External traumatic brain injury

2021-01-30 12:00 AM

Mechanisms of traumatic brain and brain damage include mechanical factors, cerebrospinal fluid dynamics, blood vessel factors, vascular factors, neuroendocrine factors. mechanisms of brain and skull damage.

External traumatic brain injury

Outline

Traumatic brain injury has been studied for a long time. From the Hippocrates period (460-377 BC) there have been studies on skull bleeding. Until the early 18th century, people understood the mechanism of hematoma compression in traumatic brain injury. Over the past 20 years, the neurosurgery industry has made rapid progress, most notably thanks to the computerized X-ray machine in 1972, and advances in surgical techniques, especially microsurgery, resuscitation anesthesia, diagnosis, and treatment have made many significant signs of progress.

Classification

Primary injury

These are injuries that happen during the trauma. Examples are brain concussions, skull fractures, brain crushing.

Secondary injury

Post-traumatic lesions are usually acute, subacute, and chronic intracranial hematomas. Epidural, subdural, and intracerebral or a combination of hematomas in the same patient.

Mechanism of pathogenesis

Mechanisms of traumatic brain and brain damage include mechanical factors, cerebrospinal fluid dynamics, blood vessel factors, vascular factors, neuroendocrine factors. mechanisms of brain and skull damage. In acute traumatic brain injury, the entire brain is shaken and stimulated, but the defining significance in the pathogenesis of acute traumatic brain injury is whether there is damage to the structure of the brain stem.

The linear and alternating displacement of the brain in the skull causes brain damage as the brain slides up the layers of the skull.

Immediate changes in the shape of the skull locally or entirely due to trauma lead to a rupture of the skull. The vasoconstriction in traumatic brain injury leads to cerebral ischemia, resulting in brain tissue and blood vessel necrosis causing secondary cerebral bleeding.

Clinical symptoms

Brain shock

Considered to be the mildest form of traumatic brain injury, the manifestation: consciousness disorder, perception disorder is usually a person with a head injury, then anesthesia for about 15 minutes until a few hours, then the patient gradually awakens.  which can be accompanied by vomiting, when headaches change position, this is especially common in children. The respiratory and cardiovascular changes are not much, the pulse can be fast or slow due to the presence of brain edema or not. The temperature usually increases in children, CSF pressure is usually within the normal range or slightly increases, sometimes decreases. Cerebrospinal fluid composition does not change.

The above symptoms such as headache, vomiting usually go away after 1-2 weeks of treatment and leave no sequelae, this indicates that the brain has no physical damage.

Skull fracture

The primary lesion in trauma can crack the skull from simple to complex, or rupture when the skull changes the size of the skull is indicated for surgery to remove or lift the subsidence. In addition, cracking is also the cause of epidural hematoma. However, craniotomy is also secondary: progressive craniotomy in children.

Is the area where bruises bleed. The bruise may be shallow at the cerebral cortex, possibly deep into the white matter of the brain, and can vary, but in general, the bruise is heavy or with brain edema has a high mortality rate. The brain shock can be just below the injury or just in the opposite area due to the collision mechanism. Often the manifestation of brainwashing is consciousness disorder immediately after trauma, depending on the degree of brain collapse, consciousness recovery time may vary from 5-10 days after the injury or 2-3 weeks after the injury.

Mental states such as screaming, struggling, and struggling are found in the vast majority of patients. Nervous and vegetative disorders are disorders of vital functions such as respiratory and cardiovascular disorders. In severe brain stroke in patients who die, in mild and moderate respiratory disturbances that are not serious and tend to improve, focal neurological manifestations detected immediately after trauma differs from hematoma.

Depending on the brain region that undertakes different functions, the localized nerve symptoms manifest differently. For example dilated pupils together with cerebral dams, damage to the cranial nerves such as III, V, VII wires; local epilepsy, hemiplegia, speech disorder, blurred vision, manifestations of cerebellar disorders.

Types of hematoma

Among the causes of brain compression, intracranial hematoma plays a leading role, depending on the location of the hematoma relative to the sclera and the brain organization that people divide the following: epidural hematoma, blood Subdural, hematoma in the brain and in the ventricles. For cerebellum tents, the blood is divided between tents and under tents.

Blood hematoma on the tent: temple, top, forehead.

Epidural hematoma

The main source of bleeding is a ruptured middle cerebral artery, which has many branches running on the sclera, which can be broken anywhere. When the arterial blood flows, the sclera separates from the bone. In fact, the epidural hematoma is formed from venous blood in the bone sinuses as well as tearing the venous sinuses of the cerebral sclera. Clinical manifestations of the typical epidural hematoma are as follows: after the patient directly trauma to the head, the patient falls immediately and loses consciousness, but after 5 to 10 minutes, he can wake up normally but after A few hours or so, the patient complains of headache, vomiting, and lethargy, so there is a suggested clinical space for diagnosis of acute epidural hematoma.

Subdural hematoma

The source of bleeding is usually a venous source of the cortex or from the cerebral cortex poured into the venous sinuses, blood formed between the cortex and the sclera. A subdural hematoma occurs in acute, subacute, and chronic forms.

Acute: Less than 3 days, when the surgery has red blood, sometimes flowing, often the manifestation of a heavily crushed brain area, the patient is lethargic and rapid after a strong injury with hemiplegia and dilated pupils on the opposite side. Severe cases will disturb breathing, have a spastic contraction, and brain loss. Subdural hematoma often has multiple damages to the brain.

Subacute: Before 3 weeks, the blood has turned black, after a minor head injury sometimes due to an insignificant injury after 2-3 weeks patient has headache, nausea, sometimes sluggishness, forgetfulness, eye edema, with mild paralysis. After surgery, patients usually recover completely.

Chronic type: After 3 weeks, the blood turns yellow due to hemoglobin nuclear rupture, the main cause is chronic meningitis (according to Virchov) and trauma is the easy factor when operating people see the components. The visible blood has been absorbed; the hematoma is only clear yellow fluid.

Coordinative injury

In severe traumatic brain injury in the same patient, there may be both an epidural, subdural, and intracerebral hematoma, and may be accompanied by open cranial lesions, or damage coordination of other organs.

Subclinical means

Today, thanks to the CT Scanner, one can clearly diagnose all kinds of lesions of the skull and brain organization as well as all types of hematomas in the skull. accurate, to help the treatment be more effective. In addition, it is also a means of monitoring traumatic brain trauma through examination scans.

Diagnose

Patients with traumatic brain injury are carefully monitored and through many exams comparing the next time with the previous time to know the progression of signs, especially those of perception. Diagnosis of an intracranial hematoma, first of all, must be based on clinical symptoms and monitor those symptoms:

Approach province: Whether it is typical or not, the lethargy increases or decreases.

Nerve changes in phytoplankton (pulse, heat, blood pressure, breathing, etc).

Symptoms of focal nerve markers:

The dilatation and light response of the pupil.

The weak state of limb paralysis is not uniform.

Subclinical facilities such as angiogram, brain ultrasound, brain angiogram, computerized tomography (CT Scanner), nuclear magnetic resonance imaging are valuable diagnostic tools.

Treatment

Cases without surgery

Medical treatment, usually brain concussion and cerebral shock is conservatively treated (without surgery) according to the following principles: anti-respiratory disorders, anti-edema, drugs with coagulant effect, determination of high body temperature and metabolic disorders, anti-psychotic drugs after trauma.

Anti-respiratory disorders: In the acute stage, the comatose patient often has hypoxemia, especially since the brain is very sensitive to hypoxia. Cerebral hypoxia leads to cerebral dilatation, increased vascular permeability causing cerebral edema. Due to coma, decreased cough reflex, phlegm stasis, a peripheral respiratory disorder leading to cerebral ischemia. If there is an obstruction of the upper respiratory tract to clear the airways such as sucking up phlegm, it is necessary to open the trachea, breathe oxygen. In the presence of mixed respiratory disorder, mechanical ventilation is indicated.

Cerebral edema: Addressing peripheral respiratory disorders, dealing with irritations are effective conditions for the prevention and treatment of cerebral edema.

In addition, it is possible to reduce water in brain tissue by using drugs and fluids such as Mannitol solution 15% x 1g / kg body, glucose solution 10% x 600ml intravenous infusion, calcium chloride 10% x 10ml intravenously. vein, Lasix x 40 x 1 intravenous tube. Depending on the condition, one of the above drugs can be used in combination. Now the Mannitol is used more and proved to be most effective.

Anticoagulants: Used for patients with physical stimulation and struggles that easily lead to cerebral edema. The drugs are used Largactil 0.05 x 0.2ml, Phenergan 0.05 x 2ml, Dolosal 0.10 x 2ml.

Solving high body temperature and metabolic disorders: When the temperature is higher than 38 0 C, hypothermia can be used, 4% x 5ml Piramdon solution injected with cold compress around the head.

To combat metabolic disorders, especially in the prolonged coma, basically solving the problem of acidosis, we can use 14% alkaline solution x 300ml intravenously.

Adjust the electrolytes by mixing 10% sweet serum with electrolytes after Potassium chloride 0.75 x 2-3 tubes, calcium chloride 0.50 x 1-2 tubes. Saline serum infusion 9%, in addition, to prevent superinfection: use antibiotics, use vitamins group B, especially B1 and B6 and vitamin C. Pay attention to nurture well patients during coma.

Surgery to remove the intracranial hematoma

Surgery is the most important link in treating the etiology of the intracranial hematoma. In the surgery of intracranial hematoma, people apply two methods of cranial drilling, cranial drilling, then gnawing wide and hinge opening. After removal of the hematoma, the hinge of the skull is placed in the original position. In the future, the patient did not have to undergo a second operation, which is reconstructive surgery of the skull by the pelvis or with other organic compounds.

Epidural hematoma

Through the opening of the skull bone to remove the hematoma. Use a scraping spoon to gently brush off the hematoma, and at the same time pump strongly with a rubber ball. Sometimes the blood sticks to the sclera, you have to use a spoon, a small ball to forcefully remove the hematoma. After the hematoma is removed, check and stop the bleeding of the damaged blood vessel.

Subdural hematoma

Open cross-shaped sclera. Mainly use a rubber balloon, pumped strongly on the sides so that the hematoma runs. Be very careful when using a tool such as a spoon, a soft fly to remove the hematoma because it can damage the brain and blood vessels. MDC hematoma is usually easily removed. After removing the hematoma, check for damaged blood vessels. In general, no damaged blood vessels were found because the blood had coagulated at the rupture site, the bleeding stopped on its own, the sclera was also sutured tightly.

Hematoma in the brain

Cross-shaped hard meningitis. Through the bruising area (if any) or changes in the surface of the brain, or touching to identify the hematoma in the brain. Use Canon to probe in the direction of suspected hematoma, about 4-5cm deep. Notice that the volume of the hematoma is not very large. Electrocautery, braking on both sides to easily reach the hematoma. Remove with a wash pump and suction. The sclera is sealed once the hematoma is removed completely.

Hematoma in the ventricles

Carry out cranial drilling in the position where the ventricular puncture is performed. Proceed to poke the two anterior horns of the ventricles (sometimes conducting posterior horns of the lateral ventricles). Aspirate by syringe with a blood clot and not clot, then proceed to pump the ventricle several times with normal saline.

Surgical treatment of brain injury

The open cranial wound is indicated for surgery, surgery as soon as possible. However, if the traumatic brain injury has brain protruding much or shows brain stem damage, the victim is in a state of lethargy, respiratory and cardiovascular disorders need to resuscitate before surgery. Management of an open cranial wound: remove the broken bones and crush the brain, remove the foreign bodies if possible, and then turn the open cranial wound into a closed inside out. There are instances where a piece of gas or a foreign object is deep in the base of the skull such as a marble fragment if the patient is awake and the wound stops bleeding on its own, emergency surgery may not be needed.

Prevention

Propaganda and community education on traffic law.

Introduced into the grassroots traffic law curriculum.

Take measures to strictly handle violations of traffic laws.

Well implementing the labor safety law in production facilities and construction.

Wear a helmet in traffic.

Related articles:

- Abnormal psychological traumatic brain injury

- Lecture of increased intracranial pressure syndrome

- Abnormal neuropsychiatric disorder