With a bullet in the head. Who will survive after being shot in the head

Any head injury is considered dangerous, as there is a high probability. At the same time, edema of the brain tissue develops rapidly, which leads to wedging of a part of the brain into the foramen magnum. The result of this is a violation of the activity of vital centers that are responsible for breathing and blood circulation - a person quickly loses consciousness, and there is a high probability of death.

Another reason high danger head wounds - excellent blood supply to this part of the body, which leads to large blood loss in case of damage. And in this case, it will be necessary to stop the bleeding as soon as possible.

It is important for everyone to know how to competently provide first aid for head injuries - correctly carried out activities can really save the life of the victim.

Head injuries and soft tissue injuries

The soft tissues of the head include the skin, muscles, and subcutaneous tissue. If they are bruised, then pain occurs, a swelling may appear a little later (the well-known “bumps”), the skin at the site of the bruise becomes red, and a bruise subsequently forms.

In case of a bruise, it is necessary to apply cold to the injured place - it can be a bottle with cold water, a heating pad with ice, a bag of meat from the freezer. Next, you need to apply a pressure bandage and be sure to deliver the victim to a medical facility, even if he feels great. The fact is that only a specialist can give an objective assessment of the state of health, exclude damage to the cranial bones and / or.

Damage to soft tissues can also be accompanied by intense bleeding, detachment of skin flaps is possible - doctors call this a scalped wound. If the blood flows slowly and has dark color, then you need to apply a tight bandage to the wound with a sterile material - as an improvised tool, for example, an ordinary bandage or a piece of fabric ironed on both sides with a hot iron is suitable. If the blood spurts, then this indicates damage to the artery and the pressure bandage in this case becomes absolutely useless. It will be necessary to apply a tourniquet horizontally above the forehead and above the ears, but only if the scalp is damaged. If the victim has a slight blood loss (help was provided quickly), then he is taken to the hospital in a sitting or lying position - it is strictly forbidden for him to stand. If the blood loss is extensive, then the victim's skin rapidly acquires a pale hue, cold sweat appears on his face, arousal may occur, which turns into lethargy - urgent hospitalization is necessary and strictly accompanied by an ambulance brigade.

Algorithm of first aid action:

1. The victim is placed on a flat surface, which is covered with something - a jacket, a blanket, any clothes. A roller is placed under the shins.
2. If the patient is, then you need to put your palms on both sides under his lower jaw and slightly tilt your head back, while pushing your chin forward.
3. The victim's mouth should be cleaned of saliva with a clean handkerchief, and then you need to turn your head to the side - this will prevent vomit from entering the Airways.
4. If there is a foreign body in the wound, then in no case should it be moved or attempted to be removed - this can increase the volume of brain damage and significantly increase bleeding.
5. The skin around the lesion site is cleaned with a towel or any cloth, then a pressure bandage is applied to the wound: several layers of cloth / gauze, then any solid object (TV remote control, bar of soap) on top of the wound and bandaged well so that the object squeezes the vessel.
6. If the bleeding is too strong and it is not possible to apply a bandage, then it is necessary to press the skin around the wound with your fingers so that the blood stops flowing. Such finger pressing must be carried out before the arrival of the ambulance team.

After the bleeding has been stopped, ice or a bottle of cold water can be applied to the wound, the victim himself should be carefully covered and urgently delivered to any medical institution.

Note:if there is a detached skin flap, then it must be wrapped in a sterile cloth (or any other rag), placed in a cold place (it is forbidden to apply it to ice!) And sent along with the victim to a medical facility - most likely, surgeons will be able to use this skin flap for performing operations to restore soft tissues.

Closed head injury

If the upper part of the skull has occurred, then it is almost impossible to determine whether there is a fracture without. Therefore, when hitting the scalp, it would be a mistake to think that there was only a bruise. The victim must be placed on a stretcher without a pillow, ice should be applied to the head and taken to a medical facility. If such an injury is accompanied by impaired consciousness and breathing, then assistance should be provided in accordance with the symptoms, up to indirect heart massage and artificial respiration.

The most severe and dangerous head injury is considered to be a fracture of the base of the skull. Such an injury often occurs when falling from a height, and brain damage is characteristic of it. hallmark fracture of the base of the skull - the release of a colorless liquid (liquor) or blood from the ears and nose. If there was an injury facial nerve, then the victim has facial asymmetry. The patient has a rare pulse, and a day later hemorrhage develops in the eye sockets.

Note:transportation of the victim with a fracture of the base of the skull must be extremely careful, without shaking the stretcher. The patient is placed on a stretcher on his stomach (in this case, it is necessary to constantly monitor the absence of vomiting) or on his back, but in this position his head should be carefully turned to his side if he begins to vomit. In order to avoid retraction of the tongue during transportation on the back, the patient's mouth is slightly opened, a bandage is laid under the tongue (it is pulled out a little forward).

Maxillofacial trauma

With a bruise, severe pain and swelling will be noted, the lips quickly become inactive. First aid in this case consists in applying a pressure bandage and applying cold to the injury site.

With a fracture of the lower jaw, the victim cannot speak, profuse salivation begins from the half-open mouth. A fracture of the upper jaw is extremely rare, accompanied by acute pain and rapid accumulation of blood in the subcutaneous tissue, which radically changes the shape of the face.

What to do in case of jaw fractures:

Note:transportation of such a patient to a medical facility is carried out lying on his stomach. If the victim suddenly turned pale, then you need to raise the lower end of the stretcher (or just the legs if you are transporting yourself) so that a rush of blood goes to the head, but you need to make sure that the bleeding does not increase.

Dislocation of the lower jaw

This injury is very common, because it can happen with laughter, yawning too much, with a blow, and in older people it can even happen. habitual dislocation jaws.

Signs of the condition in question:

• open mouth;
• severe salivation;
• there is no speech (the victim makes lowing sounds);
• jaw movements are difficult.

Help lies in the reduction of dislocation. To do this, the one who provides assistance, you need to stand in front of the victim, sitting on a chair. Introduced into the mouth thumbs along the lower molars. Then the jaw is forced back and down with force. If the manipulation was carried out correctly, then the movements in the jaw and the speech of the victim are immediately restored.

Note:when repositioning, the jaw of the victim spontaneously closes with great amplitude and force. Therefore, before carrying out the procedure, you need to wrap your fingers with any cloth and try immediately after the appearance of a characteristic click (this joint has fallen into place) to immediately pull your hands out of the victim’s mouth. Otherwise, it is possible to cause injury to the one who provides assistance.

Combat injuries of the skull and brain are gunshot injuries(bullet, shrapnel wounds, MVR, explosive injuries), non-gunshot injuries(open and closed mechanical injury, non-gunshot wounds) and their various combinations.

The operation of trepanation of the skull was known in ancient Egypt. Surgical treatment of craniocerebral wounds was performed by many famous surgeons of the past: J.L. Petit, D.J. Larrey, H.W. Cushing etc. However, military neurosurgery as a branch of military field surgery was formed only during the Great Patriotic War, when the system of specialized medical (including neurosurgical) care was first born and field surgical hospitals were created for the wounded in the head, neck and spine ( N.N. Burdenko, A.L. Polenov, I.S. Babchin, V.N. Shamov). Experience in the treatment of combat injuries of the skull and brain in local wars and armed conflicts of recent decades has made it possible to supplement modern military neurosurgery with a number of new provisions and to formulate the concept of early specialized neurosurgical care ( B.A. Samotokin, V.A. Khilko, B.V. Gaidar, V.E. Parfenov).

14.1 GUN SHOT INJURIES TO THE SKULL AND BRAIN

14.1.1. Terminology, classification

According to the period of the Great Patriotic War, gunshot injuries of the skull and brain accounted for 6-7% of all gunshot injuries, in the armed conflicts of recent decades in the North Caucasus, their frequency has increased to 20%.

There are isolated, multiple and combined injuries (wounds) of the skull and brain. isolated is called an injury (wound), in which there is one damage. Simultaneous damage to the skull and brain by one or more MS

called in several places multiple trauma (wound) of the skull and brain . Simultaneous damage to the skull and brain, as well as the organ of vision, ENT organs or MFR is called multiple trauma (wound) of the head . Simultaneous damage to the skull and brain with other anatomical areas of the body (neck, chest, abdomen, pelvis, spine, limbs) is called combined traumatic brain injury (wound) .

The classification of gunshot wounds of the skull and brain is based on their division into 3 large groups, proposed by N.N. Petrov in 1917: soft tissue injuries, components 50%; non-penetrating wounds of the skull, constituting 20%; penetrating wounds of the skull and brain, accounting for 30% of all gunshot wounds of the skull and brain.

Soft tissue injuries of the skull characterized by damage to the skin, aponeurosis, muscles or periosteum. With gunshot wounds of soft tissues, there are no fractures of the skull bones, but the brain can be damaged in the form of concussion, bruising, and even compression (hematoma) due to the energy of the lateral impact of the RS.

Non-penetrating wounds of the skull characterized by damage to soft tissues and bones while maintaining the integrity of the dura mater. This type injuries are always accompanied by brain contusion, subarachnoid hemorrhage, rarely - compression of the brain (bone fragments, epi- or subdural hematoma). Despite skull fractures and microbial contamination of the wound, the dura mater in most cases prevents the spread of infection to the brain tissue(Fig. 14.1).

Penetrating wounds of the skull and brain are characterized by damage to the integument, bone, membranes and substance of the brain, are distinguished by the severity of the course and high mortality (up to 53%, according to the period of the Great Patriotic War, 30% - in local wars). The severity of penetrating injuries is determined by the structures through which MS passes (cortex, subcortex, ventricles of the brain, basal ganglia, or brainstem) and the extent of their damage (Fig. 14.2).

The injuries of the stem and deep parts of the brain are especially severe. With penetrating wounds, severe AI most often develops - meningitis, meningoencephalitis and brain abscess, the frequency of which reached 70% during the Great Patriotic War and 30% in modern wars.

However, these data are not enough to make a complete diagnosis of a craniocerebral injury. For this purpose, it is applied nosological classification of gunshot wounds of the skull and brain(Table 14.1).

Rice. 14.1. Non-penetrating wound of the skull with bone fracture

Rice. 14.2. Tangential penetrating wound of the skull and brain

Table 14.1. Classification of gunshot wounds of the skull and brain

Gunshot wounds of the skull and brain are divided according to a number of features. According to etiology, they are bullet, shrapnel wounds and MVR - they differ in the volume and nature of the damage, because bullets have greater kinetic energy than fragments, and MVRs are distinguished by combined and combined damage patterns.

Penetrating wounds of the skull can be through and blind , and according to the location of the wound channel they are divided into tangent, segmental and diametrical (O.M. Kholbek, 1911).

The injury is called tangent(tangential), when a bullet or a fragment passes superficially and damages the bone, dura mater and superficial parts of the brain (Fig. 14.2). It should be noted that in case of tangential wounds, despite the superficial location of the wound channel and the insignificant extent of destruction of the medulla formed along the RS, morphological and functional disorders often spread to neighboring areas of the brain. This is due to the fact that the substance of the brain is a medium containing a large amount of fluid and located in a closed space, limited by dense shells and bones of the skull.

The wounds are called segmental when MS passes through the cranial cavity along one of the chord within one or two lobes of the brain, and the wound channel is located at some depth from the surface of the brain; at the same time, it has a rather significant length (Fig. 14.3).

Rice. 14.3. Segmental penetrating wound of the skull and brain

With all segmental wounds, small fragments of bone, hair, and sometimes fragments of a headgear are brought into the depth of the wound channel. Destruction of the brain substance, as with any gunshot wound, is not limited to the zone of passage of the projectile, but spreads to the sides and is expressed in the formation of hemorrhages and foci of bruising of the brain tissue at a considerable distance from the wound channel.

At diametrical In wounds, the wound channel lies deeper than with segmental ones, passing along the large chord (diameter) of the circumference of the skull (Fig. 14.4).

Diametral wounds are the most severe, because. the wound channel in these cases passes at a great depth, damaging the ventricular system, the brain stem and other deep-lying vital formations. Therefore, diametrical wounds accompanied by high mortality, and deaths occur in the early stages as a result of direct damage to the vital centers of the brain.

A variety of diametrical wounds are diagonal, in which the wound channel also runs along the diameter of the skull, but in a different plane, located closer to the sagittal one. With these injuries, the inlet of the wound channel is usually located in facial areas, jaws, neck, and the output - on the convexital (convex) surface of the skull. This location of the wound channel is accompanied by primary damage to the brain stem and defines these injuries as deadly.

Rice. 14.4. Diametric penetrating wound of the skull and brain

Blind skull wounds have one inlet and a wound channel of various lengths, at the end of which lies a bullet or fragment. By analogy with penetrating wounds, blind wounds are divided into simple, radial, segmental and diametric (Fig. 14.5).

The severity of the blind wound is determined depth of the wound channel and its dimensions. Among the most severe are blind wounds passing through the base of the brain.

Among the penetrating gunshot wounds of the skull, the so-called ricocheting injuries (according to R. Payr, 1916), characterized in that in the presence of one wound hole (inlet), only bone fragments of the skull are found in the depth of the wound channel, and the RS is absent - it, having hit a convex

Rice. 14.5. Scheme of blind penetrating wounds of the skull and brain: 1 - simple; 2 - radial; 3 - segmental; 4 - diametrical

the surface of the skull, inflicts damage and abruptly changes the flight path (ricochets), moving away from the skull ( external ricochet). At internal ricochet RS changes its trajectory upon contact with the concave surface of the skull on the opposite side of the inlet of the wound channel.

Since the determination of the severity of brain damage and the diagnosis of life-threatening consequences of gunshot injuries of the skull and brain is based on the identification of a number of clinical symptoms and syndromes, they are presented separately in section 14.1.3.

14.1.2. Clinic and diagnosis of gunshot wounds of the skull and brain

In field conditions, at the advanced stages of medical evacuation (MPP, medr, omedb), the possibilities and time for a full-fledged neurological examination of a wounded person with a gunshot injury of the skull and brain are extremely limited. The sorting of the wounded and the diagnosis is carried out by military doctors and general surgeons. Therefore, their tasks are 1) identification of the life-threatening consequences of injury for the timely provision of emergency medical care and 2) formulation of the diagnosis of injury according to the algorithm proposed in the textbook to make the correct sorting decision.

At the advanced stages of medical evacuation, the diagnosis of gunshot trauma to the skull and brain is based on the identification of common and local symptoms gunshot injury, symptoms of acute impairment of vital functions, cerebral and focal symptoms of brain damage.

The examination of any casualty at the marshalling yard begins with an assessment of the severity of his condition and the active detection of an acute impairment of vital functions. Symptoms that are not related to brain damage are referred to in this chapter as common symptoms. Identifying and assessing them is important because 60% of injuries to the skull and brain are combined with injuries to other areas of the body: neck, chest, abdomen, pelvis, spine, or extremities. Damage to the skull and brain is not always the leading one, and in some cases a severe craniocerebral injury is combined with severe damage to another area: often the limbs, less often the chest, abdomen, and pelvis. Therefore, when sorting the wounded, it is important not to randomly identify general symptoms, but targeted identification of the four major syndromes .

It manifests itself cyanosis of the skin and lips, restless behavior of the wounded, frequent and noisy breathing. The main reasons for the development of this syndrome are asphyxia or severe chest injuries with ARF.

It manifests itself pallor of the skin and lips, lethargy of the wounded, frequent and weak pulse, low SBP - less than 100 mm Hg. The main reason for the development of this syndrome is acute blood loss. Most often it is caused by severe concomitant injuries of the abdomen, chest or pelvis, less often - limbs.

Traumatic Coma Syndrome. It manifests itself lack of consciousness, speech contact, limb movements, motor response to pain. With a deep coma, respiratory and circulatory disorders of central origin are possible (with the exclusion of damage to the chest and sources of bleeding). The cause of this syndrome is severe brain damage.

Syndrome terminal state . It manifests itself gray (earthy) color of the skin and lips, severe lethargy of the wounded up to stupor, frequent (heart rate more than 140 per minute) and weak pulse only on carotid arteries, BP is not determined, breathing is rare, fading. The causes of the terminal state can be: an extremely severe injury of any localization, but most often a severe MVR, severe injuries to several areas of the body, severe injuries to the abdomen or pelvis with acute massive blood loss, gunshot wounds to the skull with extremely severe brain damage.

After evaluating general symptoms examination of wounds and other injuries- there may be several on the head and in other areas of the body. When examining a craniocerebral wound, its localization, depth, area, nature of damaged tissues are determined, that is, local symptoms. At the same time, superficial gunshot wounds are easily detected, with bleeding, its sources are specified. Important information can be obtained when, when examining a wound, bone fragments of the skull, the outflow of cerebrospinal fluid or destroyed brain matter (cerebral detritus) are visible - they indicate the penetrating nature of the injury (Fig. 14.6).

Deep wounds of the skull serious condition the wounded should not be specially examined, because the harm from this can be greater than the benefit, when, for example, bleeding or liquorrhea resumes when a blood clot is accidentally removed.

Rice. 14.6. Outflow of cerebral detritus from a wound with a blind penetrating wound of the skull in the left temporal region

In general, of the local symptoms for making a sorting decision, the following are of the greatest importance: external bleeding and the outflow of cerebrospinal fluid or cerebral detritus from the wound, the rest, if possible, clarify the diagnosis. That's why important rule staged treatment of the wounded in the head is the following: at the advanced stages of medical evacuation, the bandage previously applied to the head wound, which lies well on it, is not removed for the diagnosis of the wound. It is removed only in case of heavy contamination with earth, RV or HVTS. With intensive wetting of the bandage with blood: on the MPP (medr) - it is bandaged, in the omedb - it is removed in the operating room, where the wounded is delivered to stop external bleeding.

The basis for the diagnosis and prognosis of gunshot TBI is the determination of the severity of brain damage and its life-threatening consequences.

Diagnosis of the severity of brain damage is based on the active detection of cerebral and focal symptoms, and symptoms of impaired vital functions.

Cerebral symptoms most characterize the severity of brain damage and are available for determination

in the advanced stages of medical evacuation. Minimal brain damage is indicated loss of consciousness at the time of injury and amnesia events before or after the injury. Less informative symptoms of brain damage are headache, dizziness, tinnitus, nausea, vomiting, lethargy or motor agitation.

The most informative symptom of brain damage is impaired consciousness. . At the same time, the more pronounced the degree of impairment of consciousness, the more severe the damage to the brain. Therefore, it is necessary to know well the degree of impairment of consciousness in order to make a diagnosis of gunshot TBI and make a triage decision. There are many subjective and objective methods and scales of impaired consciousness (the Glasgow coma scale, the Shakhnovich scale, etc.), but for the advanced stages of medical evacuation, the domestic descriptive technique with the allocation of six degrees of impaired consciousness is by far the most convenient.

1. Moderate stun- wounded in consciousness, answers questions, but is inhibited or excited, disoriented in space and time.

2. Stun Deep- the wounded man is in a state of sleep, but with a strong impact on him (shout, clapping on the cheeks), he answers questions in monosyllables and sluggishly.

3. Sopor- consciousness is absent, speech contact is impossible, tendon reflexes, motor defensive reactions to pain, eye opening.

4. Coma moderate- consciousness is absent, speech contact is absent, tendon reflexes and motor protective reactions to pain are absent; spontaneous breathing, swallowing, pupillary and corneal reflexes were preserved.

5. Coma deep- consciousness is absent, speech contact is absent, tendon reflexes and motor protective reactions to pain are absent; pupillary and corneal reflexes are absent, swallowing is impaired; relatively stable hemodynamics, spontaneous breathing is inefficient, but rhythmic.

6. Coma beyond- to the symptoms of deep coma are added: hemodynamic instability of central origin [decrease in SBP less than 90 mm Hg, tachycardia (heart rate over 140 per minute), less often bradycardia (heart rate less than 60 per minute)] and pathological respiratory rhythms, bilateral mydriasis.

Focal symptoms to a lesser extent characterize the severity of brain damage. However, they have great importance in the diagnosis of brain compression - a life-threatening consequence of a craniocerebral injury - and in determining the localization of the injury. At the stages of providing first medical and qualified medical care, it is possible to determine only bright focal symptoms.

Anisocoria- often a manifestation of a volumetric process in the cranial cavity (intracranial hematoma, hydroma, local cerebral edema in the region of the brain wound) on the side of the dilated pupil.

Fixation eyeballs and heads to the side(to the right or to the left) often indicates a volumetric process in the cranial cavity on the side of fixation (“the fixed gaze of the patient shows the surgeon which side to do the trepanation”).

crooked mouth; a cheek that takes the form of a “sail” when breathing; smoothness of the nasolabial fold, non-closure of the eyelid are signs of damage to the facial nerve on the same side.

Localized leg cramps it is often a manifestation of a volumetric process in the cranial cavity on the opposite side.

Paralysis of the limbs it indicates damage to the motor areas of the brain or a volumetric process in the cranial cavity on the opposite side.

Symptoms such as speech, hearing and vision disorders- especially in one ear, eye.

Symptoms of acute impairment of vital functions indicate either an extremely severe brain injury, or the development of cerebral edema and its infringement in the opening of the cerebellar plaque or in the large occipital foramen of the base of the skull (dislocation). Violation of vital functions occurs as a result of primary or secondary (due to infringement) damage to the brain stem, in which the nuclei of the vasomotor and respiratory centers are located. They appear severe disorders hemodynamics: persistent arterial hypertension (SBP over 150 mm Hg) , or arterial hypotension(SBP less than 90 mm Hg), tachycardia(heart rate over 140 per minute) or bradycardia(HR less than 60 in 1 min). The most characteristic manifestation of violations of vital functions is violation of the rhythm of breathing requiring the use of ventilators.

14.1.3. Determination of the severity of brain damage, diagnosis of life-threatening consequences of gunshot injuries of the skull and brain

At the stages of providing first medical and qualified medical care, the diagnosis of the severity of brain damage is carried out by military doctors and general surgeons, so it should be based on simple and accessible symptoms.

From these positions, three degrees of severity of brain damage are distinguished: mild, heavy and extremely heavy. It should be clearly understood that such a division of gunshot injuries of the skull and brain is used only at the advanced stages of medical evacuation (MPp, medr, omedb), where the sorting of the wounded is carried out without removing bandages, without undressing and, of course, without a full neurological examination. The main task of sorting the wounded at these stages of evacuation is not to make an accurate diagnosis, but to identify 4 sorting groups :

those who need to eliminate the life-threatening consequences of injury, that is, in emergency measures;

to be evacuated in the 1st stage;

to be evacuated in the 2nd stage;

agonizing.

The formulation of the final diagnosis and assessment of the severity of a craniocerebral injury is carried out only in a specialized neurosurgical hospital. Therefore, the criteria for assessing the severity of brain damage at the advanced stages of medical evacuation are the stability of the condition of the wounded and the absence of violations of vital functions for the triage period, and not the neurological deficit that will remain in the wounded after the final cure.

Minor brain damage. In pathogenetic and morphological terms, mild injuries are characterized by damage to only superficial cortical structures on the convexital (convex) surface of the brain. Subcortical formations and the trunk are intact. Non-severe brain injuries often occur when the soft tissues of the skull are injured and with non-penetrating wounds of the skull, rarely with penetrating blind (superficial) and tangential wounds.

The main clinical criterion for non-severe brain damage is the preserved consciousness: clear, moderate stun or deep stun. Focal symptoms in mild brain injuries may be absent, or they may be presented very clearly, for example, with a penetrating blind wound to the left temporal lobe(speech disorders, etc.), anterior central gyrus ( movement disorders). Functional disorders vital important organs can not be. In prognostic terms, this is the most favorable group of the wounded, therefore, with non-penetrating and especially penetrating injuries of the skull, they should be quickly taken to a specialized hospital before the development of life-threatening complications.

Triage conclusion at the advanced stages of medical evacuation - evacuation in the 2nd stage in VPNhG.

Severe brain damage. In pathogenetic and morphological terms, severe injuries are characterized by damage to the cortical structures of the brain on its basal surface and subcortical formations. The brain stem can be involved in the pathological process with edema and dislocation, that is, it can be infringed in the openings of the skull. Severe brain injuries are more common with penetrating blind (deep) and penetrating segmental wounds.

The main criterion for severe brain damage is the lack of consciousness - its disturbance in the form of stupor and moderate coma. Focal symptoms in severe brain damage are mild, because they are masked by the absence of reflex activity and bright cerebral symptoms (extrapyramidal syndrome, diencephalic catabolic syndrome). Usually it is manifested only by pupillary and oculomotor disorders. Violations of vital functions are manifested only in the circulatory system: persistent arterial hypertension (BP over 150 mm Hg), tachycardia (heart rate over 120 per minute). In terms of prognosis, this group is characterized by high (about 50%) mortality, a high incidence of complications and long-term consequences. Most of the wounded with severe brain damage with penetrating wounds of the skull do not return to duty.

Triage conclusion at the advanced stages of medical evacuation - evacuation in the 1st stage in VPNhG.

Extremely severe brain damage. In pathogenetic and morphological terms, extremely severe injuries are characterized by primary damage to the brain stem. As a rule, they occur with penetrating diametrical and diagonal wounds.

The main criteria for extremely severe brain damage are: a pronounced impairment of consciousness in the form of a deep or transcendental coma and a violation of vital functions. Focal symptoms are absent due to deep coma, i.e. total absence reflex activity. Violations of vital functions are manifested by persistent hypotension (systolic blood pressure less than 90 mm Hg), tachycardia (heart rate more than 140 per minute) or bradycardia (heart rate less than 60 per minute) and respiratory rhythm disturbance requiring mechanical ventilation. In prognostic terms, the wounded with extremely severe brain damage are unpromising for survival, mortality approaches 100%. Therefore, starting from the stage of providing qualified medical care, they belong to the sorting category of “agonizing”.

Life-threatening consequences of gunshot trauma to the skull and brain- pathological processes that develop immediately after injury due to damage to vital organs and tissues. A distinctive feature of life-threatening consequences is the failure of the body's defense mechanisms to eliminate them on their own. Therefore, in the absence of emergency medical care, the life-threatening consequences of injuries lead to death. Therefore, at all advanced stages of medical evacuation, urgent medical care is performed not for injuries or injuries, but for their life-threatening consequences. In case of gunshot injuries of the skull and brain, three types of life-threatening consequences can occur: external bleeding, cerebral compression and asphyxia.

external bleeding is a life-threatening consequence of a gunshot injury to the skull and brain in cases where it does not stop on its own or under a conventional aseptic dressing. The frequency of its occurrence, according to recent armed conflicts, is low and amounts to 4%. Sources of severe external bleeding are:

Arterial vessels of the integumentary tissues of the skull and the main one - a. temporalis superficialis with its branches;

Arteries of the dura mater, primarily branches a. menin-gea media; sinuses of the dura mater;

Vessels of the brain located in the brain wound. Brain compression- a pathological process, stretched in dynamics from several hours to several days and often leading to death if it is not eliminated. Most often, compression of the brain in gunshot wounds is due to intracranial hematomas (Fig. 14.7., 14.8.), Less often - local cerebral edema in the wound area or depressed skull fracture (Fig. 14.9.).

With gunshot craniocerebral wounds, compression of the brain is relatively rare - in 3% of cases.

For a long time, there were incorrect judgments about the mechanism of development of intracranial hematomas, which was reflected in medical tactics. It was believed that an intracranial hematoma is formed by a pumping mechanism, increasing with each portion of blood and squeezing the brain after the volume of the hematoma exceeds the size of the reserve intrathecal spaces: 80 ml for the epidural

Rice. 14.7. Compression of the brain by an epidural hematoma in the right fronto-parietal-temporal region (computed tomogram)

Rice. 14.8. Subdural hematoma in the left temporal region (intraoperative photograph)

Rice. 14.9. Depressed by a fracture of the left parietal region (intraoperative photograph)

and 180 ml for the subdural space. In accordance with this, unreasonable calls for immediate trepanation at any stage of treatment and simplified ideas about the technique for eliminating compression were practiced: craniotomy - removal of a hematoma - ligation of a bleeding vessel - recovery. In practice, such situations turned out to be rare in case of non-gunshot head injury; they never occur with gunshot wounds.

Special studies of employees of the Leningrad Research Institute of Neurosurgery. A.L. Polenov under the direction of Yu.V. Zotov showed that the main volume of intracranial hematoma is formed during the first 3-6 hours, at the same time a blood clot is formed, which subsequently interacts with the damaged area of ​​the brain, causing its local edema, a decrease in the reserve intrathecal space and - brain compression syndrome. The smaller the volume of brain damage and the greater the reserve volume of the hypothecal space (for example, with hematomas resulting from damage to the meningeal vessels by fragments of the skull bones), the slower the compression of the brain is formed: from 1 day to 2 or more weeks. In gunshot wounds, when brain damage is extensive, the main role in the formation of brain compression belongs not so much to the hematoma as to the reactions of the damaged brain.

The classic neurological picture of head compression

Rice. 14.10. Typical hemilateral syndrome with cerebral compression (Yu.V. Zotov, V.V. Shchedrenok)

brain in the form of dilated pupil on the side of compression and central hemiplegia on the opposite side is described in many textbooks - and it should always be remembered when examining a wounded person with a craniocerebral wound (Fig. 14.10).

In the conditions of staged treatment, when sorting the wounded in the head, it is necessary to actively identify all the most informative symptoms of brain compression.

"Lucid interval"- the length of time between loss of consciousness at the time of TBI (injury) and repeated loss of consciousness by the time of examination; during this period of time, the wounded is conscious (usually this is specified by the attendants). This symptom is typical for mild brain damage, against which compression develops. With severe brain damage, consciousness disorders progress, more often from stupor to coma. The diagnostic reliability of this symptom is very high.

Fixation of the head and gaze towards the compression of the brain. A very reliable, but not often occurring symptom of brain compression. It is determined when examining the wounded at the sorting yard, when the doctor sets the head of the wounded to the middle position, and the wounded reflexively turns it with effort to its previous position. Similarly to the position of the head, the eyeballs are also fixed.

Local cramps of the limbs on the side opposite to the compression of the brain, are also easily identified at the sorting yard. It is impossible not to notice them, because they are unstoppable - you have to enter anticonvulsants(which, by the way, is ineffective). The diagnostic value of a symptom increases significantly if the arm or leg of the same name is subject to convulsions (hemilateral convulsive syndrome).

Anisocoria - a symptom that is easily determined by a careful examination of the wounded, but its diagnostic value in relation to compression of the brain and, moreover, the side of the pathological process, is relatively small and amounts to 60%.

Bradycardia - Heart rate below 60 in 1 min. An important symptom indicating the likelihood of brain compression, but its specificity is low - it is also a manifestation of damage to the brain stem and a number of extracranial injuries (heart contusion, contusion of the adrenal glands). Its diagnostic value greatly increases when it is combined with one of the above symptoms. Important

remember that with combined craniocerebral injuries (traumas) accompanied by acute blood loss, for example, with simultaneous injuries of the abdomen or pelvis, a heart rate below 100 in 1 min should be regarded as relative bradycardia.

Hemiplegia, monoplegia, less often - paresis of the limbs on the side opposite to the compression of the brain, are important, but non-specific symptoms compression of the brain, since they are often a neurological manifestation of a gunshot wound. On the sorting yard, where special neurological techniques are not used, only gross motor disorders are detected in the form of a lack of limb movements. This increases their diagnostic value, especially in combination with other symptoms.

The diagnostic significance of the listed symptoms for detecting cerebral compression increases significantly when they are combined: the more symptoms there are, the more likely compression of the brain.

Asphyxia- sharp developing disorder breathing (suffocation) as a result of impaired patency of the upper respiratory tract - with gunshot injuries of the skull and brain is rare - up to 1% of cases. More often, asphyxia occurs with multiple head injuries, when skull injuries are combined with injuries to the face and jaws. In these cases, the cause of asphyxia is the flow of blood from the wounds of the MFR into the oropharynx and larynx against the background of a violation of the innervation of the epiglottis or a decrease in the cough reflex. In severe isolated craniocerebral injuries, the aspiration mechanism of asphyxia is realized due to the ingress of vomit into the respiratory tract. With extremely severe injuries of the skull and brain, dislocation asphyxia develops due to retraction of the tongue: as a result of damage to the trunk, the activity of the glossopharyngeal and hypoglossal nerves is disrupted, the tongue loses muscle tone and sinks into the oropharynx, blocking the airways.

All life-threatening consequences of injuries should be actively identified. The wounded with external bleeding and asphyxia should be given emergency care at all stages of medical evacuation, and the wounded with brain compression should be urgently (by helicopter) evacuated to a specialized neurosurgical hospital - only in this hospital they can receive full-fledged emergency care.

Examples of diagnoses of gunshot wounds of the skull:

1. Multiple shrapnel blind wound of the soft tissues of the right half of the head.

2. Bullet tangential non-penetrating wound of the skull in the left parietotemporal region with mild brain damage, with an incomplete fracture of the right parietal bone.

3. Shrapnel blind penetrating wound of the skull in the right parietal region with severe brain damage, with a perforated fracture of the parietal bone. Traumatic coma(Fig. 14.11 color illustration)).

4. Bullet through segmental penetrating wound of the skull in the left fronto-temporal region with severe brain damage, with multi-comminuted fractures of the frontal and temporal bones. Brain compression. Traumatic coma.

5. Bullet penetrating diametrical bihemispheric penetrating wound of the skull in the temporal regions with extremely severe brain damage, with comminuted fractures of the temporal bones. Continued external bleeding. terminal state.

6. Severe mine-explosive wound. Combined mechanothermic combined trauma of the head, chest, limbs.

Multiple gunshot trauma to the head. Shrapnel blind penetrating left-sided fronto-orbital wound of the skull with severe brain damage, multiple fractures of the walls of the orbit and destruction of the left eyeball.

Closed chest injury with multiple rib fractures on the right and lung injury. Right-sided tension pneumothorax.

Detachment of the left leg at the level middle third with extensive destruction of soft tissues and detachment of the skin up to the lower third of the thigh. Continued external bleeding.

Flame burn of the lower extremities

Acute massive blood loss. terminal state.

14.2. NON-FIRE SHOT INJURIES OF THE SKULL

AND THE BRAIN

14.2.1. Terminology and classification

According to the etiology, non-gunshot injuries of the skull and brain are divided into mechanical (closed and open) TBI and non-gunshot wounds. In combat conditions, mechanical head injury occurs

quite often, accounting for 10-15% of the entire combat pathology of this localization.

TO closed TBI include such damage to the skull and brain, in which the integrity of the skin as a natural biological barrier is preserved. TBI with skin injury are open ; They may be non-penetrating And penetrating depending on the integrity of the dura mater . Fractures of the base of the skull with external otitis or nasoliquorrhea are considered as open penetrating TBI, since at the base of the skull the dura mater is tightly fused with the bone and is necessarily damaged along with it in fractures.

Non-gunshot wounds of the skull and brain (stab wounds, stab wounds, dowel wounds from a construction pistol, etc.) are rare in combat conditions, do not constitute a big problem and are described in neurotraumatology manuals.

As with gunshot trauma to the skull and brain, in non-gunshot trauma, there are combinations of injuries various departments head and anatomical regions of the body. The combination of brain damage with damage to the eyes, ENT organs, face and jaws refers to multiple head injuries, and the combination of TBI with damage to other areas of the body - to combined TBI.

In 1773 a French surgeon J.L. Petit proposed to distinguish 3 types of TBI: concussion, bruise and compression of the brain. In most textbooks, such a division of TBI with varying degrees of detail for each type has been preserved to this day. One circumstance was incomprehensible: why can compression develop with any type and severity of brain damage? The answer to this question was found by military field surgeons, when in the 1990s. new principles for the classification of combat damage were formed, Objective assessment the severity of injuries and a new method for formulating a diagnosis in the system of staged treatment of the wounded.

From these positions, brain compression does not characterize the type and severity of TBI (injury), but is its life-threatening consequence. The compression of the brain develops when the morphological substrate of the damage gets large vessels, CSF pathways, large bone fragments of the skull.

Thus, the basis classification of non-gunshot TBI is divided into the following types:

Brain concussion;

mild brain injury;

Brain contusion of moderate severity;

Severe brain injury.

This classification reflects not only the type, but also the severity of TBI, both in terms of clinical and morphological manifestations. At the same time, the deepening of the severity of TBI occurs from the surface of the brain to the depth: from a concussion (functional disorders at the cortical level, clear consciousness) to a severe bruise (damage to the brain stem, deep or transcendental coma).

For the correct formulation of the diagnosis of a non-gunshot injury of the skull and brain, nosological classification(Table 14.2.)

As can be seen from the classification, one of the sections in the formulation of the diagnosis is the state of the subshell spaces. It should be borne in mind that their significance increases in the late periods of traumatic disease, in the process of specialized treatment. They are not detected at the advanced stages of medical evacuation. It is important to know that epidural and subdural hemorrhages are diagnosed only in peacetime with CT or MRI or with a forensic autopsy. They are fundamentally different from epidural and subdural hematomas by their small volume, cloak-like flat character, and, most importantly, by the fact that they do not cause compression of the brain.

Cranial fractures may also not be detected in the advanced stages of medical evacuation - and this is not strictly necessary. Fractures of the bones of the base of the skull are detected by indirect signs. “Symptom of glasses” (periocular hematomas) or nasal liquorrhea (liquor leakage from the nose) indicate fractures of the bones of the base of the skull in the anterior cranial fossa. Symptoms of damage to the facial (twisted mouth, the cheek "sails", the eyelid does not close, tearing or dry eyes) or auditory (unpleasant tinnitus) nerves are signs of a fracture of the pyramid temporal bone.

The life-threatening consequences of non-gunshot injuries of the skull and brain are manifested by the same symptoms as with a gunshot injury.

Table 14.2. Classification of non-gunshot injuries of the skull and brain

Examples of non-gunshot TBI diagnoses:

1. Open traumatic brain injury. Brain concussion. A torn-bruised wound of the right parietal-temporal region.

2. Closed craniocerebral injury. Mild brain injury. Subarachnoid hemorrhage.

3. Open penetrating traumatic brain injury. Moderate brain injury. Subarachnoid hemorrhage. Fracture of the left temporal bone with the transition to the base of the skull. Rupture-bruised wound of the left temporal region. Left-sided otohematoliquorrhea.

4. Open traumatic brain injury. Severe brain injury. Subarachnoid hemorrhage. fracture frontal bone on right. A torn-bruised wound of the frontal region on the right. Traumatic coma.

5. Closed craniocerebral injury. Severe brain injury. Subarachnoid hemorrhage. Fracture of the bones of the cranial vault. Compression of the brain by an intracranial hematoma in the left fronto-parietal-temporal region. Traumatic coma.

6. Severe concomitant trauma to the head, abdomen, limbs. Open penetrating traumatic brain injury. Severe brain injury. Intraventricular hemorrhage. Fractures of the bones of the vault and base of the skull.

Closed trauma of the abdomen with damage to internal organs. Continued intra-abdominal bleeding.

Closed multiple injury of the extremities. Closed fracture right femur in the middle third. Closed fracture of both bones of the left leg in the lower third.

Acute massive blood loss. Traumatic coma.

14.2.2. Clinic and diagnosis of non-gunshot traumatic brain injury

In field conditions, the possibilities and time for a full-fledged examination of the wounded with non-gunshot injuries of the skull and brain are extremely limited. That's why remember the main symptoms of TBI and focus on them in the process of medical sorting of the wounded. Usually wounded with non-severe TBI independently move around the divisions of the sorting and evacuation department, complain of headache, tinnitus, disorientation - they need to be laid down, calmed down, examined, performed medical assistance and sent on a stretcher to the evacuation room

tent. Wounded from severe TBI delivered on a stretcher, often unconscious, which creates significant difficulties in diagnosis.

Examination of a casualty with a non-gunshot TBI begins with active detection (see section 14.1.2.) 4 main syndromes of acute impairment of vital functions. Based on their presence and severity, an assessment of the general condition of the wounded is formed. Like gunshot wounds, non-gunshot head injuries in 60% of cases are combined with damage to other areas of the body.

Syndrome acute disorders breathing indicates asphyxia (often as a result of aspiration of vomit, cerebrospinal fluid, less often - dislocation of the tongue) or severe concomitant damage to the chest.

Syndrome of acute circulatory disorders(as traumatic shock) develops with acute massive blood loss as a result of concomitant damage to the abdomen, pelvis, limbs.

Traumatic Coma Syndrome clearly indicates severe brain damage, and terminal state syndrome- about an extremely severe brain injury or a severe concomitant injury.

With closed non-gunshot TBI local symptoms poorly expressed. Most often found subcutaneous hematomas scalp, periorbital hematomas, less often - liquorrhea from the nose and ears. Since the liquor flowing from the ears and nose is often mixed with blood, they use symptom of "double spot". CSF poured onto a white sheet or towel with blood forms a double-circuit round spot: the inside is pink, the outside is white, yellow. With open non-gunshot TBI, local symptoms are also localization, nature and depth of the wound of the integumentary tissues of the skull.

Cerebral and focal symptoms brain injuries in non-gunshot head injuries are of primary importance for determining the severity of brain damage, and identification syndrome acute disorders vital functions central origin - an important prognostic value. They allow the doctor conducting triage to make the right sorting decision. The characteristics of these symptoms, methods of detection are similar to those used in the examination of the wounded with gunshot trauma to the skull and brain (see section 14.1.2).

From the nosological classification of non-gunshot TBI, it can be seen that for the diagnosis of certain forms of TBI (such as brain contusion

mild and moderate severity) of great importance are the condition of the intrathecal cerebrospinal fluid spaces, the presence and nature of fractures of the skull bones. To identify the first, it is necessary to perform a lumbar puncture, which is a general medical manipulation and can easily be performed by a surgeon or an anesthesiologist at the stage of CCP. This determines the CSF pressure (normally it is 80-180 mm of water for the prone position) and the presence of blood in the CSF - subarachnoid hemorrhage. Diagnosis of fractures of the bones of the skull is also possible in the omedb when performing x-rays of the skull in frontal and lateral projections.

At the same time, the determination of the state of the CSF spaces and the X-ray detection of skull fractures are not of fundamental importance for making a sorting decision. In addition, lumbar puncture itself may be accompanied by the development of brain dislocation (wedging of the brain stem into the foramen magnum of the skull): due to the jet exit of CSF from the needle, sharp decline cerebrospinal fluid pressure in the basal cistern - occurs sudden stop breathing on dressing table and lethal outcome. You should remember the rule: lumbar puncture is contraindicated at the slightest suspicion of brain compression!

Non-severe TBI. In pathogenetic and morphological terms, they are characterized either only by functional disorders of the central nervous system, or by damage to the vessels of the arachnoid membrane, or by foci of hemorrhages, destruction of the cortical structures of the brain. Subcortical formations and the trunk are intact.

Main clinical criteria non-severe TBI is preserved consciousness: clear, moderate stunning, deep stunning. From these positions, the group of non-severe TBI includes: brain concussion, bruises of mild and moderate severity.

Brain concussion- the mildest form of TBI, in which morphological changes in the brain and its membranes are absent, and pathogenetic and clinical manifestations are due to functional changes in the central nervous system. Main clinical symptoms are: short-term (several minutes) loss of consciousness at the time of injury and retrograde amnesia. Such wounded usually move independently (clear consciousness), but complain of headache, nausea, dizziness, and sometimes vomiting. They belong to the category of lightly wounded and are evacuated in the 2nd place by any transport to the VPGLR, where there is

a specialized neurological department for the treatment of this category of the wounded.

Mild brain injury- this is also a mild form of TBI, in which, unlike concussion, there are not only functional changes CNS, but morphological in the form of damage to the vessels of the arachnoid. The latter are detected during lumbar puncture as an admixture of blood in the cerebrospinal fluid. - subarachnoid hemorrhage. Basically, the clinical manifestations are the same as with a concussion, but are found: moderate stunning in terms of consciousness, headache and nausea are more pronounced, and vomiting occurs more often. Under staged treatment lumbar puncture for differential diagnosis not carried out, therefore, in practice, these wounded also belong to the lightly wounded and are sent to the VPGLR.

Moderate brain injury eat. This form of brain injury lives up to its name - it occupies an intermediate position between mild and severe forms of TBI. However, since there is no triage group in military field surgery " moderate”, the wounded with brain bruises of moderate severity belong to the triage group “non-severe TBI”. This is both prognostic and theoretically justified: there are no lethal outcomes, complications are rare, the treatment period does not exceed 60 days, and treatment is usually conservative. At the same time, with this form of TBI, there are often fractures of both the vault and the base of the skull, and the morphological substrate of injury is small foci of contusion (hemorrhage, subpial destruction), located only in the cortical structures of the brain. Therefore, the second (after skull fractures) pathognomonic symptom of brain contusions of moderate severity are focal symptoms brain damage. Most often, in the conditions of staged treatment, oculomotor disorders (paresis of the oculomotor, abducens cranial nerves), innervation disorders (paresis, paralysis) of the facial or auditory nerves are detected, speech, vision, and paresis of the limbs are less common. These wounded are delivered, as a rule, on a stretcher, the state of consciousness is stunning (moderate or deep), vital functions are within normal limits, stable. The wounded with moderate brain bruises are also evacuated in the 2nd place by any transport, but not to the VPGLR, but to the VPNH or VPNhG, since focal symptoms can still be a sign of slowly developing cerebral compression.

Severe TBI. In pathogenetic and morphological terms, they are characterized not only by damage to the cortical structures of the brain, but also by subcortical formations, upper divisions brain stem.

The main clinical criterion for severe TBI is the lack of consciousness - there are disturbances of consciousness in the form of stupor and moderate coma.

Since damage to these structures has a characteristic clinical picture, extrapyramidal and diencephalic forms of severe brain contusion are distinguished according to the level of damage.

Extrapyramidal form of severe brain injury. As a result of damage to the subcortical formations in this form of severe contusion, the clinical picture is clearly dominated by hypokinetic rigid or hyperkinetic syndrome. The first syndrome is manifested by waxy rigidity of all muscle groups of the wounded, a mask-like face with no facial expressions, the second, on the contrary, by constant athetoid (worm-like) movements of the limbs (especially the upper ones). Consciousness - stupor, focal symptoms - not expressed (rarely - anisocoria, oculomotor disorders), vital functions are stable. The prognosis for life is favorable (mortality rate is less than 20%), the social prognosis is often favorable.

Diencephalic form of severe brain injury. With this form of severe bruising as a result of damage to the interstitial brain, where the main autonomic centers are located, the clinical picture manifests itself brightly. diencephalic catabolic syndrome. It is characterized : arterial hypertension, tachycardia, muscular hypertension, hyperthermia, tachypnea. Consciousness - moderate coma. The pupils are usually evenly constricted, the eyeballs are fixed in the center. Focal symptoms are practically absent. Vital functions at the level of subcompensation (see Appendix 1, scales "VPH-SP", "VPH-SG"), that is, their stability is relative, sometimes correction is required during evacuation in the form of mechanical ventilation. The prognosis for life is relatively favorable, because. lethality reaches 50%; the social prognosis is often unfavorable, since most of the wounded become disabled after receiving a severe TBI.

The wounded with severe TBI, despite the relative stability of vital functions, do not linger at the stages of providing qualified assistance for intensive corrective therapy. After the normalization of external respiration, either by setting up an air duct, or by intubating the trachea with mechanical ventilation, they are urgently evacuated to the upper respiratory tract in the 1st place.

Extremely severe TBI. In pathogenetic and morphological terms, they are characterized by damage to the brain stem. The main clinical criterion for extremely severe TBI is the lack of consciousness - its disturbance in the form of a deep or transcendental coma. Damage to the brain stem has a characteristic clinical picture in the form of mesencephalo-bulbar syndrome. Therefore, these forms of TBI are called mesencephalo-bulbar form of severe brain contusion. First of all, this form is manifested by severe violations of vital functions: persistent refractory to infusion therapy arterial hypotension, uncontrolled tachycardia (bradycardia) and arrhythmia, pronounced tachy-or bradypnea or abnormal respiratory rhythms requiring IVL. The eyeballs are fixed in the center, the pupils are wide, there is no reaction to light. It should be remembered that in extremely severe TBI

Absolutely unfavorable prognostic signs are bilateral paralytic mydriasis and Magendie's sign. (unequal position of the eyeballs in relation to horizontal axis: one is higher, the other is lower). Without intensive correction of vital functions death comes within a few hours. Even in the conditions of specialized centers, the mortality rate for this type of TBI approaches 100%. Therefore, the wounded with extremely severe TBI at the advanced stages of medical evacuation are classified as agonizing.

Life-threatening consequences with non-gunshot TBI develop in 5-8% of cases. Relatively rare are external bleeding from the sinuses of the dura mater with multiple open fractures of the bones of the cranial vault - up to 0.5% and asphyxia (aspiration of cerebrospinal fluid, blood, vomit, dislocation of the tongue) - up to 1.5%. In other cases, the life-threatening consequences of TBI are represented by compression of the brain by intracranial (meningeal, intracerebral) hematomas, hydromas, and depressed fractures of the cranial vault. The clinical picture and symptoms of life-threatening consequences in non-gunshot trauma are similar to those in gunshot injuries.

14.3. ASSISTANCE AT MEDICAL EVACUATION STAGES

The main principle of the staged treatment of the wounded in the head is the fastest possible delivery to the VPNkhG, bypassing even the stage of providing a qualified surgical care.

First aid. An aseptic dressing is applied to the head wound. To prevent aspiration of blood and vomit during vomiting and nosebleeds, the upper respiratory tract is cleaned. When the tongue is retracted, the nurse opens the wounded mouth with a mouth expander, the tongue is removed with the help of a tongue holder, the mouth cavity and pharynx are cleaned of vomit with a napkin, and an air duct (TD-10 breathing tube) is introduced. The wounded, who are unconscious, are taken out in a position on their side or on their stomach (a folded overcoat, duffel bag, etc. is placed under the chest).

In case of severe wounds, promedol from a syringe tube is not injected into the head due to the threat of respiratory depression.

First aid carried out by a paramedic, who controls the correctness of the previously carried out activities and corrects their shortcomings. Elimination of asphyxia is carried out in the same ways as in the provision of first aid. If breathing is disturbed, mechanical ventilation is performed using a manual breathing apparatus, oxygen inhalation. If the bandage gets wet with blood, it is bandaged tightly.

First aid. During armed conflict first medical aid is provided as a pre-evacuation preparation for aeromedical evacuation of the wounded with severe and extremely severe injuries - directly to the 1st echelon MVG to provide early specialized surgical care.

IN large scale war wounded in the head after first aid is evacuated to the omedb (omedo).

In medical triage There are 4 groups of the wounded with gunshot or non-gunshot injuries of the skull and brain.

1. Those in need of urgent first aid measures in the dressing room - wounded with ongoing external bleeding from head wounds and wounded with asphyxia.

2. The wounded, who can be given first medical aid at the sorting yard with subsequent evacuation in the 1st turn, - wounded with signs of brain compression and wounded with severe brain damage.

3. The wounded, who can be given first medical aid at the sorting yard with subsequent evacuation in the 2nd stage, - wounded with minor brain damage.

4. agonizing- the wounded with extremely severe brain damage - are sent to a sorting tent in a specially equipped place (is fenced off with sheets from the rest of the wounded). It should be remembered that a group of those agonizing at the stage of rendering first medical aid is singled out only when there is a massive influx of the wounded. IN normal conditions any casualty with detectable blood pressure should be evacuated .

In the dressing room, the unconscious wounded are cleared of the upper respiratory tract. To prevent retraction of the tongue, an air duct is introduced. In case of ineffective spontaneous breathing, the anesthesiologist-resuscitator performs tracheal intubation, mechanical ventilation. If tracheal intubation is not possible, a conicotomy or tracheostomy is performed.

With abundant soaking of the bandage with blood, it is tightly bandaged. Continued bleeding from the soft tissue arteries visible in the wound is stopped by bandaging them or applying a pressure bandage with the introduction of napkins moistened with a 3% hydrogen peroxide solution into the wound.

The rest of the wounded in the head are assisted in the sorting and evacuation department. They are given antibiotics and tetanus toxoid, according to indications apply cardiovascular agents. Narcotic analgesics are not administered for penetrating craniocerebral injuries, tk. they oppress respiratory center. Crowded bladder in the wounded with impaired consciousness, it is emptied by a catheter.

After providing first aid, the wounded are sent to the evacuation room, from where they are evacuated in accordance with the sorting conclusion. One should strive to evacuate the wounded in the head by helicopter immediately to the VPNhG.

Qualified medical care. The basic principle of providing CCP to the wounded with severe wounds and head injuries is do not delay them at this stage of the evacuation .

In progress triage there are 5 groups of wounded with gunshot and non-gunshot injuries of the skull and brain.

1. Those in need of urgent qualified surgical care: wounded with asphyxia are sent to the dressing room for the seriously wounded, where a special dentist's table is set up for them; wounded with heavy external bleeding are sent to the operating room. After rendering assistance - evacuation to VPNhG in the 1st stage.

2. Stretcher wounded with no consciousness, but stable vital functions ( with severe brain damage, brain compression) - need to be prepared for evacuation in a ward intensive care, less often - evacuation ( only restoration and maintenance of breathing, up to intubation and ventilation ), after which evacuation is carried out to the VPNhG in the 1st stage.

3. Stretcher wounded with preserved consciousness ( with mild brain damage) - are sent to the evacuation tents for evacuation to the VPNhG in the 2nd stage.

4. Walking wounded in the head- are sent to the sorting tent for the lightly wounded, where they are preparing for evacuation to the VPGLR in the 2nd stage.

5. agonizing- wounded with extremely severe brain damage with fading vital functions and signs of a fatal wound (diagonal, diametrical with the outflow of brain detritus) - are sent to the symptomatic therapy ward, allocated specifically in the hospital department.

The wounded are sent to the operating room with ongoing external bleeding, which cannot be stopped by tightly bandaging the bandage. Surgical interventions performed for ongoing external bleeding should only include measures to stop bleeding. When hemostasis is achieved, the surgical intervention should be stopped, the wound covered with a bandage, and the wounded person is sent to the VPNkhG, where an exhaustive surgical treatment of the craniocerebral wound will be performed by a specialist.

Surgery for ongoing external bleeding is performed under general anesthesia and can consist of 3 elements: stop bleeding from a soft tissue wound; trepanation

bones in the fracture area (with continued bleeding from under the bone); stop bleeding from the dura mater, sinuses and (or) brain wounds.

The first stage of the operation is the incision of the soft tissue wound. In this case, bleeding from soft tissues is stopped by diathermocoagulation or ligation and stitching of the bleeding vessel. Then the bone wound is examined, and if bleeding continues from under the bone, the bone wound expands with bone forceps-nippers (Fig. 14.12.).

The size of the burr hole can be different, but most often - up to the border of the intact dura mater. Bleeding from the vessels of the dura mater is stopped by diathermocoagulation or stitching.

To stop bleeding from the sinus of the dura mater are used the following ways. With complete or almost complete breaks, sinus ligation. It can be done

Rice. 14.12. Expansion of the bone wound

be only with a sufficient size of the bone defect by incisions in the dura mater on the sides of the sinus, after which a silk thread is passed around the sinus with a round needle, which is tied (Fig. 14.13, 14.14).

It is impossible to ligate the sinus behind the Roland sulcus, and especially at the confluence of the sinuses, because. this may result in death.

Rice. 14.13. Ligation of the superior sagittal sinus. The needle is brought under the sinus

Rice. 14.14. The needle is passed through the crescent of the brain ( falx cerebri)

The simplest and most commonly used method - sinus tamponade, which can be done with a piece of muscle or gauze turundas (Fig. 14.15).

Sinus wall closure succeeds only with small linear wounds. The imposition of the lateral ligature possible, but only with minor damage. In a very serious condition of the wounded, clamps can be applied to the sinus wound and left for the period of evacuation. At the same time, one should strive to preserve the lumen of the sinus.

If bleeding continues from under the dura mater, it is dissected with thin scissors through the wound. Visible bone fragments are removed from the wound channel with thin tweezers. To stop bleeding from the vessels of the brain, diathermocoagulation, tamponing with turundas with hydrogen peroxide is used. The new method proposed Yu. A. Sh u l e you m, is to stop bleeding from a deep brain wound with a fibrin-thrombin mixture, which is prepared immediately before injection into the wound and fills the wound channel in the form of a cast, stopping bleeding. Human fibrinogen in the amount of 1 g, diluted in 20.0 ml of 0.9% sodium chloride solution and 200 units of activity (EA) thrombin in 5 ml of the same solution through an elastic plastic tube connected to a tee, two syringes are simultaneously injected into the wound, the cavity of which is filled with the resulting mixture (Fig. 14.16).

After the bleeding has stopped, the wound is loosely packed with napkins, not sutured, and the wounded is evacuated to the VPNhG for final surgical treatment.

With asphyxia in the dressing room, the upper respiratory tract is sanitized, removing vomit, mucus and blood clots from them, an air duct is inserted or the trachea is intubated. With simultaneous injury to the maxillofacial area or neck, an atypical or typical tracheostomy may be indicated.

Tracheostomy technique next: the position of the wounded on his back with his head thrown back, a roller is placed under the shoulder blades. Under local anesthesia A 0.5% solution of novocaine makes a longitudinal incision of the skin, subcutaneous tissue and fascia of the neck along the midline of the neck from the thyroid cartilage to a point immediately above the notch above the sternum. The skin, subcutaneous tissue and muscles are bluntly bred with a clamp in the lateral direction. The exposed isthmus of the thyroid gland is retracted upward, if not possible, it is crossed and tied up. Then the pretracheal fascia is opened and the anterior wall of the trachea is exposed. Trachea

Rice. 14.15. Stopping bleeding in wounds of the superior sagittal sinus with tight tamponade

Rice. 14.16. Scheme of filling the wound channel with fibrin-thrombin mixture

Rice. 14.17. Stages of performing a longitudinal tracheostomy: a - incision line; b - muscle breeding; c - capture of the trachea with a single-toothed hook; g - section of the trachea; e - view after insertion of a tracheostomy tube into the trachea

is grasped with a sharp hook, lifted, and then dissected. The trachea is opened with a T-shaped incision: between the 2nd and 3rd rings transversely (cut length up to 1.0 cm), then in the longitudinal direction - through the 3rd and 4th rings up to 1.5-2.0 cm long see After the incision of the trachea is made, a tracheodilator is inserted into it, the hole expands, and then a previously prepared tracheostomy tube is inserted into it (Fig. 14.17).

The wound should be sutured without tension to prevent subcutaneous emphysema. Only skin sutures are used. The tracheostomy cannula is held in place by tying it around the neck with gauze.

With signs of severe acute respiratory failure, mechanical ventilation is performed.

To all the rest wounded in the head medical care (binding bandages, injection of non-narcotic analgesics for pain, reintroduction antibiotics according to indications, etc.) is carried out in the sorting and evacuation department in the scope of first medical aid.

Wounded in the head after preparing for evacuation must be evacuated to GB immediately in the presence of transport, since neurosurgical operations at the stages of providing qualified medical care are not performed. All stretcher wounded are evacuated to VPNhG, walking - to VPGLR.

Specialized surgical care with gunshot and non-gunshot injuries of the skull and brain is based on two basic principles: 1) rendering as soon as possible after injury; 2) full, exhaustive and complete nature of surgical interventions(Fig. 14.18.) .

All stretcher wounded with gunshot and non-gunshot brain injuries receive specialized neurosurgical care at the VPNkhG.

Rice. 14.18. Tidal drainage after PST surgery of a craniocerebral wound

Walking wounded with gunshot and non-gunshot head injuries, who have no focal symptoms of brain damage and the penetrating nature of the injury are excluded, are sent for treatment to the VPGLR, where there is a specialized neurological department for them.

Control questions:

1. Name the signs of a penetrating wound of the skull and brain.

2. What criteria underlie the selection of open craniocerebral injuries and penetrating wounds of the skull? name possible complications penetrating head wounds.

3. What is different clinical picture brain injury from a concussion?

4. What is the difference between the clinical picture of moderate brain contusion and mild contusion?

5. Name the main clinical difference between severe craniocerebral injuries and non-severe ones.

6. What degrees of impaired consciousness are typical for severe brain contusions and how do they differ?

7. Name the main reasons for the development of cerebral compression.

8. What clinical picture is typical for the development of cerebral compression?

An injury resulting in human body fragments from shells, bullets and shot fall, it is called gunshot. Such an injury is classified as deadly, so the person must be immediately taken to a medical facility.

First aid for a gunshot wound is provided according to the general algorithm, regardless of the striking object that caused it. However, there are minor differences in emergency actions depending on the location of the injury.

Calling medical workers

Medical care for gunshot wounds is the only way to save the victim's life, so contacting a healthcare institution should be mandatory. However, before calling the ambulance dispatcher, you need to determine the severity of the injury and the general condition of the victim. With severe bleeding, when there is a large loss of blood, you need to stop it immediately. For this, when arterial bleeding, and with venous - a pressure bandage. After the danger of fatal blood loss has been averted, you can call an ambulance.

In a conversation with the dispatcher, you need to indicate the following facts:

• type of injury;
• Type and presence of bleeding;
• Wound localization.

The type of injury is extremely important in determining the severity of the victim. Doctors divide bullet wounds into 2 types:

1. Isolated (one cavity of the human body is damaged);
2. Combined (injured 2 or more cavities).

Combined injuries are extremely life-threatening: the lethal outcome after them reaches 80%.

Note!

If the dispatcher indicates that the ambulance cannot arrive at the scene within half an hour, then the victim must be transported independently! To do this, use personal transport or cars following the passing route.

After the issue of the delivery of the victim is resolved, they begin to provide first aid for a bullet wound.

head wounds

Gunshot wounds to the head are varied. They are made from pistols, rifles, self-propelled guns. No less dangerous are injuries caused by objects that do not belong to the category of firearms: devices for spearfishing, crossbows or pneumatics.

A characteristic feature of "modern" head wounds is the "point" location of multiple wounds (no more than 2-3 mm in diameter). Most often they are obtained as a result of hitting a shot. If a shot was fired at the head from a long distance and the bullet hit the scalp, it is difficult to determine the wound during the initial examination. When fired at point blank range or at close range, the wounds are deep and have a large volume.

Note!

The specificity of a bullet head injury is that its magnitude does not indicate the severity of the injury. A minimal wound opening may hide deep brain damage. Whereas a tangent with deep damage to the skin and soft tissues will not be so dangerous.

In the event of a head injury, the condition of the victim is assessed by 3 factors:

1. The reaction of the eyes to irritation with sound and pain;
2. Verbal responses to questions asked;
3. Motor capability.

Wounds in the head area are often accompanied. Its appearance is provoked by large external or internal blood loss. Therefore, the victim falls into an unconscious state and it is extremely difficult to get him out of it.

Note!

If the victim has a decrease in the number of heart contractions, then this indicates a developing intracranial hematoma. Only emergency surgery can save a person in this case.

With a gunshot wound to the head, it is important to try to bring the victim out of shock. To do this, use analgesics that do not contain narcotic components. It also shows the use of non-steroidal anti-inflammatory drugs with analgesic effect.

Note!

Fragments of bones or foreign objects that have fallen into the wound cannot be removed independently. This will cause profuse bleeding. Before the arrival of an ambulance or delivery of the victim to the hospital, you can only apply a sterile bandage to the wound. When using a pressure bandage.

Taking into account the fact that foreign objects (bullets, fragments) change their location during the movement of the patient to a medical facility, transportation is carried out with increased caution. In the absence of consciousness, the patient is laid on his side. In the presence of vomit, blood and mucus in the oral cavity, it must be cleaned before transportation.

Wounds of the chest, abdomen, limbs

Assess the general condition of a person using a survey. Ask him a simple question about his name or how old he is. After a gunshot wound to the chest, abdomen, or limbs, a person is most often conscious.

What not to do before the ambulance arrives:

• If the person is unconscious, do not try to bring him to his senses;
• During the provision of emergency care, one should not offer the victim drink or food (it is allowed to wipe his lips with a cloth soaked in water);
• Remove a bullet and other foreign objects from the wound;
• Reset dropped out internal organs;
• Don't try to clean the wound of dirt or gore.

Remember the correct position of a person who is unconscious: his head should be turned to the side. If the victim responds to questions, gently bend his knees.

Note!

When helping a person after a gunshot wound, try to move them as little as possible.

Stop bleeding

If there is bleeding, determine its type.

1. arterial bleeding. The blood has a bright red color, "comes out" from the body in a pulsating fountain. To stop the loss arterial blood, the vessel is pressed with a finger in the wound. To do this, insert your fingers directly into the bullet hole. If blood continues to spurt out, slowly move them around the wound until you find the damaged vessel. Then a tourniquet is applied if the wound is on a limb, or the wound is tamponade on other parts of the body.
2. . It is characterized by viscous dark blood, which comes out of the wound without pulsation. To stop it, you need to grab a part of the skin along with the damaged vessel and fix it in this state. When the wound is located above the heart, the vessel is clamped above the wound. In a situation where it is below the heart, the vessel is clamped below the wound. In case of damage to the vessels on the limbs, a pressure bandage is applied. When wounding the chest cavity or abdomen, tamponade is used.
3. capillary bleeding. From damaged vessels, blood flows in drops. As a rule, its quantity is insignificant. To stop the loss of capillary blood can apply a pressure bandage or pinch the capillary with a finger. Before this, the skin around the wound must be treated with an antiseptic.

Note!

With a bullet wound of the soft tissues of the lower leg and hands, stopping bleeding is necessary. If it is not possible to apply a tourniquet or pressure bandage, block the vessels with your fingers until medical workers arrive.

Wound care and dressing

After the bleeding is stopped, a pressure aseptic bandage is applied. Before this, it is necessary to disinfect the surface near the wound. You need to process it in the following order:

• A little antiseptic is poured onto the area of ​​\u200b\u200bthe skin near the wound;
• Gently wipe it with a bandage or cloth;
• The next area, located near the wound, is also treated, but with a different bandage or cloth;
• In the absence of an antiseptic, plain water is used.
• Then the cleansed skin is smeared with iodine or brilliant green.

Note!

It is forbidden to pour antiseptics into the wound itself! It can be sprinkled with Streptocide powder.

The bandage is applied to all bullet holes on the body: incoming and outgoing. First, a clean bandage or cloth is placed on the wound, then covered with cotton wool. For thoracic injuries chest) cotton wool is replaced with a bag or oilcloth. If they are absent, the matter is abundantly lubricated with a greasy cream, ointment or petroleum jelly. "Oiled" fabric is placed instead of polyethylene.

The finished structure is tightly tied to the body with a bandage or other improvised dressing material (torn clothes, pieces of cloth, even adhesive tape).

In case of abdominal injuries, when the internal organs have fallen out of the abdominal cavity, they are collected in a plastic bag and carefully attached to the body with a bandage. Before the arrival of medical personnel, they must be constantly watered with water.

After the bandage is applied, put a cold object on it. However, remember that snow or icicles cannot be used. Give the victim the position that, in your opinion, will be most convenient for him. For chest injuries, be sure to bend the person's legs at the knees, giving him a half-sitting position.

Keep the patient warm by wrapping him in blankets. This action must be performed regardless of the season.

Note!

If the applied bandages are soaked with blood, do not remove them to apply new ones. It is enough to apply another layer of bandage over the already existing bandage.

When allowed to enter the victim intramuscularly with an antibiotic with a wide spectrum of action. If bullet wound was in the chest, leg or arm, you can give the victim an antibiotic in tablet form. Be sure to give analgesics that do not contain narcotic components.

Before the doctors arrive or the victim is taken to a medical facility, you need to constantly talk with him. It is advisable to fix vitally all this time important indicators: and heart rate.

Tamponade

Correctly apply a tourniquet for a beginner who first encountered critical situation, is extremely difficult. Any inaccuracy in this case can cause necrosis (necrosis) of tissues on the pulled limb. Therefore, doctors recommend using tamponade as a way to stop bleeding on the limbs as well.

Consider how to properly use this method of stopping blood loss.

• Prepare bandages or materials that replace them (cloth, clean clothes);
• Tear or cut them into strips, the width of which does not exceed 10 cm;
• Place the edge of the resulting tape in the wound, push it as deep as possible;
• Then sequentially, having collected 2-3 cm of a new piece of tissue with your fingers, immerse it in the wound;
• This is done until the hole is completely closed with a “plug” of material.

Note!

Until the wound is completely covered with tissue, the vessel is covered with a finger.

Bullet wounds are a dangerous injury that leads to death due to. At the same time, recognize and stop internal bleeding in the conditions of first aid is impossible. Therefore, such an injury requires immediate hospitalization of the victim.

A wound on the head is damage to the integrity of soft tissues with their divergence (open wound) or with the formation of a hematoma (closed wound), resulting from a bruise, blow or fall from a height. Wounds, depending on the type, can be life threatening with massive bleeding. First aid and comprehensive treatment will help reduce the risk of complications.

Given the nature of the damage, wounds are of several types:

• 1. Stab wound of the head - occurs as a result of penetration into the head of a sharp thin object (nail, awl, needle), which is extremely life-threatening. The deeper the object entered the head, the higher the risk of death.
• 2. Chopped wound of the head - develops with a mechanical impact on the head area of ​​​​a sharp heavy object: a saber, an ax, parts of a machine tool in production.
• 3. incised wound head - is formed as a result of the penetration of a sharp flat object: a knife, sharpening, scalpel. Accompanied by large blood loss.
• 4. Bruised head wound - occurs when exposed to a blunt object: a stone, a bottle, a stick. Accompanied by the appearance of a hematoma.
• 5. Rupture of the head - the wound has no clear boundaries; its formation is provoked by the impact of a blunt object that damages the outer skin, muscle layer and nerves.
• 6. Gunshot wound of the head - characterized by penetration into the head of a bullet from a firearm, which can take off (through wound), or can get stuck in the meninges.
• 7. Bitten head wound - develops with animal bites. Requires complex treatment with the appointment of antimicrobial therapy and the introduction of serum against rabies.

According to the depth of damage to the head area, wounds are classified into:

• soft tissue damage;
• damage to nerve fibers;
• damage to large blood vessels;
• damage to bone tissue;
• brain damage.

Each wound has its own causes and characteristics. In the presence of accidents or catastrophes, injuries can be complex and include several types of wounds at once, which have their own characteristics.

open

An open wound of the head is accompanied by a dissection of the skin with a characteristic development of bleeding. The abundance of blood flow depends on the location of the wound, its depth and the cause. The danger of this group of wounds is that there are large vessels on the head, the violation of the integrity of which entails the development of full-scale bleeding. Lack of qualified assistance can cost a person their life.

Open wounds are accompanied by loss of consciousness, nausea, numbness of the extremities, which indicates a concussion and bruising of the meninges. Along with stopping the bleeding, resuscitation of the victim is performed, restoring all vital processes in the body.

Closed

Most often, a closed wound is the result of a blunt heavy object acting on the head area, or a fall from a height. A hematoma and a bruise are formed, while the skin does not diverge and does not provoke the development of bleeding.

Clinical manifestations are similar to open wounds except for the absence of bleeding. Since we are talking about the head, in addition to eliminating the hematoma, it is necessary to make sure that there is no damage to the meninges and the brain itself, which may develop somewhat later.

Characteristic signs and clinical manifestations of all types of wounds

Differentiation of wounds is not difficult. For this, attention should be paid to the clinical manifestations and condition of the patient.

Gunshot wounds of the head in 99% of cases are fatal. They are characterized by deep penetration of a bullet or fragment into the deep layers of the brain with damage to large blood vessels, bone tissue and nerve endings. Only in the presence of a tangential gunshot wound can a person be conscious. A blind and penetrating wound in almost all cases provokes instant death.

Bite wounds have such distinctive features as:

• lacerated wound with no smooth ends of the connective tissue;
• bleeding;
• accession of the inflammatory process.

On the teeth of animals or humans is great amount microbes that, when bitten, enter the victim's bloodstream. Therapy involves antibiotic therapy and vaccinations against rabies and tetanus.

For a lacerated wound, the following manifestations are characteristic:

• irregular shape of the wound, many edges that do not touch each other;
• heavy bleeding and severe pain;
• violation of the sensitivity of the organs located on the head.

Numerous and deep lacerations can provoke the development of pain shock, which is characterized by a complete loss of sensitivity, loss of consciousness and coma.

A bruised closed wound has a relatively even outline in the form of a circle, crumpled inside. Often the appearance of the wound resembles the imprint of the object that provoked its appearance. Small capillaries bleed, which causes the development of a hematoma of saturated purple and purple-red color. Bleeding is absent completely or partially. Predominantly superficial capillary bleeding develops, caused by a violation of the integrity of the outer layer of the skin. Swelling and swelling appear at the site of the injury. Soon a lump is formed, which gradually disappears.

Chopped wounds are characterized great depth and area of ​​head injury. From a strong blow, the victim often loses consciousness. Reproduction of soft tissues and bones is noted, after which a fatal outcome may occur. Wounds are accompanied by a high probability of infection, as the object was previously used for its intended purpose, which leads to penetration pathogenic microflora into the deep layers of the cranium.

Incised wounds are accompanied by profuse bleeding, as well as the presence of a lumen of varying depth. Soft tissues are affected and nerve fibers. The brain is not damaged. Appears sharp pain causing the development of pain shock. When pathogenic microflora enters the general circulation, the clinical picture of intoxication joins with fever, chills and fever.

For stab wounds distinctive features are:

• relatively smooth edges of the inlet;
• slight swelling and hyperemia of the skin around the puncture;
• no profuse bleeding.

When a stab object is in the wound, its edges are directed inward. The wound is accompanied severe pain, dizziness and nausea.

First aid algorithm

Wound First Aid Kit

First aid, regardless of the type of wound, is carried out according to the scheme:

• 1. Stop bleeding - apply a clean bandage, cloth or gauze to the wound site, press firmly to the wound site. Apply cold, with the help of which the vessels will narrow and the bleeding will decrease.
• 2. Disinfect the area around the wound, but not the wound itself - the surface of the skin is treated with brilliant green, iodine or any disinfectant.
• 3. Control the general condition of the victim - control of breathing and heartbeat, and in their absence, indirect heart massage and artificial respiration are performed.
• 4. Deliver the patient to the hospital, fixing the head in a fixed position.

• press the wound and independently set the bone fragments;
• flush deep wounds water;
• independently extract foreign objects from the head;
• give the victim medication.

A bruised wound of the scalp is almost always accompanied by a concussion and vomiting. Therefore, the patient is laid on his side, a roller is placed under his head.

In case of a laceration, it is necessary to take the patient to the hospital as quickly as possible, since suturing will be required.

You can treat a wound on your head with brilliant green or iodine, if it is insignificant.

Treatment methods depending on the nature of the damage

First aid for head wounds

Hematomas and closed wounds are treated with heparin-based absorbable creams. The wound does not require additional treatment. Particular attention is paid to symptomatic treatment, selecting it taking into account the individual characteristics of the organism.

Open wounds, especially lacerations, require suturing. After that, the scar is treated with brilliant green or iodine solution. At the site of the wound, a colloid scar can form, to reduce the manifestation of which, Contractubex ointment is used.

As part of complex therapy prescribed groups of drugs such as:

• 1. Analgesics: Analgin, Kopacil, Sedalgin.
• 2. Non-steroidal anti-inflammatory drugs: Nurofen, Ibuprofen, Ibuklin.
• 3. Hemostatic drugs: Vikasol.
• 4. Antibiotics: Ceftriaxone, Cefazolin, Cefix, Amoxiclav.
• 5. Nootropic drugs that improve cerebral circulation.

A scalp wound may have different kinds and shape, as well as the degree of damage. Gunshots are considered the most dangerous, since the survival rate after them is minimal. Treatment of a head wound helps prevent pathogenic microflora from entering the general bloodstream. The right help can save a life.

The frequency according to the experience of the Great Patriotic War is 5.2%. Of these, gunshot 67.9%, closed injuries 10.9%, open injuries with blunt objects 21.9%. When using nuclear weapons, the percentage of closed damage increases.

Classification of head wounds:

By type of injuring weapon: firearms (bullet, fragmentation, balls, arrow-shaped elements, etc.), from impact with blunt objects, chopped, stab, cut;

According to the depth of damage: soft tissue injury (skin, aponeurosis, muscles, periosteum), non-penetrating (extradural - soft tissues and bones of the skull), penetrating (intradural - with damage to the meninges and brain);

By the nature of the wound: tangent, blind, through, ricocheting; segmental, radial, diametrical, parasagittal;

According to the type of fracture of the skull bones: incomplete (pothole, detachment of the outer cortical plate), linear fracture (crack), depressed (usually coarsely splintered with non-penetrating wounds), crushed (more often finely splintered with non-penetrating wounds), comminuted fracture (extensive coarsely splintered damage with displacement of fragments outside from cranial cavity, more often with through and blind penetrating wounds), perforated fractures (including sheer fractures with external ricochet wounds).

Absolute sign of a penetrating wound- outflow from the wound of cerebrospinal fluid and cerebral detritus.

Table symptoms are unfavorable prognostically.: deep cerebral coma, hyperthermia, stem convulsions, abnormal breathing, absence of pupillary, corneal and tendon reflexes, swallowing disorders.

Periods of the course of gunshot wounds of the skull and brain:

1. Initial (up to 3 days): bleeding, detritus and cerebrospinal fluid from the wound, edema, swelling, early protrusion of the brain, compression by fragments, hematomas.

2. Infectious (from 3 days to 4 weeks): late (malignant) protrusion of the brain, suppuration of the wound channel, early abscesses, meningitis, meningoencephalitis.

3. The period of elimination of early complications (3-4 weeks after injury): delimitation of foci of infection, encapsulation foreign bodies, late abscesses.

4. Period late complications(up to 2-3 years): exacerbation of sluggish current inflammatory processes - brain abscesses, less often - encephalitis, meningitis.

5. The period of long-term consequences (lasts for decades) - scar formation, traumatic epilepsy, dropsy of the brain, cysts, porencephaly.

Medical triage and staged treatment

First aid:

Protective aseptic bandage;

Prevention of aspiration of blood, vomit, retraction of the tongue (laying on the side, stomach, fixing the tongue),

Careful removal.

First aid:

Stop external bleeding

Restoration of airway patency,

Respiratory and cardiac stimulants,

Antibiotics, tetanus toxoid, PSS,

Filling in the primary medical card with the registration of the initial cerebral and focal symptoms,

Evacuation in the prone position.

Qualified medical care:

Sorted into 3 groups:

1. agonizing (to the hospital ward for symptomatic treatment);

2. in need of surgical care for health reasons (external bleeding, increasing compression of the brain);

3. transportable.

Specialized medical care:

Examination by a surgeon, neuropathologist, ophthalmologist, ENT, dentist, X-ray examination,

Surgical treatment of all open injuries at any time after the injury and regardless of the condition of the wound. Contraindications: absolute - an extremely serious condition, injuries incompatible with life, accompanied by a sharp inhibition of stem functions; relative - severe concomitant injuries (wounds of the chest, abdomen, etc.). The treatment of soft tissue wounds is performed by general surgeons in the dressing room.

Surgical treatment of wounds with damage to the bones of the skull, penetrating wounds, with external bleeding, with increasing compression of the brain, is performed by a neurosurgeon in the operating room.

Terms of surgical treatment: early (1-3 days), delayed (4-6 days), late (after 6-7 days).

Surgical treatment of penetrating wounds of the skull and brain:

Excision of soft tissue wound edges

Resection of the edges of the bone defect and the formation of a trepanation window,

Excision of the edges of the damaged dura mater (the damaged dura mater should be opened according to strict indications: its tension, cyanosis, absence of pulsation, brain compression clinic),

Removal of foreign bodies only under visual control (tweezers, clamp), washing the brain wound with antiseptics (furatsilin, rivanol) or non-convulsive antibiotics,

Hemostasis (3% hydrogen peroxide),

Resection of the zone of primary necrosis by aspiration of brain debris (with early treatment),

Drainage of the wound channel (glove or active drainage),

Wound closure soft covers heads (after early processing). With late treatment and in doubtful cases, the wound is not sutured, a Mikulich-Goykhman bandage is applied.

Secondary debridement:

Primary indications - non-removal of a foreign body, ongoing bleeding; secondary indications are infectious complications requiring surgical intervention.

Non-convulsive antibiotics: kanamycin, polymyxin-M, levomycetin-succinate, monomycin, morphocycline, etc. Penicillin and streptomycin are toxic and cause convulsions.

Closed injuries of the skull and brain

The head covers are intact or the wound is superficial, does not penetrate under the aponeurosis.

Types: concussion, bruise (3 degrees of severity), compression.

Signs of a brain injury:

Persistent pronounced focal and cerebral symptoms,

Fractures of the vault or base of the skull,

Blood in liquor.

Signs of a skull fracture:

Liquorrhea and bleeding from the ears, nose,

Damage to the roots and cranial nerves: facial - with a fracture of the pyramid of the temporal bone, oculomotor - with a fracture in the region of the superior orbital fissure, visual - in the region of the optic opening,

Symptom of "glasses", subcutaneous hemorrhage in the area of ​​the mastoid process,

pneumocephalus,

Purulent traumatic meningitis.

Causes of brain compression:

epidural, subdural, intracerebral, intraventricular hematoma, contusion foci, depressed fracture.

Signs of brain compression:

The increase in cerebral and focal symptoms,

Cushing's triad: lucid gap, anisocoria, bradycardia,

Liquor hypertension (300 mm of water column and more),

Congestion in the fundus of the eye,

Mixture of median structures of the brain according to ECHO ES,

- “avascular zone” in direct projection on the carotid angiogram.