- Symptoms of the Craniocereberal injury
- Reasons of the Craniocereberal injury
- Treatment of the Craniocereberal injury
Craniocereberal injury — mechanical injury of a skull and intracranial educations — a brain, vessels, cranial nerves, a meninx.
Symptoms of the Craniocereberal injury:
The bruise — the center of traumatic crush of brain fabric — often forms in basal departments frontal and the front departments a temporal share which are closely adjoining to the acting bone relief. Diffusion axonal damage — result of rotary or linear acceleration at the time of an injury. Depending on acceleration size at diffusion axonal damage the wide range of frustration from easy confusion and a short-term loss of consciousness (is possible at a concussion of the brain) to a coma and even a lethal outcome. Secondary injury of a brain is connected with a hypoxia, ischemia, intracranial hypertensia, an infection.
Allocate the open craniocereberal injury (CI) at which there is a message of a head cavity with external environment, and closed.
The major clinical factors defining severity of an injury are: duration of loss of consciousness and amnesia, extent of oppression of consciousness at the time of hospitalization, existence of trunk neurologic symptomatology.
Conducting examination of the patient with ChMT, especially heavy, it is necessary to hold to a certain plan.
1. In the beginning it is necessary to pay attention to passability of respiratory tracts, frequency and rhythm of breath, a condition of a hemodynamics.
2. It is necessary to examine quickly a thorax and a stomach to exclude haemo - or pheumothorax, abdominal bleeding.
3. To estimate a consciousness condition. At easy ChMT it is important to estimate orientation in the place, time, own personality, attention, having asked the patient to call months of year upside-down or to take away consistently from 40 on 3, memories, having asked to remember 3 words and having checked whether the patient will be able to call them in 5 min.
4. To examine the head, a trunk, extremities, paying attention to external symptoms of an injury (wounds, bruises, bruises, fractures).
5. Identification of signs of a fracture of base of the skull is important: the expiration of cerebrospinal liquid from a nose (unlike usual slime liquor contains glucose), a symptom of points (the set aside emergence of the bilateral bruise in periorbital area limited to edges of an orbit), the expiration of blood and liquor from an ear (bleeding from an ear can be connected also with damage of outside acoustical pass or a tympanic membrane), and also the bruise behind an auricle in the field of a mastoid developing in 24 — 48 h after an injury.
6. Collecting the anamnesis at the patient or attendants of his faces, it is necessary to pay attention to circumstances of an injury (the injury can provoke a stroke, an epileptic seizure), alcohol intake or medicines.
7. Finding out consciousness loss duration, it is important to consider that for the external observer consciousness is returned while the patient opens eyes, for the patient consciousness is returned while ability to remember is returned. Duration amnezirovanny the patient of the period — one of the most reliable indicators of weight of an injury. It is defined, asking the patient on the circumstances of an injury previous and the subsequent events.
8. Emergence of meningeal symptoms indicates subarachnoidal hemorrhage or meningitis, however rigidity of cervical muscles can be checked only in that case when the injury of cervical department is excluded.
9. All patient with ChMT carries out a skull X-ray analysis in two projections which can reveal depressed fractures, linear changes in the field of an average cranial pole or on a base of skull, liquid level in a trellised bosom, a pneumocephalus (availability of air in a head cavity). At a linear change of a calvaria it is necessary to pay attention whether the line of a change crosses a furrow in which there passes the average meningeal artery. Its damage — the most frequent reason of an epidural hematoma.
10. Most of patients (even at the minimum signs of damage of cervical department of a backbone or a graze on a forehead) should appoint a X-ray analysis of cervical department (at least in a side projection, at the same time it is necessary to receive the image of all cervical vertebrae).
11. Shift of median structures of a brain at development of an intracranial hematoma can be revealed by means of an ekhoentsefaloskopiya.
12. The lumbar puncture in the acute period usually does not bring additional useful information, but can be dangerous.
13. With confusion or oppression of consciousness, focal neurologic symptoms, an epileptic seizure, meningeal symptoms, signs of a fracture of base of the skull, a splintered or depressed fracture of a calvaria urgent consultation of the neurosurgeon is necessary. Special vigilance concerning a hematoma is necessary at elderly people, patients having alcoholism or accepting anticoagulants.
Craniocereberal injury — the dynamic process demanding constant control behind a condition of consciousness, the neurologic and mental status. Within the first days it is necessary to estimate the neurologic status, first of all a condition of consciousness each hour, abstaining whenever possible from purpose of sedatives (if the patient falls asleep, then it is necessary to awake periodically him).
Easy ChMT is characterized by the short-term loss of consciousness, orientation or other neurologic functions which is usually coming immediately after an injury. Assessment on a scale of a coma of Glasgow at primary survey makes 13 — 15 points. After recovery of consciousness amnesia on events which directly preceded an injury or took place right after it (the general duration of the amnezirovanny period does not exceed 1 h), a headache, vegetative disturbances (fluctuations of the ABP, lability of pulse, vomiting, pallor, a hyperhidrosis), asymmetry of reflexes, pupillary disturbances and other focal symptoms which usually spontaneously regress within several days is found. To criteria of easy ChMT there correspond the concussion of the brain and a bruise of a brain of easy degree. The main feature of easy ChMT — basic reversibility of neurologic disturbances, however process of recovery can be dragged out for several weeks or months during which at patients the headache, dizziness, an adynamy, disturbance of memory, a dream and other symptoms (a post-accident syndrome) will remain. At car accidents easy ChMT is quite often combined with a hlystovy injury of the neck arising owing to sharp movements of the head (most often as a result of sudden overextension of the head with the subsequent bystry bending). The Hlystovy injury is followed by sprain And muscles of a neck and is shown by pain in cervicooccipital area and dizziness which spontaneously pass within several weeks, usually without leaving effects.
Patients with a slight injury should be hospitalized for observation on 2 — 3 days. The main objective of hospitalization — not to pass more serious injury. In the subsequent the probability of complications (an intracranial hematoma) significantly decreases, and the patient can be allowed to go home provided that he will be watched by relatives, and at an aggravation of symptoms he will be quickly taken to hospital. Extra care should be observed at children at whom the intracranial hematoma can develop in lack of initial loss of consciousness.
Medium-weight and heavy ChMT are characterized by a long loss of consciousness and amnesia, permanent cognitive and focal neurologic frustration. At heavy ChMT the probability of an intracranial hematoma is significantly higher. The hematoma should be suspected at the progressing consciousness oppression, emergence new or increase of already being available focal symptomatology, emergence of signs of a vklineniye. The "Light interval" (short-term return of consciousness with the subsequent deterioration) which is considered as a classical symptom of a hematoma is observed only in 20% of cases. Development of a long coma right after an injury in the absence of an intracranial hematoma or the massive contusional centers — a sign of diffusion axonal damage. The set aside deterioration, in addition to an intracranial hematoma, can be caused by wet brain, a fatty embolism, ischemia or infectious complications. The fatty embolism arises several days later after an injury, usually at patients with fractures of long tubular bones — at the shift of fragments or attempt of their reposition, at most of patients at the same time respiratory function is broken and there are small hemorrhages under a conjunctiva. Posttraumatic meningitis develops in several days after an injury, is more often at patients from open ChMT, especially in the presence of a fracture of base of the skull with emergence of the message (fistula) between a subarachnoid space and okolonosovy bosoms or a middle ear.
Reasons of the Craniocereberal injury:
The main reasons — the road accidents, falling, production, sports and home accidents. Damage of a brain can be result: 1) the focal damage which is usually causing a bruise (contusion) of cortical departments of a brain or an intracranial hematoma; 2) the diffusion axonal damage involving deep departments of white matter.
Treatment of the Craniocereberal injury:
Treatment easy чмт comes down only to the symptomatic help. At pain appoint analgetics, at the expressed vegetative dysfunction — beta-blockers and bellataminal, at a sleep disorder — benzodiazepines. At easy ChMT clinically significant wet brain therefore purpose of diuretics is inexpedient usually does not develop. It is necessary to avoid a long bed rest — much more well early return of the patient on usual Wednesday. But it is necessary to consider that efficiency of many patients within 1 — 3 month is limited. Long uncontrolled reception of benzodiazepines, the analgetics which are especially containing caffeine, codeine and barbiturates promotes synchronization of posttraumatic frustration. The patient who transferred easy ChMT often appoint nootropic means — piracetam (nootropil) on 1,6 — 3,6 g/days, Pyritinolum (Encephabolum) on 300 — 600 mg/days, Cerebrolysinum of 5 — 10 ml intravenously, glycine of 300 mg/days under language. Patients often need not so much medicines how many in a tactful and detailed explanation of an essence of their symptoms, inevitability of their regress during short time and need to adhere to the principles of a healthy lifestyle.
Treatment of heavy ChMT comes down mainly to the prevention of secondary injury of a brain and includes the following measures:
1) maintenance of passability of respiratory tracts (clarification from slime of an oral cavity and upper respiratory tracts, introduction of an air duct). At moderate devocalization for lack of disturbances of breath appoint oxygen through a mask or a nasal catheter. At deeper disturbance of consciousness, damage of lungs, oppression of a respiratory center the intubation and IVL are necessary. In order to avoid aspiration it is necessary to clear a stomach by means of the nazogastralny probe. Prevention of stressful gastric bleeding — risk factor of aspiration pneumonia — provides introduction of antacids;
2) stabilization of a hemodynamics. It is necessary to correct a gitsovolemiya which can be connected with blood loss or vomiting, having avoided at the same time an overhydratation and strengthening of wet brain. There are usually enough 1,5 — 2 l/days of normal saline solution or colloidal solutions. It is necessary to avoid administration of solutions of glucose. At substantial increase of the ABP appoint antihypertensives (beta-blockers, angiotensin-converting enzyme inhibitors, diuretics, clonidine). It is necessary to consider that owing to disturbance of an autoregulyation of cerebral circulation
bystry falling of the ABP can cause brain ischemia; extra care is necessary in relation to elderly patients, a long time having arterial hypertension. At the low ABP enter liquid, corticosteroids, vazopressor;
3) at suspicion of a hematoma immediate consultation of the neurosurgeon is shown;
4) prevention and treatment of intracranial hypertensia. The hematoma is not excluded yet, introduction of Mannitolum and other osmotic diuretics can be dangerous, but at bystry oppression of consciousness and emergence of signs of a vklineniye (for example, at a mydriasis) when an operative measure is planned, it is necessary to enter quickly intravenously 100 — 200 ml of 20% of solution of Mannitolum (previously catheterize a bladder). 15 min. later enter lasixum (20 — 40 mg intramusculary or intravenously). It allows to win time for researches or the emergency transportation of the patient;
5) at the expressed excitement enter sodium hydroxybutyrate (10 ml of 20% of solution), morphine (5 — 10 mg intravenously), галоперидод (1 — 2 ml of 0,5% of solution), however sedation complicates assessment of a condition of consciousness and can be the cause of untimely diagnosis of a hematoma. Besides, excess and unreasonable administration of sedatives can be the cause of the slowed-down recovery of cognitive functions;
6) at epileptic seizures intravenously enter Relanium (2 ml of 0,5% of solution intravenously) then at once appoint antiepileptic drugs inside (carbamazepine, 600 mg/days);
7) the patient's food (via the nazogastralny probe) is usually begun for the 2nd day;
8) antibiotics are appointed at development of meningitis or preventively at an open craniocereberal injury (especially at a likvorny fistula);
9) the injury of a facial nerve is usually connected with a change of a pyramid of a temporal bone and can be caused by injury of a nerve or its hypostasis to the bone channel. In the latter case the integrity of a nerve is not broken and corticosteroids can be useful;
10) partial or total loss of sight can be connected with the traumatic neuropathy of an optic nerve which is a consequence of a contusion of a nerve, hemorrhage in it and/or a spasm and occlusion of the vessel supplying it. At emergence of this syndrome introduction of high doses of kortikosterid is shown.