Diagnosis and treatment of traumatic brain injury. Traumatic brain injury. Brain concussion. Treatment There are several main types of interrelated pathological processes.

Traumatic brain injury (TBI) is a head injury that affects the skin, skull bones, and brain tissue.

Varieties of damage

All traumatic brain injuries can be divided into open (when the skin, muscles, tendons and aponeurosis of the skull, bones, hard and soft membranes of the brain, the brain itself are injured) and closed. Closed trauma of the skull is divided into the following varieties:

1. Concussion of the brain (CCM). It occurs as a result of a blow to the head, this is the easiest type of injury. CGM is accompanied by several obligatory signs: loss of consciousness for less than 5 minutes, amnesia, absence of focal neurological symptoms, the predominance of general symptoms (headache, dizziness, nausea, vomiting, drowsiness). Such pathological phenomena on the part of the nervous tissue arise as a result of a sharp increase intracranial pressure in case of injury .
2. Brain injury. A very serious injury, when the physical impact is already on the very substance of the brain. Either a traumatic object, or the brain hits hard on the inner wall of the cranium. A bruise is accompanied by necrosis of a certain area of ​​the brain, hemorrhage. In this case, the same symptoms are observed as with a concussion, but more pronounced, which is combined with focal symptoms (impaired sensitivity, movements in one of the areas of the body or muscle group).
3. Compression of the substance of the brain. It can occur with an increase in edema of the nervous tissue, membranes against the background of intracranial hematoma (hemorrhage). At the same time, signs of a bruise are first visible, then a period of improvement (latent well-being) begins. And then - the patient's condition deteriorates sharply, consciousness is disturbed, severe neurological symptoms appear.

CRANIO-BRAIN INJURY (TBI)- mechanical damage to the skull and intracranial structures (brain, blood vessels, cranial nerves, meninges).

TBI can result from:

• traffic accidents, falls, industrial, sports or household injuries (primary injury);
• neurological or somatic disease (fainting or epileptic seizure) causing the patient to fall (secondary trauma).

TYPES OF TBI

According to the depth of penetration through the integument of the head, there are:
1. Open TBI (the presence of soft tissue injuries of the head with damage to the aponeurosis or a fracture of the bones of the base of the skull, accompanied by the outflow of cerebrospinal fluid from the nose or ear):
a) penetrating (there is damage to the dura mater);
b) non-penetrating.
2. Closed TBI (the integrity of the head covering is not broken).

By severity:
1. Light (brain concussion and mild brain contusion).
2. Medium.
3. Heavy.

According to the nature and severity of brain damage, there are:
- concussion;
- brain contusion (mild, moderate and severe);
- severe diffuse axonal damage;
- compression of the brain.

MILD TBI characterized by a short-term (several seconds or minutes) loss of consciousness, disorientation, neurological dysfunction. After the restoration of consciousness, amnesia may persist for some time (the total duration of the amnesic period does not exceed 1 hour), headache, sleep disturbances, vegetative disorders (changes in pupillary reactions, fluctuations in blood pressure, pulse lability, vomiting, pallor, hyperhidrosis), muscle hypotension, asymmetry of reflexes , anisocoria, vestibular (dizziness, nystagmus), ataxia and other focal symptoms, sometimes mild meningeal symptoms regressing within a few days.
The main feature of mild TBI is the fundamental reversibility of neurological disorders, however, the recovery process can be delayed for several weeks or months, during which patients will continue to have headache, dizziness, impaired attention, and asthenia.

It is advisable for a patient with mild TBI to be hospitalized for observation for 2 to 3 days (with a mild bruise clinic, the duration of hospitalization is sometimes extended to 1 week). The main goal of hospitalization is not to miss a more serious injury, the formation of an intracranial hematoma. Subsequently, the likelihood of complications (intracranial hematoma) is significantly reduced, and the patient (if he has a clear mind, no vomiting or severe headache, focal and meningeal symptoms) can be allowed to go home under the supervision of relatives.

With mild TBI in the first 1-2 days, it makes sense to limit fluid intake somewhat. Prolonged bed rest should be avoided - the early return of the patient to his usual environment is much more beneficial. It should be borne in mind that due to impaired attention, the working capacity of many patients is limited for 1-3 months.

Occasionally, patients with mild TBI or soft tissue contusion experience vasodepressor syncope minutes or hours after the injury. In the vast majority of cases, such an episode does not reflect brain damage, but an autonomic response to pain and emotional stress.

Postconcussion syndrome is a condition that occurs after a mild head injury. The main symptoms are headache, dizziness, decreased attention and memory, slow mental activity, fatigue, sleep disturbance, irritability, anxiety, depression, affective lability, apathy, autonomic dysfunction.

The more severe the injury, the longer the recovery takes. In old age and with repeated TBI, the speed and completeness of recovery are reduced. A year after mild TBI, symptoms (most often headache, dizziness, asthenia) persist in 10-15% of patients. However, it loses its connection with the severity of the injury and is usually observed in the context of emotional disorders.

MODERATE AND SEVERE TBI characterized by prolonged loss of consciousness and amnesia, persistent cognitive impairment, and focal neurological symptoms.
In severe TBI, about half of patients die, and another 20% develop a severe residual defect or a chronic vegetative state.

Treatment of patients with severe TBI is carried out in the intensive care unit. TBI is a dynamic process that requires constant monitoring of the state of vital functions, level of consciousness, neurological and mental status, indicators of water-electrolyte, acid-base balance, etc. With the exclusion of an intracranial hematoma or other cause of brain compression requiring urgent surgical intervention, the treatment of severe TBI is reduced mainly to the prevention of secondary brain damage directly related to its hypoxia or ischemia.

Brain compression is one of the most dangerous complications of TBI, threatening the development of herniation and infringement of the brain stem with the development of a life-threatening condition. The most common cause of compression is an intracranial hematoma, less often a depressed fracture of the skull, a focus of contusion with perifocal edema, an accumulation of cerebrospinal fluid under the dura mater (subdural hygroma), and an accumulation of air in the cranial cavity (pneumocephalus).

Post-traumatic encephalopathy is a condition caused by severe or moderate head injury and is predominantly manifested by neuropsychological and behavioral disorders that disrupt the life and social adaptation of the patient. In post-traumatic encephalopathy, almost all cognitive spheres can suffer, but memory, attention, thinking, the ability to plan and control one's actions are especially often affected, which is explained by the frequent involvement of the frontal and temporal lobes in TBI. Neuropsychological disorders are often accompanied by emotional disturbances, sleep disturbances, unmotivated outbursts of aggression, and sexual desire disorders.

Treatment includes psychotherapy, neuropsychological training, the use of psychopharmacological agents. Nootropics are used to improve moderate cognitive functions. During the first year after the injury, rehabilitation measures should be most intensive.
Post-traumatic epilepsy usually develops after severe TBI, especially in the presence of skull fractures, intracranial hematoma, the presence of focal symptoms and early epileptic seizures (within the first week after injury). More than half of post-traumatic epilepsy cases occur within the first year. If seizures do not appear within 5 years, then they usually do not occur in the future.

Under head injury understand damage to the skull and intracranial contents (brain, meninges, blood vessels, cranial nerves) by mechanical energy.

Traumatic brain injury (TBI) is one of the most common types of injuries in peacetime, accounting for about 40% of all types of injuries. TBI belongs to the category of severe damage to the human body, accompanied by high mortality: from 5 to 70%. In wartime, the frequency of injuries to the skull and brain is constantly increasing: the Great Patriotic War - 11.9%; Vietnam - 15.7%; Afghanistan - 14.4%; Chechnya - 22.7%.

Mechanism of injury

direct and indirect.

Pathogenesis.

In the pathogenesis of TBI, special importance is attached to two main factors of a mechanical nature: 1) temporary changes in the configuration of the skull according to the type of its general or local deformation with the occurrence in some cases of a skull fracture; 2) displacement of the brain in the cranial cavity (in relation to the internal walls of the cavity and intracranial fibrous septa) - linear and rotational displacement, change in velocity in a linear direction, linear acceleration and deceleration.

Types and classification of skull injuries.

Injuries to the skull and brain are divided into closed and open (wounds) . Distinguish firearms and non-firearms wounds. Closed TBI includes injuries in which there are no violations of the integrity of the head cover. An open TBI is called with the presence of a wound of the soft tissues of the skull (aponeurosis), as well as a fracture of the base of the skull, accompanied by bleeding or liquorrhea from the ear or nose. With the integrity of the dura mater, open craniocerebral injuries are classified as non-penetrating , and in case of violation of its integrity - to penetrating .

Classification.

1. I. Closed head injuries: Brain concussion; 2. Brain contusion: - mild; - moderate severity; - severe degree. 3. Compression of the brain on the background of a bruise and without a bruise: - hematoma: acute, subacute, chronic (epidural, subdural, intracerebral, intraventricular); - hydrowash; - bone fragments; - edema-swelling; - pneumocephalus. 4. State of the subshell spaces: - subarachnoid hemorrhage; CSF pressure: normotension, hypotension, hypertension. 5. Condition of the skull: - without damage to the bones; type and location of the fracture. 6. Condition of the integument of the skull: - bruises; - abrasions. 7. Associated injuries and diseases. 8. According to its severity, a closed craniocerebral injury is divided into three degrees: - mild (concussion and mild brain contusion), moderate (medium brain contusion) and severe (severe brain contusion with compression).
2. II . Gunshot wounds of the skull and brain: By type of wounding projectile: - bullet, - fragmentation. 2. By the nature of the wound: - soft tissues, - non-penetrating with bone damage, - penetrating. 3. According to the type of wound channel: - blind, - tangent, - through, - ricocheting. 4. By localization: - temporal, - occipital, other areas. 5. According to the type of fracture of the skull bones: - linear, - depressed, - crushed, - perforated, - comminuted. 6. By the number of wounds: - single, - multiple. 7. According to the influence of combinations of various factors: - mechanical, - radiation, - thermal, - chemical. 8. According to the nature of brain damage: - concussion, - bruise, - crush, - compression. 9. According to the severity of the injury: - light, - moderate, - severe. 10. According to the severity of the condition of the wounded: - satisfactory, - moderate, - severe, - terminal. 11. Blind wounds: - simple, - radial, - segmental, - diametrical, - rebounding, - tangential. 12. Through wounds: - segmental, - diametrical, - tangential.

During TBI, it is customary to distinguish the following periods:

1) acute period - from the moment of injury to stabilization at various levels of functions impaired due to injury (from 2 to 10 weeks, depending on the clinical form and severity of TBI);

2) intermediate period - from the moment of stabilization of functions to their full or partial recovery or stable compensation (with mild TBI - up to two months, with moderate TBI - up to four months, with severe TBI - up to six months);

3) long-term period - clinical recovery or the maximum possible restoration of impaired functions or the emergence and (or) progression of new pathological conditions caused by TBI (up to two years or more). A detailed diagnosis, including all the elements of this classification, can only be made in a specialized hospital.

The clinical picture of damage to the skull and brain consists of cerebral and local (focal) neurological symptoms. Cerebral symptoms include headache, nausea, vomiting, dizziness, etc. Local (focal) symptoms depend on the location of the focus of brain damage and can manifest as hemiparesis, hemiplegia, speech and visual disorders.

Clinic of closed TBI.

1. Closed brain injury with concussion symptoms is a functionally reversible form of brain injury. It is characterized by short-term loss of consciousness from several seconds to several minutes, retro- and anterograde amnesia, vomiting, headache, dizziness, and other autonomic disorders. In the neurological status, as a rule, only cerebral neurological symptoms are noted. There are no injuries to the bones of the skull, the pressure of the cerebrospinal fluid and its composition are without deviations from the norm. The condition of patients, as a rule, improves within the first or second week.
2. Closed brain injury, accompanied by symptoms of brain contusion (degrees - easy, medium, heavy). brain contusion mild degree It is characterized by turning off consciousness from several minutes to one hour. Then there is a headache, dizziness, nausea, vomiting, retro- and anterograde amnesia. Vital functions are usually not impaired, a moderate increase in heart rate, respiration, and an increase in blood pressure are possible. Focal symptoms are mild (nystagmus, pyramidal insufficiency) and disappear after 2-3 weeks. Unlike concussion, subarachnoid hemorrhages and skull fractures are possible. brain contusion medium degree It is characterized by a loss of consciousness after an injury lasting from several minutes to several hours. Expressed retrograde and anterograde amnesia and other cerebral symptoms. Complaints of severe headache, repeated vomiting, transient disturbances of vital functions in the form of bradycardia, tachycardia are possible). Nested symptoms are clearly manifested, determined by the localization of the brain contusion - hemiparesis, speech disorders, visual disorders, etc. With a lumbar puncture, blood-colored cerebrospinal fluid is usually detected, flowing under high pressure. Craniograms often show skull fractures. brain contusion severe accompanied by a loss of consciousness from several hours to several weeks. Severe violations of vital functions are observed: bradycardia or tachycardia, often with arrhythmia, arterial hypertension, respiratory distress. In the neurological status, stem symptoms come to the fore: floating movements of the eyeballs, accommodation paresis, tonic nystagmus, swallowing disorders, decerebrate rigidity (generalized or focal convulsive seizures). As a rule, a brain contusion is accompanied by fractures of the bones of the vault or base of the skull, massive subarachnoid hemorrhages.
3. Closed trauma of the brain, accompanied by symptoms of increasing compression of the brain (against the background of bruises or without bruises of the brain). The brain compression syndrome is characterized by a life-threatening increase at various intervals after the injury (the so-called "light period") of cerebral, focal and stem symptoms. Depending on the background (concussion, brain contusion), on which traumatic compression of the brain develops, the latent period may be pronounced, erased, or absent altogether. Clinically, in this case, pupil dilation appears on the side of compression, and hemiplegia on the opposite side. The appearance of bradycardia is characteristic.

Clinical brain injury.

At the suggestion of E.I. Smirnov (1946) it is customary to divide the course of pathological processes in brain injury into five periods.

They are called periods of traumatic brain disease:

- initial period - "chaotic" according to N.N. Burdenko, lasting about three days. It is characterized by a predominance of cerebral symptoms over local ones, impaired consciousness, respiration, cardiovascular activity, and the act of swallowing;

II - the period of early reactions and complications - (infection and discirculation), lasting up to three weeks - 1 month is characterized by an increase in edema-swelling of the brain, its protrusion (benign prolapse). The wounded regain consciousness, focal symptoms are detected, the course is complicated by the development of meningitis, meningoencephalitis, suppuration of the wound channel. As a result of the development of infection, malignant protrusions (secondary prolapses) occur;

III - the period of elimination of early complications and a tendency to limit the infectious focus, begins on the 2nd month after the injury and lasts about 3-4 months (depending on the severity of the injury). With a smooth course, the wound heals and recovery occurs.

I V - period of late complications , begins 3-4 months after the injury and lasts 2-3 years, is characterized by the formation of late brain abscesses, outbreaks of meningitis, meningoencephalitis;

V - period of long-term consequences associated with the presence of a meningeal scar. May last for many years after injury.

Diagnosis of TBI:

1. Identification of an anamnesis of trauma.

2. Clinical assessment of the severity of the condition.

3. The state of vital functions.

4. The condition of the skin - color, moisture, bruising, the presence of soft tissue damage.

5. Examination of internal organs, skeletal system, concomitant diseases.

6. Neurological examination: the state of the cranial innervation, the reflex-motor sphere, the presence of sensory and coordinating disorders, the state of the autonomic nervous system.

7. Shell symptoms: stiff neck, symptoms of Kernig, - Brudzinsky.

8. Echoencephaloscopy.

9. X-ray of the skull in two projections.

10. Computed or magnetic resonance imaging of the skull.

11. Ophthalmological examination of the condition of the fundus.

12. Lumbar puncture - in the acute period, it is indicated for almost all victims with TBI (with the exception of patients with signs of brain compression) with the measurement of cerebrospinal fluid pressure and the removal of no more than 2-3 ml of cerebrospinal fluid, followed by laboratory testing.

Providing assistance at the stages of medical evacuation.

First aid

is reduced to the imposition of an aseptic dressing on the wound, the careful removal of the wounded. The wounded, who are unconscious, are taken out on their side (in order to prevent aspiration of vomit), they need to unfasten the collar, loosen the belt. In case of retraction of the tongue and signs of asphyxia, introduce an air duct (S-shaped tube, breathing tube TD-1). Do not inject drugs (respiratory depression).

First aid

– bandage bandaging, ventilation of the lungs with the help of a breathing apparatus DP-10, DP-11, oxygen inhalation with a KI-4 apparatus, maintenance of cardiovascular and respiratory activity (intramuscular injection of 2 ml of cordiamine, 1 ml of caffeine). Evacuation of the wounded in the first place on a stretcher.

First aid

- fight against asphyxia, artificial lung ventilation with the DP-9, DP-10 apparatus, oxygen inhalation with the KI-4 apparatus, maintenance of cardiovascular and respiratory activity (introduction of 2 ml of cordiamine, 1 ml of caffeine, 1 ml of 5% ephedrine).

If necessary, the bandage is corrected, a prophylactic dose of antibiotics is administered (500,000 units of streptomycin, 500,000 units of penicillin), tetanus seroprophylaxis is carried out by subcutaneous injection of 0.5 ml of tetanus toxoid.

The wounded are directed to the dressing MPP in the skull with ongoing bleeding from soft tissue wounds for hemostasis with a pressure bandage, applying a clamp to the bleeding vessel. The wounded are not detained at this stage, they are evacuated first of all with ongoing intracranial bleeding and liquorrhea, and secondarily those wounded in the soft tissues of the skull. Before transportation, according to indications, cardiovascular and respiratory means, an air duct are introduced.

It is necessary to transport the wounded to the skull in the prone position and it is better to immediately go to the SMP stage, bypassing the intermediate stages of medical evacuation.

Qualified medical care .

The wounded deserve special attention, who, as a result of medical triage, are subject to surgical treatment at this stage for health reasons (refusal to operate can lead to death).

Urgent surgical interventions are performed for the following wounds and injuries: wounds and injuries of the head and neck, accompanied by: - ​​asphyxia (tracheal intubation or tracheostomy); - external bleeding (stopping external bleeding by ligation of the vessels of the integumentary tissues or tight tamponade of the wound); - trepanation of the skull and PST of a brain wound at the stage of rendering qualified assistance (including with compression of the brain).

Sorting of the wounded in the skull on OMedB and OMO in case of mass admission will often have to be carried out without removing the bandage.

Determination of transportability is made on the basis of an assessment of the general condition, preservation of the reaction of the pupils and corneal reflexes, the state of the pulse, respiration, dressing, etc.

When evacuating, provide for: - wounded with damage to the soft tissues of the skull without focal neurological symptoms - in the GLR; - wounded with concussion - in VPNG. All other wounded with open skull injuries are sent to a specialized neurosurgical hospital.

Specialized assistance .

The hospital provides comprehensive specialized surgical care to the wounded who have not received qualified surgical care.

1. Questions for self-control.
2. Mechanism of traumatic brain injury.
3. Classification of gunshot injuries of the skull and brain.
4. Classification of non-gunshot injuries of the skull and brain.
5. Clinical picture of concussion.
6. Clinical picture of brain injury.
7. Clinical picture of brain compression.
8. Diagnosis of combat trauma of the skull and brain.
9. The volume of medical care at the stages of medical evacuation.
10. Possible complications in traumatic brain injury and their prevention.

Clinic. Distinguish between closed and open traumatic brain injury. With a closed craniocerebral injury, there is no violation of the integrity of the integument of the head or there are soft tissue wounds without damage to the aponeurosis, or a fracture of the bones of the cranial vault without damage to the aponeurosis and soft tissues.

Injuries accompanied by injuries of the soft tissues of the head and aponeurosis, fractures of the base of the skull, accompanied by liquorrhea or bleeding (from the ear, nose), are classified as open craniocerebral trauma. Open craniocerebral injuries without damage to the dura mater are considered non-penetrating, and if its integrity is violated, penetrating.

By severity, traumatic brain injury is divided into three degrees: mild - concussion, mild contusion of the brain; moderate - moderate brain contusion; severe - severe brain contusion and compression of the brain.

There are six clinical forms of traumatic brain injury: concussion, mild brain contusion, moderate brain contusion, severe brain contusion, (pressure of the brain against the background of its contusion, compression of the brain without concomitant contusion.

Concussion - the impact of mechanical energy during a concussion of the brain covers the brain as a whole, in the process of moving the brain, due to anatomical features, the hypothalamic region is the most vulnerable. Hence the variety of autonomic symptoms in concussion. A short-term shutdown of consciousness is characteristic, lasting from a few seconds to several minutes. There is retrograde amnesia for events preceding the trauma, vomiting. After the patient regains consciousness, complaints of general weakness, headache, dizziness, tinnitus, flushing of the face, sweating and other vegetative signs are typical. There may be complaints of pain when moving the eyeballs, reading disorder, sleep disturbance, unsteady gait, etc. An objective neurological examination can reveal slight asymmetry of tendon and skin reflexes, small-scale nystagmus, the phenomenon of meningism - all this, as a rule, disappears by the end of the first week. The pressure of the cerebrospinal fluid and its composition are unchanged, the integrity of the bones of the skull is not broken.

Brain contusion differs from concussion by changes in the physicochemical properties of brain tissue, the functional state of neuronal membranes, and swelling of synapses, leading to disruption of communication between individual groups of neurons. In connection with a change in vascular tone, plasma penetrates into the intercellular spaces. This leads to the development of edema-swelling of the brain, and in the case of penetration of erythrocytes (erythrodiapedesis) - extravasation. Numerous small hemorrhages are often the only morphological sign of a brain contusion.

Mild cerebral contusion - characterized by a loss of consciousness lasting from several minutes to 1 hour. After the restoration of consciousness, complaints of headaches, nausea, dizziness, etc. are typical. Repeated vomiting, retrograde amnesia, sometimes bradycardia or tachycardia, arterial hypertension are observed. -zia. Body temperature and respiration are not changed. Nistagmus, mild anisocoria, anisoreflexia, meningeal symptoms that disappear by the end of the 2-3rd week after injury. The pressure of the cerebrospinal fluid and its composition can be changed. Possible fractures of the bones of the vault and base of the skull.

With a moderate brain contusion, the duration of the loss of consciousness after an injury is from several tens of minutes to 4-6 hours. Severe headache, retrograde and anterograde amnesia, and repeated vomiting are typical. There are bradycardia (40-50 in mi-NUTU), tachycardia (up to 120 per minute), arterial hypertension (up to 180 mm Hg), tachypnea, subfebrile temperature. Nystagmus, meningeal symptoms, pupillary, oculomotor disorders, paresis of the extremities, disorders of sensitivity, speech, etc. Focal neurological symptoms can last for 3-5 weeks or more. Pressure, cerebrospinal fluid increased to 250-300 mm of water. Art. Find fractures of the bones of the vault and base of the skull, subarachnoid hemorrhage.

Severe brain contusion - the duration of the loss of consciousness after an injury from several hours to several weeks, there is motor excitation. Severe disorders of vital functions: bradycardia (up to 40 beats per minute), tachycardia (over 120 beats per minute), arrhythmia, arterial hypertension (over 180 mm Hg), tachypnea, bradypnea, hyperthermia. Focal neurological symptoms: gaze paresis, floating eye movements, multiple spontaneous nystagmus, dysphagia, bilateral miosis or mydriasis, divergent strabismus, changes in muscle tone, decerebrate rigidity, areflexia, pathological foot reflexes, symptoms oral automatism, paresis (paralysis) of the limbs, convulsive seizures. The symptomatology regresses very slowly, subsequently there are gross residual effects on the part of the motor system and the mental sphere. The pressure of the cerebrospinal fluid is sharply increased (up to 400 mm of water column). Fractures of the bones of the vault and base of the skull, massive subarachnoid hemorrhages are characteristic.

Brain compression - observed in the presence of intracranial hematoma (epidural, subdural, intracerebral), pronounced edema-swelling of the brain, foci of its softening, depressed fractures of the skull bones, subdural hydromas, pneumocephalus. For the growing compression of the brain, a period of imaginary well-being is characteristic. After an injury in such cases, for some time, calculated in minutes, and more often in hours, the general condition of the patient is satisfactory. Then there is a headache, growing in its intensity, vomiting, possibly psychomotor agitation. Pathological drowsiness occurs, bradycardia increases. Tendon and periosteal reflexes become uneven or decrease. Perhaps an increase in hemiparesis, the appearance of anisocoria, focal epileptic seizures. With increased compression of the brain, a soporous develops, and in more severe cases, a coma. Bradycardia is replaced by tachycardia, blood pressure rises. Breathing becomes hoarse, stertorous or of the Cheya-Stokes type, the face becomes purplish-blue, and cardiac activity stops after a short-term increase.

A similar clinical picture develops with supratentorial hematomas complicated by edema-swelling of the brain, which leads to compression of the oral sections of the brain stem, hippocampus and their incarceration in the opening of the cerebellar tenon, and then in the large occipital. This is the direct cause of death of patients.

The most dangerous are epidural and subdural hematomas, less often - subarachnoid hemorrhages. An epidural hematoma is a collection of blood between the dura mater and the bones of the skull. It usually appears when the meningeal arteries are damaged, less often when the veins of the outer surface of the dura mater, as well as the sinuses or veins leading to them, are damaged. Most often, an epidural hematoma occurs when the integrity of the middle meningeal artery or its branches is violated. Damage to the artery is often combined with a fracture, fracture of the temporal or parietal bone. Such cracks are often not detected on craniograms. As a rule, epidural hematoma occurs at the site of damage to the skull, less often - in the area opposite to it (due to counter-strike).

Bleeding from the damaged artery lasts for several hours and leads to the formation of an epidural hematoma, involving the temporal, parietal and frontal regions. Peeling off the dura mater from the bone, it gradually compresses the brain.

The first signs of brain compression appear a few hours (3-24) after the injury. The presence of a light gap is characteristic, followed by the development of pathological drowsiness, stupor or coma and symptoms of focal brain damage (hemiparesis, pupil dilation on the side of the hematoma).

Usually, the clinical picture of compression occurs against the background of a concussion or contusion of the brain, which often makes it difficult to recognize it in time.

Subdural hematoma - accumulation of blood under the dura mater in the subdural space. Most often, it is located on the convex surface of the cerebral hemispheres, sometimes occupying a significant area. Its symptoms develop relatively quickly: severe headache, psychomotor agitation, pathological drowsiness, stupor, coma. The skin of the face and visible mucous membranes are hyperemic, the pulse is slow or rapid. Breathing changes. The temperature rises. Signs of intracranial hypertension, dislocation of brain regions, secondary stem syndrome appear relatively quickly, which is manifested by a disorder of vital functions. Symptoms of focal brain damage are mild or absent. Sheath symptoms can be determined. There is an admixture of blood in the cerebrospinal fluid.

Subarachnoid hemorrhage is an accumulation of blood in the subarachnoid space of the brain. It is characterized by severe headaches, the presence of pronounced shell symptoms, an abundant admixture of blood in the cerebrospinal fluid, and fever. Focal symptoms are absent or mild. Possible psychomotor agitation. Consciousness can be preserved. But with massive hemorrhages, there is an increase in intracranial hypertheia with the subsequent development of a dislocation syndrome.

For an objective assessment of severity in the acute period of traumatic brain injury, it is necessary to take into account the state of consciousness, vital functions and the severity of focal neurological symptoms.

There are five levels of the state of patients with traumatic brain injury: satisfactory, moderate, severe, extremely severe, terminal.

Satisfactory condition: clear consciousness, no violation of vital functions, absence or low severity of focal neurological symptoms.

State of moderate severity: clear consciousness, moderate stunning, no violation of vital functions (may be bradycardia), the presence of focal neurological symptoms (damage to individual cranial nerves, sensory or motor aphasia, spontaneous nystagmus, mono- and hemiparesis, etc.). The severity of the headache is also taken into account.

Severe condition: deep stunning, stupor; violation of vital functions, the presence of focal neurological symptoms (anisocoria, sluggish pupillary reaction to light, upward gaze restriction, hemiparesis, hemiplegia, epileptic seizures, dissociation of meningeal symptoms along the axis of the body, etc.).

Extremely serious condition: moderate or deep coma, severe violations of vital functions, severe focal neurological symptoms (paresis of upward gaze, severe anisocoria, exotropia along the vertical and horizontal axes, tonic spontaneous nystagmus, a sharp weakening of pupillary reactions, decerebrate rigidity, hemiparesis, tetraparesis, paralysis, etc.).

Terminal state: transcendental coma, critical impairment of vital functions, general cerebral and stem symptoms prevail over hemispheric and craniobasal.

Giving help. First of all, it is necessary to decide whether the victim needs urgent neurosurgical care or whether conservative treatment can be limited.

The need for emergency care arises with a growing intracranial hematoma and depressed skull fracture, compressing the brain and threatening the development of dislocation phenomena. If there are no indications for urgent surgical treatment, then conservative treatment is carried out. With a concussion of the brain, therapeutic measures should be aimed at restoring the functional activity of the structures concerned. They include: strict bed rest for several days (up to a week), antihistamines (diphenhydramine, pipolfen, fenkarol, suprastin), sedatives (tincture of valerian, peony, motherwort, bromides), tranquilizers (diazepam, oxazepam, rudotel, sibazon, etc.), anticholinergic drugs (bellataminal, belloid, platifillin, antispasmodic, etc.) in usual doses.

With pronounced neurovegetative reactions, in order to improve microcirculation, eufillin is administered intravenously.

In connection with the development of moderate intracranial hypertension in concussion of the brain, dehydrating agents are indicated, mainly saluretics (diacarb, furosemide, dichlothiazide, ethacrynic acid), which are taken in the morning for 4-5 days while monitoring the content of potassium in the blood - if necessary, appoint potassium orotate, panangin.

In case of sleep disturbance, sleeping pills are prescribed (methaqualone, nitrazepam, noxiron), in case of asthenia - CNS stimulating agents (caffeine, 2 ml of a 10% solution intramuscularly 2-3 times a day, acephene 0.1 g, sydnocarb 0.005 g orally 2 times a day - in the morning and in the evening). In the future, nootropic drugs (piracetam, pyriditol, aminalon, etc.) are prescribed to prevent traumatic brain disease.

The patient should stay in the hospital for 7-10 days. In case of brain contusion, therapeutic measures should be aimed primarily at restoring cerebral microcirculation, which is achieved by improving the rheological properties of blood (reducing the aggregation ability of formed elements, increasing blood fluidity, etc.) For this, reopoliglyukin, cavinton, xanthinol nicotinate, trental, 5% albumin solution under the control of hematocrit.

To improve the energy supply of the brain, glucose is used as part of a glucose-potassium-insulin mixture (the amount of glucose administered should not exceed 0.5 g / kg), insulin - 10 units for every 200 ml of 20% glucose solution in combination with oxygen therapy. Purine derivatives (theophylline, euphyllin, xanthinol nicotinate, etc.), isoquinoline (papaverine, nikospan) contribute to the restoration of the function of the blood-brain barrier. With increased vascular permeability, 10 ml of a 5% solution of ascorbic acid is administered intravenously for 1-2 weeks.

Prophylactic desensitizing therapy (diphenhydramine, pipolfen, suprastin, etc.) is shown. Dehydration therapy is used under the control of blood plasma osmolarity (normal 285-310 mosm/l). For this, osmotic diuretics and saluretics are used. In severe arterial hypertension and cardiovascular insufficiency, the use of the former is limited - a recoil phenomenon is possible (secondary increase in intracranial pressure after its decrease).

Saluretics reduce the volume of circulating plasma. From osmotic
Glucocorticoids are used for dehydration purposes. They help to reduce the permeability of the vascular wall. The initial * dose of dexamethasone is 40 mg or more intravenously, the next 4 days, 8 mg every 3 hours and 5-8 days - 8 mg every 4 hours. Barbiturates are used for dehydration: nembulate ps 50-300 mg / g is administered intravenously 1.5-4 mg/kg) for 12 hours.

In case of subarachnoid hemorrhage, in the first 8-10 days, amino-caproic acid is intravenously administered intravenously - 100 ml of a 5% solution 4-5 times a day (you can use isotonic sodium chloride solution) in the future, it can be used orally 1 g every 4 hours a day. within 10-12 days. Assign transilol and kontrykal. To stop psychomotor agitation, 2 ml of a 0.5% solution of seduxen or 1-2 ml of a 0.5% solution of haloperidol are injected intramuscularly or intravenously.

In case of fractures of the vault and base of the skull with nasal or ear liquorrhea, wounds of the soft tissues of the head, for the prevention of meningitis, encephalitis, an antibiotic is prescribed - benzylpenicillin sodium salt, 1 million units 4 times a day, intramuscularly, in combination with sulfadimethoxine, 1-2 g per day. the first day and 0.5-1 g in the next 7-14 days.

Patients with brain bruises of moderate severity, not complicated by inflammatory processes, stay in the hospital for 3 weeks. At the final stage of inpatient treatment, and then in the clinic, intramuscular injections of lidase are prescribed at 64 units per day (20 injections per course of treatment). Anticonvulsants are shown. The use of alcoholic beverages is strictly prohibited, insolation is contraindicated.

In the recovery period, cerebrolysin, aminalrn, pantogam, piracetam and others are used, as well as drugs that improve microcirculation (cinnarizine, cavinton).

Severe brain contusions are accompanied by persistent impairment of consciousness, severe focal neurological symptoms, often with massive subarachnoid hemorrhages. Foci of crushing are formed, combined with compression of the brain, which leads to its edema-swelling and dislocation syndromes. Hence the necessity and urgency of surgical intervention

Traumatic brain injuries rank first among all injuries (40%) and most often occur in people aged 15–45 years. Mortality among men is 3 times higher than among women. In large cities, every year, out of a thousand people, seven receive head injuries, while 10% die before reaching the hospital. In the case of a minor injury, 10% of people remain disabled, in the case of a moderate injury - 60%, and a severe one - 100%.

Causes and types of traumatic brain injury

A complex of damage to the brain, its membranes, bones of the skull, soft tissues of the face and head - this is a traumatic brain injury (TBI).

Most often, participants in road accidents suffer from craniocerebral injuries: drivers, passengers of public transport, pedestrians hit by vehicles. In second place in terms of frequency of occurrence are domestic injuries: accidental falls, bumps. Then there are injuries received at work, and sports.

Young people are most susceptible to injuries in the summer - the so-called criminal injuries. The elderly are more likely to get TBI in the winter, with falling from height becoming the leading cause.

Statistics
Residents of Russia most often get TBI while intoxicated (70% of cases) and as a result of fights (60%).

Jean-Louis Petit, a French surgeon and anatomist of the 18th century, was one of the first to classify traumatic brain injuries. Today there are several classifications of injuries.

• by severity: light(concussion, slight bruising) average(serious injury) heavy(severe brain contusion, acute compression of the brain). The Glasgow Coma Scale is used to determine severity. The condition of the victim is estimated from 3 to 15 points, depending on the level of confusion, the ability to open the eyes, speech and motor reactions;
• type: open(there are wounds on the head) and closed(there are no violations of the skin of the head);
• by type of damage: isolated(damages affect only the skull), combined(damaged skull and other organs and systems), combined(the injury was received not only mechanically, the body was also affected by radiation, chemical energy, etc.);
• according to the nature of the damage:
• shake(minor injury with reversible consequences, characterized by a short-term loss of consciousness - up to 15 minutes, most victims do not require hospitalization, after examination, the doctor may prescribe a CT scan or MRI);
• injury(there is a violation of the brain tissue due to the impact of the brain on the wall of the skull, often accompanied by hemorrhage);
• diffuse axonal brain injury(axons are damaged - processes of nerve cells that conduct impulses, the brain stem suffers, microscopic hemorrhages are noted in the corpus callosum of the brain; such damage most often occurs during an accident - at the time of sudden braking or acceleration);
• compression(hematomas are formed in the cranial cavity, the intracranial space is reduced, foci of crushing are observed; emergency surgical intervention is required to save a person's life).

It's important to know
Brain injury most often occurs at the site of impact, but often damage occurs on the opposite side of the skull - in the zone of impact.

The classification is based on the diagnostic principle, on its basis a detailed diagnosis is formulated, in accordance with which treatment is prescribed.

Symptoms of TBI

The manifestations of traumatic brain injury depend on the nature of the injury.

Diagnosis « brain concussion » based on history. Usually the victim reports that there was a blow to the head, which was accompanied by a short loss of consciousness and a single vomiting. The severity of the concussion is determined by the duration of the loss of consciousness - from 1 minute to 20 minutes. At the time of examination, the patient is in a clear state, may complain of headache. No abnormalities, except for the pallor of the skin, are usually not detected. In rare cases, the victim cannot remember the events that preceded the injury. If there was no loss of consciousness, the diagnosis is made as doubtful. Within two weeks after a concussion, weakness, increased fatigue, sweating, irritability, and sleep disturbances can be observed. If these symptoms do not disappear for a long time, then it is worth reconsidering the diagnosis.

At mild brain injury and the victim may lose consciousness for an hour, and then complain of headache, nausea, vomiting. There is twitching of the eyes when looking to the side, asymmetry of reflexes. X-ray can show a fracture of the bones of the cranial vault, in the cerebrospinal fluid - an admixture of blood.

Dictionary
Liquor - liquid transparent color, which surrounds the brain and spinal cord and performs, among other things, protective functions.

Moderate brain injury severity is accompanied by loss of consciousness for several hours, the patient does not remember the events preceding the injury, the injury itself and what happened after it, complains of headache and repeated vomiting. There may be: violations of blood pressure and pulse, fever, chills, soreness of muscles and joints, convulsions, visual disturbances, uneven pupil size, speech disorders. Instrumental studies show fractures of the vault or base of the skull, subarachnoid hemorrhage.

At severe brain injury the victim may lose consciousness for 1-2 weeks. At the same time, gross violations of vital functions (pulse rate, pressure level, frequency and rhythm of breathing, temperature) are detected in him. The movements of the eyeballs are uncoordinated, the muscle tone is changed, the process of swallowing is disturbed, weakness in the arms and legs can reach convulsions or paralysis. As a rule, such a condition is a consequence of fractures of the vault and base of the skull and intracranial hemorrhage.

It is important!
If you or your loved ones assume that you have received a traumatic brain injury, it is necessary to see a traumatologist and neurologist within a few hours and carry out the necessary diagnostic procedures. Even if it seems that health is in order. After all, some symptoms (cerebral edema, hematoma) may appear after a day or even more.

At diffuse axonal brain injury a prolonged moderate or deep coma occurs. Its duration is from 3 to 13 days. Most of the victims have a respiratory rhythm disorder, different horizontal pupils, involuntary movements of the pupils, arms with hanging hands bent at the elbows.

At brain compression two clinical pictures can be observed. In the first case, a “light period” is noted, during which the victim regains consciousness, and then slowly enters a state of stupor, which is generally similar to stunning and stupor. In another case, the patient immediately falls into a coma. Each of the conditions is characterized by uncontrolled eye movement, strabismus, and crossed paralysis of the limbs.

long head compression accompanied by soft tissue edema, reaching a maximum 2-3 days after its release. The victim is in psycho-emotional stress, sometimes in a state of hysteria or amnesia. Swollen eyelids, impaired vision or blindness, asymmetric swelling of the face, lack of sensation in the neck and back of the head. Computed tomography shows edema, hematomas, fractures of the bones of the skull, foci of brain contusion and crushing.

Consequences and complications of TBI

After suffering a traumatic brain injury, many become disabled due to mental disorders, movements, speech, memory, post-traumatic epilepsy and other reasons.

Even a mild TBI affects cognitive functions- the victim experiences confusion and decreased mental abilities. In more severe injuries, amnesia, impairment of vision and hearing, speech and swallowing skills can be diagnosed. In severe cases, speech becomes slurred or even completely lost.

Disturbances of motility and functions of the musculoskeletal system expressed in paresis or paralysis of the limbs, loss of sensation of the body, lack of coordination. In the case of severe and moderate injuries, there is failure to close the larynx, as a result of which food accumulates in the pharynx and enters the respiratory tract.

Some TBI survivors suffer from pain syndrome- acute or chronic. Acute pain syndrome persists for a month after the injury and is accompanied by dizziness, nausea, and vomiting. Chronic headache accompanies a person throughout life after receiving TBI. The pain can be sharp or dull, pulsating or pressing, localized or radiating, for example, to the eyes. Attacks of pain can last from several hours to several days, intensify at moments of emotional or physical exertion.

Patients have a hard time with the deterioration and loss of body functions, partial or complete loss of working capacity, therefore they suffer from apathy, irritability, and depression.

TBI treatment

A person with a traumatic brain injury needs medical attention. Before the arrival of the ambulance, the patient should be laid on his back or on his side (if he is unconscious), a bandage should be applied to the wounds. If the wound is open, cover the edges of the wound with bandages, and then apply a bandage.

The ambulance team takes the victim to the traumatology department or intensive care unit. There, the patient is examined, if necessary, an x-ray of the skull, neck, thoracic and lumbar spine, chest, pelvis and limbs is taken, ultrasound of the chest and abdominal cavity is performed, blood and urine are taken for analysis. An EKG may also be ordered. In the absence of contraindications (a state of shock), a CT scan of the brain is done. Then the patient is examined by a traumatologist, a surgeon and a neurosurgeon and a diagnosis is made.

The neurologist examines the patient every 4 hours and assesses his condition on the Glasgow scale. If consciousness is disturbed, the patient is shown tracheal intubation. A patient in a state of stupor or coma is prescribed artificial ventilation of the lungs. Patients with hematomas and cerebral edema regularly measure intracranial pressure.

The victims are prescribed antiseptic, antibacterial therapy. If necessary - anticonvulsants, analgesics, magnesia, glucocorticoids, sedatives.

Patients with hematoma require surgical intervention. Delaying surgery within the first four hours increases the risk of death by up to 90%.

Recovery prognosis for TBI of varying severity

In the case of a concussion, the prognosis is favorable, provided that the victims follow the recommendations of the attending physician. Complete recovery of working capacity is noted in 90% of patients with mild TBI. In 10%, cognitive functions remain impaired, a sharp change in mood. But these symptoms usually disappear within 6-12 months.

The prognosis for moderate and severe forms of TBI is based on the number of points on the Glasgow scale. An increase in scores indicates positive dynamics and a favorable outcome of the injury.

In patients with TBI of moderate severity, it is also possible to achieve a complete restoration of body functions. But often there are headaches, hydrocephalus, vegetative vascular dysfunction, coordination disorders and other neurological disorders.

In severe TBI, the risk of death increases to 30-40%. Among the survivors, almost one hundred percent disability. Its causes are pronounced mental and speech disorders, epilepsy, meningitis, encephalitis, brain abscesses, etc.

Of great importance in the return of the patient to an active life is the complex of rehabilitation measures rendered to him after the relief of the acute phase.

Directions of rehabilitation after traumatic brain injury

World statistics show that 1 dollar invested in rehabilitation today will save 17 dollars to ensure the life of the victim tomorrow. Rehabilitation after a head injury is carried out by a neurologist, a rehabilitation doctor, a physical therapist, an ergotherapist, a massage therapist, a psychologist, a neuropsychologist, a speech therapist and other specialists. Their activities, as a rule, are aimed at returning the patient to a socially active life. The work to restore the patient's body is largely determined by the severity of the injury. So, in case of a severe injury, the efforts of doctors are aimed at restoring the functions of breathing and swallowing, at improving the functioning of the pelvic organs. Also, specialists are working on the restoration of higher mental functions (perception, imagination, memory, thinking, speech), which could be lost.

Physical therapy:

• Bobath therapy involves stimulating the patient's movements by changing the positions of his body: short muscles are stretched, weak ones are strengthened. People with movement limitations get the opportunity to learn new movements and hone the ones they have learned.
• Vojta therapy helps to connect brain activity and reflex movements. The physical therapist irritates various parts of the patient's body, thereby inducing him to make certain movements.
• Mulligan therapy helps to relieve muscle tension and pain relief.
• Installation "Exarta" - suspension systems with which you can relieve pain and return atrophied muscles to work.
• Training on simulators. Classes are shown on cardio simulators, simulators with biofeedback, as well as on a stabiloplatform - for training coordination of movements.

Ergotherapy- the direction of rehabilitation, which helps a person to adapt to the conditions of the environment. The ergotherapist teaches the patient to take care of himself in everyday life, thereby improving the quality of his life, allowing him to return not only to social life, but even to work.

Kinesiology taping- the imposition of special adhesive tapes on damaged muscles and joints. Kinesitherapy helps to reduce pain and relieve swelling, while not restricting movement.

Psychotherapy- an integral component of high-quality recovery after TBI. The psychotherapist conducts neuropsychological correction, helps to cope with the apathy and irritability characteristic of patients in the post-traumatic period.

Physiotherapy:

• Medicinal electrophoresis combines the introduction of drugs into the body of the victim with exposure to direct current. The method allows you to normalize the state of the nervous system, improve blood supply to tissues, and relieve inflammation.
• Laser therapy effectively fights pain, swelling of tissues, has anti-inflammatory and reparative effects.
• Acupuncture can reduce pain. This method is included in the complex of therapeutic measures in the treatment of paresis and has a general psychostimulating effect.

Medical therapy It is aimed at preventing brain hypoxia, improving metabolic processes, restoring active mental activity, and normalizing the emotional background of a person.

After craniocerebral injuries of moderate and severe degree, it is difficult for the victims to return to their usual way of life or come to terms with forced changes. In order to reduce the risk of developing serious complications after TBI, it is necessary to follow simple rules: do not refuse hospitalization, even if it seems that you feel fine, and do not neglect various types of rehabilitation, which, with an integrated approach, can show significant results.