Technique of primary surgical treatment of wounds of the cranial vault. Wound on the head: types and features of treatment Primary surgical treatment of head wounds
Primary surgical treatment of soft tissue wounds of the head is a surgical intervention, the task of which is to excise tissues, disinfect them and prevent bleeding.
If there are blood clots or any foreign bodies in the wound, they require immediate removal, as they can cause suppuration and further development of the inflammatory process. The main goal of PHO is to direct all actions towards the prevention of infection and create the maximum good conditions for healing. Damaged soft tissues are often accompanied by profuse bleeding, which may require suturing of a skin flap to combat it.
Indications for primary surgical treatment
After a wound, microorganisms almost always enter the affected area, in this case we are not talking about aseptic surgical wounds. Any such wound must undergo PST, the only exceptions are:
- shallow wounds of small localization;
- numerous cut-stab wounds, if there are no hematomas around them.
The main indications for primary surgical treatment are:
- Wounds characterized by prolonged bleeding and a wide area of damage;
- Scalped type wounds;
- Lacerations and bruises, in which there was a stratification of soft tissues and an accumulation of blood formed, as well as abundant wound fluid and a necrotic process is born;
- Purulent wounds of a strong degree of infection.
For some reason, doctors consider it necessary to postpone PST for some time, if such a decision was made, then the patient is credited with taking potent antibiotics. However, with progressive severe pain, fever and excessive swelling, late PST is urgently performed.
Technique for PST of soft tissue wounds of the head
Preparatory measures for PHO include general antibiotic treatment and anti-tetanus medication. Since the injury may occur as a result of an animal bite, the patient will need a vaccination aimed at preventing rabies.
The choice of method of anesthesia varies and depends on the extent of the localization of the wound. For minor lesions of the soft tissues of the head, one local anesthesia is sufficient, and for deep wounds with purulent inflammation, general anesthesia is required.
It is important to observe not only all the stages of the primary surgical treatment, but also to create conditions that can ensure 100% sterility.
The stages of PHO are as follows:
- Excision of the skin edges. It must be of high quality and clear, if necessary, all affected and dead tissues are removed, because they are no longer able to function.
- Dissection of the aponeurosis. To do this, a zigzag incision is made, after the completion of the surgical intervention, it will not compress the soft tissues.
- Removal foreign bodies from the wound. The edges of the defective area are bred and the necrotic area is excised, removing all foreign elements that have previously entered the wound. It is possible to determine that the tissue has already become dead by bleeding, it will be absent, as well as by the functioning of the muscular system. In necrotic tissues, there is no muscle contraction and proper elasticity. It is rather difficult to diagnose the state of tissues during primary surgical treatment, because it is impossible to independently monitor changes in the cellular level, and at first they may be invisible. Only delayed and late PST can determine the level of necrosis.
- Stop bleeding. If at this stage nerve or vascular trunks were seen, then they are pushed aside with a non-sharp hook. Also, some cases force ligation of vessels or further suturing.
- Inspection of the bottom of the wound. This stage is extremely important, since the bones of the skull, among other things, can be damaged. It is best to cover the exposed bone area with intact muscle tissue, fixing it with stitching (sparse stitches). This action cannot be carried out on all soft tissues, because the scalp muscles are located on the upper part of the skull. With such wounds, the bones of the skull are protected by the adjacent edges of the tendon helmet.
- Irrigation with antibiotics. They are sprayed not only on the entire surface of the wound, but also on its walls.
- Suturing and suturing of the lost skin flap. If this is absent, then a flap is used from other parts of the patient's body, because with extensive localization, complete tissue regeneration will not occur.
- Drainage. Often, vacuum devices are used to aspirate the wound discharge and the wound is washed with an antiseptic solution.
To determine the scale and complexity of the work, it is necessary to carefully analyze the condition of the wound. The size and type of the defective area affects the specifics of the PST, consider the following nuances:
- Large wounds do not need additional dissection, therefore, during PST, it is enough to push their edges apart.
- Wounds resulting from a bruise are subjected to both the procedure of dissection and excision.
- Stab and incised wounds with hematomas and profuse bleeding are first dissected, and then the blood is stopped. In most cases, excision is not performed for them.
- In case of local wounds and the complex structure of the wound channel, the wound is first dissected, all necrotic material is removed, providing access for drainage with additional incisions.
Contraindications to primary surgical treatment
It is strictly forbidden to carry out PST of head wounds in case of extremely complex clinical pictures and also if the patient is in a state of shock. This procedure can be carried out later, when the condition stabilizes a little and specialists will conduct anti-shock therapy.
Complications of a controversial nature include those that require careful analysis, comparison of positive and negative sides. Here, an example of injuries to the facial region will become relevant, PST can be canceled due to cosmetic consequences, but if there is a threat of serious infection, then the primary surgical treatment is still carried out.
Complications in PST of soft tissue wounds of the head
The main problem of the postoperative stage, which leads to complications, is caused by incorrect medical actions. If surgeons make a mistake at one of the stages of its implementation, then re-bleeding is possible, and this already becomes a reason for unscheduled PST. With excessive tissue excision, the defectiveness of the operated area will become pronounced for others even after complete healing. Suppuration also occurs, they appear due to an erroneous revision of the wound and insufficient dissection.
When examining a patient with a head wound, it is extremely important to determine: 1) its depth, 2) the presence of damaged arterial vessels in the wound, 3) the presence or absence of damage to the bones of the cranial vault. The obtained data determine the surgical tactics. The presence or absence of bone lesions is extremely important to clarify not only when examining the wound, but also using X-ray of the skull and computed tomography of the head.
With superficial non-bleeding wounds are washed with hydrogen peroxide, the edges are treated with iodine solution and an aseptic dressing is applied.
For deep wounds without damaging the bones of the skull or bleeding heavily, the hair on the head is shaved around the operation area. The wound is chipped with a solution of novocaine, preferably with an antibiotic. The wound cavity is washed with a solution of hydrogen peroxide. Bleeding arterial vessels are coagulated or stitched with Z-shaped sutures. The edges of the wounds, if possible, are not excised, only obviously non-viable crushed tissues are removed. Interrupted sutures are applied through all layers (skin, subcutaneous tissue, aponeurosis). Injection and puncture of the needle at a distance of 1 cm from the edges of the wound, the distance between the sutures is 1.5-2 cm.
Wounds in the frontal region anterior to the hairline for a better cosmetic effect are sutured in two layers: the first line of sutures is on the frontal muscle, the second is a continuous intradermal suture.
Surgical anatomy of the facial and trigeminal nerve. Incision for purulent mumps.
Surgical anatomy of the facial nerve
facial nerve mixed. The motor part starts from the nucleus of the facial nerve in the pons Varolii. The cells of the motor nucleus have numerous sensory collaterals coming from the sensory nuclei of the trigeminal nerve. Sensory (gustatory) fibers of the facial nerve are peripheral processes of pseudo-unipolar cells of the geniculate ganglion located in the canal of the facial nerve. Οʜᴎ are part of the sensory pathways related to the system of the intermediate nerve. The axons of the geniculate ganglion cells enter the pons Varolii and end in the nucleus of a single bundle. The dendrites of the cells of the geniculate node form the largest branch of the string tympani, which exits through the awl-mastoid fissure and merges with the lingual nerve. The drum string carries out gustatory innervation of the anterior 2/3 of the half of the tongue of the same name. Upon exiting the fissure, the facial nerve splits into a number of small branches, which anastomose abundantly with the branches of the trigeminal nerve.
Primary surgical treatment of head wounds. - concept and types. Classification and features of the category "Primary surgical treatment of head wounds." 2017, 2018.
All wounds of the skull are divided into: 1) non-penetrating (the dura mater is not damaged) and 2) penetrating (the dura mater is damaged).
The wounded with craniocerebral injuries are subject to active primary surgical treatment as soon as possible after the injury. In some cases, primary surgical treatment can be performed later, on the 2-3rd day after the injury. A contraindication to surgery is an extremely severe brain injury with extensive destruction of the medulla and injury to large blood vessels, as well as the development of shock in the wounded.
Preliminary X-ray examination of the victim allows you to determine the presence, size and localization of foreign bodies, the extent of bone damage.
Anesthesia. Typically, local infiltration anesthesia is used with a 0.25-0.5% novocaine solution. The use of anesthesia is indicated with a sharp excitation of the wounded. Modern types of anesthesia are widely used in this area.
Operation technique. Shave the hair on the head of the patient and gently wash the head with warm water and soap, or wipe the skin with a solution ammonia. In case of severe contamination, the skin around the wound is cleaned with gasoline or alcohol, and then treated with iodine.
The edges of the wound of the soft integument of the skull are excised in layers to a width of 0.3-0.5 cm with a fringing or arcuate incision, taking into account the location and direction of the main vessels and nerves. The periosteum should be preserved if it and the underlying bone are intact. With significant bone exposure, osteomyelitis can develop. All non-viable areas of damaged soft tissues, blood clots, foreign bodies are removed from the wound. The wound is washed from a rubber balloon with a 3% hydrogen peroxide solution or antiseptic solutions (furatsilin, rivanol). In case of comminuted and crushed fractures, freely lying bone fragments are carefully removed. Bone fragments associated with the periosteum should not be removed. Bone defect is expanded with nippers to the right sizes, the edges are aligned.
When the middle meningeal artery is injured, both of its ends are cut off with a sharp round needle and bandaged.
Linear wounds of the upper wall of the venous sinus of the dura mater are sutured with interrupted sutures. If it is not possible to suture the wound, bleeding is stopped using a hemostatic sponge or by tamponade with a piece of muscle. A piece of muscle is cut out in the area of the surgical wound, crushed with scissors and pressed to the bleeding site with a wet gauze ball. When finger pressure on a piece of muscle fails, the muscle is sutured to the dura mater with several interrupted silk sutures or inserted into the sinus lumen. With significant damage to the venous sinus, it is squeezed with long gauze tapes that are inserted between the bone and the dura mater on both sides of the sinus injury site.
With extensive destruction of the wall and complete rupture of the sinus, the surgeon is forced to bandage it. Having stopped severe bleeding by pressing with a finger or gauze tamponade, the burr hole is expanded to the required size. With the help of a large round needle, which should pass under the base of the sinus, strong silk ligatures are passed in front and behind the injury site and tied up. It is also necessary to tie off all the veins that flow along the damaged area of the sinus, otherwise the bleeding may continue. Ligation of the posterior sections of the longitudinal sinus or transverse sinuses sharply disrupts the venous outflow, and in the area of the confluence of the sinuses it always ends in death (L. V. Abrakov).
When the dura mater is not damaged and there is no subdural hematoma, the membrane is not dissected, since an unjustified incision of it turns a non-penetrating wound into a penetrating one and deprives the brain of its natural defense against secondary infection. If the dura mater is tense, does not pulsate, and a hematoma shines through it, then first you need to try to suck the hematoma through the needle into the syringe. This can be done before the blood has clotted. Otherwise, it is necessary to cut the dura mater with a linear or cruciform incision. Clotted blood is washed off with a stream of saline or carefully removed with a gauze ball. The bleeding vessel is tied up or coagulated. The dura mater is sutured tightly. In case of penetrating wounds, embedded bone fragments are carefully removed from the defect of the dura mater. The edges of the dural defect are excised very sparingly. Sometimes it is dissected with additional incisions for better access to the brain wound.
The wound channel is emptied, increasing intracranial pressure, for which the victim is offered to cough or strain, and in case of loss of consciousness, the jugular veins are squeezed by the patient. These methods are best combined with washing the wound channel with a stream of warm saline from a rubber balloon.
To detect bone fragments or other foreign bodies in the depth of the wound, very careful probing of the wound with a light bellied probe or fingertip is acceptable. Following this, narrow brain spatulas are carefully introduced into the brain wound, with which it is expanded until it becomes possible to grab a bone fragment with tweezers or a clamp and remove it. Attempts to remove a foreign body with tweezers or a finger blindly are unacceptable.
Hemostasis with moderate bleeding is carried out with strips of gauze with a solution of hydrogen peroxide or a hemostatic sponge. Severe bleeding requires finding the damaged blood vessel, coagulation or clamping it with clips.
The dura can be sutured with silk interrupted sutures or continuous suture. In case of large defects, the membranes are plasticized using a fibrin film or in another way. Silk sutures are applied to the skin, rubber graduates are introduced into the corners of the wound for 1-2 days.
Closure of a skull defect. Elimination of the soft tissue defect of the cranial vault is carried out according to general rules skin plasty. The closure of a bone defect has its own characteristics, arising in connection with a sharply reduced ability of the bones of the gadfly of the skull to regenerate. Having lost a piece of bone, the body is not able to replenish it on its own. This has given rise to a number of ways to eliminate the defect that has arisen.
Autoplasty with a portion of the cortical bone adjacent to the defect. The edges of the bone defect are refreshed. On the vault of the skull, the periosteum is dissected and a flap is cut out nearby so that its leg is as close as possible to the defect. The chisel knocks down the outer plate of the bone adjacent to the cut out flap of the periosteum. This step of the operation is relatively easy, as the tool follows the diploe. The unfolded periosteal-osseous plate is moved to the bone defect and fixed with rare sutures to the periosteum. The skin flap is sutured into place.
Autoplasty using a free bone graft (according to V. I. Dobrotvorsky). A piece of the rib of the desired length is resected while maintaining the periosteum on its outer surface (see Fig. 96). To do this, the periosteum is dissected with incisions following the edges of the rib and going across in the bite zones. In this area, the rib is released from the periosteum on the inner surface with a raspator. A section of the rib is bitten out. At a thick rib, the inner surface can be bitten off or sawed off. The bone defect of the skull is freed from scar tissue, the rib plate is placed in the defect with the periosteum outward. For the ends of the ribs, correspondingly sized recesses are created at the edges of the defect with a temporarily displaced periosteum. The bone graft is fixed into place through the periosteum with catgut sutures. The wound is sewn up tightly.
Currently, to close the defect of the skull, plates made of quickly hardening plastic - styracryl are used. Excised scars, align the edges of the bone defect. From plastic at the operating table, a plate of the appropriate shape and size is prepared, taking into account the curvature of the bones of the cranial vault. The plate is strengthened with sutures, the wound is sutured.
Features of the arteries involved in the blood supply to the soft tissues of the cranial vault
Only ten arteries supply blood to the soft tissues of the head. They make up three groups:
1. front group- aa. supraorbitalis, supratrochlearis from the system a. carotica interna;
2. side group- a. temporalis superficialis and a. auricularis posterior from a. carotica externa;
3. rear group- a. occipitalis from a. carotica externa.
All arteries involved in the blood supply to the soft integument of the skull, widely anastomose with each other on both sides. In this regard, with injuries of the soft tissues of the cranial vault, clamping the artery trunk does not lead to a complete stop of bleeding. On the other hand, a good arterial blood supply to the soft integuments of the head leads to rapid healing of wounds. The blood vessels of the regions are located in the subcutaneous tissue and are directed radially from the base to the crown, as to the center. Vessels with their adventitia are connected with fibrous fibers and gape when injured, which leads to profuse bleeding. Venous system of the cranial vault
The venous system of the cranial vault is well developed and is located in three floors.
1. Ground floor- represented by the saphenous veins of the head, which accompany the arteries of the same name. The venous outflow from them is made into the internal jugular vein and, in particular, into the facial and mandibular veins, as well as into the external jugular vein.
2. Second floor- diploetic veins, which are located in the spongy substance of the flat bones of the skull. Until the sutures are completely ossified, the diploetic veins are weakly expressed and limited to the limits of one bone.
3. Third floor- represented by intracranial venous sinuses of the hard shell of the brain.
All three floors are interconnected by emissary veins. The largest emissary veins, located in the occipital, parietal and mastoid regions, pass through small holes in the bones. With the development of suppurative processes in the head area, there is a danger of involvement in inflammatory process subcutaneous tissue veins. This leads to their septic thrombosis and retrograde flow of infected blood to the sinuses of the hard shell, followed by their thrombosis, the development of osteomyelitis, meningitis, meningoencephalitis.
Primary surgical treatment of skull wounds
Cranial wounds may be non-penetrating(without damage to the dura mater) and penetrating(with damage to the dura mater).
Execution rules:
Economical excision of soft tissues, taking into account the topographic and anatomical features of the area: the skin, together with fiber and aponeurosis, is excised, retreating 3-5 mm from the edges of the wound, the wound is given an oval shape. To stop bleeding from soft tissues, the following techniques are used:
1) finger pressing of the skin to the bone along its incision;
2) the imposition of clamps on the bleeding vessels with the capture of the aponeurosis, followed by ligation or electrocoagulation;
3) stitching of soft tissues around the wound along with vessels (Heidenhain's method);
4) metal brackets (clips);
5) electrocoagulation.
Economical excision of the damaged periosteum and removal of non-periosteal bone fragments and foreign bodies. The edges of the bone defect are leveled with Luer cutters. The outer plate is bitten so that all fragments of the inner plate can be removed. To stop bleeding from the diploetic veins of the bone, the following methods are used:
1) rubbing wax paste into the edges of the bone;
2) crushing the bone with Luer cutters, pressing the outer and inner plates against each other to destroy the beams of the diploetic layer.
Dura treatment:
1) with non-penetrating wounds and the absence of tension of the shell (pulsates well), it is not opened;
2) if a subdural hematoma is visible through a tense, weakly pulsating dura mater, it is sucked out through a needle;
3) if blood clots are not removed in this way, or with penetrating wounds, the dura mater is cut crosswise or in the radial direction to access the brain wound; edges are damaged
Noah shells excised very sparingly.
In case of wounds of the membrane or during the removal of bone fragments, if the fragment covered the wound of the sinus, bleeding from the sinus of the dura mater may occur, which is stopped in the following ways:
1) suturing small wounds;
2) plasty of a sinus wall defect with a flap from the outer layer of the dura mater or an autograft from the fascia lata of the thigh;
3) with large gaps - sinus tamponade with a muscle fragment or gauze turundas, which are removed after 7 days;
3) sinus ligation (with a complete rupture); this method is dangerous, as it leads to the development of cerebral edema, venous encephalopathy and death of the victim
4) due to impaired intracranial hemocirculation.
Brain wound treatment. Removal of the destroyed brain tissue and superficially located bone fragments is carried out by carefully washing off the detritus with a stream of warm saline. Better removal the content of the wound channel contributes to an increase in intracranial pressure. For this purpose, the patient, operated under local anesthesia, is offered to strain, cough. The victim, in an unconscious state, squeeze the jugular veins. To stop bleeding from the cerebral vessels, the following methods are used:
1) electrocoagulation;
2) filling the wound channel of the brain with a mixture of fibrinogen and thrombin.
Closure of a tissue defect. The wound of the dura mater is sutured with thin silk ligatures, the bones are connected with sutures through the tendon helmet and periosteum, with thin silk or threads made of polymeric material; the edges of the skin wound are connected with silk interrupted sutures.
Surgical anatomy of the temporal region. Anatomical substantiation of operational approaches for opening phlegmons of various localization.
The main stages of surgical intervention for penetrating wounds of the skull are shown in Fig. 30. Under local anesthesia, the edges of the soft tissue wound are excised.
Penicillin can be added to the novocaine solution in an amount of up to 50,000 IU per operation. However, during anesthesia, leakage of the solution into the brain wound must be strictly avoided, since direct contact of the antibiotic with the medulla can cause severe seizures and death of the patient. If the bones of the skull are intact, then the soft tissue wound should be excised as economically as possible and the bone should not be exposed for a long distance. It is desirable to finish the treatment of the wound of the soft integument of the skull with the application of a blind suture.
Rice. 30. Stages of primary surgical treatment of a wound with a penetrating wound of the skull (from the book "Experience of Soviet medicine in the Great Patriotic war"). a - excision of a soft tissue wound;
Rice. 30. Stages of primary surgical treatment of a wound with a penetrating wound of the skull (from the book "Experience of Soviet Medicine in the Great Patriotic War"). b - trepanation of the bone;
If the bone is damaged, trepanation is performed with the expansion of the traumatic defect until the appearance of an unchanged dura mater. The usual dimensions of a trepanation defect are 3X3, 4x4 cm. It is important during trepanation to give the edges of the bone a rounded shape, smooth them and remove fragments from under the bone, which sometimes get there when injured.
Rice. 30. Stages of primary surgical treatment of a wound with a penetrating wound of the skull (from the book "Experience of Soviet Medicine in the Great Patriotic War"). c - washing the wound channel;
After the expansion of the bone defect, the dura mater is examined. In the presence of an epidural hematoma, the latter is removed with a spoon. At the same time, it should be borne in mind that blood clots are sometimes located far under the bone, from where they must be removed with a probe or a spoon bent at an angle. Bleeding from the meningeal vessels is stopped by sheathing them. Bleeding from the venous sinuses and pachyon granulations is best stopped with a piece of muscle or galea aponeurotica, which should be pressed against the bleeding area, and then fixed with 2-3 sutures to the dura mater. With significant ruptures of the walls of the venous sinus, sheathing and ligation of the adductor and efferent sections of the sinus are indicated. In some cases, as a temporary measure, tamponade of the sinus with a gauze strip or leaving a hemostatic clamp in the wound is allowed. A hemostatic sponge is used only for diffuse bleeding or when blood seeps from under the bone.
Rice. 30. Stages of primary surgical treatment of a wound with a penetrating wound of the skull (from the book "Experience of Soviet Medicine in the Great Patriotic War"). g - excision of the edges of the dura mater;
If the dura mater is intact, the indications for its opening should be strictly limited, since when the membrane is opened, a wound infection can penetrate into the intrathecal spaces and cause serious complications. The dura mater is opened only when there are grounds for the diagnosis of intrathecal hematoma. These grounds are: the presence in the wounded of signs of brain compression, identified before the operation and on the operating table, - cyanotic color of the membrane in combination with the absence of pulsation (in the absence of brain compression syndrome, the cyanosis of the membrane may depend not on the hematoma, but on the adjacent bruised, imbibed with blood area brain). With these indications, the dura mater is opened and the intrathecal hematoma is emptied.
Rice. 30. Stages of primary surgical treatment of a wound with a penetrating wound of the skull (from the book "Experience of Soviet Medicine in the Great Patriotic War"). e - the imposition of a long-term bandage of the Mikulich-Goykhman type.
With a penetrating wound of the skull and brain, i.e., in the presence of a defect in the dura mater, bone trepanation is followed by removal of the contents of the wound channel in the brain. First, with tweezers, with the necessary care, bone fragments are removed that fill the defect in the dura mater or are located immediately below it. Removing this "plug" creates a free outflow from the wound channel. Under the influence of traumatic cerebral edema, destroyed brain particles (detritus), blood clots and small bone fragments move to the superficial sections of the wound (according to N. N. Burdenko, “like paste from a tube”) and can be easily removed.
Then the wound channel is washed with warm saline (using a soft rubber balloon), which helps to evacuate the remnants of the hematoma and cerebral detritus. The next stage of the operation is an artificial increase in intracranial pressure. This is achieved by coughing or straining (if the wounded person is conscious) or short-term compression of the jugular veins (if the operated person is unconscious). Thanks to this technique, bone fragments, and sometimes small metal fragments, move from the deep sections of the wound channel to the superficial ones, which facilitates their removal.
An indicator of the radical treatment of a craniocerebral wound is the complete removal of all bone fragments and accessible metal and other foreign bodies.
After removal of foreign bodies, the brain wound is washed again with a weak antiseptic solution and a gauze ball moistened with a 3% hydrogen peroxide solution is placed in the wound channel for 1-2 minutes to stop parenchymal bleeding. After removal of the ball, a restored brain pulsation is usually detected. At the end of the operation, the edges of the dura mater are economically excised so as not to disturb the delicate gluings with the surface of the brain that have formed around the defect, and not to create conditions for the spread of infection into the intrathecal spaces.
The issue of applying a blind suture to the wound is decided strictly individually and depends on the condition of the wounded, the timing of treatment and the radical nature of the operation performed. With the introduction of antibiotics, a blind suture can be used quite often. The main conditions for the imposition of primary sutures are radical primary wound treatment performed in the early stages (1-3 days) after injury, the absence of inflammatory changes in the wound and the possibility of hospitalization of the operated person on the spot until the sutures are removed. In doubtful cases, rubber graduates should be left between the seams (i.e., strips of glove rubber folded in several layers with an “accordion”) or, refusing to use primary seams, apply a long-term bandage-tampon of the Mikulich-Goykhman type.
Some features are the treatment of combined injuries of the skull, paranasal sinuses and ear. In case of non-penetrating wounds of the frontal sinus, i.e., while maintaining the integrity of its cerebral wall, it is necessary to clean the sinus from bone fragments and blood clots, scrape out the mucous membrane, create an anastomosis with the nose, remove rubber drainage there and put a blind suture on the external wound. Drainage is removed from the nose after 6-8 days.
In case of penetrating wounds of the frontal sinus and skull, the frontal sinus is first treated (its contents are removed, the bone walls are bitten, the remains of the sinus are washed with a weak disinfectant solution and temporarily covered with a gauze ball moistened with 3% hydrogen peroxide solution), and then the brain wound is treated according to the method described above . The wound with such injuries is usually somewhat sutured from the edges in order to cover the exposed bone with soft tissues. Then a long-term Mikulich-Goykhman bandage is applied.
With combined injuries of the skull and the inner ear, a radical ear surgery is first performed (with opening of the antrum and removal of the sound-conducting bones), and then the brain wound is treated. Such wounds are treated under bandages in order to epidermize the behind-the-ear wound.
After the initial treatment of a craniocerebral wound, endolumbar administration of antibiotics is indicated (prophylactic dose of 25,000 IU of crystalline penicillin diluted in distilled water; the usual therapeutic dose is 50,000 IU). The drug is administered gradually, after dilution in the cerebrospinal fluid, by "tow".
To prevent infectious complications, the antibiotic is administered endolumbally 2-3 times - immediately after the operation, in a day and after 3 days. Therapeutic eidolumbar antibiotic use is carried out daily for 5-7 days or more, until the meningitis is eliminated. For endolumbar administration, only the sodium salt of penicillin is used. In order to avoid complications, concentrated solutions should not be used (the drug is dissolved so that 1 ml contains no more than 5000 IU of the antibiotic). In addition to penicillin, endolumbar and streptomycin (streptomycin calcium chloride complex, 100,000 IU) can be used. With increased sensitivity to antibiotics, epileptiform seizures may occur in the affected person after endolumbar administration. In such cases, barbiturates are administered intramuscularly, and intravenously calcium chloride, prescribe diphenhydramine. Repeated administration of antibiotics endolumbally should be avoided (even if indicated). Other antibiotics should not be injected into the spinal canal. Along with endolumbar use, one of the following drugs is infused intravenously: morphocycline (150,000 IU 2 times a day) or oletethrin (200,000 IU 2 times a day) or ristomycin (500,000 IU 2 times a day). If intravenous administration is not possible, then to combat antibiotic-resistant strains of staphylococcus, mycerin is used intramuscularly (200,000 IU 2 times a day, for 5-7 days), or erythromycin and tetracycline are taken orally (200,000 IU 4 times).
In the postoperative period, the victims need qualified care. A three-week hospitalization for an uncomplicated course of a craniocerebral wound is the minimum period for which a protective shaft around the wound channel in the brain and adhesions between the membranes have time to develop, which protects the victim from generalization of infection. Those wounded in the skull need silence. They often develop pneumonia. If the psyche is disturbed, the wounded can tear off the bandage, damage the exposed medulla, injure himself, etc. The wounded with the medulla that has fallen out or protrudes into the wound (prolapse or protrusion of the brain) require special attention. In such cases, the protruding part of the brain should be protected from possible damage with a cotton-gauze “donut”; dressings should be carried out very carefully so as not to injure the brain protruding into the wound.
Those wounded in the skull, especially those in a stunned state, must be fed high-calorie food, often, but in small portions, so as not to induce vomiting.
In order to raise the body's defenses, intravenous administration of glucose, the use of vitamins, and blood transfusion are recommended.
Military field surgery, A.A. Vishnevsky, M.I. Schreiber, 1968
- Dignities and clothes of Orthodox priests and monasticism
- Healers and fortune tellers - why do people go to them?
- During confession. Preparation for confession. List of sins for confession. How to dress for confession
- Praise of the Most Holy Theotokos Praise of the Mother of God with an Akathist for what they pray