Debridement of craniocerebral rebound injury

The projectile hits the head and collides with the skull to cause a penetrating brain injury, while the metal foreign body is bounced back and distant. There is only one wound in the head, which is both the entrance and the exit. The skull has a hole-shaped fracture. The broken bone piece penetrates the dura mater into the brain, and the depth is different. This type of injury accounts for about 5% of craniocerebral penetrating penetrating injuries. The injury is generally lighter, but it is necessary to be alert to the emergency caused by the combined intracranial hematoma to avoid delay in treatment. Treatment of diseases: brain trauma, open brain trauma 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. 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 Scalp incision An "S" shaped incision 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. The entrance is in the face, the ankle or the forehead. Because the craniotomy is required, a flap incision is often used. 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. 2. Skull and dura treatment According to the size of the bone fragments in the brain and the depth of the distribution, the size of the bone window is determined, or the fracture of the skull is small, and the craniotomy with the bone fracture as the center can be used. Can avoid 1 skull surgery. The dura mater can be prepared for brain debridement with a little pruning. 3. Brain debridement This type of broken bone fragments is concentrated in the brain injury, and there are no metal foreign bodies, and there are fewer shredded brain tissues and blood clots. The debridement surgery is not complicated. The brain plate is opened and the brain is wounded. All the bone fragments and blood clots are removed. Inactivated brain tissue to achieve thorough debridement. 4. Wound suture The fascia was used to repair the dural defect, and the aponeurosis and the skin were sutured without tension. 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 Most epileptogenic lesions are located in the marginal zone of the 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.