

By brain region wounds are divided as follows: frontal, parietal, temporal, occipital. Parabasal injuries are divided into anterior (fronto-orbital, temporo-orbital, with damage paranasal sinuses nose, wounds of the eyeball), middle (temporomastoid, with damage to the paranasal sinuses) and posterior (posterior cranial fossa, craniospinal). Parabasal injuries are often combined.

Rice. 73.

1 – simple; 2 – radial; 3 – segmental; 4 – diametrical

Skull injuries may be single-legged And multiple, isolated And cohet.

Type of gunshot fracture 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 skull defect or move inside the skull;

– perforated – characterized by a small defect of the skull, deep displacement of bone fragments and foreign bodies. Perforate fractures can be blind, through and vertical. Depending on the location of the foreign body, a perforated blind fracture can be simple, radial, segmental, diametrical or comminuted (Fig. 73). At penetrating wounds The entrance hole of the skull and brain is usually small; not far from it along the wound channel there are small bone fragments. The exit hole is much larger in size and is characterized by greater bone damage and extracranial displacement of bone fragments. A perforated vertical fracture occurs as a result of bone trauma and the 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 skull defect and deeply located (plumb) bone fragments;

– comminuted – characterized by extensive fragmentation of the bone with the formation of large bone fragments and gaping cracks extending from the defect.

For bullet wounds Peacetime is characterized by the proximity of a shot (suicide attempt, crime 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 homemade weapons typically result in a combination of injuries to the face, neck, jaws, eyes, and hands. Shot wounds are usually multiple and blind. In a gunshot wound, three zones are distinguished: the zone of the primary wound channel, the zone of contusion (primary traumatic necrosis) and the zone of molecular concussion. The wound canal is filled with scraps of dead tissue, blood clots, and foreign bodies. The walls of the wound canal form a zone of contusion (primary necrosis). To the periphery of this zone are tissues exposed to the shock wave, and not the wounding projectile itself (molecular concussion zone). Figuratively speaking, a gunshot wound is a “cemetery nerve cells, conductors and blood clots." Under unfavorable conditions, the tissues of this area may become partially necrotic (secondary or subsequent necrosis).

All gunshot wounds from the moment they are inflicted contain a variety of microorganisms and can be considered primarily infected. If medical care is not provided adequately, germs can get into and out of the wound. environment(secondary microbial contamination).

Bacterial contamination of a wound must be distinguished from an infected wound, when microbes that have penetrated into non-viable tissue 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 the TBI and lasts from 2 to 10 weeks. All victims with gunshot wounds are considered the most severe, urgent, requiring specialized assistance. Therefore, such victims must be transported as soon as possible to a specialized hospital, where the necessary conditions are available to provide full assistance. In the absence of the possibility of transportation and contraindications to it, surgical intervention at the stage of qualified care is carried out only in case of increasing bleeding and compression of the brain.

Emergency care for patients with gunshot wounds consists of normalizing breathing and hemodynamics, preventing and stopping increasing edema-swelling of the brain, and infectious-inflammatory complications.

General principles of intensive care for gunshot herepno-cerebral wounds.

1. Ensuring adequate gas exchange (breathing). If necessary, intubation and mechanical ventilation.

2. Maintaining optimal systemic and cerebral perfusion pressure, blood volume, central venous pressure.

3. In order to increase the brain’s resistance to possible disorders gas exchange and blood circulation, 5 mg of veropamil is administered intravenously as a bolus, followed by a slow infusion of 2 mg/hour. In addition, with infusion media it is introduced magnesium sulfate 10 mg/kg, lidocaine 4 - 5 mg/kg, sodium thiopental, GHB, diazepine drugs (Relanium, Sibazon, Seduxen, etc.), antioxidants (Vit E - 5ml/m2 - 3 times a day).

4. Maintaining water-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, and decreased perfusion in the first place queue of damaged structures. Maintain hematocrit at 30-35%.

5. With increased intracranial pressure (ICP) - elevated position of the head end by 30°, moderate hyperventilation, mannitol 20% - 0.5 - 1.0 g/kg body weight in 10 minutes. To enhance the effect of the osmodiuretic, furosemide 0.5-1.0 mg/kg is additionally administered.

6. Corticosteroids: metiped - 20 mg/kg or dexamethasone 1 mg/kg, then 0.2 mg/kg intramuscularly every 6 hours.

7. Stable acid-base state.

8. Improving metabolism (nootropics, essentials).

9. Inhibitors of proteolytic enzymes (trasylol, contrical, gordox).

11. For convulsions - sodium thiopental, diphenine, seduxen, etc.

12. For hyperthermia - lytic mixtures and physical cooling methods.

13. Prevention of infectious and inflammatory complications, antibiotics, PCP of wounds.

14. Providing nutrition of approximately 30 kcal/kg body weight per day.

15. Control collateral damage, 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 into a wound infection, therefore all gunshot wounds should be considered infected and subjected to surgical treatment. Thus, surgical treatment of gunshot wounds is the main therapeutic measure.

Surgical debridement helps prevent wound infection, promote successful wound healing, and provide more favorable results. The quality of surgical treatment depends on the level of qualification of the specialist, clear knowledge of the topographic anatomy of the damaged area, good practical skills and the availability of appropriate equipment and instruments.

Main types of surgical treatment of wounds:

primary – the first surgical intervention performed on a wounded person for tissue damage. Its main task is to create unfavorable conditions for the development of wound infection;

secondary - intervention undertaken regarding subsequent (secondary) changes in the wound caused by various complications;

repeated – the second operation, performed even before the development of wound complications if the primary treatment is inadequate.

Primary surgical treatment (PST) of head wounds is more effective the earlier it is performed. It helps accelerate wound healing and improve treatment results. The earlier and more radical the surgical treatment is performed, the better the results. The appearance of signs of wound suppuration does not prevent surgical intervention, which prevents more severe infectious complications. Delay in surgical treatment of the wound, even under the protection of antibiotics, can lead to the development infectious complications.

Depending on the timing of the PHO, it 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 surgical treatment of wounds requires early use of antibiotics, which reduce the risk of infectious complications.

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 the free outflow of discharge from the wound in case of already developed infectious complications, mainly by opening purulent leaks, applying counter-openings and good drainage. Excision of dead tissues during these periods can be carried out more completely, since by this time their delimitation from living tissues (demarcation) is clearly visible.

Before surgical treatment, it is necessary to clarify the nature of the wound, determine the direction of the wound channel for penetrating wounds, and study x-rays, perform echoencephaloscopy and outline a preliminary operation plan, taking into account the general condition of the patient and existing neurological symptoms.

Primary surgical treatment should be carried out with strict adherence to asepsis, antiseptics and adequate pain relief.

When choosing a method of pain relief, an individual approach is required, 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 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) adequate drainage.

Searching for and removing foreign bodies located far from the wound canal should not be more dangerous for the wounded than the wound itself, especially for metal objects in the cranial cavity.

It must be taken into account that even radical and early PST of a gunshot wound does not guarantee the absence of the appearance of new foci of necrosis and the development of infectious complications. Therefore, PCP of wounds is supplemented with various chemical and by physical methods her cleansing.

As already mentioned, the best results are obtained by early treatment of the wound. This makes it possible to achieve smooth wound healing, minimize infectious complications, and apply primary plastic surgery of the dura mater and skull defect. The sooner a person wounded in the skull is taken to a specialized department, and the sooner he is operated on, the more opportunities there are for an uncomplicated course of the injury.

Preparation of the surgical field start by shaving your head. It is imperative 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 rules of asepsis and antiseptics. The planned surgical incisions are marked on the prepared area.

After this, the surgical field is isolated with sterile linen.

In addition to the standard set of neurosurgical instruments, it is necessary to have a magnet pin for removing 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 given 1 - 2 ml of a 2% solution of promedol, diphenhydramine, analgin. In patients with penetrating wounds, treatment is carried out under general anesthesia. Local anesthesia is performed with a 0.5 - 1% solution of novocaine with the addition of a non-epileptogenic antibiotic.

Selecting the type of section must take into account the location, direction of blood vessels and nerves, as well as cosmetic considerations. Usually a bordering or arcuate incision is made. Through wounds with a short skin bridge are excised with a single incision.

It is not advisable to use horseshoe-shaped incisions to avoid infection of gunshot wounds.

In the fracture projection, soft tissues are excised immediately to the entire depth to the bone in one block. The periosteum is peeled off to the periphery for more convenient biting of the bone. Incomplete skull fractures in the form of superficial scratches, gouges or usurs are processed 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 vault cracks without gaping and visible contamination (hair, dirt, particles of headwear), and in the absence of signs of intracranial hematoma.

Surgical treatment of depressed fractures without significant displacement of fragments is carried out according to the rules set out in Chapter VII. When treating comminuted fractures, first, small bone fragments of the outer plate are removed using a sharp spoon, then the fragments of the inner plate of the skull are carefully removed with tweezers. Perforated fractures are carefully cleaned of loose bone fragments and foreign bodies. Subsequently, the bone defect is successively expanded with pliers until an unchanged dura mater appears.

When performing trephination of the skull, it is necessary to treat the cracks extending from the defect, especially if they gape. To do this, semi-oval excision of the edges is performed at the beginning of the extending crack at a distance of 0.5 - 1 cm along the course of the latter.

Penetrating wounds are treated starting from the entrance hole. In case of perforated through fractures of the segmental type, when there is a small bone bridge between the entrance and exit 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 holes is large, then it is advisable to preserve the bone bridge and cover 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 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 tissue and have not lost connection with the periosteum should not be removed. In such cases, the edges of the bone fragments facing the wound are brought together. To avoid tearing them off from the periosteum, movable bone fragments are fixed with bone forceps. And then their edges are refreshed.

The decision on the need to dissect the intact dura mater is responsible. Indications for its dissection are set out in the section general principles craniotomy.

At penetrating wound primary processing deep parts of the wound are more complex. First, the bone fragments filling it (“bone plug”) are carefully removed from the dura defect. This removes the obstacle to outflow from the wound canal. Then the tip of an aspirator or a vinyl chloride tube is inserted into the wound canal and, gradually immersing it, the contents of the wound canal are sucked out: destroyed brain particles (detritus), blood clots, bone fragments, hair, pieces of headgear and other foreign bodies. In this case, the depth of insertion of the aspirator or tube is correlated with craniography data on the depth of bone fragments and their location. Aspiration of the contents of the wound canal is 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 brain matter and not cause bleeding from thrombosed vessels.

In the absence of signs of brain swelling, a technique that artificially increases intracranial pressure can be used. Temporary compression of the victim's jugular veins promotes the movement of the contents of the wound canal to more superficial parts of the wound. In this case, brain detritus, blood clots and bone fragments are squeezed out of the wound canal, after which they are removed. Subsequently, the wound is carefully washed from a rubber bulb with an isotonic solution of sodium chloride, and the remaining contents of the wound canal are removed. The appearance of pulsation of the medulla after these measures indicates the completeness of the treatment of the wound canal.

What to do in those situations when, with the above techniques, metallic fragments and deep-lying bone fragments do not move independently to the surface of the wound? It is necessary to carefully expand the wound canal with brain spatulas and illuminate it in order to remove the fragment under visual control with tweezers or using an aspirator. It is also possible to use a special magnet.

Is it possible to perform a digital inspection of a brain wound in search of foreign bodies? Only in exceptional cases is a foreign body felt with the tip of the little finger. For this purpose, the tip of the little finger is carefully inserted into the wound canal. Having determined the localization of the foreign body in the brain, tweezers with long jaws or nasal tweezers curved at an angle are inserted along the little finger, with which the bullet or fragment is grasped. Then the finger is removed and the instrument with the foreign body is very carefully removed. This procedure sometimes has to be repeated several times. Only after removal of all bone and accessible metal foreign bodies is the brain wound considered radically treated.

In case of penetrating wounds, it is necessary to perform radical PSO - removal of all non-viable tissues: detritus, blood clots, accessible foreign bodies, crush areas. Subsequent repair of dura mater defects can be performed with artificial or preserved hard meninges. It is advisable to use a constant rinsing system to treat the wound channel. The washing liquid washes out necrotic tissue, blood clots, brain detritus, and brain decay products without causing additional trauma to the brain. The inflow drainage, through which solutions with antibiotics are infused, is tightened daily by 1 - 2 mm until it is completely removed from the wound channel, and after that the system is completely removed.

Hemostasis is carried out according to generally accepted rules set out in Chapter VI.

How to complete the operation? Is it possible to stitch a wound tightly? In peacetime practice, blind soft tissue closure is generally accepted. Primary plastic surgery of artificial dura mater defects using alloplastic films (polyethylene, etc.) or lyophilized shells is becoming widespread. In the absence of contraindications, the bone defect can be closed with quick-hardening plastics (protacryl, butacryl, noracryl, etc.). However, it is advisable to perform primary plastic surgery in specialized departments, during early operations and long-term observation of the wounded in the postoperative period. A blind suture is placed on a cranial wound in cases where a neurosurgeon treats a wounded person in the skull and brain in the early stages, when the operation can be performed carefully and radically. A blind seam is applied to the covers in one row. The graduate is left between the seams for 1 - 2 days. The use of antibiotics for prophylactic purposes, as well as systematic observation of the operating specialist, is mandatory.

Thus, PST of a gunshot wound of the skull and brain comes down to solving 4 main issues: indications, timing, technique and place of primary trepanation.

PSO is not performed on wounded people with impaired vital functions or with extensive wounds incompatible with life. In case of shock, anti-shock therapy is carried out in the pre- and postoperative period. Wounded people with depression of consciousness to the point of coma should be operated on only if the severity of their condition is due to increasing compression or expansion of the area of ​​brain contusion.

We agree with the opinion of many authors that only a neurosurgeon should treat traumatic brain wounds. To do this, in cases of non-transportability of the victim, a neurosurgeon from the regional center for disaster medicine must be called to the stage of qualified assistance. This can significantly reduce the number of errors made by general surgeons and traumatologists, thereby improving outcomes.

During surgical treatment non-penetrating gunshot wounds You can limit yourself only to the removal of bone fragments, and, if necessary, bone resection, removal of bone fragments that have moved into the epidural space, removal of epidural hematomas, followed by installation of a flushing system and the application of a blind suture. The indications for dissection of the dura mater and revision of the subdural space have already been discussed in previous chapters.

Basic rules for surgical treatment of gunshot wounds of the skull and brain.

1. In the absence of contraindications, treatment of a gunshot wound should be carried out in the first 24 hours after the wound.

2. If transportation is necessary, use modern, fully equipped vehicles: helicopters, airplanes, ambulances.

3. Early implementation of a complex of intensive therapy at the emergency stage in order to stabilize vital functions and prepare for surgery: analgesics, intubation, cardiotonics, etc.

4. Prevention of infectious complications through 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. PCO should be as radical as possible.

9. A closed suture can be placed on the wound only after radical surgical treatment has been performed in the first 24 hours in a specialized hospital.

10. Use of tidal systems.

Tactics for managing the wounded in the postoperative period

Victims with gunshot wounds require careful ongoing care and qualified treatment.

The patient should be laid with the head end of the bed raised in such a way that the site of the skull injury where the operation was performed is not pressed against the pillow. An elevated head position of 15–30° reduces intracranial pressure by improving venous outflow.

Food should be high-calorie and highly digestible.

To avoid vomiting, it is recommended to feed the wounded 5 to 6 times a day in small portions. If swallowing is impaired, feeding is provided through a tube. In those wounded in the skull and brain, the functions of urination and defecation are often impaired, which requires the necessary therapeutic and hygienic measures.

After treatment of a wound to the head and brain, patients are drowsy, lethargic, do not ask to drink or eat, and may long time be motionless. Attentive care for them, careful feeding, monitoring the cleanliness of the bed are a necessary condition in the treatment of neurosurgical wounded, and 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 postoperative wound management. The wound is examined the day after the operation, accumulated blood is removed, and drainage tubes are tightened. The infected wound is examined 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 the release of pus. When the body's resistance decreases, microbial contamination leads to the development of infectious complications.

After treating damage to only the soft tissues of the skull, it is recommended to remove the sutures on the 7th – 8th day. If the injury is penetrating in nature, with a tendency to the formation of brain protrusion or postoperative liquorrhea, the sutures are removed on the 9th – 10th day. With “open management” of a wound, the frequency of inspection depends on the severity infectious processes. So, when an ointment bandage-tampon (such as a Mikulicz bandage) is applied and the course is smooth, dressing and inspection of the wound is carried out no more than once a week. For an infected wound with a fetid odor and purulent discharge, loose dressings moistened with a hypertonic sodium chloride solution should be used. Such dressings have to be changed daily, or even 3-4 times a day. It is advisable to use sorbents and hygroscopic gauze. Quartz irradiation of the wound, recommended 7–10 days after injury, promotes rapid rejection of necrotic areas and the appearance of granulations. In the presence of liquorrhea, applying a bandage without changing it for 10 to 12 days is recommended. Lumbar punctures or lumbar drainage are performed.

Particular attention is required in the management of wounded patients with secondary cerebral prolapse, which develops under the influence of traumatic cerebral edema or as a result of infectious complications. When bandaging, the brain protrusion is carefully washed with a 3% solution of hydrogen peroxide or a weak antiseptic solution.

It is unacceptable to cut off the protrusion in order to avoid generalization of the encephalitis process into the depths of the brain or perforation of the cerebral ventricle with the development of porencephaly. Depending on the state of brain protrusion, the type of bandage is chosen. With “benign prolapse” (according to the terminology of N. N. Burdenko), when the protruding substance of the brain does not have visible damage or covered with granulations, the use of emulsions and ointments containing antibiotics or antiseptics is recommended.

For “malignant prolapse” of the brain, which has the appearance of disintegrating and necrotizing brain matter, wet-dry dressings moistened with a hypertonic sodium chloride solution are indicated. If “benign” protrusions are recommended to be bandaged once every 5–6 days, then disintegrating ones (purulent-necrotic, hemorrhagic) require daily dressings.

Application ultraviolet irradiation promotes the rejection of purulent-necrotic masses and the appearance of granulations. After applying the bandage, the brain protrusion must be protected with a cotton-gauze “donut” secured over the bandage. This is especially important for the restless behavior of those wounded in the head.

When treating head wounds, the issue of continuity is very important. What should be the minimum length of stay of a wounded person in the hospital where the operation was performed? 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 cranial 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 evacuation of the wounded.

For non-penetrating injuries of the skull, transportation in most cases is possible within 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 period of hospitalization should be increased.

The most typical mistakes in surgical care for head wounds are:

1. Carrying out non-radical surgical treatment of a gunshot wound leaving non-viable tissue, 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 “nickels” for multiple superficial wounds from small fragments.

4. Unreasonable expansion of emergency indications surgical interventions at the stage of qualified medical care for those wounded in the head, conducting surgical intervention wounded in a state of shock with disturbances in vital functions without appropriate anti-shock infusion-transfusion and intensive care.

All this leads to an increase in the number of unfavorable outcomes in the treatment of head wounds.

Compliance with the basic rules of surgery and pathogenetic treatment for victims with gunshot wounds to the head, outlined in this chapter, will improve the quality of medical care and increase the survival rate.