Fracture of the base of the skull and possible consequences. Treatment methods for skull fracture

Skull fractures are among the most severe injuries. Such damage to the integrity of the cranial bones occurs after severe blows to the head and is often accompanied by brain damage. Therefore, these injuries are life-threatening. And even with a favorable outcome, they have serious consequences for the patient’s health. It is very important that first aid for a traumatic brain injury is provided on time. This will help prevent But in any case, the treatment of such injuries is very long and requires complex rehabilitation.

Features of skull fractures

Traumatic brain injuries are very common, especially in young and middle age. They cause about half of the deaths among all injuries. This is due to the fact that a violation of the integrity of the cranial bones often leads to compression or damage to the brain and blood vessels. In addition, the skull has a very complex structure. Many bones are connected by sutures and have different structures and thicknesses. Some bones are riddled with blood vessels or have air cavities. There are facial and cerebral sections of the skull. It is in the brain that injuries most often occur.

The peculiarity of fractures of the cranial bones is that upon impact, external damage may not be noticeable. After all, the cranial vault consists of internal and external plates, between which there is a spongy substance. The inner plate is very fragile, so upon impact it is most often damaged, even without damaging the integrity of the outer plate.

Causes of such injuries

Skull fractures occur as a result of the application of great force. They most often affect young and middle-aged people who lead an active life or play sports. As well as alcoholics, drug addicts and representatives of criminal structures. There are several reasons why skull fractures occur:

• strong blows to the head with a hard object;
• falling from a height;
• car crashes;
• gunshot wound.

There are two mechanisms for obtaining such an injury: direct and indirect. When a bone breaks where force is applied, it is a direct fracture. This is how cranial vault injuries usually occur. Damaged bones are often pressed inward and damage the meninges. With an indirect fracture, the impact is transferred from other bones. For example, when falling from a height onto the pelvis or legs, a strong blow is transmitted through the spine to the base of the skull, often leading to a fracture.

Symptoms of skull fractures

The patient’s further condition depends on how correctly first aid was provided for a traumatic brain injury. With any strong blow to the head area, you should suspect the possibility of a fracture of the skull bones. After all, sometimes such an injury is not accompanied well visible symptoms. But there is also special features, which can be used to determine not only the presence of a fracture, but sometimes the location of it and damage to the meninges.

Classification of skull fractures

Injuries to the cranial bones can be different. They are classified according to the nature of the fracture, location, and severity of the lesion. Various parts of the skull may be affected. Based on the nature of the injury, there are three types:

• the most severe is a comminuted fracture, which can result in damage to the meninges and blood vessels;
• a depressed fracture also has serious consequences, because with it the bones of the skull are pressed inward, which causes crushing of the brain;
• linear fractures are considered harmless, since there is no displacement of bone fragments, but they can cause damage to blood vessels and the appearance of hematomas;
• very rarely, a perforated fracture occurs as a result of a gunshot wound; as a rule, such an injury is incompatible with life.

Based on the location of the injury, a fracture of the temporal bone, occipital or frontal is distinguished. They refer to cranial vault injuries. If the base is damaged cranium, this causes cracks to appear in the facial bones, they spread to the eye sockets, bridge of the nose and even the ear canal. In addition, a fracture of the skull bones can be open or closed, single or multiple. The patient’s condition depends on the severity of the injury, the degree of damage to the meninges and blood vessels, as well as on the timely medical care provided.

Fracture of the calvaria

Occurs from a blow to scalp heads. Therefore, the main symptom of such an injury is a wound or hematoma in this place. But the difficulty of diagnosing this injury is that the impact often damages the inner plate of the cranial bone, which is almost invisible from the outside. The patient may even regain consciousness, but gradually the symptoms of brain damage will increase. A fracture of the skull vault can occur for various reasons, most often due to an impact. People under the influence of alcohol and drugs are especially susceptible to such injuries. Indirect impact, for example from a fall on the pelvis, may be accompanied by a fracture of the base of the skull. In this case, the patient's condition is especially serious, and the injury can be fatal.

Fracture of the base of the skull

Survival from such injuries depends on timely medical care. A fracture in this location can be independent or accompany a trauma to the cranial vault. In addition, a fracture of the anterior, middle and posterior cranial fossa is distinguished. Such injuries, depending on the location and severity, are accompanied by bleeding from the nose and ears, and leakage of cerebrospinal fluid. A characteristic symptom of a fracture of the anterior cranial fossa is bruising around the eyes. With such injuries, all the patient’s senses are affected: vision, hearing, smell, and coordination of movements are impaired. A fracture of the base of the skull is considered a very serious injury. The survival rate for it is approximately 50%.

Diagnosis of injuries

For any traumatic brain injury, an examination is performed to rule out a fracture. In addition to questioning the victim or his accompanying persons about the circumstances of the injury, the doctor examines the patient. Sensitivity, the presence of reflexes are assessed, the pulse and the reaction of the pupils to light are checked. It is also done in two projections. To confirm the diagnosis, the results of magnetic resonance and computed tomography, brain puncture and echoencephalography are used. Such a study must be carried out even in the absence of visible consequences of the injury, since only the inner plate of the skull bones can be damaged after the impact.

Features of skull fractures in children

Despite the belief of many that a child’s cranial bones are stronger, such injuries often occur in children. Moreover, their diagnosis is difficult, and the consequences are usually more serious. A skull fracture in a child is dangerous because the victim may feel well immediately after the injury. This is due to insufficient development of the frontal lobes and other parts of the brain. The consequences appear later: a strong increase in blood pressure, loss of consciousness, vomiting, anxiety, tearfulness. Features of skull injuries in children are multiple linear cracks, suture dehiscence and bone depression. Less common than in adults are comminuted fractures, hematomas and hemorrhages. But complications can be just as serious: epilepsy, hydrocephalus, developmental delays, visual and hearing impairments often develop.

First aid

When receiving a traumatic brain injury, it is very important how quickly the victim receives health care. Often his life depends on it. Until the victim is taken to the hospital, he must be laid on a hard surface without a pillow, his head supported with soft objects. If he is conscious, he can lie on his back. If the victim faints, turn him on his side, supporting his head with pillows so that he does not choke when vomiting. It is advisable to remove all jewelry, glasses, dentures, and unbutton clothes. The victim must be provided with free access to air.

If a head injury bleeds, cover it with a sterile bandage and apply ice, but do not touch or put pressure on the injury site. It is not recommended to give the patient any medications before the doctor arrives, since, for example, narcotic analgesics can cause breathing problems. The victim should be taken to a doctor as soon as possible, even if he is conscious and feels normal. After all, skull injuries never go away without leaving a trace. And without timely treatment, they can cause serious consequences.

Features of treatment of skull fractures

A victim with a traumatic brain injury must be hospitalized. Depending on the severity and location of the injury, conservative or surgical treatment may be prescribed. Bed rest is mandatory. The head should be slightly elevated to reduce the flow of cerebrospinal fluid. In case of injury, a lumbar puncture or drainage is needed. For fractures of moderate and mild severity, drug therapy is performed. The patient is prescribed the following drugs:

• painkillers, non-steroidal anti-inflammatory drugs;
• diuretics;
• antibiotics to exclude purulent infection;
• nootropic and vasotropic drugs;
• enhancement drugs cerebral circulation.

If the fracture is severe, such as comminuted or depressed, with multiple bone damage, then surgical treatment is performed. It is necessary to remove fragments and areas of necrotic tissue, as well as accumulated blood. During the operation, damage to the nerves and blood vessels is also eliminated. Surgical treatment is used if a purulent infection has begun, which is not eliminated with the help of conservative therapy.

The consequences of such injuries

If the skull fracture is linear, without bone displacement and large hematomas, and if purulent infection has been avoided, then the prognosis for recovery is usually favorable. But not always without complications passes a skull fracture. The consequences of such an injury can be very serious:

• meningitis, encephalitis;
• intracerebral hematomas can lead to encephalopathy;
• profuse bleeding most often ends in death;
• after a fragmental fracture of the base of the skull, paralysis of the entire body may develop;
• often patients suffer from psychological and emotional disorders, mental decline.

Rehabilitation after skull fractures

With minor injuries, the recovery of the patient is quick. Rehabilitation is mainly carried out at home and includes rest, walks on fresh air, taking nootropic and sedative medications, a special diet. More severe injuries are rarely without consequences. Rehabilitation of such patients is long, sometimes taking years. But still, many remain disabled and cannot return to their normal lives.

A fracture of the skull, as a violation of the integrity of its bones, is quite common. If we consider the ratio of this injury to all fractures, then the number is close to ten percent. The skull has a certain elasticity. If the mechanical factor acts stronger than elasticity, a fracture occurs.

Usually, with such a fracture, damage to the brain, as well as its membranes, occurs, so the condition is life-threatening. In view of such serious consequences, it is very important to be able to recognize the symptoms of such an injury and provide first aid in time. However, first you need to understand what causes such serious damage.

Causes

Typically, cranial fractures occur due to severe injuries such as falling from a height, blows to the head with a massive hard object, car accidents, and so on. Most often this occurs active people middle-aged or young people, as well as disadvantaged citizens such as alcoholics and drug addicts.

The frequency of fractures is explained by the activity of patients, and situations such as playing sports, traveling in cars, injuries at work, etc. are important. Injuries in another group of victims are usually associated with crime or accidents that occurred as a result of drug or alcohol intoxication.

A skull fracture can also occur in a child, and this is quite common. This usually occurs due to a blow to the head, a fall from a bicycle or sports equipment, or as a result of an accident. Since a child’s body is weaker than an adult’s, the consequences can be even more severe.

Classification

The classification of cranial fractures includes various types of this injury. First, consider the two main groups of skull fractures.

1. Fractures of the cranial vault. In this case, the inner bone plate suffers to a large extent. By being pressed in, bone fragments can damage the dura mater and medulla. If the membrane vessels rupture, subdural hematomas form. If the fracture is closed, it does not have clear boundaries. Focal symptoms may not be observed.
2. Fracture cranial base. In this case, cracks appear that extend to the bones of the nose and orbit. If the damage occurred in the middle fossa, a crack will be observed in the area ear canal. The victim exhibits characteristic signs, which we will talk about a little later.

According to the nature of the fracture, three types of fractures can be distinguished.

1. Linear fractures. In this case, the bone injury looks like a thin line. No displacement of bone fragments. Linear injuries are not very dangerous, but because of them, meningeal arteries can be injured, which leads to the formation of epidural hematomas.
2. Depressed skull fractures. This happens when the bone is pressed into the skullcap. This can lead to damage to the meninges, substance and blood vessels, causing brain injuries and hematomas.
3. Comminuted fractures. Several fragments are formed. They can damage the meninges and brain, and the consequences are the same as with depressed skull fractures.

Symptoms

Symptoms depend on the specific injury. It is very important to be able to identify the first signs in order to know how to provide first aid and proceed further, especially if the victim is a child.

The most common fractures that occur are linear. They are usually accompanied by epidural or subdural hematomas. Most linear fractures are uncomplicated, however, there is a possibility of liquorrhea, carotid-cavernous fistula, or pneumocephalus. Hemorrhage often occurs in the middle ear, and hematomas are observed where the mastoid process or periorbital tissue is located. Such signs help when a linear fracture of the skull bones is not detected by an x-ray.

Cerebrospinal fluid leaks through the paranasal sinuses or the cribriform plate of the ethmoid bone, resulting in cerebrospinal fluid rhinorrhea. If a fracture of the temporal bone occurs, damage to the facial nerve occurs. Destruction of the auditory ossicles may occur, as well as cerebrospinal fluid leakage from the ears.

Fractures of the frontal bone are considered severe injuries. This usually happens upon impact. In this case, a severe headache occurs in the frontal area. In this case, a bruise or concussion almost always occurs. Fractures of the frontal bone manifest themselves with such signs as severe subcutaneous hematoma in the frontal area, deformation, headache, nausea, vomiting, dizziness, blurred vision, and loss of consciousness. There may be bleeding from the ears, accumulation of air under the skin of the face and forehead, as indicated by swelling of these areas. A frontal bone fracture is a serious injury that requires immediate treatment.

General signs depend on how severe the injury is and how much brain structures are damaged. Any disturbance of consciousness may occur, including short-term loss of consciousness and coma. Damage to the cranial nerves and brain leads to sensory impairment, paralysis and paresis. Cerebral edema may develop, accompanied by nausea, vomiting, impaired consciousness and bursting headaches. Compression of the brain stem leads to impaired blood circulation and breathing, in addition, the reaction of the pupil is inhibited.

It is important to understand that the impairment of consciousness is more pronounced the more severe the brain injury. However, with an intracranial hematoma, a period of lucidity may occur, followed by loss of consciousness. Therefore, the patient's satisfactory condition does not need to be assessed as minor or no injury. Diagnosis and assessment of symptoms may be difficult if the victim is intoxicated, so any head injuries should be subject to immediate and thorough examination.

In the case of fractures, a child has one feature - distant manifestations of injuries. It often happens that after a tragic incident, a child feels well for some time. The disturbances become noticeable later when he loses consciousness due to sharp increase HELL. The frontal lobes in children develop until the age of 16; it is at this age that the consequences of previous injuries become noticeable.

Diagnostics

Fractures of the skull bones are determined first based on the clinical picture. The doctor assesses the general condition of the patient, conducts a neurological examination, checks the condition of the pupils, and so on. However, it is imperative to conduct more specific studies, for example, an x-ray of the skull. It is useful to perform a CT scan and MRI.

There are circumstances that make it difficult to make a diagnosis, for example, structural features of the skull and the serious condition of the patient. In such cases, the diagnosis is made based on the clinic, and subsequently other studies are carried out.

Treatment

First, it is very important to provide first aid. The patient must be placed in horizontal position, if he is conscious, then on his back, if unconscious, then half turn. The head should be turned to the side so that in case of vomiting the person does not choke. You need to create peace for your head with the help of improvised means, bolsters, pillows and blankets. You can stop bleeding by applying a pressure bandage to the wound. Ice should be applied to the damaged area. You also need to check the permeability respiratory tract and, if necessary, eliminate tongue retraction, vomit, and so on. Of course, even before all this you need to call an ambulance.

Subsequently, a skull fracture is treated mainly conservatively. There are times when surgery is required. All patients are prescribed bed rest. Its duration depends on the injury. If a fracture of the base of the skull occurs, a lumbar drainage is applied or repeated lumbar punctures are performed. Treatment is prescribed depending on the type and severity of the injury. It should be followed carefully.

Consequences

Fractures do not go away without consequences, and in the case of the skull, everything can be very serious. Bacteria can enter the cerebrospinal fluid, which can lead to the development of meningitis. If air gets in, pneumocephalus will develop. These are just a few examples of complications. In fact, there can be a serious threat to human life.

Fractures of the skull bones in a child have a strong impact on the physical and emotional state. It also affects his mental abilities. The most serious consequence is complete paralysis of the body, the risk of which is high with a fracture of the base of the skull, because this part is the connecting link between the spinal cord and the brain.

Both adults and children need to be attentive at all times to reduce the risk of fracture. If you cannot avoid it, it is important to make every effort to reduce the likelihood of serious consequences and quickly return to a normal rhythm of life.

Closed trauma of the skull and brain ( general provisions) . Traumatic brain injury is a disease that develops as a result of damage to the brain and its membranes, blood vessels, nerves, bones and outer coverings. With closed craniocerebral injuries, there is no violation of the integrity of the soft coverings of the head or the location of the wounds does not coincide with the projection of the fracture of the skull bones (the closed cavity of the skull is preserved and there are no conditions for primary microbial contamination of the brain and its membranes). Exceptions are fractures of the skull (usually its base), in which, despite the absence of damage to the skin, a communication occurs between the cranial cavity and the air sinuses with the leakage of cerebrospinal fluid through the nose and ear and the possibility of primary infection of the subarachnoid space. The nature and scale of damage, their clinical manifestations depend on the characteristics of the mechanical impact on the skull and its contents (impact force, place of application of force, shape and structure of the traumatic agent, etc.).

Closed brain injury is traditionally divided into concussion, contusion and cerebral compression. This division is to a certain extent arbitrary; combinations of these forms are usually observed. Damage to the brain substance is usually represented by a combination of reversible (functional) and irreversible (morphological) changes, especially in severe cases closed craniocerebral injury.

Fractures of the skull bones account for 18-20% of the total number of severe traumatic brain injuries and about 10% of all skeletal fractures. Closed skull fractures account for about 2/3 of injuries.

Classification of closed skull and brain injuries

Condition of the skull	Bruises, abrasions, wounds (not communicating with the bone fracture area), bruises, bleeding from the nose, mouth, ear canals
Condition of the skull	No bone damage	With bone damage (fracture of the arch, base, both; crack, depressed, comminuted fracture)
Types of damage (concussion, contusion and compression of the brain) can be combined with each other and with extracranial injuries	Concussion with minor clinical manifestations; with severe clinical manifestations	Brain contusions: mild, moderate, severe. Localization - cerebral hemispheres, basal sections, cerebellum, paraventricular sections (single, multiple)	Compression of the brain. Epidural, subdural, intracerebral, intraventricular hematoma (single, multiple). Hydroma. Edema - swelling. Pneumocephaly. Bone fragments
Condition of the intrathecal spaces	The cerebrospinal fluid is not changed; her blood pressure can be normal, high, low	Subarachnoid hemorrhage; liquorrhea from the nose and ear; normal cerebrospinal fluid pressure, hypertension, hypotension; inflammatory changes (cytosis, protein)

Closed skull fractures are divided into vault, base and combined injuries. In children and young people, fractures of the vault (high elasticity of the bones) are more common; in the elderly, fractures of the base and severe combined injuries of the vault and base of the skull predominate.

Cranial vault fractures arise as a result of the direct impact of a traumatic factor and depend on the magnitude, direction and location of the application of force, as well as on the elasticity of the bones of the skull. The parietal bones are most often damaged, then the frontal, temporal and occipital bones. There are linear, comminuted, and depressed fractures. When the surface of contact with the traumatic body is small, an impression fracture occurs, in which the damaged area of ​​the bone is pressed in a cone shape, the inner plate ruptures, and then the outer plate ruptures due to compression. Exposure to a wide surface causes a depression fracture, in which a section of bone breaks out from the general bone mass, is pressed into the cranial cavity and causes compression of the brain. Linear fractures may not cause significant brain damage.

When the fracture is localized in the temporal region, damage to the branches of the middle meningeal artery is common, and in the area of ​​the sagittal suture - to the walls of the superior longitudinal sinus. Comminuted fractures with deep displacement of fragments often lead to ruptures of the dura mater with damage to the cerebral hemispheres, clinically manifested by focal neurological symptoms of irritation (limited convulsions) or loss (paresis, paralysis, sensitivity disorders, aphasia, etc.).

Recognition. Take into account the history and mechanism of injury (see. ). Pay attention to changes in the contours of the cranial vault, the presence of depressions, and movable fragments. A neurological examination is carried out aimed at identifying general cerebral and focal symptoms. Skull fractures are often accompanied by clinical manifestations of closed brain injury, although these may not be present in children. The nature of the damage to the cranial vault is determined by x-ray. This can also reveal hemorrhage in the sinuses or air in the cranial cavity (see. Pneumocephalus). Linear fractures (cracks) must be differentiated from the shadows of the arterial grooves of the bones of the arch and from the shadows of the diploetic veins. The cracks are characterized by transparency, bifurcations, they have a zigzag “run” with the intersection of tortuous vessels.

Treatment determined by the nature of the fracture and brain damage. For linear fractures without displacement, intracranial hematoma, or brain contusion, treatment is conservative. Cracks in the vault that extend to the base of the skull can also be treated conservatively. A victim with a closed fracture of the cranial vault is hospitalized; he is put on bed rest. Duration of treatment and therapeutic measures determined by the severity of the brain injury.

A linear fracture without displacement is first filled with fibrous and then bone tissue. Comminuted and linear fractures with displacement (fragments of the internal plate are displaced by 1 cm or more into the cranial cavity), depressed fractures, both with and without neurological symptoms of brain compression, are subject to surgical treatment(cm. Brain compression). The only exception is a depressed fracture of the outer wall of the frontal sinus, since it does not put pressure on the brain.

Fractures of the base of the skull arise from indirect trauma as a continuation of a fracture of the vault, as well as from a fall from a height onto the head due to impact through the spine, lower jaw, and nasal bones that articulate with the base of the skull. Fracture lines run along the areas of the base of the skull that are most thinned or weakened by holes and crevices. In this case, as a rule, ruptures of the dura mater intimately fused to the bones occur along with the venous sinuses (petrosal, cavernous, small wings) and the middle meningeal artery. In rare cases, the wall of the internal carotid artery is damaged at the point of passage through the cavernous sinus with the subsequent formation of a carotid-cavernous anastomosis (aneurysm). In places of exit from the cranial cavity, cranial nerves are often damaged.

In more than half of the cases, fractures are located in the area of ​​the middle cranial fossa and temporal bone. Relatively less often, they are localized in the anterior and posterior cranial fossae; they can spread to all fossae and be combined with vault fractures, crossing bone sutures and openings of the skull.

Recognition. IN acute period, in addition to the picture of bruises of the basal-polar sections of the frontal and temporal lobes of the cerebral hemispheres, cerebellum and brain stem, there is an outflow of blood, cerebrospinal fluid and, in especially severe cases, cerebral detritus from the ear, nose or pharynx; increasing bruises in the orbital area, in the infratemporal fossa and temporal cavity, in the mastoid area (due to blood leakage into the subcutaneous or retrobulbar tissue), damage to the cranial nerves where they pass through the bone canals and openings of the skull base (facial, auditory, olfactory, oculomotor and etc.); Sometimes subcutaneous emphysema of the face occurs, especially in the area of ​​the orbits and bridge of the nose.

Fractures of the anterior cranial fossa passing through the ethmoid and frontal sinuses cause bleeding from the nose, and when the meninges are ruptured, liquorrhea (rhinorrhea) mixed with blood. With fractures of the orbital vault and its inner wall, retrobulbar hematomas occur with protrusion of the eyeball, often masked by a sharply swollen upper eyelid, colored dark purple. With bilateral lesions, a symptom of "points" is noted.

Fractures of the middle cranial fossa are accompanied by bleeding, and when the membranes are ruptured, liquorrhea from the external auditory canal occurs when the eardrum is ruptured. Hemorrhages can spread through cracks under the temporal muscles, where they are detected in the form of swelling with a doughy consistency. When the pyramid of the temporal bone is fractured, damage to the branches of the facial and auditory nerves and taste disturbances occur.

With fractures of the posterior cranial fossa, scales occipital bone severe bulbar symptoms associated with direct trauma or compression of the medulla oblongata by peribulbar hematoma. In this case, the vagus, glossopharyngeal, and sometimes hypoglossal nerves are often damaged. In the posterior cranial fossa, the spilled blood is usually located between the edge of the pyramid, the sigmoid sinus and the foramen magnum. From here it can penetrate through cracks into the area behind the mastoid processes.

When recognizing, anamnesis and the mechanism of injury are also taken into account (see. Primary examination of the victim - examination of the skull). Pay attention to early and reliable signs: leakage of cerebrospinal fluid or blood from the ear, nose or mouth. In more than half of patients, cranial nerves are damaged - auditory, facial, abducens, oculomotor. In addition, the victims exhibit meningeal symptoms, the general condition is usually severe, which is caused by contusion mainly of the basal parts of the brain (see. Brain contusion). Subsequently, clinical data are supplemented by hemorrhages in the periorbital tissue, under the temporal muscle at the mastoid process. Bruising in the indicated places can also occur from a direct blow, but in this case they appear very quickly, and in the case of a fracture of the base of the skull - only a few hours after the injury. Often, a fracture of the base of the skull cannot be detected on plain radiographs. A detailed X-ray examination is carried out only if the victim’s condition is satisfactory. Radiographs must be taken in three projections - anterior, lateral and oblique.

Treatment. Prehospital care, as well as inpatient treatment, is determined by the nature of the brain damage. In case of severe closed brain injury, general medical measures are necessary (see Brain contusion) and prevention of infectious complications. When cerebrospinal fluid leaks from the nose or ear, a protective aseptic bandage is applied, but the cavities are not tamponed. Treatment of nasal and ear liquorrhea - see Open (gunshot) injuries of the skull and brain. Comminuted, depressed fractures of the parabasal parts of the skull with damage to the air sinuses are subject to surgical treatment to reduce the penetration of infection into the cerebrospinal fluid spaces. The essence of the operation is a fairly wide exposure and removal of bone fragments, scraping of the mucous membrane and damaged air cavities and sealing of the dura mater if it is damaged.

Brain compression- the most severe form of closed craniocerebral injury, usually requiring urgent surgical intervention according to vital indications. Unlike concussion and brain contusion (see), compression syndrome and progressive intracranial hypertension do not occur immediately after injury, but gradually, after a “lucid interval” and are accompanied by a life-threatening increase in cerebral, focal and brainstem symptoms. Compression of the brain can occur as a result of progressive intracranial hemorrhage, edema - swelling of the brain, increasing accumulation of cerebrospinal fluid in the subdural space (hydroma due to rupture of the arachnoid membrane), traumatic pneumocephalus (with damage to the air sinuses), compression of the brain by bone during a depressed fracture. Compression of the brain develops acutely (in the first hours and days after injury), acutely (in the first days and weeks) and chronically (after 3 weeks and later).

Traumatic intracranial hematomas are the most common cause of brain compression, accounting for 3-5% of all traumatic brain injuries. Depending on the location of the hemorrhage, the relationship to the membranes and substance of the brain, epidural, subdural, intracerebral, and intraventricular hematomas are distinguished (Fig. 85). In relation to the cerebellar tentorium, hematomas are divided into supra- and subtentorial (hematomas of the posterior cranial fossa). Subtentorial hematomas are divided into epidural, subdural and intracerebellar.

At first, intracranial hemorrhage does not manifest itself clinically, since compensation is possible due to “reserve” spaces in the cranial cavity. First, the cerebrospinal fluid spaces on the fornix and base of the brain undergo compression with the movement of cerebrospinal fluid into the subarachnoid spaces of the spinal cord. As the hematoma grows, the most pliable veins on the surface of the brain are compressed. A slowdown in venous blood flow entails increased vascular permeability with impaired tissue respiration with hypoxia and the subsequent development of metabolic acidosis in the cellular and extracellular spaces, which in turn further increases permeability vascular wall with the formation of local edema, increased volume, deformation of the brain, blockade of the outflow tract of cerebrospinal fluid. An increase in the production of cerebrospinal fluid contributes to general edema and dislocation of the brain stem with the development of severe pathophysiological and irreversible pathomorphological changes. The dynamics of compression depend on the source of bleeding, the volume and location of the hematoma, the capacity of the reserve intracranial spaces, the reactivity of the brain, etc. The age and individual characteristics of the victim’s body affect the clinical picture of compartment syndrome.

Recognition. The circumstances of the injury and its mechanism are taken into account (see. Primary examination of the victim - examination of the skull), increasing impairment of consciousness and general cerebral and focal symptoms following a period of clear or cleared consciousness after the injury, progressive deterioration of the general condition of the victim. Diagnosis is based on the dynamics of the neurological picture and vital disorders.

The victim is restless, tosses about in bed, groans due to a painful, bursting headache, and gets chills. He often tends to lie on the side of the hematoma. Breathing becomes more frequent (up to 50-60 per minute) with a simultaneous slowing of the pulse (60-40 beats/min) and an increase in blood pressure (especially on the side opposite the hematoma) and cerebrospinal fluid pressure (see. Lumbar puncture). Repeated vomiting and anisocoria occur. The pupil is often dilated on the affected side, although in initial stage compression it can be narrowed. Of the focal hemispheric symptoms, the dynamics of the pyramidal signs are of particular value.

The earliest brain stem symptoms are usually mesencephalic: decreased corneal reflexes, impaired reaction to light, asymmetry of deep and tonic reflexes according to the hemitype. Psychomotor agitation (hallucinations, delusions) may increase. Following excitement, mental depression, general lethargy, drowsiness occur, and respiratory failure occurs (cyanosis of the lips, tip of the nose, etc.). IN advanced cases a disorder of the pelvic organs occurs - involuntary urination, defecation. Vital disturbances depend on the rate of development of brain compression. Lower brain symptoms (severe breathing disorders, cardiovascular activity and swallowing) indicate far-reaching changes. If the cause of compression is not eliminated, respiratory paralysis and death occur. Timely recognition of an intracranial hematoma is possible with a systematic comprehensive neurological examination of the patient, which determines the indications for the use of instrumental ( ultrasonography, electroencephalography) and surgical methods (see. Carotid angiography, Trefination of the skull).

Epidural hematomas constitute about 1/5 of the total number of intracranial hematomas. The source of bleeding is the branches of the meningeal (usually middle) arteries, veins outer surface dura mater and diploe, less often - damage venous sinuses and veins leading to the sinuses. Blood accumulates between the dura mater and the bone. Symptoms of compression increase after a short “lucid interval” (from 1 to 24-48 hours) and are manifested by a progressive disorder of consciousness. After the stage of excitement with a sharp increase in headache, inappropriate behavior, nausea and vomiting, a stage of inhibition begins - lethargy, drowsiness, turning into stupor and coma, bradycardia up to 40-50 beats/min; Blood pressure increases on the side opposite the hematoma, signs of displacement and compression of the brain stem appear along with local symptoms. The most constant of them are progressive and persistent dilation of the pupil on the affected side (at first it may narrow briefly) and pyramidal symptoms on the side contralateral to the lesion, manifested either by signs of irritation in the form of Jacksonian epileptic seizures, or by progressive paresis and paralysis.

On the side of the epidural hematoma, which usually occurs at the site of the impact, radiographs of the skull reveal a crack or depressed fracture of the squama of the temporal bone. In the temporal region, increasing swelling of the soft tissues is detected due to blood leaking through the bone crack under the temporal muscle. Shell symptoms are usually not pronounced. Changes in the fundus are not permanent.

Subdural hematomas are more common than epidurals; arise not only on the side of the application of traumatic force, but also on the opposite side. Blood accumulations are located in the subdural space, in most cases they arise quickly (in the first 3 days), less often - subacutely (up to 15 days). The source of bleeding is the pial veins, less often the occipital veins and veins flowing into the transverse sinus. Hematomas are most often localized in the parietotemporal, parietofrontal and parietofrontotemporal regions. Located predominantly on the convex surface of the hemispheres, they can spread basally. Acute subdural hematomas usually occur with severe brain contusion. The clinical picture of acute and subacute subdural hematoma is similar to that of epidural hematoma, but compression of the brain increases slowly, the “light gap” is less clearly expressed. Against the background of symptoms of severe traumatic brain injury, local signs (corresponding to the topical location of the hematoma) and compression syndrome are visible less clearly.More often than with an epidural hematoma, pronounced meningeal syndrome and congestion in the fundus. Patients with acute and chronic subdural hematoma may have stagnant discs with a sharp decrease in visual acuity and elements of atrophy. In contrast to epidural hematomas, in acute subdural hematomas the damage to the skull bones is more extensive, and isolated fractures of individual bones of the vault are relatively rare.

In chronic subdural hematoma, blood, accumulating between the dura and arachnoid membranes, is gradually encapsulated, turning into an encysted or saccular hematoma. A pneumoencephalogram usually reveals compression of the lateral ventricle on the side of the hematoma and a displacement of the ventricular system towards the undamaged hemisphere. An anterior angiogram reveals a characteristic avascular zone corresponding to the localization of the encysted hematoma under the cranial vault and a typical displacement of the vascular pattern of the hemisphere to the midline.

Subdural hydromas occur with severe brain contusions, as a result of rupture of the arachnoid membrane and limited subdural accumulation of clear or hemorrhagic cerebrospinal fluid. Increasing (up to 100-150 ml), it leads to an increase in compression syndrome, usually simulating a subdural hematoma, however, with subdural hydroma, brain compression develops more slowly and softly. After a “light interval” (3 days or more), contralateral monohemiparesis, mydriasis on the side of the hydroma and impaired consciousness increase until it is lost. Severe stem symptoms and congestive discs are not typical.

According to the speed of development, hydromas are also divided into acute, subacute and chronic. Acute hydromas (with the development of compression up to 3 days after injury) are usually combined with severe brain contusion (with the development of brain compression within 4-14 days after injury); subdural hydromas are often isolated. With any form, a bilateral location of subdural hydromas is possible. Angiographic manifestations of subdural hydromas are similar to those of hematomas. Preoperative recognition of hydromas is difficult, and patients are usually operated on with a diagnosis of acute or subacute subdural hematoma.

Intracerebral hematomas located in the brain substance to form a cavity filled liquid blood, blood with brain detritus, blood clots; make up about 10% of intracranial hematomas and occur more often with very severe traumatic brain injuries. Hematomas are usually localized in the white matter or coincide with the area of ​​brain contusion; may be combined with epidural or subdural hematomas. The source of bleeding is mainly the vessels of the middle cerebral artery system. Intracerebral hematomas are localized mainly in the temporal and frontal lobes, occasionally in the parietal lobe, and have a rapid clinical course with the rapid manifestation of severe focal symptoms in the form of hemiparesis or hemiplegia. Symptoms consist of increasing compression of the brain and local signs. The latter may be minimal with intracerebral hematomas in “silent” zones (the pole of the frontal lobe, the semioval center of the right temporal lobe, etc.).

Intraventricular hematomas found in 1.5-5% of all intracerebral hematomas, usually localized in the III-IV ventricles of the brain, and can fill most of the ventricular system. The degree and uniformity of filling the ventricular system with blood depends on changes in the patency of the interventricular communication. This type of hematoma is rarely isolated; more often they accompany severe brain contusion or meningeal hematomas. Blood enters the ventricles from damaged choroid plexuses, deep veins of the brain, subependymal vessels (when the medulla is ruptured) or from paraventricular hematomas.

Clinical manifestations are caused by the direct impact of the shed blood on paraventricular formations (higher autonomic centers, reticular formation and other stem structures). There is practically no “light gap”. Stupor or coma that occurs immediately after injury does not have remission. Symptoms of severe damage to the upper trunk with tonic convulsions predominate (hormetonic syndrome, prolonged convulsions such as decerebrate rigidity). Vegetative-stem disorders are represented by hyperthermia, arterial hypertension, repeated vomiting, sweating, hyperemia or pallor of the skin. Vital functions suffer: regulation of breathing and blood circulation. A large admixture of blood is detected in the lumbar and ventricular cerebrospinal fluid.

Traumatic pneumocephalus- a relatively rare complication of severe closed head injury, resulting from the entry of air into the cranial cavity, usually through holes in the cribriform plate or in the wall of the frontal sinus. There are extradural, subdural, subarachnoid, ventricular and intracerebral pneumocephalus. The entry of air into the cranial cavity can lead to increased intracranial pressure with subsequent development of brain compression. The clinical picture of pneumocephalus, along with general cerebral symptoms, consists of the patient’s complaints of a feeling of transfusion, gurgling, noise, splashing in the head, liquorrhea, and signs of increased intracranial pressure. Craniography reveals a shadow of an air bubble in the frontal lobe.

Surgical treatment of brain compression. Direct indications for emergency craniotomy arise in acute, subacute, episubdural and intracerebral hematomas, and in subdural hydromas with clearly defined brain compression syndrome. With compression of the brain by bone fragments displaced deep into (see Fig. Fractures of the skull bones) perform a craniotomy, they are lifted or removed. With pronounced local symptoms of irritation of the cerebral cortex ( epileptic seizures, intense headache, etc.) or increasing loss (paresis, paralysis, aphasia), this operation becomes urgent. In recent years, they have resorted to surgical treatment of bruises of the cerebral hemispheres, mainly lesions in the polar-basal-medial and frontotemporal regions. Craniotomy for closed craniocerebral injury is performed when the localization of the focus of the injury is beyond doubt, and the functional significance of the affected area of ​​the brain is high, and when traumatic swelling or bleeding can lead to brain dislocation with subsequent life-threatening disorders (see. Brain contusion).

Operations are performed under general anesthesia or local infiltration and conduction (cutaneous nerves) anesthesia with a 0.5% solution of novocaine, including the dura mater along its vessels.

Craniotomy is performed by expanding the diagnostic burr hole (see. Trefination of the skull) and creating a resection trepanation window over a hematoma, hydroma, focus of bruise, or performing osteoplastic craniotomy in the area of ​​the suspected pathological focus.

Intracranial hematomas, especially epidural ones, are most often localized in the area of ​​​​the projection of the middle meningeal artery and its branches, and therefore a burr hole is usually placed in the squama of the temporal bone. If there are clear neurological signs of damage to the frontal, parietal, or occipital regions, holes are placed immediately in the corresponding sections. The localization of an intracranial hematoma (due to bleeding from pachyonic granulations) can be indirectly indicated by cracks in the bones of the skull.

For trefination, an incision is made into the soft tissue of the head, which does not cross the large vessels of this area and, if necessary, can easily be continued into a horseshoe-shaped incision in order to cut out an aponeurotic skin flap. These conditions are met by an anterior oblique incision from the middle of the zygomatic arch obliquely upward and forward (Fig. 86) and a posterior oblique incision starting 1-1.5 cm upward from the anterior edge of the auricle, its helix and going obliquely backward and upward (Fig. 87). The length of both cuts is about 4 cm. They can be easily extended forward or backward. An incision in the skin, fascia, temporal muscle and periosteum is made through all layers to the bone. The periosteum is moved. If a pathological focus is detected through the burr hole, then with the help of pliers the hole is expanded to form a trepanation window measuring 4x6 cm or 6x6 cm. In case of epidural hematoma, liquid blood is evacuated with an aspirator, blood clots are removed with a bone spoon. If a bleeding artery is detected, it is coagulated or ligated after suturing along with the dura mater.

Often, by the time of surgery, the lumen of the bleeding vessel is already thrombosed and the source of bleeding is not identified. When the hematoma is visible through the dura mater, it is dissected crosswise or arcuately, and the subdural hematoma (together with brain detritus from the focus of contusion and crush of the brain) is sucked out with an aspirator. If intracerebral and intraventricular hematoma is suspected, a puncture of the brain and ventricles is performed with a blunt cerebral cannula. Extraction of a small amount of stale dark blood from the depths of the brain indicates an intracerebral hematoma, usually represented by clots and a small amount of liquid blood. When the hematoma is localized in functionally important parts of the cortex, the brain tissue is dissected at some distance from these areas to empty it. Dissection of the brain towards the hematoma is performed bloodlessly, in good lighting. In depth, against the background of normal grayish tissue, foci of hemorrhagic imbibition are determined, confirming the existence of a hematoma. Blood clots mixed with liquid blood are found in her cavity. The contents of the hematoma are sucked out or washed out with a stream of liquid and the cavity is cleared of clots, after which the brain collapses and begins to pulsate.

After the revision of the brain wound and coagulation of the bleeding pial vessels, it is thoroughly washed with a warm isotonic sodium chloride solution. The intervention on the brain tissue is completed by suturing the dura mater or its plastics using one of the generally accepted materials and methods (auto-alloplasty). Cerebral edema or its likelihood in the future makes it necessary to perform shell plastic surgery with a "margin": a large donor flap is taken, after its laying there should be a reserve space. In all cases, it is necessary to strive for sealing the intrathecal spaces in order to avoid liquorrhea and secondary infection brain tissue, and in case of a bone defect - to the separation of the brain and soft tissues.

In the absence of biological grafts, a polyethylene film sterilized in disinfectant solutions or in formaldehyde vapor (when boiled it becomes hard). The film can be laid (but not sutured) on or under the meninges, overlapping the edges of the defect by 1–2 cm.

A more physiological intervention than resection craniotomy is osteoplastic trepanation. A semicircular incision of the integument is performed with separation and folding of the skin-aponeurotic flap having a wide base in the frontal or temporal region. Through 4-6 cutter holes, a Gigli file is carried out under the protection of an elastic conductor. Between the holes, the bone is cut with preservation of the base of the bone flap in the region of the temporal muscle. The osteoplastic flap on the muscular pedicle is folded back. Subsequent actions on brain tissue depend on its damage. After the end of the intervention, the osteoplastic flap is placed in place and fixed with interrupted sutures placed behind the periosteum and muscles of the skull. Sometimes a bone fragment is removed due to severe cerebral edema. It can later be used for plastic surgery using autologous bone. The bone fragment is stored at a temperature of -75°C or in the patient's body - in a subcutaneous pocket on the abdomen created during trepanation.

In case of depressed fractures of the cranial vault, a skin-periosteal flap is cut out in the depression zone with a sufficiently wide base to provide it good food, satisfying cosmetic requirements. After detachment of the flap from the bone, free bone fragments that have penetrated into the cranial cavity and press on the brain are carefully lifted, and some of them are removed. Particular care should be taken when localizing fragments in the area of ​​the longitudinal and transverse venous sinuses, since the bone fragments that wound their walls simultaneously plug the sinuses. Bleeding from the sinus is first stopped by pressing a finger, then the head end of the operating table is quickly raised and a piece of muscle tissue or aponeurosis is brought to the bleeding area, which is sutured to the wall of the damaged sinus. If there is significant damage to the sinus, plastic surgery of its wall is performed by dissection of the dura mater. In case of threatening bleeding from a sinus wall defect, tamponade is resorted to. Sometimes for these purposes you can use a bundle of catgut, which is fixed with sutures to the dura mater (the patency of the sinus is not impaired). If it is impossible to stop the bleeding using these methods, bandage the sinus. If the depressed bone fragments are large and not separated from the periosteum, then they are only lifted and left in place. After lifting the fragments and removing free small fragments, inspection of the damaged dura mater and crushed area of ​​the brain, hemostasis, removal of blood clots, brain detritus are carried out with washing the wound with a warm isotonic solution of sodium chloride. The dural defect is closed. If the patient’s condition is satisfactory, the bone defect can be closed after smoothing out the irregularities with a quick-hardening polymer.

Conservative therapy after surgery - see. Brain contusion - treatment.

Brain concussion- occurs in almost all cases of traumatic brain injury and is considered its mildest form. Reversible functional changes in the brain predominate. Clinically, a concussion is manifested by symptoms of diffuse brain damage with loss of consciousness and a predominance of general cerebral symptoms. In the acute period, there may be microfocal symptoms that disappear in the next 2-3 days. Pathomorphological manifestations of a concussion are represented by hyperemia of the pia mater, venous stagnation, edema, small hemorrhages, and sometimes dystrophic changes in nerve cells and fibers. A concussion is accompanied by a disturbance of consciousness from mild (somnolence) to severe (stupor), nausea, vomiting, headache, dizziness, impaired memory for the circumstances of the injury (anterograde amnesia), and in some cases for the period preceding the injury (retrograde amnesia), combined (anteroretrograde amnesia), pallor of the skin, sweating, slow or increased pulse with insufficient tension, minor changes in blood pressure, adynamia. There is uniform hypotonia of the muscles of the limbs, uniform hyporeflexia, decreased pupillary response, sometimes anisocoria, pain on movement. eyeballs up and to the sides, often in combination with dizziness, spontaneous nystagmus of varying nature and intensity. Microfocal symptoms that have topical diagnostic significance are relatively rare in the first hours after injury (impaired sense of smell, slight deviation of the tip of the tongue, slight unevenness of deep reflexes, absence or decrease in abdominal and cremasteric reflexes, etc.). In the following days, patients complain of headache, less often nausea, dizziness, lethargy, irritability, insomnia, and a rush of blood to the head. Otoneurological examination sometimes reveals vestibular symptoms. In the fundus of the eye, during the first week after the injury, dilation of the veins is detected, sometimes blurring of the boundaries of the optic discs. With a concussion, the composition of the cerebrospinal fluid does not change significantly; it is transparent, without any admixture of blood. Liqueur pressure in 60% of cases is increased (200 mm water column and above), in 20% of victims it can remain normal (120-180 mm water column), in 20% of patients it is PO mm water. Art. and below. A sign of hypotension syndrome is the leakage of cerebrospinal fluid during puncture from a needle with rare drops or the absence of leakage - the so-called dry puncture with patent cerebrospinal fluid tracts. With hypotension syndrome, victims often experience thirst, pallor and cyanosis, physical inactivity and asthenia, pronounced membrane symptoms and severe compressive headaches, which intensify when moving to a vertical position and decrease in a horizontal position. Patients prefer to lie with their head down, without a pillow (symptom of “lowered head”). Clinically, hypotension syndrome is manifested by the symptom of "lowered head", tachycardia, arterial and venous hypotension. General cerebral signs are more pronounced. Hypertensive syndrome is characterized by bradycardia and arterial-venous hypertension.

With a concussion with minor clinical manifestations, the loss of consciousness is short-term (up to several minutes), the victim quickly comes out of a stunned state. The headache does not differ in intensity, there are practically no vegetative and neurological symptoms. Improvement occurs after 3-5 days, the condition returns to normal within 10-15 days.

A concussion with pronounced clinical manifestations is characterized by a longer loss of consciousness - from several minutes to 3 hours. The patient slowly recovers from a state of general stupor, confusion and psychomotor agitation are possible; autonomic disorders are expressed for several days after the injury. The condition improves after 7-10 days, and clinical manifestations disappear after 2-4 weeks. Neurological “microsymptoms” can be detected for several months after the injury. Without treatment (failure to comply with bed rest, etc.), the victim’s condition can noticeably worsen and the symptoms become severe, the disease becomes protracted.

Recognition(cm. Primary examination of the victim - examination of the skull). The circumstances and mechanism of injury, the fact and duration of loss of consciousness, retrograde amnesia, vomiting, and various autonomic disorders are clarified. A plain radiography of the skull is required. To exclude subarachnoid hemorrhage, a diagnostic lumbar puncture is performed (see).

Treatment. Hospitalization, mandatory bed rest for 1-3 weeks depending on the severity of clinical manifestations. Symptomatic therapy aimed at eliminating headaches, insomnia, dizziness, nausea (amidopyrine, analgin, phenacetin, paracetamol, sodium barbital, sodium etaminal, noxiron, eunoctin, radedorm, platifillin, bellaspon, etc.). Sedatives and antipsychotics are contraindicated in cases of suspected organic traumatic brain damage (intracranial hematomas). For dehydration, diuretics are prescribed, glycerol orally (at the rate of 1 g/kg with water or fruit juice in a ratio of 1:2 or 1:3). For concussion with severe clinical manifestations, ganglion blockers (1-2 ml of 5% pentamine solution intravenously), antihistamines, and cardiovascular drugs are used from the first days of hospitalization.

In case of a pronounced increase in intracranial pressure, to relieve cerebral edema, a 10% mannitol solution is injected intravenously at a dry matter rate of 0.5-1 g/kg in an isotonic sodium chloride solution or 5% glucose solution. In case of cerebrospinal fluid hypotension, it is necessary to replace fluid with subcutaneous or intravenous administration of a 5% glucose solution, isotonic sodium chloride solution, and drinking plenty of fluids. It is advisable to use drugs that increase blood pressure (caffeine, ephedrine, norepinephrine). Unilateral vagosympathetic blockade has a positive effect in hypotensive syndrome (see. Vagosympathetic blockade). Disability in concussion without pronounced clinical manifestations is 4-6 weeks, with more severe damage, it depends on the elimination neurological disorders(6-8 weeks).

Brain contusion. More severe brain damage than a concussion. Unlike a concussion, brain contusion has pronounced clinical manifestations organic damage. Macroscopically expressed foci of damage and clearly visible hemorrhages appear in the brain tissue. In the area of ​​application of force, there are foci of hemorrhagic softening, impaired blood and lymph circulation in the perifocal zone; Similar outbreaks also occur at a distance from the impact site. The formation of distant foci of brain contusion is explained by the fact that at the moment of impact the brain moves sharply, performing complex rotational movements, and is injured on the opposite wall of the skull (counter-impact) or intracranial bone protrusions (small wings of the sphenoid bone, protrusions of the sella turcica, the upper edge of the pyramid of the temporal bone and etc.), about the processes of the dura mater. The main localizations of contusion foci are the cerebral hemispheres (orbital surfaces of the frontal lobes, pole and basal parts of the temporal lobes) and the brain stem. A combination of foci of contusion in the cerebral hemispheres, cerebellum and brainstem is possible. Particularly dangerous are foci of contusion in the brain stem and close to the cerebral ventricles, where vital centers are located.

Symptoms of a brain contusion occur suddenly, they are more pronounced, stable, and prone to progression than the symptoms of a concussion. In most cases, brain contusion is accompanied by a combination of general cerebral and focal symptoms. Only with force applied to a limited area of ​​the skull can a brain contusion manifest itself as local symptoms of cortical prolapse. Along with microfocal symptoms in the form of deviation of the tongue and smoothness of the nasolabial fold, disorders of taste and smell, paralysis and paresis, and sensitivity disorders can develop. Meningeal signs are also possible - photophobia, uncontrollable vomiting, severe headache, hypertonicity of the extensor muscles of the torso and limbs, positive symptoms of tension - Kernig, Lasegue, Brudzinsky. Depending on the mechanism of injury, brain contusion can be combined with a fracture of the vault and base of the skull (see), intracranial hematomas and pneumocephalus, severe edema-swelling of the brain (see. Brain compression). There are light, moderate and severe bruises. A mild contusion of the brain is accompanied by mild focal symptoms that do not disappear during the first week after the injury, subarachnoid hemorrhage, and often damage to the bones of the skull. With moderate brain contusion, cerebral and local symptoms are more pronounced. Focal symptoms, determined for the most part by the return of consciousness, are represented by paralysis, paresis, decreased vision, hearing, aphasia, etc. (the location of the bruise can be determined from them). Severe brain contusions cause damage to subcortical formations (phenomena of diencephalic, mesencephalic-bulbar insufficiency, etc.) and stem structures (disturbances in breathing, swallowing, cardiovascular activity). The patient loses consciousness for a long time and often falls into a coma. In the most severe cases, the victim dies without leaving a coma. The victim comes out of the unconscious state after a long period of stupor (from several days to 1-2 weeks, in some cases up to 1 month). Stunning can be combined with various psychopathological syndromes - delirious agitation, somnolence, oneiroid states, etc. As a rule, retrograde and often anterograde amnesia occurs.

Brain contusion is accompanied by subarachnoid hemorrhage - from a slight admixture of blood in the cerebrospinal fluid, determined only by microscopy of the sediment, to massive bleeding, when only blood is found in the test tube during puncture. Clinically, hemorrhage is manifested by a sharp headache, nausea, vomiting, photophobia, often pain in the lower back, lower extremities, stiff neck and Kernig's symptom, fever and other meningeal symptoms. In patients in a coma, the meningeal symptom complex manifests itself less clearly; with a small hemorrhage, especially in the first hours after the injury, its signs are practically absent and the diagnosis can only be made according to the data of spinal puncture. In the cerebrospinal fluid, the protein content is increased (0.46-6.76%), erythrocytosis and pronounced leukocytosis are noted due to concomitant aseptic meningitis. In an uncomplicated course, traces of blood disappear by the end of the 2nd week after the injury; in some cases, the cerebrospinal fluid becomes xanthochromic already a day after the injury.

A brain contusion, especially a severe one, is often accompanied by symptoms of compression of the brain. Clinical picture usually consists of symptoms of a depressed fracture, intracranial hematomas, pneumocephalus, etc. Symptoms of brain contusion undergo a reverse development no earlier than 2-3 weeks after the injury. Small cortical contusion softenings are scarred over the course of 2-3 weeks. Extensive lesions turn into cysts. The outcomes of brain contusion are varied: from death in the first minutes or hours after the injury to recovery. Most often, recovery is accompanied by certain residual effects (headache, dizziness, memory loss, emotional imbalance, paresis and paralysis of the limbs, sensory impairment, decreased ability to work). IN long term Epileptic seizures often occur.

Recognition. Anamnesis and mechanism of injury are taken into account (see. Primary examination of the victim - examination of the skull). In difficult clinical cases, where symptoms and syndromes (concussions, bruises, and sometimes compression) are closely intertwined, the leading diagnostic indicator is pronounced and persistent focal symptoms of organic damage to the brain stem and hemispheres. A brain injury, as a rule, immediately manifests itself as a prolonged loss of consciousness (hours, and sometimes days, weeks). Symptoms and dynamics are determined by the nature, localization of the main lesion and perifocal phenomena, depending on the disturbance of blood and lymph circulation. Signs of prolapse are expressed when the lesion is localized in functionally significant parts of the brain. Perifocal phenomena develop later and regress earlier and more completely. When the frontal lobes are damaged, psychopathological symptoms with relatively sparse neurological signs come to the fore; peripheral signs (as a result of contusion of the cerebral hemispheres) are represented by paresis of the facial nerve. With a contusion of the left frontal lobe (Broca's center), temporary or persistent motor aphasia is possible. The focus of a bruise in the area of ​​the central gyrus causes paresis or paralysis of the upper and lower extremities (anterior central gyrus), as well as sensitivity disorders (posterior central gyrus) on the side opposite to the bruise, accompanied by pathological reflexes. Damage to the occipital lobe is accompanied by changes in visual fields. With damage to the left temporal lobe (Wernicke's center), amnestic and sensory aphasia and sometimes central deafness are noted. Severe lesions of the parietotemporal region of the left hemisphere cause aphasic, agnostic and apractic syndromes. Contusions of the basal parts of the brain - the hypothalamic-pituitary region and the trunk, in addition to prolonged loss of consciousness, are accompanied by severe neurovegetative disorders (respiration, cardiovascular activity, thermoregulation), metabolic, endocrine changes, etc. In the diagnosis of brain contusion they acquire important data from instrumental methods. EEG evaluates the dynamics of focal and cerebral changes. Dynamic rheoencephalography allows you to identify signs of increasing compression of the brain, which is especially important for bruises with compression. For the differential diagnosis of brain contusions and intracranial hematomas, echoencephalography is used.

Treatment. Prehospital care is as follows. 1. If the patency of the upper respiratory tract in victims is impaired, the oral cavity and pharynx are emptied, obstructions to breathing are eliminated (due to impaired tone of the muscles of the pharynx, tongue and lower jaw, especially with a reduced swallowing reflex and impaired swallowing). The victim in unconscious laid on its side (if combined injuries allow) or on the back, the head is turned to the side, the air duct is inserted through the nose or mouth. In case of severe occlusive-obstructive breathing disorders, immediate tracheal intubation and aspiration of the contents of the trachea and bronchi are indicated. It is necessary to restore adequate breathing (combat hypoxia and hypercapnia), and, if necessary, mechanical ventilation until spontaneous breathing is restored; oxygen therapy. 2. Restoration of adequate hemodynamics (in specialized first aid conditions) by intravenous administration of fluid, glucose, saline solutions. 3. Transportation to a hospital (all victims with traumatic brain injury are subject to hospitalization). A patient with a brain contusion of any severity (even if he insists on moving independently) should be transported lying down from the scene of the incident to the hospital emergency department. During transportation, measures must be taken against aspiration of vomit (see. First aid). 4. Combating diclic focal or generalized clonicotonic convulsions, psychomotor agitation. It is advisable to introduce 15-20 ml of a 0.25% solution of novocaine (intravenously slowly, preferably drip). In the absence of effect, general anesthesia is used with nitrous oxide with oxygen (1: 1). This measure does not interfere with the rapid (after the termination of anesthesia) neurological and surgical examination of the patient in the hospital and prevents an increase in venous pressure, intracranial hypertension, cerebral edema, and its dislocation.

Victims with mild and moderate brain contusions for approximately 2/3 of the time of inpatient treatment, which is usually 25-45 days, observe strict bed rest. The main clinical manifestations in this category of victims, subject to bed rest, are stopped by bromides and fractional doses of barbiturates (phenobarbital, etaminal sodium, barbital 0.3 g / day or amytal sodium 0.1-0.2 g each). In the stage of normalization of higher nervous and aegetative activity, stimulating drug therapy with small doses of bromine with caffeine, vitamins C and B 1 is used; TFC and physiotherapy as indicated. Patients with severe brain contusions are shown bed rest from 1 1/2 to 3 months or more.

With severe brain damage, the focus is on the fight against disorders of vital important functions organism. Three protracted central respiratory disorders and profound impairment of consciousness with loss of cough and swallowing reflexes for more than a day, as well as pulmonary edema, cranio-spinal injuries, combined gross violations of the ribs, a tracheostomy is performed with the patient transferred to a long-term mechanical ventilation. In parallel with maintaining vascular tone and replenishing the BCC, stimulation of cardiac activity is carried out (see. Traumatic shock, acute blood loss). The required amount of blood, plasma, high-molecular-weight solutions (polyglucin, syncole) and other blood-substituting fluids, as well as cardiac agents and vasotonics are intravenously administered.

In recent years, the indications for the early removal of broad foci of contusion softening of the brain have expanded, especially on the lower surface of the temporal and frontal regions. The operation consists in removing non-viable tissues, washing them out with a jet of liquid, or even resection of a part of the brain (within the physiological permissibility); if necessary, decompression is also performed (see. Brain compression). To assess the CSF pressure, 6-12 hours after the injury, a spinal puncture is performed (see Fig. Lumbar puncture). High cerebrospinal fluid hypertension (300-400 mm water column) leads to a violation venous outflow from the cranial cavity and contributes to cerebral edema. Dehydration osmotherapy is carried out by intravenous infusions of 40% glucose solution (60-100 ml), intramuscular injections of 25% magnesium sulfate solution; diuretics (furosemide) are used and unloading spinal punctures are performed. Prescribe antihistamines and anticholinergic drugs that have antihypertensive properties (pipolfen). Atropine helps reduce the production of cerebrospinal fluid. The use of urea and mannitol (1 g/kg) in the acute period is risky due to the possibility of increased intracranial bleeding. They are contraindicated in cases of massive subarachnoid bleeding, suspected intracranial hematomas, and impaired renal function. After hemostasis (during surgery), it is advisable to use urea and mannitol. To combat cerebral edema, unilateral and bilateral vagosympathetic cervical blocks are performed (see. Therapeutic blockades). To prevent cerebral edema, patients are administered concentrated protein solutions. For the purpose of dehydration, in the absence of pronounced intestinal paresis, glycerin is injected into the stomach (80-100 g/day through a tube).

For hypotensive syndrome (with low cerebrospinal fluid pressure), moderate hydration is used - subcutaneous administration of an isotonic sodium chloride solution, intravenous administration of distilled water (50-100 ml), subarachnoid administration of oxygen (20-25 ml).

Treatment of subarachnoid hemorrhage consists of the use of cold on the head, means that help stop bleeding from damaged pial vessels and stop diapedetic hemorrhage (calcium chloride solution, Vicasol, gelatin solution, rutin, ascorbic acid), as well as pipolfen, diphenhydramine. In case of continuous subarachnoid bleeding, fibrinogen and aminocaproic acid are infused intravenously (under the control of blood coagulation systems). Perform systematic (every other day) lumbar punctures to monitor hemostasis; to sanitize the cerebrospinal fluid and prevent adhesions between the membranes, 15-20 ml of oxygen is injected into the intrathecal space (in case of fresh subarachnoid hemorrhage with a large amount of blood in the cerebrospinal fluid, more than 4-5 ml of fluid should not be removed so as not to increase the bleeding).

At a temperature of 40-41° C, the patient's condition becomes dangerous. The fight against hyperthermia that occurs with diencephalic lesions includes physical cooling with ice packs placed on the area of ​​large vessels and craniocerebral hypothermia. Enter lytic mixtures, consisting of antipsychotics, antihistamines, pyrolytic drugs, vitamins.

Prevention and treatment of infectious complications begin from the very first days after injury, using broad-spectrum antibiotics and other chemotherapeutic drugs.

Correction of metabolic disorders - combating frequently developing acidosis with the help of sodium lactate, glucose and intravenous administration of a freshly prepared 4% solution of sodium bicarbonate at a rate of 4 ml/kg. Hypoproteinemia is compensated by transfusion of protein drugs. In order to improve redox reactions, vitamins C and group B are prescribed.

Patients with brain contusion, especially in the critical period, need careful care (see Fundamentals of care for patients with injuries), prevention of bedsores, keratitis, ankylosis of the joints, pulmonary complications. Prevention of pulmonary complications includes adequate ventilation of the lungs, oxygen therapy, breathing exercises, vibration chest massage, and careful care of the tracheostomy.

The restoration of impaired functions of the central nervous system is started as soon as possible after the elimination of vital disorders and the improvement of the general condition of patients. Resolving and stimulating therapy is prescribed according to the generally accepted method (drugs that prevent the formation of adhesions and reduce collagenization - lidase, biyoquinol, iodine preparations, trypsin, pyrogenal; biostimulants - aloe, FiBS, vitreous body). This treatment is combined with physiotherapy, especially in cervical-collar area, massage, passive and then active gymnastics, mainly in patients with combined motor disorders(paresis, paralysis).

To improve neuromuscular conduction and restore muscle strength, anticholinesterase drugs (proserin, galantamine, etc.) are prescribed, to reduce muscle tone and prevent contractures - mydocalm, millectin, condelfin, as well as special therapeutic poses and relaxation exercises. Restorative treatment for lesions of the cranial nerves (facial, optic, auditory) begins on the 5-7th day after the injury or the patient’s recovery from unconsciousness. When the facial nerve is damaged, exercise therapy, positional treatment - adhesive plaster tension, facial massage, physiotherapy (galvanization, electrophoresis, Sollux, UHF, heat therapy), drug therapy (vasodilators, proserin) are used. Prevention of keratitis is very important. For visual and auditory nerves Vasodilators, nicotinic acid, B vitamins, dehydration, stimulating and resorption therapy (iodine preparations, fractional blood transfusions, biostimulants) are prescribed, followed by repetition of such courses.

Open (gunshot) injuries to the skull and brain - injuries in which the wound of the integument of the cranial vault communicates with a fracture. Fractures of the base of the skull without damage to the integument, but with the outflow of cerebrospinal fluid and blood from natural openings (nose, ear, mouth) can also be attributed to open trauma due to the constant threat of infection entering the cranial cavity. Skull injuries are divided into soft tissue injuries without bone damage, in which closed brain injuries (concussions, bruises, compression) are possible; non-penetrating injuries of the skull, in which there is a bone fracture, but the dura mater remains intact, which is the main barrier against the penetration of infection into the brain substance; penetrating wounds of the skull and brain. According to localization, injuries are distinguished in the frontal region, parietal, temporal, occipital, parabasal - fronto-orbital, temporomastoid, etc.; on the side of damage - right, left, parasagittal, bihemispheric; according to the type of fracture of the skull bones - incomplete, linear, depressed, perforated, splintered, crushed. The type of wound and type of skull damage depend on the mechanism of injury (see. Wounds and wound infection, Skull fractures). So, with a blunt injury, the wound of the skull is mostly lacerated and bruised, and the fracture of the skull bones is depressed, with radiating cracks, or splintered. The dura mater is injured by fragments of the vitreous plate, and the membranes, blood vessels, and cerebral cortex are also damaged. When injured with a cold weapon, the wound of the integument will be chopped or punctured, and the fracture will be perforated and splintered. This type of injury is accompanied deep damage brain substances. Pathomorphological changes in the brain in open trauma due to ruptures and crushing of the cerebral hemispheres are represented by massive destruction of the medulla with damage to the walls of the lateral ventricles and leakage of cerebrospinal fluid. Gunshot wounds of the skull and brain are also distinguished by the nature of the wound channel (blind, tangential, through, ricocheting with external and internal ricochet), by the type of wounding projectile (bullet, fragmentation), and the number of wounds (single, multiple).

Clinical manifestations in the acute period are represented by a complex combination of symptoms of wounds of the skull and brain, reversible and irreversible neurological syndromes - cerebral, meningeal, focal, stem. General cerebral symptoms are manifested by impaired consciousness of varying severity, sometimes with severe respiratory and cardiac dysfunction. Meningeal symptoms in the acute period are caused primarily by direct damage to the membranes or subarachnoid hemorrhage. Focal symptoms are very diverse and depend on damage to various cortical and subcortical structures along the wound canal (presence of foreign bodies, bone fragments, etc.). Vital disorders are caused by damage or secondary involvement (edema, entrapment) of the brain stem. The most severe disturbances of consciousness and pronounced brain stem symptoms are observed when the brain is injured by modern gunshot wounds, when a temporary pulsating cavity is formed in the brain not only with an extensive area of ​​primary traumatic necrosis of the brain substance, but also with secondary disorders of brain functions due to large secondary necrosis, disorders blood circulation and liquor circulation. A brain stem injury can be fatal at the scene or during transport to a hospital. Acute compression of the brainstem usually leads to vital disturbances during the first hours or days as a result of increasing intracranial bleeding. Subacute brainstem syndrome develops over several days with progressive edema - swelling of the brain due to both injury and associated infectious complications.

Recognition. The mechanism of injury is taken into account (see Primary examination of the victim - examination of the skull). A surgical examination of the wound, a neurological examination, and radiography of the skull are performed. When the dura mater is ruptured, blood, cerebrospinal fluid, and brain matter may be released from the wound. A study of the nervous system allows us to establish the location, nature and depth of brain damage. In the first hours and days after injury, general cerebral symptoms prevail over focal ones (see. Concussion, Brain contusions). Special attention pay attention to consciousness, breathing, cardiac activity, and the act of swallowing. Based on radiographs, one can judge the nature of the bone defect, the direction of cracks, the number and position of bone fragments, the presence of foreign bodies, etc. If necessary, instrumental research methods are used (see. Ultrasound diagnostics of damage).

Treatment. First aid - preventing the entry of blood, cerebrospinal fluid or vomit into the respiratory tract, for which the body of the wounded person or his head is turned to the side; A bandage is applied to the wound (see. Wounds and wound infection); in case of circulatory and respiratory disorders, measures are taken to normalize them (see. Brain contusion). Early primary surgical treatment of the wound is performed with radical excision and removal of dead tissue and tissue of questionable viability (see. Primary surgical treatment). Contraindications to primary treatment: injuries incompatible with life, accompanied by destruction of the skull and brain (especially its basal and deep-trunk parts); pronounced disorders of breathing, cardiovascular activity and swallowing; severe coma or preagonal state. The most favorable time frame for primary surgical treatment is the first 24 hours after injury. Delayed initial wound treatment is possible.

An x-ray determines the nature of the bone fracture and the location of bone and metal foreign bodies in the wound. The hair on the head is shaved off, the skin near the wound is treated. Contaminated and nonviable edges of skin and soft tissue are excised sparingly with two semi-oval incisions. The uneven edges of the bone wound are bitten off to give them a regular round or oval shape; loose bone fragments are removed from the wound and foreign bodies. If the dura mater is intact and there is no clinical evidence of an intracerebral or subdural hematoma or severe brain contusion, then it should not be opened. If the integrity of the dura mater is damaged, it is dissected to the extent necessary to examine the brain wound. Bone fragments, hair, and easily accessible foreign bodies are removed from the wound channel. To increase intracranial pressure, the patient is asked to cough, strain, and in unconscious persons, the jugular veins are briefly compressed, which promotes the release of brain detritus, blood clots, hair, etc. from the depths of the wound. Then the wound is washed under pressure with a warm isotonic solution of sodium chloride and peroxide solution hydrogen. Metal foreign bodies (bullets, fragments, balls, etc.) must be removed if they are located no deeper than 5-6 cm from the edges of the wound. Removal of deeply located foreign bodies is carried out strictly according to radiographs by expanding the wound channel and under visual control. In this case, they use special tools that have a platform with notches, magnet pins with a large attracting force, etc. Only accessible foreign bodies are removed. The brain wound is washed again with a weak antiseptic solution and a gauze ball moistened with a 3% hydrogen peroxide solution is placed in the wound canal for 2-3 minutes to stop parenchymal bleeding. An x-ray is taken on the operating table at the final stage of the operation to control its radicality. With severe cerebral edema or serious condition In a patient with brainstem symptoms, sutures are placed only on the soft integument of the skull, and the dura mater is not sutured. Drainage is left in the wound. In case of very contaminated wounds and the extremely serious condition of the victim, which does not allow complete surgical treatment, the wound is treated under a long-term Mikulicz bandage.

After the end of the primary surgical treatment in order to prevent purulent complications broad-spectrum antibiotics are used. Carry out measures to combat cerebral edema (see. Brain contusion). Nasal and ear liquorrhea in the acute period is treated conservatively. The head and upper half of the body are placed in an elevated position, strict bed rest is prescribed, straining is avoided (blowing the nose is prohibited, laxatives are prescribed), and fluid intake is limited. The cerebrospinal fluid should flow freely into sterile bandage covering the nose or ear. A solution of antibiotics is instilled into the nose and ear repeatedly (6-8 times a day). For the purpose of dehydration, furosemide (0.04 g 1-2 times a day) and mannitol (20% solution at the rate of 1-2 g/kg) are prescribed. Spinal punctures are performed daily. The cerebrospinal fluid is removed until the pressure drops to 100-120 mm of water. Art. The therapeutic effect is achieved by repeated injection of a small amount of oxygen (10-20 ml) into the subarachnoid space during puncture. After the administration of oxygen, in case of otorrhea, the patient is placed on the side opposite to the leakage of cerebrospinal fluid; in case of nasal liquorrhea, the patient is placed on his back without a pillow (with the upper half of the body elevated). Surgical treatment is usually resorted to 2-3 weeks after the injury.

Among injuries with high mortality, fracture of the base of the skull is considered one of the most common. As a result of damage to bone structures, such an important organ as the brain suffers. Often, a base fracture is accompanied by damage to the cranial vault. What is the outcome of such a wound is best told by statistics - they lead to death in 20% of cases. Survival from a basal skull fracture is directly related to the complexity of the injury and the age of the victim. over the age of 50 are more likely to result in death.

Only a strong impact can cause damage such as a skull fracture. The bones of the head are highly durable, and they cannot be damaged under any circumstances.

In the case of a closed injury, the survival rate is higher. The classification of skull fractures allows us to distinguish several types of injuries:

• linear- the least dangerous damage without displacement. A linear fracture of the skull implies a crack of clear geometry. It is possible that the integrity of the meninges is damaged, but the prognosis is favorable compared to other injuries;
• comminuted- are closed and open. The latter occur more often and are accompanied by polytrauma. Of particular danger is the crushing of the brain;
• dented– the presence of multiple fragments is not necessary, but a depressed skull fracture is dangerous because part bone tissue penetrates into the cranium. An impression fracture of the skull is often fatal;
• breakdown They account for the highest percentage of deaths. Perforated fractures of the skull are characterized by penetrating injuries. The characteristics of the entry hole provide clues as to how the injury was caused. Most often it is a gunshot wound.

It is not always possible to unambiguously determine the type of skull fracture, since various disorders occur simultaneously. Thus, a comminuted fracture of the skull is accompanied by damage to the optic nerve, organs of vision and hearing, and bone structures of any location. In this regard, injuries are classified according to the location of the cranial fossa:

• front– single fractures of the anterior cranial fossa are less common;
• average– fractures of the middle cranial fossa account for 60% of total skull injuries;
• rear– with fractures of the posterior cranial fossa, concomitant disorders of the bone tissue of other organs are observed, for example.

Trauma to the base of the skull, that is, a basilar fracture, is accompanied by cases of scalping of the skull. If compression is the cause of the damage, then comminuted fractures. A depression fracture of the skull is one of the varieties of depressed fracture.

The mechanism for the formation of such an injury is as follows: an object with enormous impact force and a large contact area hits the base of the skull. Such damage is typical for the frontal sinus and temporal region, where the structures are thinner. When an old wound is re-injured, a terrace-shaped fracture occurs - the fragments are arranged in a stepwise order, which is why the injury got its name.

ICD 10 injury code

According to the international classification of diseases, the code for cranial injuries is S02. A skull fracture is determined by the location of the injury. Thus, vault injury is indicated by code S02.0, – S02.3. A direct fracture of the base of the skull according to ICD 10 is coded S02.1. Additional numbers after the main code indicate the nature of the fracture - open or closed.

Causes

Fractures of the skull bones usually occur in accidents. In the event of an accident, a strong impact occurs with a large surface area. Not only the head suffers, but also other organs. The risk group includes representatives of motorcycling and cycling.

One of the most common causes of childhood injuries is falls from height. In infants, uncomplicated fractures of the bones of the skull base are the result of falling out of a stroller or from a changing table. But usually such an impact is not enough to severely damage bone tissue.

A fracture of the base of the skull occurs when exposed to a blunt object with great force. A falling beam or log causes a fractured skull. With such an injury, death may occur immediately after impact. If the victim received a minor blow, a crack will occur. Due to damage to the skull, dizziness and loss of orientation occur.

How else can you get a skull injury? It is difficult to break a skull during a fight. But if you hit the face with a heavy object, then cracks in the temporal area are possible. In such cases, an eyebrow dissection occurs or. The nasal passage is destroyed, the eye sockets are injured, bone fragments can disrupt the functions of important organs. How hit harder, the greater the likelihood of a comminuted fracture.

The most dangerous injury is caused by compression of the skull. This occurs in car accidents when the victim is pinned between vehicles. During combat operations there are fragmentation and gunshot wounds. If the meninges are damaged, the probability of death is high. When a bullet wound occurs, brain fluid leaks out through the hole and brain tissue dies.

Symptoms

Signs of a skull fracture are lack of consciousness or disorientation of the victim. If a person is conscious, he will complain about unbearable pain. Vision and hearing may be impaired due to damage to the olfactory or optic nerve. Due to brain swelling, breathing is impaired, pressure on the eyes causes multiple hemorrhages. If the blood vessels burst, then the whites of the eyes turn completely red. A symptom of glasses also occurs - hematomas around the eyes.

At the same time, there is a sharp decrease in hearing and bleeding from the ears. Symptoms of a skull fracture include facial paresis, abnormal reflexes, and motor abnormalities. The patient begins to vomit, the pulse weakens, convulsions and other atypical reactions occur.

Symptoms of a fracture of the base of the skull include nasal discharge of an unclear nature. It could be cerebrospinal fluid. The work of the vestibular apparatus is disturbed, consciousness is confused. Typical manifestations of a fracture of the base of the skull include different pupil diameters, loss of taste, cardiac dysfunction, and spontaneous urination.

If a person does not have characteristic signs of injury, but has open wounds on the head, then a fracture should not be immediately ruled out. Injuries can be minimal, but its consequences are dangerous. A skull fracture is rarely without symptoms, but a victim in a state of shock may not feel characteristic changes for some time.

First aid

Skull fractures are extremely severe injuries, and primary care should be performed by medical professionals. skull refers to the immobilization of the victim. Even turning the head can be dangerous after an injury, so unnecessary movements are excluded. However, the patient often has profuse vomiting, causing suffocation. If the patient is conscious, then it is necessary to lay him on his side or stomach.

Emergency first aid involves removing tight clothing, jewelry, and watches. If the victim is conscious and breathing smoothly, then it is permissible to give analgin to reduce pain. At open wounds carry out antiseptic treatment, avoiding sudden or violent movements.

For skull fractures with severe blood loss, painkillers are not given. Because of them, bleeding may increase. For internal hemorrhages and visible hematomas, dry cold can be applied. The rest of the treatment must be done in the clinic.

For a fracture of the base of the skull, first aid includes assistance to medical workers in transporting the victim. What needs to be done is to place the patient on a hard surface and immobilize the head. Try to minimize shaking and displacement. The victim's head is held with hands until complete immobilization.

What should not be done until the ambulance arrives is to give strong painkillers. They provoke respiratory arrest.

Diagnostics

A traumatologist makes a diagnosis based on x-rays and questioning of the victim, if he is conscious. The examination is carried out on an emergency basis, since a skull fracture causes immediate complications that can lead to death. X-ray images show the location and nature of the fracture. But taking an x-ray is not always possible, so other research methods are used:

• MRI – allows you to assess the condition of soft tissues in case of concussion and damage from bone fragments;
• CT is a more informative method than radiography, showing the condition of bone structures.

If there is a hemorrhage, then edema and large hematomas appear. To assess the contents of nasal discharge or other tissues of the head, a fluid sample or smear is taken. An experienced traumatologist is able to diagnose a fracture of the base of the skull even without instrumental examination. But differential diagnosis may be required to determine the nature of head injuries. The tactics of treatment also depend on this.

Treatment

First of all, efforts are directed to save the life of the victim. Through and depressed fractures are considered the most severe, and before starting primary therapy, it is necessary to ensure the integrity of vital organs. Fractures of the skull bones take a long time to recover even in the absence of complicating factors.

In open trauma, the focus is on fighting infections. The wound is sanitized, the patient is given antibiotics. In the case of a closed fracture, conservative treatment is used: the patient is kept at rest, placed in an elevated position to avoid leakage of brain fluid, and a cleol bandage is applied. Typically, an adhesive shingle bandage is applied for fractures of mobile joints, but for serious skull injuries it will replace the traditional circular sling.

Typical lines of skull base fractures do not require significant reduction. The main methods of treatment are adequate drug therapy. The victim is prescribed painkillers, drugs for cerebral circulation, and lumbar punctures. Of particular importance is dehydration therapy. With simultaneous concussion, nootropic and vasotropic agents are indicated.

Until complete recovery, the patient is prescribed rest. The prognosis is favorable if the injury was not displaced and infection was avoided. At the discretion of the attending physician, they are prescribed to improve the fusion of bone tissue. They are especially needed in the case of taking diuretics.

• endonasal electrophoresis– activates blood circulation, prevents hypothalamic syndrome, eliminates bruising in the affected area;
• central electroanalgesia– relieves stress reactions, has a sedative effect;
• galvanic collar– soothes, relieves spasms, has a local analgesic effect.

Motor development

In case of paralysis or decreased accuracy of movements, exercise therapy and treatment by a kinesiotherapist are prescribed. Massage and hardware effects on nerve endings And muscle fibers, balneotherapy. To restore motor activity, special simulators are used, classes on which are conducted in rehabilitation centers.

Acupuncture prescribed by a doctor will relieve tremors, muscle weakness, stagnation of blood in the extremities. Alternative medicine methods will help enhance the effectiveness of classical rehabilitation programs. To activate blood circulation and improve sensitivity, hot stone massage, reflexology, and apitherapy are performed. All these methods are aimed at activating the parts of the brain responsible for motor activity.

The types of recovery methods are much similar to stroke therapy. The set of measures is selected by the attending physician and specialized specialists: neurologist, neurosurgeon, rehabilitation specialist.

Help from a psychologist

Brain injuries not only affect the functioning of all body systems, they change the personality of the victim. A previously sociable and active person can become withdrawn, depressed, and apathetic.

Changes in higher nervous activity lead to the fact that a person becomes a “stranger” to his environment. At the stage of rehabilitation with a psychologist, the victim manages to accept his changed personality and return to old life. Psychological practices can help with this: art therapy, group treatment, etc.

The neuropsychologist promotes the socialization of the victim. This is especially important if it was accompanied by partial or complete amnesia, previous coma, decreased mental abilities, and deterioration in imaginative thinking. With good motivation, the patient will be able to restore memory, regain speech and mental abilities.

Complications and consequences

Negative consequences after a fracture of the base of the skull occur with open displacement injuries. An extremely serious condition occurs when brain structures are damaged, and even timely medical care does not guarantee full recovery. According to statistics, patients who survive the first day after injury do not die. But this does not mean that they return to their previous life. The victim may fall into a long coma, but even after regaining consciousness, parts of the brain will not function fully.

In the case of a cerebral hematoma, compression of the soft tissue occurs. This is another reason why patients fall into a coma. The condition is dangerous because brain tissue may die.

Infectious diseases often lead to encephalitis and meningitis. These consequences of a fracture of the base of the skull are the most difficult to treat. In case of purulent complications, repeated trephination has to be performed. Another intervention threatens to deteriorate brain function even with successful treatment.

Sometimes complications arise over a period of time, which is associated with the period of formation of new bone tissue in places of cracks. Problems may occur up to 5 years after the injury. Typical consequences include:

• convulsions and epileptic seizures;
• mental disorders;
• cerebral hypertension with risk of stroke;
• paresis and paralysis of the limbs;
• problems with vision, hearing, attention;
• partial or complete amnesia;
• migraines, headaches when the weather changes;
• pressure surges.

Often occurs, back pain appears, progresses joint diseases, osteochondrosis. Hearing problems often occur. If the structures in the middle ear cavity have been damaged, hearing cannot always be restored. It is interesting that during the period of injury they go unnoticed due to the vivid symptoms of TBI. When the bone tissue of the skull is restored and the pain goes away, problems with the hearing organs become obvious.

The lifestyle of a patient after a TBI must change. To maintain brain health and performance, you should completely abandon bad habits and periodically take medications to improve cerebral circulation. Throughout his life, a person has to be observed by a doctor and undergo courses of maintenance therapy. Unfortunately, only 50% of trauma survivors can return to normal life.

Dear readers of the 1MedHelp website, if you still have questions on this topic, we will be happy to answer them. Leave your reviews, comments, share stories of how you experienced a similar trauma and successfully dealt with the consequences! Your life experience may be useful to other readers.

Author of the article:| Orthopedic doctor Education: Diploma in General Medicine received in 2001 from the Medical Academy named after. I. M. Sechenov. In 2003, she completed postgraduate studies in the specialty “Traumatology and Orthopedics” at the City clinical hospital No. 29 named after. N.E. Bauman.

Like any injury, injuries to the skull and brain can be closed or open. Damage to this anatomical area human body, where the most important part of the central nervous system, the brain, is located, represents a severe injury that is life-threatening to the victim.
Closed damage Characterized by the absence of external bleeding, they usually occur as a result of blunt trauma (a blow to the head with a hard object, a fall, etc.).

Concussion (commotion) of the brain is the most common injury that occurs even with minor trauma to the skull.

Most authors, both domestic and foreign, consider the main cause of it to be a short but strong push (or blow) to the head, as a result of which the entire substance of the brain, its membranes, blood vessels and cranial fluid experience a sharp movement. Depending on the degree of concussion, the nerve cells (neurons) of the brain themselves are primarily affected; at the same time, the complex relationships between them are disrupted, which leads to severe functional and even morphological disorders.

Clinic. The first sign of a concussion is a loss of consciousness that develops at the time of injury, which can be short-term (several seconds, minutes) or long-term (several hours or even days). The victim’s eyes are wide open, the pupils are constricted, unlike clinical death when they are dilated (areflexia); there is a disturbance in respiratory and cardiovascular activity (shallow breathing, the pulse is weak, slow or rapid, the face is pale). In severe cases, involuntary urination and bowel movements may occur. Incomplete loss of consciousness (foggy consciousness) is also observed - with minor trauma.
A characteristic feature is that, having regained consciousness, the victim loses memory of events and cannot remember and explain what happened to him (retrograde amnesia). Subsequently, tinnitus, irritation from bright light, and a sharp headache, which can persist for a long time, are noted; the patient suffers from nausea and vomiting of a reflex nature (due to irritation of the corresponding nerve centers). There are no symptoms of organic disorders of the central nervous system.
Based on the severity of the injury, it is customary to distinguish between 3 degrees of concussion, which are based on the main symptom - loss of consciousness.
Concussion mild degree characterized by short-term loss of consciousness (seconds, minutes) or clouded consciousness. The prognosis is favorable, recovery occurs in 5-10 days.
With a moderate concussion, loss of consciousness can last from 20 minutes to 3 hours. All the symptoms mentioned above intensify; both excitement and inhibition are possible; reflexes are depressed, vomiting occurs, breathing and swallowing are not impaired. Treatment - 3-4 weeks.
A severe concussion is characterized by a prolonged loss of consciousness (for a day or more). The patient does not respond to irritations, he skin pale and cyanotic, no reflexes, including pupillary reflexes, shallow and hoarse breathing, weak pulse, arterial pressure low. This very life-threatening condition is called coma. In such cases, the prognosis is serious, even death, especially if first aid is not provided in a timely manner. It must be remembered that, being in this condition, the victim may suddenly die as a result of asphyxia from the closure of the airways with vomit, blood clots, saliva or a sunken tongue.

First aid is to prevent asphyxia and create absolute rest: the patient is not allowed to get up and walk, regardless of his condition, which subjectively is often deceptive and does not correspond to the severity of the injury. A cold head and urgent gentle evacuation to a specialized medical facility accompanied by a medical worker are necessary.
During transportation, the victim’s head must be placed on a cotton pad or a cotton-gauze roll (shaped like a bagel), turning the head to one side to avoid aspiration asphyxia during vomiting. It is better to transport young children while holding them in your arms. When transporting a victim, you must be prepared to use drugs that stimulate respiratory and cardiac activity, and carry out simple resuscitation measures.
In medical institutions, for victims in serious condition, strict and long-term bed rest is established, complex therapy is carried out aimed at preventing cerebral edema, maintaining respiratory and cardiovascular activity. Lobelia and cititon (1 ml of 1% solution) are administered intramuscularly; in case of cardiac dysfunction, camphor, caffeine, and cordiamine are administered. To reduce blood pressure, neuroplegics and ganglion-blocking agents are used (aminazine - 2 ml of a 2% solution), mepazine, etc. When intracranial pressure increases, decongestant therapy is carried out (administration of 60-100 ml of 20-40% glucose solution, 15-20 ml 10-15 % sodium chloride solution, spinal tap). Oxygen therapy is also used. In case of severe agitation, thiopental or hexenal (5-10 ml of 1% solution) is injected intramuscularly. To maintain a protective regime, bromine preparations are prescribed.
The prognosis for concussion (except for severe concussion) is favorable. The patient can return to his previous job 2-8 weeks after discharge from the hospital. In severe and doubtful cases, accompanied by complications, patients are subject to referral to VTEC to resolve the issue of ability to work, establish the group and duration of disability, receive special recommendations, etc.

Brain contusion in contrast to a concussion, it is accompanied by a violation of the integrity of the brain matter in a limited area, caused by the impact of the brain on the inner wall of the skull at the time of injury. Foci of brain contusion can occur both in the area of ​​impact (direct blow) and at a distance from the place of application of traumatic force as a result of a side impact.
Often severe bruises are accompanied by intracranial bleeding, as well as damage to the bones of the skull, leading to injury to brain tissue. After some time, softening of the brain tissue forms in the areas of damage, most often in the cortex and subcortical layer. Such changes are most dangerous in the brain stem and near the ventricles of the brain.

Clinical manifestations of bruise also occur suddenly, but unlike a concussion they are focal in nature with a more persistent tendency to progress and the appearance of serious morphological changes. Therefore, the leading diagnostic sign is already focal symptoms of an organic nature, expressed in the form of paralysis, paresis, changes in visual fields and the appearance of pathological reflexes. Focal changes depend on the location of the injury. Thus, a bruise of the cerebral hemispheres in the frontal region can cause paresis of the facial nerve, psychomotor agitation, delirium and speech disorders; bruise in the area of ​​the central gyri - paresis and paralysis of the upper and lower extremities on the side opposite to the bruise; bruise of the occipital lobe - changes in visual fields, and of the left temporal zone - speech disorders.
The severity and prognosis of the injury are judged by the severity and persistence of focal changes. It is especially important to take into account the degree and duration of swallowing disorders (fluid retention in the mouth, flowing out of the nose and entering the windpipe). The more severe the injury, the stronger these symptoms and more serious prognosis.
With bruises, the symptoms inherent in a concussion are more clearly expressed. In severe cases, the victim loses consciousness instantly and this state continues for a long time; consciousness returns slowly, remaining confused and incomplete for a long time. The cardiovascular and respiratory systems are severely affected; vomiting becomes persistent and debilitating. Increased body temperature, leukocytosis, delirium, and convulsions are noted.
Other signs of a bruise that facilitate diagnosis include subcutaneous hemorrhages, abrasions and swelling in the area of ​​injury. Due to the fact that a bruise is usually accompanied by a concussion, such a combined injury has the general term “commotion-contusion syndrome”
The victims are transported on stretchers in a lying position to specialized medical institutions, where they are placed on long-term bed rest and constant medical supervision. The treatment is the same as for a concussion. The duration of treatment depends on the severity of the injury. For minor lesions, treatment can be successfully completed in 2-3 weeks; in more severe cases, it lasts 3 months or more.

Compression of the brain arises from various causes associated with both trauma (intracranial bleeding, pressure on the brain tissue of a skull fragment during injury and bruise, etc.) and with individual diseases (brain tumors, increased intracranial pressure, etc.). Without touching on all the reasons, we will focus only on the mechanism of compression caused by a closed skull injury.
Most often, the initial (trigger) moment of compression of the brain is intracerebral (intracranial) bleeding with the appearance of a hematoma as a result of a bruise or head injury. Compartment syndrome in these cases usually develops slowly, in waves, and therefore, immediately after the injury, clinical symptoms characteristic of concussion and brain contusion may be observed. After providing assistance to the patient, the patient may feel better; a so-called light interval appears, which has a varying duration - from several hours to several days. However, this condition is deceptive, subjective and does not correspond to severe disorders occurring in the cranial cavity. Subsequently, the hematoma, continuing to compress the brain tissue, causes venous stasis, increases the amount of brain fluid, which ultimately leads to general swelling and compression of the brain. The first and ominous symptom of developing edema is the resumption or intensification of headache, which often appears after the “light interval”. With a severe injury, such a gap and temporary improvement in health may not exist, or they may be masked by general symptoms of concussion and bruise, which greatly complicates the diagnosis of edema.
It should be remembered that the onset of cerebral edema progresses very quickly. Psychomotor agitation soon sets in, symptoms of brain irritation are noted, accompanied by vomiting, constriction of the pupil on the side of the hematoma, increased heart rate (tachycardia) and breathing. Then comes a period of suppression of brain activity, and the victim becomes lethargic, lethargic, loses consciousness, bradycardia occurs (40-50 per minute), blood pressure quickly decreases, respiratory and cardiovascular activity is sharply inhibited, and the act of swallowing is disrupted. These symptoms indicate the presence of serious pathological changes in the body, which are based on acute cerebrovascular accident, leading to oxygen starvation brain tissue and death of nerve cells. If the main cause of brain compression is not eliminated in a timely manner and measures are not taken to reduce intracranial pressure, the victim may die from respiratory and cardiac arrest.

When providing first medical and pre-medical aid It should be taken into account that compression and swelling of the brain are conditions life threatening the victim. Due to the fact that they may not develop immediately, it is necessary to consider every head injury as serious, capable of causing severe complications, including death.
Such victims must be urgently, in compliance with all precautions, taken to a medical facility to provide emergency specialized medical care.
The basis treatment consist of anti-edematous therapy, elimination of cardiovascular and respiratory disorders. Hematoma is treated only surgically, for which osteoplastic trepanation is performed under general anesthesia. With bruises and swelling of the brain, patients after hospital treatment often have to be referred to VTEC.
Despite the difficulties in diagnosing closed skull injuries and brain damage, the medical professional who provided assistance to the victim and made the decision to evacuate him to a medical facility must indicate in the accompanying document his preliminary opinion about the nature of the injury. This is usually done in the form of an abbreviated entry: closed brain injury (CBT); if there are grounds, it is necessary to add: concussion, bruise or compression of the brain. In addition, it is advisable to indicate the main symptoms: loss of consciousness (duration), vomiting, involuntary urination and defecation, disturbances in speech, hearing, vision, swallowing, mental disorders, etc. This information will greatly help the attending physician quickly make the right decision regarding the victim .

For calvarial fractures one or more flat bones that make up the cranial vault (parietal, frontal, occipital and temporal bones, part of the large wings of the sphenoid bone) may be damaged. The main cause of such an injury, as with bruises, is a strong blunt blow to the head, resulting in fractures or cracks in the bones.
Severe fractures are usually accompanied by concussion and contusion of the brain, pressure from a bone fragment on the brain, intracranial bleeding with subsequent development of cerebral edema.
Damage to the skull bones is characterized by well-known signs of fractures: pain that increases with palpation, subcutaneous hemorrhage, depression of bone tissue and mobility of bone fragments in the area of ​​injury. Recognize fractures and especially bone cracks without x-ray examination it can be difficult.
In case of damage to the integrity of the dura mater and the substance of the brain, a closed injury is also considered to be penetrating, which is more dangerous and more difficult to treat.

Fracture of the base of the skull is one of the most severe injuries, often incompatible with life. This is explained by the fact that in this anatomical region formed by the bones of the skull (ethmoid, sphenoid, occipital, pyramids of the temporal bones), the most important parts of the brain are located (pituitary gland, cerebellum, visual centers, auditory and vestibular apparatus, medulla oblongata, connected through the occipital magnum hole with the spinal cord).
Sometimes the cause of such an injury is not a direct, but an indirect impact on the base as a result of the continuation of a crack in the cranial vault. Severe bone and brain injuries occur when you fall from a height and land on your feet or hit your head on a hard object, such as when diving in shallow water. In these cases, the base of the skull seems to be pushed onto the spine.
As a result of trauma, communication between the cranial cavity and the external environment may occur through the ear, mouth and nasal cavity, which threatens the transition of a closed injury to an open one with the possibility of wound infection. When providing first medical and first aid, it is sometimes difficult to establish an accurate diagnosis of a basal skull fracture. The main signs of such an injury are those that are characteristic of a severe concussion and contusion; in addition, severe traumatic shock, discharge of blood or light brain fluid through the ears, mouth and nose, one-sided distortion of the face, hearing and vision disorders are noted. A characteristic sign is the formation of bruises around the eyes (“spectacles symptom”), as well as in the infratemporal fossa, behind the ear and mastoid process. Unlike a black eye that occurs after a direct blow, the “glasses symptom” appears much later (after 12-24 hours), which is used in forensic practice to determine the cause of the injury.

First aid is to provide the victim with absolute rest before evacuation to a specialized medical facility. The patient should not get up or sit down. It is strictly forbidden to wash the ears, mouth, nose, or use tamponade to avoid introducing wound infection into the cranial cavity. The use of morphine and its preparations as an anesthetic is unacceptable due to their inhibitory effect on the respiratory center. A sterile bandage is applied to the wound, an ice pack is applied to the head, asphyxia is prevented, and drugs that stimulate cardiovascular and respiratory activity are prescribed. Persons providing first aid and accompanying the victim to the hospital should carefully monitor his pulse and breathing.
To prevent the development of infectious complications, broad-spectrum antibiotics, sulfonamide drugs, etc. are indicated.
Patients with damage to the skull and brain require constant care and monitoring. When excited, sedatives are used, patients are protected from falling out of bed, and a separate post is posted. Such patients experience constipation and urinary retention; They are often unable to feed themselves while unconscious. Prolonged stay of patients in bed requires measures to combat bedsores and maintain personal hygiene. Such patients are especially susceptible to colds and gastrointestinal diseases.