Debridement of craniocerebral duct injury

In craniocerebral penetrating penetrating injuries, blind tube injuries account for 60% to 70%, and the projectile penetrates into the cranial cavity, with only the entrance and no exit. In the near segment of the brain injury, many skull fragments and foreign objects such as hair and sediment are carried, and the projectiles of the shrapnel and bullets stay at the farthest end of the wound. Brain injury varies in depth and direction, and Babchin divides the brain tube blind injury into one: 1 simple type. 2 radius type. 3 segment type. 4 diameter type 4 type. The severity of the injury is often related to the length of the injury and the importance of the damaged structure. The incidence of this type of injury is high, there are many foreign bodies in the skull, and infectious complications are common. It is the focus of debridement surgery in wartime craniocerebral firearm injuries. The purpose of brain debridement is to remove broken bone fragments and achievable (without increasing damage) metal foreign bodies, inactivated brain tissue, clots and hematomas, and completely stop bleeding, to maximize the preservation of nerve function, requiring 1 time Surgery is the purpose of debridement. To this end, in addition to intracranial hematoma caused by cerebral palsy in the first line of emergency surgery, those who can be sent to second-line hospitals within 2 or 3 days, should be debrided by the neurosurgical team. When many wounded people arrive at the same time, the order of debridement is as follows: 1 Immediately, the brain wound has active bleeding. 2 Hematoma wounds on one side or both sides of the pupils are generally more quickly by the entrance to enlarge the bone window to clear the proximal hematoma of the wound, the hematoma is far from the entrance, or in the contralateral hemisphere, should be opened separately in the adjacent hematoma Clear it. 3 brain wounds a large number of cerebrospinal fluid outflow should be operated early. 4 Intracranial penetrating wounds, the longer the injury time, the first surgery. 5 pairs of craniocerebral penetrating injuries should precede the brain non-penetrating injury surgery. Treatment of diseases: head injury Indication 1. The wounded are generally in good condition. Debridement should be prepared after the wound examination and skull imaging to understand the distribution of foreign bodies. 2. The wounded are in a coma, and those with intracranial hypertension and cerebral palsy should be debrided immediately. 3. The wounded have been debridement in the first-line hospital. After the hospital, the cranial bone film proves that there are many broken bone fragments or large shrapnel above 1cm in the brain, and should be prepared for reoperation. Contraindications 1. The injury is serious, manifested as deep coma, pathological respiration, blood pressure drop, pulse frequency is weak, suggesting brain stem failure, not suitable for brain debridement, supportive therapy should be performed. 2. With multiple injuries such as chest and abdomen visceral injuries, pale complexion, weak pulse, and decreased blood pressure, it is not suitable for brain debridement. Should first resist shock and treat chest and abdomen organ injury, and then go to brain debridement after the condition is stable. 3. A few days after the injury, the brain has a purulent discharge in the wound. It is not suitable for brain debridement. After the infection is controlled, the debridement is performed in the late stage. 4. After the brain debridement, the wound has healed. After imaging examination, it shows that there is still a single bone piece or a <1cm shrapnel in the deep brain. Without signs of infection, there is no need to debride again. Preoperative preparation 1. Prepare the skin, first wash the head with soap and water, and shave the head on the eve of surgery. Fasting before surgery. One hour before the operation, 0.1 g of phenobarbital, 0.4 mg of atropine or 0.3 mg of scopolamine were intramuscularly injected. 2. Tetanus antiserum 1500U. 3. Take the positive and lateral slices of the skull to understand the number, size and location of intracranial fragments and metal foreign bodies. 4. CT scans are available when conditions are available to understand the extent and extent of brain injury. There is no intracranial hematoma, its size and location. Surgical procedure 1. Treatment of common type injuries (1) Scalp incision: An "S" shaped incision (Fig. 4.2.2.1-2A) or a fusiform incision is made centering on the entrance. Tripod incisions that have been used in the past are rarely used because of the often necrosis of the tip of the flap and the poor healing of the wound. When the entrance is in the face, the forehead or the forehead, or the metal foreign body reaches the contralateral cerebral hemisphere or the ipsilateral hemisphere, because the craniotomy is required, the flap incision is often used, but some authors use the incision. Blind tube injuries in the front, top, and ankle also advocate a flap incision centering on the entrance. When the scalp has a large defect in the scalp, it is difficult to suture, and the brain is exposed, a transfer flap can be used and an incision can be designed. The scalp wound edge cuts a narrow strip so that it does not cause difficulty when suturing. (2) Skull treatment: Generally, a cranectomy or a bone window craniotomy is performed by using a rongeur to enlarge the cranial cavity fracture from the entrance, and a bone window of 4 to 6 cm in diameter can be satisfied. The need for debridement of the brain, excision of the bone to reveal a normal dura mater about 1 cm. If the entrance is through the face, the forehead, or the forehead, or when removing a large metal foreign object that reaches the contralateral cerebral hemisphere or the ipsilateral hemisphere, in order to avoid causing a large skull defect, the craniotomy can be performed. In recent years, some authors reported that there is a tendency to perform brain debridement with a craniotomy of the craniotomy. (3) Dural incision: the entrance of the dura mater is cut with scissors and then trimmed, then cut longitudinally, and then retracted through the two sides of the suture to reveal the brain area of the entrance; When the bone flap is craniotomy, the dura mater is cut open and turned in the opposite direction to the bone flap, ready to enter the brain for debridement. (4) Brain debridement: When the brain entrance is enlarged, the important functional area of the brain should be avoided. The brain pressure plate should be gently pulled along the brain injury to both sides. Pay attention to the tracking of the brain injury and avoid creating false roads. Missing the wounded, this not only increases brain damage, but also is difficult to thoroughly debride. Broken bone fragments scattered in the proximal segment of the cerebral injury, such as broken shrapnel, hair, scalp fragments, hat fragments and sediment, etc. should be removed one by one, the number, size, shape and position of the removed bone fragments should be related to the skull The plain film is carefully checked. If there is any leftover, you can gently touch the injured road with your fingers. By using your fingers to identify the sensitive functions of different tissues, it is very helpful to find the bone fragments or shrapnel adjacent to the injured road. Weaver proposed to take the positive and lateral slices of the skull next to the operating table, and to find the number and location of the remaining bone fragments, and strive to completely remove them. Some size shrapnel that remains in the proximal wound can also be sucked out by magnetic bars. Excised bone fragments and shrapnel should be kept for bacterial culture. Small shrapnel or single broken bone pieces that are less than 1cm in the deep part of the brain are not easy to be infected. In the search, the damage can be increased, and it is not worth the loss. For large shrapnel or bullets with a length of 1cm or more, the chance of causing intracranial infection is greater, and it remains in the deep or distant parts of the brain. For example, in the case of debridement and craniotomy, the wounded are more difficult to tolerate. A few weeks after debridement, the patient was re-craniotomy or removed by stereotactic surgery when the injury was stable. During and after the removal of foreign bodies in the brain injury, it should be washed repeatedly with a large amount of normal saline (antibiotics can be added). Brandvold et al (1990) proposed that the less aggressive approach is mainly: 1 repeated flushing of the brain injury with saline; 2 using the brain platen without excessive pulling; 3 the aspirator head does not directly contact the brain parenchyma. Minimize the damage of the surgery. The brain injury is treated by bipolar electrocoagulation to stop bleeding. For example, the brain injury is soft or collapsed, and there is brain pulsation, which indicates that the brain is completely debrided and can be prepared to close the skull. For example, due to brain swelling and difficulty in craniotomy, after removing deep brain hematoma or a large amount of necrotic brain tissue, the bone window can be enlarged, and the dura mater can be cut for decompression. (5) Wound suture: During the Second World War, after traumatic brain injury, whether the wound was sutured or not, there were differences of opinion. At present, due to the accumulation of specialist treatment experience, the development of antibiotics, wounds can be sutured after a thorough debridement by a neurosurgical team or hospital several hours after the injury. However, if the conditions are limited, the first-line hospital only removes the hematoma in the wound, and the brain bone fragments are not cleared or mostly cleared, or the brain debridement performed more than 3 days after the injury, the wound should not be sutured or only done after the operation. Partially stitched. 2. Treatment of special types of injuries (1) Transethmoidal sinus wounds: The projectile is injected through the face and enters the brain through the ethmoid sinus and the sieve plate. Often accompanied by cerebrospinal fluid rhinorrhea, and occasionally intracranial gas accumulation. The facial injection edge is slightly trimmed and stitched. A coronal incision is made in the hairline of the forehead to form a lateral or bilateral forehead bone flap. The bone flap and the dura mater are opened, the frontal lobe is retracted backward, and the dura mater is seen at the sieve plate, the olfactory bulb, and the olfactory bundle. mouth. Look for the entrance to the brain injury, complete the brain debridement along the brain injury, and then take a cap-like aponeurosis or fascia fascia covering the dura mater, olfactory bulb and olfactory bundle of the sieve plate, and suture it at the edge of the fascia with silk thread. . This dural repair method is easier to operate than the epidural repair method, and can also retain the olfactory nerve, and is reliable for preventing cerebrospinal fluid leakage. (2) Transfrontal sinus wounds: a blind tube injury through the frontal sinus, debridement and sinus sinus injury, the scalp soft tissue wound edge is slightly cut and repaired, and then forehead The intracranial coronal incision, unilateral or bilateral prefrontal craniotomy (Figure 4.2.2.1-5A), the cranial flap turned to the temporal side, the dural flap turned back. After the brain debridement (with blind tube wound debridement), the dura mater is trimmed and tightly sutured, and then a fascia is used to cover the suture to strengthen the repair. Suture the dural incision to achieve no leakage of cerebrospinal fluid. The posterior wall of the frontal sinus on the injured side was removed, and the frontal sinus mucosa was scraped off. The frontal nasal canal was filled with bone wax or with a drainage tube through the frontal nasal tube and nasal cavity. The drainage of the epidural space was performed, the bone flap was repositioned, and the suture was layer by layer. (3) Transorbital wounds: The projectile enters the skull through one eyelid. The debridement surgery should be studied together with the ophthalmologist to determine or preserve the eyeball according to the condition of the eyeball injury. Generally, the intracoronary coronary incision is made, and the ipsilateral frontal anterior frontal craniotomy is performed. The dura mater is opened and the foreign body of the brain is removed. The brain debridement is the same as before, and the metal foreign matter remaining depends on its size and position to decide whether to remove it. (4) transventricular wounds: the projection of the projectile into or through the ventricles, the incidence of which accounts for about 15% of craniocerebral penetrating injuries. Most of them are lateral ventricle injuries, and the third ventricle is rare. If there are broken bone fragments, shrapnel and a large number of blood clots in the ventricle, it should be removed along the injured road into the lateral ventricle. If the metal foreign body moves inside the ventricle, the injured person's head position can be moved during the operation, and the foreign body is moved to the rupture of the ventricle to be removed. (5) sinus injury (wounds of venous sinus): the projectile penetrates into the cranial cavity and damages the sinus. Its incidence accounts for about 4% of craniocerebral penetrating injuries. The above sagittal sinus injury is more common, and the transverse sinus and sinus sinus damage are second. Other sinuses are rare. In order to restore patency of the sinus and prevent infection, large fractures and shrapnel piercing the sinus should be removed. However, it is absolutely impossible to remove the bone fragments or shrapnel that have been pierced into the sinus before the surgical field is ready for exposure to the surrounding area of the sinus injury. It is difficult to directly compress the sinus or press the sinus cavity effectively. Controlled bleeding can be life-threatening. The correct treatment method is to drill 4 holes in the periphery of the skull entrance, that is, the sinus injury, bite the bone with a rongeur, and then prepare the muscle or fascia, gelatin sponge, massive blood and pressurized blood transfusion. In this case, the isolated bone piece and the bone piece or shrapnel piercing the sinus are taken out. At this time, the bleeding is often very turbulent, the surgeon can immediately block the sinus of the sinus with a finger or temporarily close the sinus cavity, check the size and extent of the sinus rupture, according to its different damage conditions for corresponding treatment. complication Traumatic infection Seen in the time delay of brain debridement, or insufficient debridement, the brain still contains some broken bone fragments, inactivated brain tissue and clots. The infection should be controlled and the local treatment of the wound should be strengthened and debrided again if necessary. 2. Brain highlight More common after debridement, the brain tissue bulges outward through the bone defect, due to brain swelling and edema, traumatic hematoma or local infection of the wound, etc., should be treated according to the cause. Since the brain tissue of the external process is still lifeless and should not be removed, a cotton ring should be placed around it to protect it with rubber strips. 3. Meningitis Most of them are due to insufficient brain debridement, leaving a variety of foreign bodies, inactivated tissues and blood clots to cause good breeding conditions for bacteria. Sensitive to antibiotics for pathogenic bacteria, including intrathecal injection. 4. Skull osteomyelitis Trauma infection affects the skull and forms marginal osteomyelitis, also seen in frontal sinus infections. The wound forms part of the chronic sinus, often with dead bone formation and with epidural abscess or granulation tissue. After the infection is controlled, the surgery extensively removes the bone damaged by the inflammation to reveal the normal dura mater, and the wound can be cured. 5. Brain abscess If there are no debridement in the brain, the brain remains in the brain. Among them, about half of them have intracranial infections, mainly brain abscesses, especially in dense bones. Large shrapnel above 1cm can also cause brain abscess. CT examination can understand the location, size and film formation of the abscess, and its relationship with the bone piece or shrapnel. Treatment is based on the formation of an abscess membrane, using different surgical methods. 6. Traumatic epilepsy The incidence rate is 15% to 20% in craniocerebral penetrating penetrating wounds, and most epileptic lesions are located in the marginal zone of meningeal brain scar. The antiepileptic drug should be taken first. If the episode is frequent and the drug control is ineffective, the epileptic foci can be found under the examination of the EEG cortical electrode, and the subdural transverse fiber is cut or the lesion is removed.

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