The closed craniocereberal injury. 303 Open craniocereberal injury. 304 Radiological inspection at
a craniocereberal injury..... ZS6
Resuscitation at a craniocereberal
Mental disturbances at cranial
- a brain injury..........
Children have 309 Features of a craniocereberal injury........... 311
Medicolegal aspects of a craniocereberal trama...... 312
H erep N about - a brain injury — injury of a skull and brain as a result of mechanical influence.
H - m of t. makes 30 — 40% in the general structure of traumatism (see), at the same time among the combined injuries on a share of Ch. there is a m of t. it is necessary apprx. 80%.
Craniocereberal injuries subdivide on closed and opened. To the closed Ch. - m of t. refer damages, at to-rykh the integrity of soft covers of a skull is not broken or there are wounds of soft tissues without damage of a nadcherepny aponeurosis (a tendinous helmet). Open Ch. - m of t. damages of soft tissues of the head with disturbance of an integrity of an aponeurosis, and also fractures of bones of a skull are. Open damages of a base of skull are complicated by a nasal or ear liquorrhea (see). Ch.'s division - m of t. on closed or opened has basic value since at open Ch. - m of t. always there is a danger of infection of intracranial educations and fabrics defining tactics of conservative and operational treatment.
The closed craniocereberal injury
the Closed injuries of a skull are various. They can be followed by the linear changes (or cracks) bones of a skull (see) pressed and splintered fractures of bones of the arch with their transition to bones of a base of skull. At the same time the most often linear changes extend to area of adnexal bosoms of a nose (see), a trellised plate of a sievebone and a pyramid of a temporal bone. Changes can proceed on a seam of a skull, leading to a rupture of a seam and expansion of its gleam, i.e. to discrepancy of a seam.
A pathogeny of the closed Ch. - m of t. includes complex combinations of the functional and morphological changes caused by mechanical impact on a skull and a brain. Mechanical influence consists of direct stroke with local injury of a skull and brain and so-called anti-blow (see the Contusion of a brain). At antiblow there is a bruise of a brain about bone and shell intracranial educations owing to its shift in a head cavity aside, opposite to a place of application of the injuring force. In addition to rectilinear, at the time of an injury there can be a rotational and axial shift of a brain in a head cavity, at Krom there are ruptures of blood vessels and damage of various areas of a brain as a result of its bruises about bone and shell intracranial structures, and also its trunk departments suffer. A significant role in injury of a brain at Ch. - m of t. plays the hydrodynamic blow connected with movement of cerebrospinal liquid in ventricles of a brain, a face-voprovodyashchikh ways and subarachnoidal (subshell) spaces. Mechanical impact on a brain in it
is resulted by various changes at the cellular and subcellular levels with disturbance of colloid balance in nervous cells, changes of membranes of neurons and swelling of synapses that causes blockade of an afferent and efferent impul-sation with development of a functional asinapsiya. In the centers of a bruise of a brain kinina, biogenic amines, products of hemolysis of the streamed blood are released, to-rye influence elements of nervous tissue and vascular system of a brain and promote edematization of a brain (see Hypostasis and swelling of a brain), secondary disturbances of circulation of cerebrospinal liquid with increase of a hypoxia of a brain (see the Hypoxia). It leads to switching of energy balance of a brain to an anaerobic way with hyperproduction of nedookislenny products and development of a metabolic acidosis (see).
In character and degree of manifestation of iost-traumatic reactions of a brain, especially at repeated injuries, the autoimmune mechanisms caused by receipt on humoral Wednesdays of proteins of the damaged tissue of a brain have a certain value. An important role during and heavy Ch.'s outcome - m of t. play intracranial hypertensia (see. Hypertensive syndrome) and the secondary dislocation phenomena leading to infringement of a brain trunk at the level of cutting it is mashed a cerebellum (see Dislocation of a brain).
At a pathoanatomical research local damages of tissue of brain are shown by focal destruction of various degree up to a necrosis (see), edges is in most cases combined with hemorrhagic treatment of the centers of destruction. In the centers of destruction the proteolytic enzymes causing an autolysis of tissue of brain (see the Autolysis) and expansion of zones of necrotic changes are released.
Classification. As a basis of classification of the closed Ch. - m of t. at different times suggested to use various criteria, napr, anatomic features of injuries of a brain, nek-ry pathogenetic signs, features a wedge.
manifestations, etc. Large number and variety of these classifications complicated comparative study of Ch. - m of t., and also comparison of results of treatment according to various neyrotravmatologiches of ky
institutions. In this regard uniform working classification of the closed Ch. - m of t was recommended to M3 of the USSR. The classification offered Zh. Pti is its basis, edges covers the main forms of the closed brain injuries. By drawing up working classification also many modern morphological, pathophysiological and clinical data on the closed Ch. - m of t were considered. According to this classification allocate a concussion of the brain, bruises of a brain of easy, average and heavy degree, a prelum of a brain against the background of a bruise of a brain and without the accompanying bruise of a brain.
On severity the closed Ch. - m of t. divide on easy, moderately severe and heavy. To easy Ch. - m of t. carry a concussion of the brain and a bruise of a brain of easy degree, to a moderately severe craniocereberal injury — a bruise of a moderately severe brain, to heavy Ch. - m of t. — bruise of a brain of heavy degree and all types of a prelum of a brain.
At assessment of severity of Ch. - m of t. consider also weight of a condition of the victim at the time of the research. Estimates of weight of an injury and weight of a condition of the victim in most cases match. At Ch. - m of t. distinguish satisfactory condition, a moderately severe state, serious condition, extremely heavy and terminal. The condition of the victim is estimated on the basis of the analysis of three key parameters — conditions of consciousness, extent of disturbance of trunk vital functions and expressiveness focal nev-rol. symptoms. According to working classification mark out the following gradation of a condition of consciousness at Ch. - m of t.: clear, devocalization (moderate and deep), a sopor, a coma (I — moderate, II — deep, III — ultraboundary). The correct assessment of the listed parameters and gradation allows to define rather accurately a condition of the victim, to carry out a purposeful intensive care and to specify indications to a timely operative measure.
Clinical picture. A concussion of the brain — preferential functional, a reversible and easy form Ch. - m of t. Its characteristic signs are short-term (lasting not more than 30 min.) the loss of consciousness which is quickly regressing scattered focal nevrol. symptomatology in the form of reflex asymmetries, passing trunk disturbances (nausea, vomiting), vestibular (a nystagmus, etc.) and vegetosoyeudisty disturbances (see the Concussion of the brain).
Bruise — more severe form of injury of a brain which is characterized by development of the centers of destruction of its fabric, a wedge, symptoms of focal damage of a brain, existence of subarachnoidal hemorrhage (see the Stroke) and in some cases fractures (cracks) of bones of a calvaria (see the Contusion of a brain).
Bruises of a brain of easy degree are shown not roughly expressed, but accurate focal not in a beater. symptoms, to-rye regress more slowly, than at concussion. Duration of loss of consciousness varies, but usually slightly exceeds duration of a loss of consciousness at concussion. In some cases the bruise of a brain of easy degree proceeds without disturbance of consciousness. The subarachnoidal hemorrhage which is quite often combined with a fracture of bones of a calvaria is typical.
Bruises of a brain of moderate severity are characterized by deeper and long disturbance of consciousness (to 4 — 6 hours), rough and resistant symptoms of local injury of a brain, up to a monoplegia or a hemiplegia (see Paralyses, paresis), hemianaesthesias (see Sensitivity), aphasias (see) etc., passing disturbances of trunk functions and reversible disturbances of the vital functions; subarachnoidal hemorrhages, sometimes massive; often fractures of bones of the arch and base of skull are found.
Bruises of a brain of heavy degree are followed by deep disturbance of consciousness (from a sopor to an ultraboundary coma) lasting more than 6 hours (frequent several days and even weeks). In nevrol. the status into the forefront the symptomatology of primary damage of a brain trunk acts, edges in the acute period shades symptomatology of focal damage of cerebral hemispheres; the heavy, menacing disturbances of the vital functions are noted.
The prelum of a brain more than develops in 90% of cases against the background of its bruise. Pathogenetic it is connected with increase of the additional volume in a head cavity leading to a prelum and dislocation of a brain, disturbance of circulation of cerebrospinal liquid (see) and to frustration of cerebral circulation (see). Intracranial hematomas (epidural, subdural, intracerebral, forming in the centers of a bruise of a brain), and also depressed fractures of bones of a skull, the centers of bruises-razmozzhe-niya of a brain, the accruing wet brain are the most frequent reason of a prelum of a brain (see Hypostasis and swelling of a brain). Also intracranial bleedings at ruptures of venous vessels of para-sagittal area, side lacunas of an upper sagittal sine, the diploichesky veins which were available for the patient of vascular malformation (arteriovenous aneurisms) and also at other patol can be the reasons of a traumatic prelum of a brain. changes of blood vessels, a traumatic pneumocephalus, (see), etc.
Klin, manifestations of a prelum of a brain can directly develop after an injury (quickly accruing intracranial hematoma, the massive center of bruises-times-mozzheniya with formation of an intracerebral hematoma) or to arise after a so-called light interval. The progressing disturbance of consciousness, increase of focal and trunk symptomatology with a bystry decompensation of the vital functions is characteristic (see the Prelum of a brain).
Treatment. Identification about Bol ochechny (epidural or subdural) the hematoma squeezing a brain is the direct indication for its operational removal. The exception is made by only small plane hematomas. At intracerebral hematomas and the centers of a bruise of a brain of the indication to an operative measure are defined by their size, localization, dynamics of symptoms of defeat, secondary dislocation and trunk symptoms.
The philosophy at operative measures concerning a bruise of a brain — the greatest possible shchazheniye of the tissue of a brain surrounding the centers of a bruise. Only sites of crush of marrow are subject to radical removal. The so-called perifocal zone of the center of a bruise of a brain shall be whenever possible kept. Especially it belongs to important departments of a brain in the functional relation since degree of irreversibility of changes of tissue of brain can not always be expected in the acute period. Efficiency of operational treatment of victims with the intracranial hematomas and heavy bruises of a brain proceeding with the accruing phenomena of a prelum of a brain depends not only on massiveness of a hematoma and primary center of destruction, but also on time which passed from the moment of an injury before an operative measure. The overdue operation made against the background of the progressing dislocation syndrome in most cases does not allow to prevent secondary irreversible damages of a brain.
Postoperative therapy includes a complex of the means eliminating hypostasis and a hypoxia of a brain, providing recovery of a homeostasis and normalization of function of the vital systems of an organism. For control of dynamics of intracranial pressure use constant registration of intracranial pressure through a ventrikulyarny drainage or nadobolochechny and podobolochech-ny sensors. Dehydrational therapy (see) carry out under control of water and electrolytic balance and a fatwood of a yarnost of plasma.
The forecast at the closed easy Ch. - m of t. in most cases favorable. At 20 — 30% of victims with Ch. - m of t. moderate severity has the permanent functional and organic disturbances limiting their working capacity and social rehabilitation. At heavy Ch. - m of t. the lethality fluctuates within 45 — 60%, reaching 85% at development of a deep coma and nearly 100% at an ultraboundary coma. Among the survived faces of this group in the remote period working capacity is lost or limited more than at 50% of patients; approximately at 20% the epileptic syndrome develops, at 45% mental disorders come to light (see below).
Open craniocereberal injury
Distinguish wounds of soft covers of a skull with damage of a nadche-turnip aponeurosis, the open not getting injuries of bones of a skull (without disturbance of an integrity of a firm cover of a brain) and the getting wounds (with injury of bones of a skull, a meninx and a brain).
At open Ch. - m of t. fractures of bones of a calvaria, fractures of bones of a base of skull and their combination are observed. Fractures of bones of a base of skull, as a rule, are followed by damage of the firm cover of a brain spliced with them that leads to the message of a head cavity with the environment, a liquorrhea (see) also creates danger of infection of intracranial educations.
Distinguish linear changes (cracks), incomplete fractures of bones of a skull pressed and splintered changes. At fighting open Ch. - m of t. also the shattered fractures of bones of a skull are typical perforated (blind, through and steep).
In peace time open Ch. - m of t. arise at the road accidents more often. The udarpo-shaking mechanism of an injury causing a combination of open local damages to concussion or its bruise, subarachnoidal hemorrhage or an intracranial hematoma is characteristic of these damages. At open Ch. - m of t. peace time the fragmentary hurt wounds of soft covers of a skull with formation of the contaminated pockets, amotio of fabrics, crush of edges of a wound, an exposure of a bone, the skulls which are combined with fractures of bones and injury of a brain (bruises, crush of its sites) are observed. As a result of amotio or a separation of a skin and aponeurotic rag on a surface of a calvaria scalped wounds are formed (see Wounds, wounds). Cut wounds of soft covers of a skull usually have the linear or semicircular form and smooth edges, quite often are followed by plentiful bleeding, especially strong in cases of injury of a superficial temporal or occipital artery. At chopped wounds bones of a skull and a brain are injured, as a rule. The severe bleeding accompanying these wounds quite often is connected with damage of an upper sagittal sine. Chipped wounds usually have the small sizes and the deep wound channel getting into a brain. At the same time a part of the damaging tool can break off and remain in the wound channel.
At gunshot craniocereberal wounds the injury is done on rather limited site by the shell (a bullet, steel balls, arrow-shaped hurting shells, etc.) having big penetrative force. The extensive through wound channel in a skull and a brain or the blind channel is as a result formed if the shell was spent.
Depending on the direction of flight of a hurting shell there can be gutter (tangential) wounds, and also ricocheting — with an outside or intracranial ricochet. The last is characteristic of wounds steel balls. Strelovisible hurting shells spent plunge into a bone of a skull to the stabilizer more often or with the sufficient penetrative force get into a head cavity on various depth.
On Ch.'s localization - m of t. distinguish wounds of frontal, parietal, temporal, occipital areas and their various combinations or wounds of temporal and orbital, frontal and orbital, temporal and mastoidal areas and a back cranial pole.
A clinical picture of open Ch. - m of t. in many respects
the Terra of injury of a brain and its trunk educations depends from harak. Along with local destruction of soft covers of a skull, bones of a skull, covers and a brain at the same time arising concussion and a contusion of a brain are of great importance. At the getting craniocereberal wounds in a wedge, a picture distinguish five periods: initial
(acute), period of early reactions and complications, period of elimination of early complications and tendency to restriction inf. center, period of late complications and period of the remote effects.
The initial (acute) stage can proceed to 3 days. By definition of H. N. Burdenko, it is the chaotic period, in time to-rogo against the background of serious condition of the victim bystry dynamics nevrol is observed. disturbances. The all-brain symptoms and disorders of consciousness reaching degree of a sopor or a coma (see) prevail, disturbances of the vital functions are expressed (breath, blood circulation, cordial activity). In this period there can be a need for an urgent operative measure concerning the proceeding intracranial bleeding and the accruing intracranial hematoma. The outcome depends on Ch.'s compatibility - m of t. with life.
The period of early reactions and complications (lasting from 3 — 4 days to 3 — 4 weeks) is characterized by increase of hypostasis and swelling of a brain, preferential around the wound channel. Along with reduction of all-brain symptoms and gradual recovery of consciousness are shown focal nevrol. symptoms — paralyzes, disturbances of the speech, sight, hearing, cortical functions. At the beginning of the 2nd week wet brain usually decreases, improves circulation of cerebrospinal liquid in subarachnoidal (subarachnoid) space. During this period activators of a wound fever can extend on likvoroprovodyashchy ways that leads to development of meningitis (see) or encephalitis (see Encephalitis). Timely recognition of complications, use of dehydrational therapy (on the 1st week) and antibiotics (at emergence inf. complications) is obligatory.
Period of elimination of early complications and tendency to restriction inf. the center proceeds depending on weight of an injury and the postponed complications of 3 — 4 weeks up to 3 — 4 months after wound. By this time the wound heals and if in the wound channel there are no foreign bodys (bone fragments, scraps of a headdress, hair, etc.), then the hem which is not causing irritation of a brain forms.
At not radical roughing-out of a craniocereberal wound (see. Surgical treatment of wounds) during the period from 3 — 4 months to 2 — 3 years after wound development of late complications (the fourth period) is possible. During this period late abscesses of a brain (see the Brain, abscess of a brain), osteomyelitis of bones of a skull (see), purulent fistulas, an ulceration of a hem, the abscessing encephalitis are observed.
Effects of the postponed wound of a skull and a brain can be shown also in later terms (the fifth period) depending on conditions of formation of a brain hem, its localization and impact on structures of a brain. The period of the remote effects is characterized by developing of epileptiform attacks (see Epilepsy), about-lochechno-bo left syndromes, a traumatic arachnoiditis (see) and hydrocephaly (see), traumatic encephalopathy (see), mental disorders (see below), etc.
All diagnostic actions at heavy Ch. - m of t. carry out in parallel with an intensive care and resuscitation (see below). The diagnostic complex includes detailed nevrol. and rentgenol. inspection.
Results of treatment of victims from open Ch. - m of t. to a great extent depend on timeliness of recognition and assessment of nature of the process developing in limited intracranial space.
The current and an outcome of an open cherepnomozgovy injury, including and fire, in many respects are defined by roughing-out of a wound, edges shall be made timely and considerably. In peace time at early delivery of victims in hospital, use of modern means of anesthesiology and resuscitation (see below) roughing-out of a wound carry out in the 1st days after an injury. In such conditions wide scrappy cuts are admissible, at indications — a craniotrypesis (see), opening of a firm cover of a brain, removal of nadobolochechny and subshell hematomas, the centers of a bruise of a brain, foreign bodys and imposing of deaf seams on a debrided wound.
In field conditions, at mass defeats there are contraindications to roughing-out of a wound. Roughing-out do not make at destructions of a skull and brain, extensive, not compatible to life, and also the expressed disturbances of the vital functions (breath, blood circulation, se rdechny activity), testimonial of defeat of a brain trunk. Relative contraindications to roughing-out of a wound are also meningitis and pneumonia, at to-rykh terms of processing of a wound are defined by weight of inflammatory process and a condition of the wound. Distinguish early (to 3 days), delayed (on 4 — the 6th days) and late (in 6 days) roughing-out of a wound. Terms of processing of a wound depend on time of delivery of the wounded in specialized hospital, mass character of arrival of wounded and features of a fighting and medical situation.
The wound is processed under local anesthesia or under anesthetic, after preparation of a surgery field (shaving of hair and processing of skin around a wound). If only soft covers of a skull are damaged, then edges of a wound layer-by-layer economically exsect to avoid an excess exposure of a bone; audit of a bone is made through a periosteum or after its section a small linear section.
At not getting wounds carry out a resection craniotrypesis, delete bone fragments and clots from a surface of the unimpaired firm cover of a brain. The firm meninx is opened only at strong indications of a prelum of a brain owing to increase of intracranial pressure and education under Bol of an ochechny hematoma.
Processing of a brain wound at the getting wounds is begun with removal of the bone fragments which were implemented into a firm cover of a brain («a bone stopper») for ensuring free outflow from the wound channel. Then in the conditions of artificial increase in intracranial pressure (a tussiculation or a natuzhivaniye of the wounded, a temporary prelum to it jugular veins on a neck) empty the wound channel from the bones of clots, a brain detritis mixed with fragments, to-rye are squeezed out from deep departments of the wound channel. The wound is cleared by means of a suction machine, washed out weak antiseptic solution. Metal foreign bodys (see. Foreign bodys of a brain) delete a pin magnets with the help. For a stop of parenchymatous brain bleeding into the wound canal enter the gauze ball moistened in 3% solution of hydrogen peroxide. Economically excise edges of the damaged firm cover of a brain, remove a gauze ball from the wound channel and apply Mikulich's bandage or a friable bandage with hypertensive solution for clarification of the suppurating wound a wound. The deaf seam is admissible in field conditions only at early and radical processing of a craniocereberal wound and in case of a possibility of rather long overseeing by the wounded (not less than 3 weeks) in the conditions of specialized hospital.
In the postoperative period the bed rest, rest, overseeing by a wound, prescription of antibiotics, feeding by high-calorific food is necessary (it is frequent also in the small portions).
Use of nuclear weapon can cause emergence of the mass combined defeats, in particular open Ch. - m of t. in combination with burns and effects of impact of ionizing radiation. At such defeats carry out treatment of a radial illness (see), burns (see) and, the main thing, early primary radical processing of a wound (to the so-called eclipse period of radiation injury) with imposing of deaf seams on a wound for the prevention of development of infectious intracranial processes.
At first-aid treatment (see) and the pre-medical help (see) apply an aseptic bandage, prevent hit of emetic masses in respiratory tracts, undo a collar and a belt. Use of anesthetics, respiratory or cordial analeptics, antibiotics is shown, at the combined defeats — radioprotectors (see). The careful carrying out of wounded from the battlefield and their evacuation in perhaps short terms on the most sparing transport is necessary (see Evacuation medical, Stage treatment).
At a stage of the first medical assistance (see) if necessary correct a bandage, according to indications enter antibiotics, antitetanic serum, analeptics, radioprotectors. Allow the wounded to drink, warm it. Send wounded for a stop of the proceeding outside bleeding, introduction of an air duct or imposing of a tracheostoma to a dressing room (see T a rakheostomiya).
At a stage of the qualified medical care (see) to the operating room first of all send wounded with the proceeding intracranial bleeding, the increasing intracranial pressure or a plentiful liquorrhea for removal of a hematoma or imposing of a deaf seam after roughing-out of a wound for the purpose of the termination of life-threatening plentiful loss of cerebrospinal liquid. The wounded who is in a preagonal or agonal state appoint analgesic and sedatives. At this stage in team recovering leave wounded, terms of treatment to-rykh do not exceed 7 — 10 days (e.g., at the superficial grazes or tangent wounds of the head which are not getting more deeply than an aponeurosis without signs of a concussion of the brain). Other wounded are subject to evacuation in hospital for wounded in the head, a neck and a backbone where provide them specialized medical care (see). After sanitary cleaning and diagnostic testings make roughing-out of a wound, and first of all the wounded with the getting wounds of the head. In the most hard cases of wounded after operation send to antishock chamber. Further treatment is carried out in a hospital of neurosurgical department.
At damages of soft tissues of the head and lack of the expressed symptoms of defeat of a nervous system wounded after roughing-out of a wound can be transferred to hospital for lightly wounded (see), Wounded with expressed not in a beater. the disturbances (paralyzes, disturbances of the speech, sight, hearing, mentality) caused by Ch. - m of t. or its complications, evacuate to the countries specialized hospital of the back.
Observed earlier sometimes at open Ch. - m of t. loss and protrusion of a brain (see the Prolapse of a brain) at modern dehydrational therapy practically do not arise.
Radiological inspection at a craniocereberal injury
Radiological inspection is obligatory in the general complex of diagnostic actions at Ch. - m of t. It should be seen off in reception, intensive or any other care unit as soon as possible to lay down. institutions, having the corresponding x-ray equipment. Rentgenol. inspection of victims with Ch. - m of t. or at suspicion on it carry out for the purpose of an exception of a fracture of bones of a skull, and at detection of a change — for definition of its look, localization, prevalence, the relation to vascular furrows, venous sine, pneumatic cavities.
As a rule, rentgenol. inspection of patients with a craniocereberal injury is made in two stages. The first stage is primary, urgent survey research of a skull, the second — detailing of the found damages (see Kraniografiya). Phasing rentgenol. inspections it is caused by the general condition of the victim, an originality of a current of Ch. - m of t., and also those tasks, to-rye face the clinical physician at the choice of the general tactics of treatment and first-priority to lay down. actions. At the first stage carry out survey kraniogramma and if the condition of the patient, additional pictures in a back semi-axial projection (for a research of an occipital bone), on a tangent (tangentsialno) to the place of impression of bone fragments in a head cavity (for establishment of depth of impression allows), contact pictures (for differential diagnosis of a linear change with a vascular furrow), pictures of a facial skeleton. The survey kraniografiya is made in two mutually perpendicular projections — perednezadny (or posteroanterior) and side. It is reasonable to do a picture in a side projection in position of the patient on spin; the cartridge is put to a side surface of the head from external damages, and from the opposite side of the head have a X-ray tube. Such laying for a craniography in a side projection is least traumatic, allows to receive the roentgenogram with necessary symmetry of the image of bones of a skull. Reliable diagnosis of Ch. - m of t. on survey kraniogramma it is possible at their high technical quality — a sharp image of bones of a skull and absence on the roentgenogram of a shadow of soft covers of a skull.
Radiological fractures of bones of a skull subdivide into linear (cracks), splintered and pressed. It is most difficult rentgenol. diagnosis of linear changes. Their characteristic signs on kraniogramma are transparency of the line of a change, its linearity or a zigzagoobraznost (fig. 1). The Zigzagoobraznost or linearity of the line of a change allow to distinguish it from a vascular furrow or the diploichesky channel in a bone of a skull, besides, the image of a vascular furrow is less transparent, has certain though N rather variable, anatomi-
Fig. 1. Kraniogramma at the closed craniocereberal injury (a side projection): the crack of a bone in parietotemporal area in the form of the transparent zigzag line is visible.
Fig. 2. Kraniogramma at a depressed fracture of bones of a skull (a perednezadny projection): the arrow specified impression in a head cavity of the right parietal bone at which its communication with the next bones was not broken.
chesky arrangement and dichotomizing division. At the pressed and splintered changes in one cases fragments of a bone get into a head cavity, but keep communication with the next bones and among themselves (fig. 2), in others — bone fragments break away and implemented into a head cavity (fig. 3).
The most informative modern way of diagnosis of intracranial damages is the computer tomography (see the Tomography computer). This method allows to make inspection of victims in any state, to establish existence of intracranial pathology, to precisely define localization, a look and prevalence of defeat.
To the second stage rentgenol. inspections start only after obtaining results of the first stage and survey of the victim by the neurosurgeon or traumatologist. Inspection is carried out for the purpose of identification of details of damage and diagnosis of possible complications of Ch. - m of t. According to indications make more difficult rentgenol. researches, napr, a X-ray analysis of pyramids of temporal bones, bases of skull, etc., and also apply such methods rentgenol. inspections as a cerebral angiography (see), a pneumoencephalography (see), a usual or computer tomography.
Rentgenol. diagnosis of a fracture of skull and definition of its look play an important role at the choice of surgical access and establishment of severity of intracranial damages. At cracks in frontal area of a skull the centers of a bruise of a brain and an intracranial hematoma come to light on the party of a crack in basal departments of a brain. At cracks of an occipital bone intracranial hematomas and the centers of a bruise of a brain are located, as a rule, in frontal and temporal lobes. Epidural hematomas most often are near a fracture of a skull, especially if the line of a change passes through a furrow of the shell artery. Subdural and intracerebral hematomas find equally often both on the party of injury of a bone, and on the party, opposite to a change. The centers of a bruise of a brain on the party of a fracture of bones of a skull are usually less extensive also Bolit are superficial, than on the party of antiblow.
A certain value in rentgenol. to diagnosis of intracranial hematomas has the shift of a calciphied pinus (see) more than on 2 mm from the centerline of a skull aside, opposite to the party of an arrangement of a hematoma (fig. 4). Most often this sign is observed at the subacute course of an intracranial hematoma. It comes to light and at sharply I develop -
Fig. 3. Kraniogramma 'at a splintered fracture of a skull in frontal area (a side projection): the multiple bone fragments which were implemented into a head cavity are visible.
Fig. 4. Kraniogramma at the closed craniocereberal injury with a left-side intracranial hematoma (a perednezadny projection): the crack of a frontal
bone (I) and calciphied pinus (2) which is displaced from the centerline aside, opposite to an intracranial hematoma are visible.
be sewed to a hematoma, but not earlier than in 3 hours after an injury.
Identification of species and localizations of a fracture of bones of a skull plays a large role in the choice of medical actions for the purpose of the prevention of late complications of open Ch. - m of t. Fractures of base of the skull in the field of a front cranial pole cause usually nasal liquorrhea, changes of pyramids of temporal bones lead to the expiration of cerebrospinal liquid from an ear. However in some cases the expiration of cerebrospinal liquid from a nose arises also owing to a change of a pyramid of a temporal bone in the absence of a fracture of bones of a front cranial pole. Therefore at a nasal or ear liquorrhea, in addition to a radionuclide tsisternografiya, make rentgenol. inspection of both front cranial pole, and pyramids of temporal bones. The clearest idea of a condition of bones of a front cranial pole is given by a X-ray tomographic research in the frontal plane; kraniotomogramma do layer-by-layer, through each 10 mm on depth up to 70 mm (including from a front surface of frontal scales). At absence of damage of a front cranial pole make pictures of pyramids of temporal bones according to Maier, Müller and Stenvers (see. Middle ear).
For diagnosis of the hidden liquorrhea use the radionuclide method based on detection in allocations from a nose or an ear of the radioactive phosphorus which is previously entered into likvorny system by means of a lumbar puncture.
Later complications of Ch. - m of t., such as chronic intracranial hematoma, abscess of a brain, posttraumatic arachnoiditis (see), etc., cannot be authentically found by means of usual rentgenol. methods of a research. Diagnosis of these complications requires use of a cerebral angiography (see), to a pneumoencephalography (see), a computer tomography, a radionuclide encephalography (see) etc.
Resuscitation at a craniocereberal injury
At heavy (opened or closed) Ch. - m of t. the leading role in a wedge, a picture is played by disturbances of neurodynamic processes, to-rye are shown by disorder of consciousness, focal neurologic and all-brain symptomatology, disturbance of the central mechanisms of regulation of the vital functions and systems (breath, blood circulation, exchange mechanisms). They are connected both with a direct injury of a brain, and with secondary heavy disturbances of cerebral circulation, circulation of cerebrospinal liquid, energy and mediator balance of a brain, change of permeability of a blood-brain barrier, edematization of a brain and intracranial hypertensia that, in turn, aggravates primary disturbances of blood circulation, metabolism and functions of a brain.
Resuscitation actions at Ch. - m of t. begin at a pre-hospital stage. They are directed to maintenance of the broken vital functions and the prevention of ischemia and hypoxia of a brain owing to disturbance of passability of respiratory tracts, blood losses. heavy frustration of a hemodynamics. For ensuring adequate gas exchange release respiratory tracts, enter an air duct, carry out an intubation of a trachea (see the Intubation), a tracheostomy (see), inhalation of oxygen air mixture, and if necessary artificial ventilation of the lungs (see. Artificial respiration). At shock (see) blockade nociceptive (sharp, damaging) influences, completion of deficit of volume of the circulating blood, administration of glucocorticoid hormones is necessary. In cases of psychomotor or dvigateldy excitement, convulsive readtion use sedatives or hydroxybutyrate of sodium.
Victims with heavy Ch. - m of t., followed by disorder of consciousness, increase of focal neurologic and all-brain symptomatology, disturbances of the vital functions, hospitalize in intensive care units and an intensive care. In a hospital continue the main actions for normalization of gas exchange, a hemodynamics, exchange processes and apply special methods of the prevention and treatment of wet brain, intracranial hypertensia, disturbances of cerebral circulation and metabolism, means and methods of protection of a brain against ischemia and hypoxia.
The most important condition of adequate, purposeful carrying out an intensive care at heavy Ch. - m of t. overseeing is functional activity of a brain and indicators of its homeostasis, a cut includes, in addition to a dynamic nevrol. observations, periodic or constant (monitor) control of likvorny pressure. Whenever possible carry out an electroencephalography (see) with use of computer methods of the analysis of EEG, registration of the caused biopotentials in response to somatosensory and acoustic stimulation, continuous control of brain perfused pressure, a research of a brain blood-groove. Assessment of processes of metabolism in a brain is carried out on the basis of these biochemical researches of cerebrospinal liquid, the arterial and flowing from a brain venous blood. Use of the specified methods, especially in combination with data of a computer tomography, researches of a brain blood-groove and long control of intracranial pressure, allows to define the reasons of intracranial hypertensia, dynamics of dislocation of a brain, character and prevalence of wet brain, a condition of likvorny spaces and cerebral circulation. Results of these complex researches define the choice of the general and specific means and methods of resuscitation and an intensive care at heavy Ch. - m of t.
During the carrying out medical diagno-sticheskikh manipulations in case of heavy Ch. - m of t., even at the patients who are in coma (see Côme), it is necessary to eliminate nociceptive irritants as they cause sharp increase in a volume brain blood-groove and intracranial pressure, promoting increase of wet brain, its dislocation and the subsequent ischemia.
Management of gas exchange is provided преимуществен^ with artificial ventilation of the lungs in the mode of a hyperventilation (Rso2 25 — 30 mm of mercury., 3,3 — 3,9 kPa) with use of oxygen air mixture, supporting the partial pressure of oxygen 100 mm of mercury are not lower. (13,3 kPa). Use of positive pressure on an exhalation is admissible when it does not cause increase in intracranial pressure above normal amounts — 200 mm w.g. (2 kPa). Management of the central hemodynamics shall be directed to maintenance of the normal ABP and elimination of hypertensia since the last against the background of disturbance of an autoregulyation of a brain blood-groove and permeability of a blood-brain barrier leads to increase of intracranial pressure and wet brain. For improvement of venous outflow from a head cavity position of the patient with the raised head is reasonable. The main actions directed to fight against wet brain and intracranial hypertensia along with management of a hemodynamics and a hyperventilation, include use of glucocorticoid hormones, saluretics and osmotic diuretics. Glucocorticoid hormones, preferential dexamethasone (Dexasonum), begin to apply at a pre-hospital stage (or at arrival of the patient in a hospital). They are entered within a week intravenously in an initial dose 0,2 mg/kg, and then intramusculary in 4 — 6 hours in a daily dose from 0,3 to 0,4 mg/kg. In a crust, time appeared this, testimonial of high performance of high doses of Dexasonum at wet brain, however patients with Ch. have a m of t. their wedge, efficiency it is completely not established. In the first days after an injury appoint lasixum in a dose
of 0,5 — 1 mg/kg. In the next days, in the presence of intracranial hypertensia, enter osmotic diuretics — a mannitol intravenously or glycerin via the probe into a stomach. Repeated use of osmotic diuretics and saluretics is admissible only on condition of careful control and correction of water and electrolytic balance and osmolarity of plasma.
In specialized institutions of a neurosurgical profile as one of methods of treatment of intracranial hypertensia and wet brain use the dosed removal of cerebrospinal liquid by means of long catheterization of side cerebral cavities. When the specified methods do not provide normalization of intracranial pressure, apply barbiturates (sodium thiopental on 2 — 5 mg/kg). Use of barbiturates demands continuous control of the ABP and intracranial pressure. Stabilization of intracranial pressure within one days within normal amounts is the indication for consecutive cancellation of barbiturates, osmotic diuretics and reduction of degree of a hyperventilation. After achievement of normal ventilation of the patient transfer on auxiliary, and then to independent breath.
Clinical and experimental data demonstrate that barbiturates in combination with a moderate hypothermia reduce intracranial pressure more effectively. Limited use of a hypothermia as a method of treatment of wet brain and intracranial hypertensia at Ch. - m of t. it is caused by its side effects (disturbances of a heart rhythm, deterioration in microcirculation, decrease in immunity and
the Intensive care at Ch. - m of t. includes also maintenance of exchange processes with use of enteral and parenteral food, correction of disturbances of acid-base and water and electrolytic balance, normalization osmotic and colloid osmotic pressure, system of a hemostasis, microcirculation and thermal control, prevention and treatment inf. complications. For the purpose of normalization of functional activity of a brain according to indications appoint psychotropic drugs, including nootropic means, predecessors of neurotransmitters idr.
Mental disturbances at che - a turnip and brain injury
the Nature of mental disturbances is defined by a form Ch. - m of t. (concussion, bruise of a brain, prelum of a brain), degree of its weight, localization of injury of a brain, and also simultaneous defeat of other bodies, blood loss, accession of an infection, age of the victim, etc.
Mental disturbances at Ch. - m of t. take the second place among the mental disorders caused by the external (exogenous) reasons. Distinguish mental disorders of the acute period of Ch. - m of t. and period of the remote effects. In the acute period of Ch. - m of t. mental disturbances are characterized by the maximum expressiveness. Further, if there are no complications, usually there is a regress patol. symptoms also there occurs recovery; otherwise in the remote period of Ch. - m of t. the resistant residual phenomena form.
In the acute period of the closed and open Ch. - m of t. there are distinctions in the nature of mental disturbances, to - ry it is necessary to consider during the carrying out to lay down. actions. In the remote period these distinctions smooth out, at the same time mental disorders and changes of the identity of patients are defined preferential by severity of the postponed damage of a brain.
At the closed Ch. - m of t. in the acute period disturbances of consciousness of various depth and duration — from devocalization (see) to a coma are in most cases observed (see). Extent of disturbance of consciousness, duration of the period of transition to clear consciousness, periodic motive excitement are one of criteria of weight of Ch. - m of t. and conditions of the patient. In the acute period of various forms Ch. - m of t. often there is amnesia (see), usually retrograde, extending only to circumstances Ch. - m of t. or for the days, weeks, months or even years preceding it more rare, in hard cases antero-retrograde or retardirovanny amnesia can develop, edges it is more often observed in Ch.'s cases - m of t. against the background of a drunkenness. In the acute period of Ch. - m of t. the adynamy is always noted (see. An asthenic syndrome) with the expressed adynamia. Duration of similar mental disturbances in the acute period of the closed Ch. - m of t. it is variable and fluctuates depending on its weight from several hours to several weeks and more.
In the acute period of Ch. - m of t. psychoses can develop. Usually they arise in the first days or in the first 1V2 weeks, sometimes 1 month later and more after an injury (is more often after a heavy bruise of a brain). Twilight states are observed (see. Twilight stupefaction), a delirious syndrome (see), seldom oneiric syndrome (see). The twilight state can repeatedly arise. The Korsakovsky syndrome (see) at Ch. - m of t. develops or at once, or several days later after disappearance of symptoms of devocalization. Development of a korsakovsky syndrome is preceded in the latter case by a delirium or twilight stupefaction. In the acute period the korsakovsky syndrome can be followed by the phenomena of the changed consciousness — in the afternoon patients remind got drunk (Rausch - simp - volume), there are not developed delirious frustration at night. This type of mental disturbances can proceed from several weeks to several months.
After the deep and prolonged coma at heavy Ch. - m of t. there can be an apallichesky syndrome (see). The akinetic mutism (see the Speech) can be a stage of regression of an apallichesky syndrome. In other cases the akinetic mutism develops right after disappearance of a coma. At an akinetic mutism patients lie not movably, with open eyes, the look is comprehended, the movements of eyes are kept. The patient is capable to monitor actions of the doctor, however does not react to the speech turned to it either the word, or a mimicry, or the movement. As the outcome of an akinetic mutism quite often arises a psychoorganic syndrome (see) various expressiveness with dominance of psychomotor block and lack of motives.
At easy Ch. - m of t. and a moderately severe injury affective psychoses can develop. The lowered mood is shown usually by a dysphoria (see), in some cases with twilight stupefaction. Alarming depressions with morbid depression are quite often observed (see. Depressive syndromes). Hypomaniacal and maniacal states are sometimes noted (see. Maniacal syndromes), combined with unproductive motive excitement, silliness or, on the contrary, slackness and lack of motives against the background of easy change of consciousness. There can be maniacal states with incoherent speech and motive excitement, sketchy nonsense and unstable hallucinations (see), and also psychoses with figurative nonsense (see). Psychoses proceed several days or weeks and are replaced by an adynamy.
At different forms Ch. - m of t. varying severity paroxysmal states are observed. Epileptiform attacks prevail various on duration (several seconds or minutes) and to manifestations (quite often partial and abortal) (see. Epileptiform syndrome). Attacks happen single and multiple, up to development of the epileptic status. Paroxysms of frustration of a body scheme (see), the states reminding the prolonged absentias epileptica (full switching off of consciousness for 1 — 2 min. with an obezdvizhennost and amnesia), short-term are noted (several seconds or minutes) conditions of ecstasy with feeling of flight, bystry movement and detachment from surrounding, to-rye it is possible to carry to special states (see Epilepsy, mental disorders).
At open Ch. - m of t. with injury of a brain to the acute period the deep oglushennost most often develops. sopor and coma. At gradual weakening of an oglushennost periodically there are conditions of chaotic motive excitement. After end of the acute period focal nevrol. symptoms (paralyzes, paresis, aphasia, etc.) prevail over mental. There comes the sharp adynamy.
The period of reconvalescence proceeds of 1 — 2 month dabout 1 years. During this time gradually all smooth out patol. symptoms and at considerable number of patients there occurs recovery. In more hard cases the adynamy, paroxysmal disturbances, various manifestations of a psychoorganic syndrome prevail, occasionally there are twilight states.
At mental disturbances in the period of the remote effects of a craniocereberal injury, according to Yu. Ya. Buntov, etc. (1971), Yu. D. Arbatskoy (1975), the most frequent symptom observed at 62,4 — 64,8% of patients during the entire period of the remote effects of Ch. - m of t., the traumatic adynamy is (traumatic encephalopathy with an asthenic syndrome). All other mental disorders arise against the background of an adynamy. The adynamy with irritability and an exhaustion is characteristic; dominance of irritability testifies to less expressed adynamy. Vegetative frustration, complaints to headaches and dizzinesses, absent-mindedness, forgetfulness, inability to concentrate are constantly observed, sleep disorders are often noted. Overfatigue, differences of barometric pressure, high temperature of the environment, etc., and also negative mental impacts worsen a condition of patients. At a traumatic adynamy with apathy (traumatic encephalopathy with apathy) the raised exhaustion, slackness, the general slowness, falloff of motives prevail; interests of the patient are limited to hl. obr. questions of life.
Psychopatholike frustration (traumatic encephalopathy from the psikhopatizatsiy personality) are most often shown by hysterical lines, explosiveness (a hyperexcitability, an explosibility), and also their combination. Easy Ch. - m of t. and moderately severe injuries at teenage and youthful age to a thicket lead to emergence of hysterical lines; at heavy Ch. - m of t. and moderately severe injuries, especially at persons of mature age, explosiveness prevails.
Paroxysmal frustration and conditions of the changed consciousness (traumatic epilepsy, traumatic encephalopathy with epileg a tiformny syndrome) in the period of the remote effects of Ch. - m of t. (open and heavy) differ in polymorphism. Both big convulsive attacks, and the partial jacksonian attacks (developed and abortal) are observed. Much more often paroxysms are registered convulsiveless (or with the minimum convulsive component): small attacks, absentias epileptica, snopodobny states, kataplek-the sichesky paroxysms and so-called epileptic dreams, frustration of a body scheme, paroxysms of convulsive and vegetative frustration accompanied with rudimentary tonic spasms (mesodiencephalic attacks) or without convulsive component (diencephalic attacks), a dysphoria. From conditions of the dulled consciousness twilight conditions of various structure prevail.
In the remote period of Ch. - m of t. there are mental disorders — the so-called endoformny psychoses reminding on the wedge, to manifestations maniac-depressive psychosis and schizophrenia. They develop preferential at persons of middle and mature age, is more often 10 — 20 years later after the postponed Ch. - m of t.
Easy Ch.' investigation - m of t. or moderately severe injuries in the remote period there are affective psychoses, to-rye in most cases occur at women. Maniacal attacks are observed more often than depressive and happen heavier. Monopolar and
bipolar types of affective attacks are noted (see. Maniac-depressive psychosis). Monopolar attacks, it is especially frequent at maniacal states, are followed by twilight stupefaction or a delirium. Attacks of a depression are usually combined with morbid depression, alarm and agitation; more slight depressions — with hysterical symptoms. Duration of attacks is 1 — 4 month. A current of attacks as «cliche» with gradual simplification of symptoms. Maniacal attacks proceed with changeable affect: the increased mood
easily is replaced by irritation, faintheartedness, silliness, anger. At stupefaction there is divagation, in-coordinate motive excitement (it is frequent with stereotypic actions), sketchy figurative nonsense. Duration to a prist
of p of 1 — 6 month. A current of attacks as «cliche». At persons 50 years the period of attacks quite often more long are more senior, the frustration inherent
to a konfabulyatorny paraphrenia appear (see P arafrenny syndrome), decrease in memory accrues. In the remote period after Ch. - m of t. moderately severe and severe injuries at men hallucinatory-dilision psychoses meet more often. Psychosis usually begins with twilight or delirious stupefaction, in structure to-rogo always exists verbal
ny hallucinosis (see Hallucinations). At repeated attacks verbal hallucinosis can be combined with nonsense. Sometimes there are separate components of ideatorny automatism, first of all acoustical pseudohallucinations (see Kandinsky — Klerambo a syndrome). Duration of attacks is various (several months, 1 year and more). In one cases repeated attacks can become simpler, in others — the pristupoobrazny course of hallucinatory-dilision psychosis is replaced chronic, sometimes with development of a hallucinatory paraphrenia. Organic changes of mental functions can reach degree of dis-mnestichesky weak-mindedness (see).
Paranoiac states and paranoiac psychoses are most often shown supervaluable (see. The supervaluable ideas) and crazy jealousy, long reactions of barratry (see Psychopathies) or litigious nonsense. The crazy jealousy is inherent preferential to men; the litigious behavior, especially in the form of reactions, meets at women more often.
Traumatic weak-mindedness makes 3 — 5% among mental disorders of the remote period of a craniocereberal injury. It develops after open Ch. more often - m of t. and heavy bruises of a brain with fractures of base of the skull. In some cases weak-mindedness happens a final state at traumatic psychoses or Ch. - m of t develops in connection with repeated., the joined vascular process in a brain, alcoholism. Dismnestiche-sky weak-mindedness, occasionally globarny is usually observed. In one cases at weak-mindedness weakness of motives, slackness, an aspontannost in combination with an adynamy prevails, in others — the complacent and careless mood, revaluation of the opportunities, importunity, disinhibition of inclinations, i.e. pseudoparalytic weak-mindedness dominates.
At correctly collected anamnesis and assessment of severity of Ch. - m of t. the diagnosis of mental disorders during various periods of Ch. - m of t. comes easy. However endo-formny psychoses of the remote period of Ch. - m of t. it is necessary to differentiate with schizophrenia (see) and maniac-depressive psychosis (see).
At medium-weight and heavy Ch. - m of t., complicated in the acute period by psychosis, duration of hospitalization increases and defined by features of regress a wedge, symptoms. In the acute period of Ch. - m of t., in addition to special treatment, at the psychomotor excitement connected, in particular, with conditions of the dulled consciousness parenterally enter aminazine, Seduxenum, a haloperidol. At affective and crazy psychoses use antidepressants (see) and neuroleptics (see Neuroleptics). Apply anticonvulsants to treatment of paroxysmal frustration (see). During subsiding of the acute phenomena carry out fortifying therapy. From psychotropic drugs appoint tranquilizers (see), neuleptil (at an acrimony), nootropic means (see), napr, piracetam, Encephabolum.
In the remote period of asthenic and psychopatholike states conduct a course (1 — 2 time a year, is sometimes more often) fortifying and dehydrational therapy. At sleep disorders appoint hypnotic drugs of not barbituric row — uradal, eu-noktin, Radedormum. At dominance of slackness and apathy after a course of fortifying treatment apply stimulating and tonics — small doses of Sydnocarbum, tincture of a magnolia vine, ginseng. In case of the expressed vegetovascular disturbances use Seduxenum, Phenazepamum.
At treatment of endoformny psychoses the same psychotropic drugs are shown, as at treatment of schizophrenia (see) and maniac-depressive psychosis (see). In the remote period of Ch. - m of t. treatment shall include nootropic drugs.
The forecast of mental disorders at Ch. - m of t. both in ostrokhm, and in the remote period considerably worsens the previous or joined alcoholism.
Prevention of mental disturbances consists in systematic treatment of Ch. - m of t. and stimulations of social activity of patients, in a cut the main place belongs to work corresponding to interests of the patient and his professional opportunities.
Features of a craniocereberal injury at children
of the Injury of a skull and brain at children are an important medikosotsialny problem since often result in disability. Even the easy concussion of the brain can affect all subsequent period of development of the child. At the same time at children thanks to high compensatory opportunities of an organism more often than at adults, the favorable outcome even by heavy Ch. - m of t is observed.
The most frequent Ch. - m of t. at children home accidents are, behind them on frequency there are Ch. - m of t. as a result of the road accidents. The heads are traumatized children aged from 3 up to 7 years more often. To three-year age Ch.'s frequency - m of t. at boys and girls it is approximately identical, and 3 years are aged more senior the frequency of such injuries at boys increases.
At Ch. - m of t. at children much more often than adults, have injuries of bones of a skull. It is connected with absence in bones of a skull at early children's age diploichesko-go (spongy) layer. Fractures of bones of a skull at children of early age can result from easy falling and proceed asymptomatically. These are preferential linear changes, the pressed splintered and concave one-fragmentary changes are slightly more rare. The parietal bone is more often injured. Linear changes can pass through lines of seams of a skull (see the Skull), extending to adjacent bones, to have considerable extent. Less often the line of a change passes from the arch to a base of skull. The isolated fractures of base of the skull arise only at children of advanced age.
Idiosyncrasy of fractures of bones of a skull at children of early age is expansion of the line of a change on 2 — the 3rd days after an injury that is connected with increase in intracranial pressure, elasticity and a pliability of thin bones of a skull of the child, and also formation of defect of a bone tissue in the place of the former fracture of bone in 5 — 6 weeks after an injury of the head (the «growing» changes). Formation of defects of a bone is promoted a rupture of a firm cover of a brain in the place of a fracture of skull and damage of tissue of brain, to-rye complicate processes of regeneration of a bone, cause trophic disturbances in the field of a change and gradual increase in bone defect. In the absence of the factors complicating a change the complete recovery of structure of bones of a skull at children occurs in 1 — 2 years after an injury.
Children of chest age have bones of a calvaria very thin and practically do not protect a brain even at a slight injury of the head. Despite it, a wedge, symptomatology of focal damage of a brain at Ch. - m of t. can be absent or be poorly expressed. This feature of a current of Ch. - m of t. it is connected with imperfection of structure and insufficient differentiation of cortical functions of a brain at this age, and also with existence of fontanels, mobility of bones of a skull, etc.
Children of early age have an expressed disorder of consciousness as the main symptom of Ch. - m of t. note seldom. Moderate devocalization, slackness, drowsiness, sometimes with the periods of motive concern, vomiting, sometimes repeated is more often observed. Only at a bruise of a brain of average and heavy degree against the background of all-brain symptoms comes to light focal nevrol. symptomatology — asymmetry of reflexes, a spontaneous nystagmus (see), an unstable ayizokoriya (see), oculomotor disturbances. Children at Ch. have a m of t. seldom there is bradycardia, tachycardia against the background of decrease in systolic pressure is more often observed. Bystry dynamics nevrol is characteristic. symptoms and disturbances of the vital functions.
At early children's age falling of the child even from small height can cause formation of an intracranial hematoma (see Lodobo-lochechny hemorrhages), is preferential on the party of blow. Subdural and enidural-ny hematomas, extremely seldom intracerebral are observed. Epidural hematomas arise at children up to 5 years more often and happen the investigation of a rupture of emissarny veins or break of veins of a firm cover of a brain without disturbance of an integrity of bones of a skull.
Diagnosis of intracranial hematomas at children, especially early age, is complicated. This results from the fact that in these cases often there is no loss of consciousness, quite often directly after an injury excitement or drowsiness are observed. Sometimes after an injury the so-called light interval lasting several hours, sometimes 2 — 3 days takes place, later to-rogo symptoms of an intracranial hematoma can be shown. At the same time the condition of the child quickly worsens, disturbance of consciousness goes deep and passes into a coma with disorder of the vital functions. Along with the progressing disturbance of consciousness sometimes appears focal nevrol. symptomatology — asymmetry of tendon jerks, partial spasms, an anisocoria, etc. At children till 1 year development of hemorrhagic shock is possible (see) as main manifestation of intracraneal hemorrhage.
For diagnosis of intracranial hematomas and assessment of weight of Ch. - m of t. at children, in addition to a wedge, observations, additional diagnostic testings are necessary. Essential help in it is given by a computer tomography. The combination of focal symptomatology to the shift of median structures of a brain revealed with the help ekhoentsefa-lo of a raffia (see) can also testify to an intracranial hematoma. The electroencephalography allows to localize the center of a bruise or a prelum of a brain, and also to define a functional condition of a cerebral cortex in general that important in the predictive relation.
At the closed Ch. - m of t. at children conservative treatment is in most cases shown. But even when an operative measure is necessary (existence of a depressed fracture, an intracranial hematoma, etc.), complex treatment should be begun as soon as possible. To lay down. actions are directed to fight against shock, a hypoxia of a brain (see the Hypoxia), increase in intracranial pressure (see. Hypertensive syndrome), hypostasis and swelling of a brain (see), on normalization of function of breath, blood circulation, cordial activity, prevention of infections. Children at Ch. have a m of t. often wet brain develops, but it is possible to apply dehydrational means (see Degidr atatsionny therapy) only under control of osmolarity of plasma, volume of the circulating blood, loudspeakers of acid-base equilibrium, water and electrolytic balance since dehydration of an organism and acidosis lead to weighting of a condition of the patient.
At the solution of a question of operational treatment it is necessary to consider ana-tomo-fizio logical features of the growing organism (see the Baby, the Newborn). At linear and depressed fractures the firm cover of a brain is quite often damaged. In these cases make its sewing up or plastic closing of defect (see the Meninx). During operation in connection with a possibility of an osteanagenesis keep all bone fragments, give them the correct situation, connecting them silk seams or sticking together medical glue. Concave changes at children of early age correct from the frezevy opening imposed at edge of impression.
The forecast at the children who transferred Ch. - m of t., serious. In the remote period the delay of intellectual development, lag in physical development, emergence of epileptiform attacks, neurosis, disturbance of vegetative functions (see above Mental disturbances are possible at a cherepnomozgovy injury), development of hydrocephaly (see),
Medicolegal aspects of a craniocereberal injury
Court. - medical examination of Ch. - m of t. make for the purpose of establishment of nature of injuries at victims and a cause of death. In tasks court. - medical examinations definition on features of the put damages of a subject (the tool, weapon), the Crimea pr entersCh.'s ichinena - m of t., a way of injuring, the mechanism of the damage, a place of application of force and time which passed after getting injured and also qualification of severity of injuries, specification of a causal relationship of death or disorder of health with the mechanical influence which entailed Ch. - m of t.
In court. - medical practice distinguish Ch. - m of t., the put blunt firm objects, tools having a keen edge or the end, and the injuries caused by firearms (see). This division is connected with need of establishment of an origin of an injury on character and features of damages of soft covers, bones of a skull and tissue of a brain.
In court. - medical practice Ch. - m of t most often meet., put with firm blunt objects. Parts of the moving vehicle, a part of a body of the person (a fist, a leg), any solid surface belong to such objects, during the falling on to-ruyu there is Ch. - m of t. Methods of experimental modeling of Ch. - m of t. on biodummies and mathematical modeling allowed to establish that an important factor in the mechanism of this type of Ch. - m of t. local and general distortion of bones of a skull of the victim and forces of tension, removal and stretching arising at the same time in them is. Certain consistent patterns between the size of force of blow and the arising damages are determined. According to
V. N. Kryukov (see t. 25, additional materials), the extreme force of blow, at a cut there are craniocereberal damages, varies from 160 to 800 kgfs. It is explained by influence on the size of force of a number of factors, from to-rykh allocate the impact speed of the head with a blunt object, strength properties of a subject, its area and a form, thickness of a bone of a skull and its curvature in a place of application of force, an anatomic form and the sizes of a skull, weight (weight), growth and age of the victim, etc.
At Ch.'s examination - m of t. it is important to determine the fact of striking a blow on the motionless head or on the head which was in the movement at its sharp stop motionless or rather mobile subject (e.g., during the falling on any plane or at a transport injury). Craniocereberal damages during the falling on the plane are fullestly studied, At this mechanism of an injury a certain interrelation of character and extent of injuries of a skull and brain with growth and weight (weight) of the victim, a shape of a skull, a place of application of force, existence or lack of a headdress, rigidity of a surface of collision, etc. is revealed.
At repeated traumatization of a skull court. - medical examination of Ch. - m of t. becomes complicated. In this case establish the sequence of emergence of damages.
H - m of t., put with sharp objects (tools), meets less often and has rather characteristic morfol. signs. Determine species and group characters of the damaging tool by features of injury of hair, the nature of skin wounds and injuries of bones of a skull (cutting, cutting, kolyushche-cutting, pricking), and in some cases by a research of features of a relief of the injured bone reveal signs of a specific subject, the Crimea damage is put. For definition of the group and individual characteristic of the damaging blunt and sharp objects use also trasological research, special sledoobrazuyushchy masses, various devices and tekhnol. devices.
Refer both damages by a shell (bullet), and damage owing to explosion to gunshot wounds (ammunition, explosive substances, etc.). The shape, character and features of fire injuries of the head are defined by a motive energy and a type of a shell (bullet). Are developed morfol. the signs allowing to diagnose bullet, shot and fragmental damages of tissues of the head. So-called disturbing factors of a shot, a research have important diagnostic value to-rykh demands use of a complex of special physics and technology methods (see Firearms).
At Ch.'s examination - m of t. any origin quite often there is a need of definition of time which passed after injuring. The conclusion is based on results of a morphological research of a brain and soft covers of a skull with assessment of a pathoanatomical picture and features of its dynamics in the acute period of an injury.
One of the most frequent tasks court. - medical examinations of Ch. - m of t. definition of severity of injuries is. As the management to conducting examination serve the existing «Rules of medicolegal definition of severity of injuries» and the methodical recommendations published by the main thing court. - medical expert of M3 of the USSR. Accepted a wedge, Ch.'s division - m of t. on closed and opened and the combined craniocereberal defeats it is used at court. - medical assessment of a complex of the questions connected with treatment of the victim, his death in a hospital in need of checking of medicolegal and clinical diagnoses.
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