Traumatic brain injury (TBI) is damage to the brain, skull bones, and soft tissues. Every year, about two hundred people per thousand of the population face such an injury, with varying degrees of severity. The most common cause of head injury is car accidents and WHO statistics are relentless. Every year the number of CHMT received in this way increases by 2%. The reason for this is the increase in the number of vehicles on the roads, or the excessive recklessness of drivers ... a mystery.

Types of injury

There are two types of chmt:

• open craniocerebral injury - accompanied by a fracture of the skull and damage to the integrity of the soft tissues of the brain structures. This form of injury is considered the most dangerous, as the risk of infection of the brain is high. It is diagnosed in 30% of cases;
• a closed craniocerebral injury may be accompanied by a skull fracture, brain contusions, but without touching the integrity of the soft tissues.

Interesting fact! According to statistics, 2/3 of all traumatic brain injuries are fatal!

ZTCHMT has its own gradation, according to the violations caused:

• brain contusion without compression;
• contusion of the brain with compression;

According to the severity are distinguished:

• mild degree. This may be a concussion or bruise of the brain, accompanied by a slight stun, while the mind remains clear. The Glazko coma scale is used to determine the severity of brain injury. On this scale, with a mild degree, the patient scores 13-15 points. Treatment in this case lasts no more than two weeks, neurological disorders do not occur. More often outpatient treatment, rarely in a hospital;
• moderate severity with a closed injury is accompanied by a brain contusion and deep stunning. According to the Glascow scale, the patient scores 8-12 points. Treatment on average lasts up to a month in a hospital. The condition is accompanied by a short loss of consciousness, the presence of neurological signs that may persist for the first month after the injury;
• a severe degree is accompanied by a prolonged loss of consciousness and even coma. Occurs with acute compression of the brain, on a scale the patient gains no more than seven points. There are persistent neurological disorders, often surgical treatment is required, the outcome of the pathology is often unfavorable. Even with recovery, persistent neurological changes remain, and a fatal outcome is often diagnosed.

There is also a gradation of the state of consciousness:

• clear. There is a quick reaction and full orientation in the surrounding space;
• moderate stunning is accompanied by slight lethargy and slow execution of certain instructions;
• deep stunning - there is disorientation, the ability to execute only simple commands, mental difficulties;
• stupor is an oppressed consciousness, during which there is no speech, but at the same time the patient is able to open his eyes, feel pain, and can indicate the location of the pain syndrome;
• moderate coma is characterized by a blackout of consciousness, tendon reflexes are preserved, eyes are closed, but pain receptors are not disabled, pain is felt;
• deep coma. Breathing and heart rate are knocked down, but they are preserved, tendon reflexes are absent, there is no reaction to external stimuli;
• transcendental coma is incompatible with life, complete muscular atony, breathing is supported by ventilation of the lungs.

Interesting fact! About 75% of victims are men under the age of 45.

Causes

ZTCHMT and also an open form arises as a result of:

• traffic accidents, this category also includes fans of skateboards, rollerblades and bicycles. This reason is the most common in the diagnosis of head injury;
• workplace injuries;
• falling from a height;
• domestic injuries, including fights.

Pathological conditions such as:

• sudden dizziness and loss of coordination, falling and, as a result, injury;
• alcohol intoxication;
• epileptic attack;
• sudden fainting.

Possible signs

• The symptoms of head injury can be different depending on whether the injury is open or closed, it is a concussion, bruise or compression of the brain. But, despite this, there are a number of general symptoms that are characteristic of any brain injury. These signs include:
  fainting occurs with a moderate or severe degree of brain injury. With a mild degree, loss of consciousness is possible, but literally for a few seconds or minutes, as a rule, does not occur;
• loss of orientation in space, unsteadiness of gait and coordination of movements. The severity of this symptom also depends on the complexity of the injury;
• headache and dizziness, these signs are characteristic of any degree of severity of the pathology;
• nausea, gushing vomiting, the latter is the result of a painful shock, not associated with the gastrointestinal tract;
• inhibition of reaction, slowness of answers to the questions posed, scarcity of speech;
• increased sweating, pallor of the skin;
• sleep disturbances and loss of appetite occur later;
• bleeding from the nose or ears may occur with moderate to severe trauma.

Brain concussion

One of the varieties of brain injury is a concussion, which is considered the mildest possible brain injury, the consequences of which are reversible. Pathology occurs as a result of vibration in the brain structures. The clinical picture grows instantly, following the injury, depending on the severity of the concussion, it also quickly recedes, not counting the severe forms. Among the characteristic symptoms are:

• vomiting, often multiple;
• short-term fainting, as a rule, lasts several minutes;
• tinnitus and dizziness;
• painful reaction to bright light and loud noises;
• headache;
• sleep disturbance;
• tachycardia;
• increased sweating;
• irritability, etc.

The prognosis for concussion, as a rule, is favorable for any degree of severity of the pathology. The symptoms that have arisen are stopped with the help of medications and rest, as a result, they disappear completely.

Patients with a concussion are hospitalized in a hospital, treatment there lasts, as a rule, from three to fourteen days, depending on the severity of the situation.

Concussion First Aid:

• call an ambulance;
• lay the patient on a flat surface;
• turn your head to the side;
• unbutton a shirt, jacket, remove a tie and other items that may impede breathing;
• if there is a bleeding wound on the head, apply a sterile bandage.

Upon admission to a medical institution, the patient is given an x-ray to exclude the possibility of a skull fracture, further treatment is prescribed.

Patients with concussion require bed rest with complete rest. Do not watch TV, read or write. To eliminate cerebral symptoms, ganglionic blocking agents are prescribed, among them chlorpromazine or pentamine. To improve brain activity in the treatment of concussion, nootropic drugs are prescribed:

• piracetam;
• aminalon;
• pyriditol.

It is also recommended to take B vitamins, calcium preparations, anesthetics for headaches. If the patient has damage to the soft tissues of the head, antibiotic therapy is carried out in order to avoid infection and suppuration of the wound.

In severe cases, when 3-5 days after the start of treatment, the symptoms do not subside or, on the contrary, increase, a lumbar puncture is prescribed to examine the cerebrospinal fluid. If increased intracranial pressure is detected, dehydration drugs are prescribed:

• mannitol;
• diacarb;
• magnesium sulfate;
• albumen.

If the pressure, on the contrary, is reduced, intravenous administration of drugs such as:

• polyglucin;
• peptides;
• hemodez;
• sodium chloride solution.

In the case of a favorable course of pathology treatment, patients are discharged from the hospital after 7-10 days of their stay there. In cases where cerebral and focal symptoms are preserved, hospital stays are extended. After discharge from the hospital, patients require a sparing regimen.

brain contusion

Another type of brain injury is a brain contusion, which is a more serious injury than a concussion. Pathology is accompanied by necrosis of neurons in the focus of injury. Often, a bruise is accompanied by a rupture of small vessels of the brain, hemorrhage or leakage of cerebrospinal fluid.

A bruise can be with or without tissue compression. Also, like other brain injuries, it has three degrees of severity from mild to severe.

The main symptoms of brain injury:

• loss of consciousness, diagnosed with moderate and severe, in the second case there is a deep coma;
• vestibular disorders;
• paresis of the limbs and impaired coordination of movements;
• metabolic disorders;
• frequent fractures of the skull and the presence of blood in the cerebrospinal fluid;
• often meningeal symptoms join the general clinical picture, in particular, severe headaches that persist for a long time;
• repeated vomiting;
• rapid, shallow breathing;
• arrhythmia and tachycardia;
  high blood pressure;
• elevated body temperature as a response to a stressful situation.

With severe brain contusions, the prognosis is extremely unfavorable, and a fatal outcome is more often observed.

Treatment in this case directly depends on the severity of the process. With a mild form of bruising, the treatment is the same as with a concussion.

If the bruise is of moderate or severe severity, treatment is aimed at normalizing cardiac and respiratory function, as well as nervous reactions. Perhaps the appointment of surgical treatment, which consists in the excision of necrotic brain tissue. To combat a number of symptoms, they prescribe:

• with increased blood pressure - neuroleptic drugs, for example, diprazine or chlorpromazine;
• to eliminate tachycardia - novocainamide, strophanthin;
• antispasmodic and sympatholytic agents;
• at elevated body temperature above 38 degrees, antipyretics are prescribed;
  with severe cerebral edema, diuretics are administered, for example, furosemide, as well as agents such as eufillin, diacarb, etc.;
• nootropics to improve cerebral circulation and the activity of its structures: aminalon, cerebrolysin, piracetam.

Brain compression

This pathological condition can occur immediately at the time of injury or later as a result of the formation of a hematoma. In the first case, a depressed fracture requires surgery. Depressed fragments are straightened, as a rule, after surgery and recovery, the person continues a normal life. Neurological symptoms disappear if surgical treatment is not carried out, especially in childhood, the risk of later epileptic seizures is great.

In 2-16% of all head injuries, compression of the brain occurs due to the development of an intracranial hematoma. The cause of its occurrence can be both a bruise and a stroke. A hematoma after an injury develops in a matter of hours, but it begins to show its symptoms of brain compression later. More often as a result of an injury, a single hematoma occurs, but multiple hematomas can also be diagnosed.

Hematomas can be:

• sharp;
• subacute;
• chronic.

In the case of an acute hematoma, the patient's condition progressively worsens, prompt surgical intervention is necessary. In the second two types of hematomas, the symptoms increase gradually, and their progress can be noticeable days, weeks and even months after the injury, as a result of a slow increase in the volume of the hematoma.

When squeezing the brain with a hematoma, symptoms such as:

• decreased tendon and abdominal reflexes;
• convulsive convulsions;
• the occurrence of hallucinations and delusions;
• decreased sensitivity of the limbs, up to paresis or paralysis;
• increased ICP;
• disturbances in the work of the optic nerves.

Traumatic brain injury is damage to the brain of varying severity. Each of the injuries: concussion, bruising or squeezing the brain requires serious medical attention. The severity of the consequences of a head injury can be very different, depending on the complexity of the injury. A mild degree of brain injury, as a rule, does not leave any consequences, as a result of moderate severity, persistent neurological disorders are possible. The consequences of a severe form can be fatal.

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Closed craniocerebral injury (CTBI) includes damage to the brain when the integument of the head (skin, aponeurosis) remains intact, including fractures of the bones of the vault or base of the skull. Closed craniocerebral injury includes concussion, contusion of the brain and its compression.

Strict bed rest is mandatory at the heart of the treatment of CBI.

Treatment of victims should begin immediately, often at the scene, and the fate of the patient, especially with a severe closed craniocerebral injury, often depends on the measures taken in the first minutes and hours. All patients who have received a head injury with loss of consciousness or the presence of antero- or retrograde amnesia should be hospitalized for observation, examination and treatment. This is due to the fact that the course of CTBI is dynamic and its formidable complications may not appear immediately.

Principles of conservative treatment of traumatic brain injury

Conservative treatment of the acute period of CTBI is pathogenetic. There are two stages in the treatment of a closed craniocerebral injury.

At the first stage, in case of impaired consciousness, especially for persons who are in a state of alcoholic intoxication, it is necessary to administer analeptic mixtures: 2 ml of 20% caffeine and 25% cordiamine subcutaneously or 10% sulfocamphocaine 2 ml subcutaneously (intramuscularly or intravenously slowly).

In cases of intracranial hypotension, manifested by an increase in stupor, severity of neurological focal symptoms, tachycardia, a decrease in arterial and cerebrospinal pressure, 500-1000 ml of 5% glucose, distilled water at a dose of 10 ml 2 times a day should be administered intravenously , hydrocortisone 100 mg per 500 ml of physiological solution 2-3 times a day intravenously. Up to 40 ml of polyglucin or rheopolyglucin can be administered intravenously. Additionally, 1 ml of 1% mezaton, 1% fetanol or subcutaneously 5% ephedrine is used. It is also advisable to inject a mixture of 40% glucose (100 ml), 10 units of insulin, 100 mg of cocarboxylase, 0.06% corglucone (0.5 ml), 5% ascorbic acid (6 ml).

With high blood pressure, ganglionic blockers are used: 5% pentamin or 2.5% benzohexonium is injected intravenously, 0.5-1 ml per 50 ml of physiological saline, until blood pressure drops by 20-30%. This can be supplemented by intravenous administration of 5-10 ml of 2.4% aminophylline.

In the fight against increasing cerebral edema, diuretics and glucocorticoid hormones are administered. Already at the prehospital stage, 2 ml of 1% lasix in 20 ml of 40% glucose is used intravenously or 50 mg of uregit in 100 ml of 5% glucose. It is recommended to use 15% mannitol (mannitol) at a dose of 1-1.5 g per 1 kg of the patient's body weight. In severe cases, intravenous drip of glucocorticoid hormones should be administered: 8-12 mg of dexazone or 40-80 mg of methylprednisolone in 200 ml of 5% glucose. After 6-8 hours, they switch to intramuscular administration of one of the drugs in smaller doses (4 mg of dexazone or 40 mg of methylprednisolone).

If there is psychomotor agitation, convulsive syndrome, it is necessary to inject 2-4 ml of Seduxen intravenously, if there is no effect, repeat the injection after 20 minutes. For the same purpose, an intramuscular mixture is used. 2 ml of 2.5% chlorpromazine, 1% dimedrol, 0.5% seduxen and 50% analgin or 2 ml of dropidol with fentacyl. In the case of a convulsive syndrome during a traumatic illness or registration of epileptic activity on the EEG, a longer anticonvulsant therapy is indicated. Depending on the form and frequency of paroxysms, phenobarbital, difenin, benzonal, finlepsin, chloracone, etc. are used. A control EEG is performed after 6 months. treatment.

Treatment of mild MCT

The basis of therapy for mild CTBI is desensitizing (diphenhydramine, tavegil, pipolfen, calcium preparations) and vasoconstrictor drugs. Of the vasomotors, Cavinton 2 ml (10 mg) intravenously 1-2 times a day for 200 ml of saline has a good therapeutic effect. You can also use eufillin, halidor, papaverine. Means that improve microcirculation are used (Curantyl 0.05 mg, 1 tab. 3 times a day, Trental OD mg, 1 tab. 3 times a day, Prodectin 0.25 mg, 1 tab. 3 times a day day), venotonic agents (anavenol 20 drops 3 times a day, escusan 15 drops 3 times a day orally), as well as diuretics (diacarb, triampur, veroshpiron) in medium therapeutic doses. According to the relevant indications, symptomatic therapy is carried out with analgesics (acetylsalicylic acid, amidopyrine, baralgin, analgin, pentalgin, etc.), tranquilizers (seduxen, tazepam, mebicar, elenium, eunoctin). Increased excitability of the autonomic nervous system is reduced by bellataminal, belloid, phenibut, butyroxane. Vitamin therapy, glutamic acid, nootropil, aminalon, encephabol are prescribed.

Treatment for mild brain injury

Treatment of severe brain contusion is aimed at correcting vascular and metabolic disorders, combating increasing hypoxia, cerebral edema, hemorrhagic syndrome, and preventing complications. At the very early stage, brain protection against hypoxia is used. Enter 20% sodium oxybutyrate - 20 ml in 200 ml of 5% glucose, for the prevention of hypokalemia also 10% potassium chloride - 10 ml or panangin (asparkam) 10 ml intravenously drip. In parallel, a neurovegetative blockade is carried out, which includes: 2.5% chlorpromazine, 0.5% seduxen solution, 1 ml intramuscularly after 4 hours. In the case of arterial hypertension, ganglionic blockers are included in the mixture or 100 ml of 0.25% novocaine is injected intravenously. The initial period of treatment can also be carried out under light barbiturate anesthesia (sodium thiopental, hexenal, etc.). This increases the resistance of the brain to hypoxia, reduces its energy needs and delays the processes of lipolysis, preventing metabolic disorders. Against the background of dehydrating therapy, 400 ml of a glucose-insulin-potassium mixture from rheopolyglucin, rheogluman or hemodez can be administered.

Treatment of hemorrhagic syndrome

Hemorrhagic syndrome is stopped by the following means: 10% calcium chloride - 10 ml intravenously, 1% vikasol - 1 ml intramuscularly, ascorbic acid - 2 ml intravenously or intramuscularly. For the same purpose, proteinase inhibitors are used - trasylol (or contrical) 25 thousand U drip in saline after 12 hours, or 5% aminocaproic acid - 100 ml intravenously, drip after 6 hours. With massive subarachnoid hemorrhages together with neurosurgeons, repeated lumbar punctures are performed with active washing of the CSF spaces with saline or CSF drainage is established with the removal of 200-300 ml of cerebrospinal fluid during the day. This accelerates its sanitation and serves as a preventive measure for the development of aseptic arachnoiditis.

To improve microcirculation and prevention of thrombosis, in the absence of hemorrhagic syndrome, heparin is administered subcutaneously - 2-3 thousand units every 8 hours. In the acute period (up to 1 month) for the prevention of infectious complications (pneumonia, pyelonephritis) in In medium therapeutic doses, broad-spectrum antibiotics are used: erythromycin, oletethrin, tseporin, etc. If swallowing is impaired in a coma, one should not forget about parenteral nutrition. The loss of protein is compensated by the introduction of hydrolysin or aminopeptide through the probe up to 1.5-2 l / day, anabolic hormones (nerobol, retabolil).

Medical therapy for CTBI

On the 3-5th day of PTBI, drugs are prescribed that stimulate metabolic processes in the brain. These are aminalon (0.25 g, 2 tablets 3 times a day), glutamic acid (0.5 g, 1-2 tablets 3 times a day), cocarboxylase (200 mg intramuscularly), vitamins 5% B 6, B 12 (200-500 mcg), ATP (1 ml intramuscularly). A course of treatment is carried out with nootropic and GABAergic drugs - cerebrolysin, nootropil (piracetam), encephabol (pyriditol), etc. Desensitizing therapy (gluconate and calcium chloride, ascorutin, tavegil, diphenhydramine, diazolin) is also recommended. They use vasodilators (cavinton, halidor, papaverine, eufillin) and drugs that improve the condition of the venous wall (anavenol, aescusan, troxevasin). According to indications, dehydrating therapy is continued (diacarb, veroshpiron, triampur).

Differentiated treatment of the acute period of severe CTBI can be schematically presented in the following form. The first five days of treatment is carried out in the intensive care unit. On the day of admission, an X-ray of the skull and a lumbar puncture are mandatory. This makes it possible to exclude or confirm a skull fracture, pneumocephalus, intracranial hematoma, as well as to clarify the massiveness of subarachnoid hemorrhage and the presence of CSF hyper- or hypotension. Attention should be paid to the displacement of the pineal gland. In cases of an increase or appearance of focal neurological symptoms, the patient's stupor, or the development of a convulsive syndrome, an urgent consultation with a neurosurgeon is necessary. EEG, Echo-EG, carotid angiography or diagnostic burr holes are made to exclude intracranial hematoma.

Surgical treatment for intracranial hematoma of any localization is practically performed without taking into account contraindications. Explorator milling holes overlap even in the final stage.

Examination of working capacity: MSEC after CTBI.

With a mild closed craniocerebral injury (concussion), the period of inpatient treatment is 2-3 weeks. The total duration of temporary disability is 1-1.5 months. In some cases, with continued poor health, the period of temporary disability can be extended up to 2 months. Employment through MSEK is shown, it is possible to determine the III group of disability.

In the case of a moderate injury (brain bruises of mild and moderate severity), the duration of inpatient treatment is from 3-4 weeks to 1.5 months. The terms of temporary disability are on average 2-4 months and depend on the nearest labor forecast. With a favorable prognosis, sick leave through MSEC can be extended up to 6 months. If signs of persistent disability are found, then patients are sent to MSEC after 2-3 months. after injury.

If severe CCI (severe contusion, brain compression), the duration of treatment in the hospital is 2-3 months. The clinical prognosis is often either unclear or unfavorable, therefore, to resolve the issue of temporary disability for up to 4 months. inappropriate, except for operated hematomas. Depending on the severity of the motor defect, psychopathological, convulsive and other syndromes, it is possible to establish (with the participation of a psychiatrist) II or I group of disability. The duration of temporary disability and the group of disability after removal of surgical hematomas are determined individually, taking into account the immediate prognosis and the nature of the work performed.

doctor of medical sciences, Leonovich Antonina Lavrentievna, Minsk, 1990 (as amended by MP site)

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Sergei Anatolievich Derevshchikov.
659700 Republic of Altai, Gorno-Altaysk. 130 Kommunistichesky Ave., Republican Hospital, Department of Anesthesiology and Resuscitation.
Tel. 2-58-89, E-mail: [email protected]

1. GENERAL PRINCIPLES OF MANAGEMENT OF PATIENTS WITH TBI.

1.1. In case of violation of the functions of vital organs, the examination should be preceded by urgent measures - tracheal intubation, mechanical ventilation, the introduction of vasopressors.

The collection of information should be carried out according to the scheme: Who? Where? When? What happened? For what, after what? What was before?

1.2. Determine the depth of impaired consciousness on the Glasgow scale.

Nature of activity
eye opening	Independent
to a verbal command
missing
motor response	verbal command execution
localization of pain
limb withdrawal
limb flexion for pain
limb extension for pain
missing
verbal response	definite
confused
inadequate
incomprehensible
missing

Total 3 - 15 points.

CONSISTENCY of Glasgow performance with traditional methods.

15 - clear consciousness

13 - 14 - stun.

9 - 12 - sopor.

4 - 8 - coma.

3 - brain death.

1.4 Patients diagnosed with TBI should be subjected to dynamic neurological monitoring and instrumental methods of examination.

upon admission to the department.

after 3 hours.

every other day and then daily.

1.4 Scope of examination in case of TBI diagnosis:

Neurological examination (neuropathologist).

X-ray of the chest and skull in two projections.

echoencephaloscopy.

Computed tomography - with an unclear diagnosis.

Lumbar puncture if other methods do not provide sufficient information.

Laboratory examination according to the standard scheme.

Surgeon's consultation.

2. ANESTHETIC MANUAL

USE:

semi-open circuit.

mode of moderate hyperventilation.

sodium thiopental, midazolam, ftorotane up to 1% vol., narcotic analgesics, benzodiazepines.

sodium oxybutyrate in unstable hemodynamics.

DO NOT USE:

Calypsol, ether, nitrous oxide, glucose solutions, dextrans (if there is no shock, hypovolemia).

ATTENTION!

avoid hypotension.

After the end of the intervention, do not transfer the patient to spontaneous breathing until consciousness is restored. Transfer to the intensive care unit to carry out controlled breathing!

3. TREATMENT OF ACUTE PERIOD TBI (1 PERIOD) GENERAL ACTIONS.

GENERAL EVENTS. Performed as soon as possible. They must be completed within 2 hours of receipt.

3.1 MAINTENANCE OF THE UPPER AIRWAY.

If there are signs of aspiration syndrome, impaired consciousness by the type of coma, deep stupor - immediate tracheal intubation.

In the presence of solid particles of food in the aspirated liquid, the progression of acute respiratory failure, an emergency therapeutic and diagnostic bronchoscopy is indicated.

3.2 STABILIZATION OF HEMODYNAMICS.

Strive for a normodynamic or moderately hyperdynamic state of hemodynamics. If the patient has traumatic shock, infusion and other antishock therapy should be carried out in full.

3.3 ARTIFICIAL LUNG VENTILATION.

Indications for IVL in TBI:

Coma (3 - 8 points on the Glasgow scale).

Hyper and hypoventilation syndrome.

Violation of the rhythm of breathing.

The need for medical anesthesia.

With signs of increasing intracranial hypertension.

With concomitant injuries of the chest.

With traumatic shock 2 - 3 tbsp.

With signs of decompensated respiratory failure of any origin.

IN ANY DOUBT IN THE STATE OF THE PATIENT, THE QUESTION IS TO BE DECIDED IN FAVOR OF ALV!

If prolonged mechanical ventilation is expected, nasotracheal intubation is desirable. The endotracheal tube is additionally fixed with adhesive tape.

If the synchronization of the patient with the ventilator is disturbed in the early period, it is advisable to use muscle relaxants.

ATTENTION!

If it is not possible to carry out mechanical ventilation, refuse to administer sedatives and narcotic drugs to the patient.

3.4 BASIC THERAPY IN PATIENTS WITH TBI.

Purpose: to strive to maintain the parameters within the specified limits until the patient recovers from a serious condition.

Give the patient a position with a raised head end (30-40 degrees).

PaO2 > 70 mmHg SpO2 > 92%.

PaCO2 35 - 40 mmHg

BP syst. > 100< 160 мм.рт.ст.

Water balance ±500 ml.

Blood sodium 135 - 145 mmol / l.

Osmolarity 280 - 295 mosm/l.

Hb > 100 g/l. Hematocrit - 30 - 35 percent.

Body temperature< 37,50 С градусов.

Central perfusion pressure > 60 mmHg

Attention!. Do not place the blood pressure cuff on the paresis side of the limb.

3.5 ANTIBACTERIAL THERAPY.

Start no later than three hours from the moment of receipt.

Closed injury - penicillin 2.0 after 4 hours i/v, i/m. or ampicillin 1.0 * 6r / day i.v., i.m.

Penetrating, open TBI, condition after craniotomy, need for mechanical ventilation, aspiration syndrome.

Penicillin 3.0 after 4 hours IV, IM + cephalosporins, preferably third generation (claforan, ceftriaxone).

Consider the advisability of prophylactic subarachnoid administration of antibacterial agents (kanamycin 1 mg/kg or gentamicin 0.1 mg/kg or dioxidine 0.5 mg/kg).

3.6. SYMPTOMATIC TREATMENT.

Used for TBI of varying severity.

With tachycardia; 110 beats per minute - anaprilin (obzidan) 20 - 40 mg * 1 - 4 r / day in a probe or other blockers.

Attention! If the patient is receiving nimotop blockers do not prescribe.

With an increase in body temperature over 37.50 C - non-steroidal analgesics in normal doses (for example, analgin 50% at 2.0 - 4.0 in / in * 3 - 4 r / day). If it is ineffective, the patient is physically cooled (for example, wet wrapping and blowing with air flow, wrapping the limbs with ice bubbles, etc.) against the background of neurovegetative blockade (seduxen, chlorpromazine).

4.1 TREATMENT IN THE ACUTE PERIOD OF SEVERE TBI (first period).

Criteria: 3 - 8 points on the Glasgow scale. The upper and lower parts of the brain, the medulla oblongata are affected.

Clinic: coma, rarely stupor, normothermia or hyperthermia, decrease or increase in blood pressure, heart rate, respiratory rhythm disturbance. Neurodystrophic changes in internal organs, skin, asymmetry of blood pressure. The approximate duration of this period is 7 - 14 days.

4.1.1 Sodium thiopental

2 - 4 mg/kg IV bolus. Then 0.5 - 3 mg/kg per hour continuously by doser or bolus. The dose of sodium thiopental should be selected, focusing on the clinic: normalization of body temperature, reduction of tachycardia, normalization of blood pressure, relief of motor excitation, synchronization of the patient with the ventilator. Maintain superficial anesthesia (so that the patient's voluntary moderate motor activity, reaction to pain stimuli, cough reflex is preserved. From day 2, reduce the dose by approximately 50%. On the fourth day, stop the drug administration and prescribe long-acting barbiturates, for example, benzonal 0.2 * 1 - 2r / day.

In unstable hemodynamics, instead of sodium thiopental, ataractics are used (for example, seduxen 10 mg/v 3–5 r/day). If there is a combined injury, then narcotic analgesics are additionally used.

4.1.2 Magnesia therapy.

If there are no contraindications (hypovolemia must be eliminated, blood pressure system. > 100 mm Hg), the introduction should be started from the moment the patient arrives.

Magnesium sulfate: 20 ml of a 25% solution (5 g) is administered intravenously over 15-20 minutes, then intravenous infusion at a rate of 1-2 g/hour for 48 hours. The use of magnesium sulfate is contraindicated if the patient has symptoms of renal failure.

4.1.3 Glucocorticoids.

Attention! - Appoint as soon as possible. 8 hours after injury, the following therapy is less effective!

When prescribing, take into account contraindications: the presence of a purulent infection, gunshot wounds, peptic ulcer in exacerbation, etc.

The drug of choice is methylprednisolone sodium succinate. Other glucocorticoid drugs may be less effective.

Methylprednisolone 30mg/kg bolus over 10-15 minutes. Then 5 mg/kg/hour by dispenser or bolus throughout the day. In the next 48 hours - 2.5 mg / kg per hour. Other glucocorticoid drugs - in equivalent doses.

In the absence of a sufficient amount of the drug - use in smaller dosages.

4.1.4 Tirilazad mesylate

(Fridox) 1.5 mg/kg IV cap. every 6 hours for 8 days.

Note: The cost of a course of treatment with this drug is several thousand dollars. If there is no specified drug, then Vit. "E" 30% - 2.0 i / m * 1 r. day for 8 days.

4.1.5 Infusion therapy.

Physical solution 0.9% i.v.

Evenly throughout the day - 2.0 -2.5 liters (30 - 35 ml / kg / day) 2 days. physical solution 0.9% in / in

Evenly throughout the day - 1.5 -2.0 liters (25 - 30 ml / kg / day)

From the end of the second or at the beginning of the third day, the transition to tube feeding with caloric content

1 -1.5 Kcal / day in total up to 1.5 - 2.5 l / day.

In the following days, the caloric content of the diet is gradually brought to the real metabolic needs of the patient.

4.2 TREATMENT IN THE ACUTE PERIOD OF TBI OF INTERMEDIATE Severity (first period).

Criteria: 9 - 12 points on the Glasgow scale. Cerebral hemispheres, extrapyramidal system are affected

Clinical features: stupor, hypokinesia, hypomimia, increased muscle tone of the extremities, cataleptic state, hyperthermia>37<38,5, АД, ЧСС нормальные или умеренно повышены, асимметрия рефлексов.

4.2.1 Sedative therapy.

Attention! Hypovolemia should be absent. Prevent BP drop< 100мм.рт.ст!

The selection of the dose and the frequency of administration of sedative drugs is carried out individually for each patient. Strive for the normalization of blood pressure, heart rate, body temperature, relief of psychomotor agitation, convulsive syndrome.

Long-acting barbiturates, for example, benzonal at 0.2 * 1 - 2r / day. If there are episodes of psychomotor agitation - neuroleptics. Approximate doses: chlorpromazine 12 - 50 mg * 2 - 3r / day. or haloperidol 12 - 25 mg * 2 - 3r / day. in / in or in / m.

4.2.2 Tirilazad mesylate

(Fridox) 1.5 mg/kg IV cap. every 6 hours for 5 days. If there is no specified drug, then Vit. "E" 30% - 2.0 i / m * 1 r. days for 5 - 8 days. (Bruising of the brain, a combination of contusion of the brain and hematoma, condition after surgery for acute hematomas, fracture of the vault and base of the skull in adults).

4.2.3 Fluid therapy

Physical solution 0.9% i.v. Evenly throughout the day - 2.0 -2.5 liters (30 - 35 ml / kg / day) 2 - day and subsequent days.

Liquid and food intake

PER OS in a volume of 1.5 - 2.5 liters with a calorie content of 2 - 3 Kcal / day.

4.3 TREATMENT IN THE ACUTE PERIOD OF SEVERE AND MODERATE TBI UNDER THE CONDITIONS

NON-SPECIALIZED DEPARTMENT (there are no specialists, equipment for ventilation and monitoring, the possibility of intensive treatment).

Therapy is symptomatic. In patients with severe TBI, early tracheostomy is recommended. Do not prescribe narcotic analgesics, and sedatives are used very carefully, in minimal dosages. The patient should not be deeply sedated. Most patients need osmotic diuretics to reduce intracranial pressure from the second to third day (see section 6.1). In treatment, you can use the recommendations given in sections 3.6 and 4.2.

5.SECOND PERIOD (early compensation)

5.1. "ACTIVATIVE THERAPY"

ATTENTION! This therapy should be used when the patient's consciousness is restored or when the patient's level of consciousness is stabilized at the same level.

It is contraindicated in the acute period of head injury, with increased intracranial pressure.

In the period of early compensation, it is indicated in patients with symptoms of "loss" of neurological functions and is contraindicated in patients with symptoms of "irritation"

Assign, usually, from 4 to 5 days in case of TBI of moderate severity, and from 8 to 14 days in patients with severe TBI.

Instenon 2.0 * 3r / day.

Cavinton 20 mg * 3r / day.

Eufillin 2.4% - 10.0 * 3r / day.

Piracetam 20% - 5.0 * 4r / day

Instenon 4mg * 3 r / day.

Nimodipine 30 mcg/kg/hour for 5 days.*

Cerebrolysin 10.0 1 r/day

Cynarizine 0.05 (2t) * 4 r / day

Actovegin, Solcoseryl 10 - 1000 ml 1r / day. in / in cap. (But do not exceed the daily volume of infusion therapy. Joke!).

Most often, intravenous administration is used, but if the patient is conscious, the enteral route of administration is also possible. As a rule, two drugs are prescribed simultaneously with a different mechanism of action depending on the patient's condition (age, blood pressure, etc.). If necessary, change drugs after 7-10 days.

*Note: In the absence of high intracranial pressure, nimodipine can apparently be used in the acute period of TBI.

Careful hemodynamic monitoring should be carried out during its appointment.

With the developed akinetic state

(functional decortication, akinetic mutism), vegetative state, additionally selegelin hydrochloride (Umex) 5 mg * 2 r / day. From the second - third days (from the beginning of the reception), the dose of the drug is increased to 20 mg / day. If there is no effect within 4-5 days, then additionally calypsol (ketalar) 1 mg/kg intramuscularly 1 time per day. If necessary, the introduction of Calipsol is repeated once every three days.

In the absence of selegelin hydrochloride (yumex), levodopa preparations (Nakom, Sinemet, etc.) are used - 1.0 - 4.0 per day, however, the clinical efficacy of this group of drugs is noticeably lower, and the frequency of side effects is higher.

In the presence of symptoms of "irritation"

(convulsive syndrome, vegetative crises) use mainly sedative therapy: benzonal 0.1 - 0.2 * 1 - 2 r / day, chlorpromazine 12 - 50 mg * 3 r / day / m (with psychomotor agitation), Relanium 10 mg * 2 - 3 r / day / m. etc. The dose of the drug and their combination must be selected individually.

With motor disorders galantamine 5 - 10 mg 2 r / day in / in, in / m, if not, then prozerin 0.5 - 1 mg in / in, in / m, * 3 r / day. if not, then prozerin 0.5 - 1 mg IV, IM, * 3 r / day.

6. INCREASED INTRACRANIAL PRESSURE. THERAPY.

Manifestations

A. Non-specific signs: headache, nausea, vomiting, increased blood pressure, bradycardia, edema of the nipples of the optic nerves, paresis of the VI cranial nerve, transient visual disturbances and fluctuations in the level of consciousness.

B. The herniation is due to pressure causing displacement of the brain tissue. Manifestations depend on the localization of the pathological process that led to the increase in ICP.

1. Diencephalic herniation occurs when the medial supratentorial localization is damaged and consists in the displacement of the diencephalon through the notch of the cerebellar tenon. This process causes: (1) Cheyne-Stokes respiration; (2) constriction of the pupils with preservation of their reaction to light; (3) upward gaze paralysis; and (4) changes in mental status.

2. The herniation of the medial parts of the temporal lobe occurs when the lateral supratentorial localization is affected and consists in the displacement of the medial parts of the temporal lobe through the notch of the cerebellar tenon. The resulting pressure on the structures of the midbrain is manifested by: (1) impaired consciousness;

(2) a dilated, non-reactive pupil on the side of herniation, which is associated with compression of the 3rd cranial nerve;

(3) hemiparesis on the opposite side. The movements of the eyeballs are not always disturbed.

3. The herniation of the cerebellar tonsils is caused by pressure pushing the lower part of the cerebellum through the foramen magnum, which leads to compression of the medulla oblongata. It causes:

(1) impaired consciousness; and (2) respiratory rhythm disturbances or apnea.

INDICATIONS FOR ANTI-EDEMOTIC THERAPY:

with the development of dislocation syndromes.

on the operating table at the request of the surgeon.

with an increase in intracranial pressure more than 200 mm. rt. Art.

with a rapid (within a few hours) worsening of neurological symptoms.

6.1 Mannitol (mannitol) is administered rapidly (in 15-20 minutes) at the rate of 1 g/kg of body weight. After that enter 3 - 4 times a day at the rate of 0.25 - 0.3 mg/kg.

With insufficient effect or hydrocephalus, Lasix 1 mg / kg is additionally used, if necessary, 2-3 r / day. If the osmolarity is >320 mosm/l, osmodiuretics should not be used.

6.2 If there is no effect from this therapy, the transfer of the patient to mechanical ventilation and the appointment of sodium thiopental are indicated, as indicated in section 4.1. But in this case, the first (loading dose) of sodium thiopental is increased to 8-10 mg/kg.

6.3 CSF drainage through a ventricular catheter is indicated for hydrocephalus. But it is not always feasible, it increases the risk of purulent complications.

6.4 Moderate hypothermia (31 - 330 C), performed for several hours, is quite effective, but requires special equipment and is not yet available.

6.5 In the most severe cases: with a rapid deterioration of neurological symptoms (hours and minutes) and the absence of the effect of the therapy by other methods, if it is impossible to use other methods (for example, low systemic blood pressure), hypertonic sodium chloride solution can be used.

Rapid infusion (4-5 minutes) of 7.5% sodium chloride solution is performed at the rate of 4 ml/kg. Then the treatment provided for in paragraph 6.2 (more often) or 6.1 of this section is carried out.

7. PREVENTION AND TREATMENT OF PNEUMONIA.

Sanation-diagnostic fibrobronchoscopy. Mandatory examination of the tracheo-bronchial tree in the first hours after injury. The frequency of bronchoscopy during mechanical ventilation is determined individually, re-appointed with the progression of broncho-obstructive syndrome.

2. Turns in bed every two hours.

3.Toilet of the oral cavity every six hours.

4. In the presence of purulent discharge from the endotracheal tube, tracheostomy - the introduction of antibiotics, antiseptics into it.

5. The imposition of a tracheostomy is indicated if, a week after intubation, the patient cannot independently and voluntarily cough up sputum. The imposition of a tracheostomy is indicated in the early stages, if the estimated duration of the disturbance of consciousness exceeds 2 weeks.

8. TRAUMATIC MENINGITIS,

Occurs more often on the 2nd and 6th day after the injury. For diagnosis, subarachnoid puncture, bacterioscopy of cerebrospinal fluid is indicated. Treatment to begin immediately after diagnosis!

For traumatic meningitis, if previously untreated:

Penicillin 3.0 * 12 r / day IV + third-generation cephalosporins, such as cefotaxime (Claforan) 2.0 * 6 r / day or ceftriaxone 2.0 * 2 r / day IV + gentamicin 0.2 mg / day kg or kanamycin 2 mg/kg subarachnoid.

If there is no effect from this therapy within two days, consider using one or more of the following drugs: Meronem or Tienam 4–6 g/day, dioxidine 1.0–1.2 g/day, ciproflosacin 1.2–1 .8 g / day. With penicillin-resistant coccal microflora - rifampicin 0.9 - 1.2 g / day or vancomycin 3 - 4 g / in. The daily dose of all the listed drugs is administered intravenously for 3-4 injections.

Amikacin 1 mg/kg or brulamycin 0.2 mg/kg is administered subarachnoidally.

Additionally: metrogil 500 mg * 4 r / day IV - in case of suspected anaerobic infection, in the presence of a brain abscess.

ATTENTION!

do not inject penicillin subarachnoidally (very often develops a severe convulsive syndrome).

carry out subarachnoid punctures daily (with severe meningitis), or every other day (with stable positive dynamics), until the cerebrospinal fluid is sanitized.

9. FEATURES OF MANAGEMENT OF PATIENTS WITH SOME NEUROSURGICAL INTERVENTIONS

after operations associated with craniotomy in case of TBI against the background of preserved consciousness (in patients without signs of severe brain contusion, cerebral hypertension) - depressed fracture, fracture of the vault, epi and subdural hematomas in the early stage of a small volume, etc.

Extubation of the patient should be carried out against the background of fully restored consciousness, usually not earlier than 2 hours after the end of the intervention.

Do not use narcotic analgesics in the postoperative period. If necessary (combined injury), it is allowed to use them in reduced doses, organizing continuous monitoring of the patient.

Use 0.9% sodium chloride solution to replenish daily fluid losses.

The patient should be in bed with a raised head end.

Medication is the same as for moderate TBI (section 4).

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the duration and severity of which depends on the degree of mechanical impact on the brain tissue.

Long-term consequences

Long-term consequences of TBI can be manifested by neurological disorders:

• sensitivity disorders (numbness of the hands, feet, burning sensations, tingling in various parts of the body, etc.),
• movement disorders (trembling, coordination disorders, convulsions, blurred speech, stiffness of movements, etc.),
• vision changes (double vision, blurred focus)
• mental disorders.

Mental disorders and behavioral disorders due to brain injuries can be expressed in different states: from a state of fatigue to a pronounced decrease in memory and intelligence, from sleep disturbances to incontinence of emotions (attacks of crying, aggression, inadequate euphoria), from headaches to psychoses with delusions and hallucinations.

The most common disorder in the picture of the consequences of brain injuries is asthenic syndrome.

The main symptoms of asthenia after traumatic brain injury are complaints of fatigue and rapid exhaustion, the inability to endure additional stress, unstable mood.

Characterized by headaches, aggravated by exertion.

An important symptom of an asthenic condition that has arisen after a traumatic brain injury is increased sensitivity to external stimuli (bright light, loud sound, strong smell).
It is very important to know that a lot depends on whether the concussion or brain contusion happened for the first time, or whether the patient has repeatedly been able to endure such injuries at home. This directly affects the outcome and duration of treatment.

If the patient has more than 3 concussions in the anamnesis, the period of treatment and rehabilitation is significantly lengthened and the likelihood of complications also increases.

Diagnosis of traumatic brain injury

With craniocerebral injuries, it is necessary to undergo diagnostic procedures urgently.

It is also important to be examined and observed by specialists every month after injury.
As a rule, in the diagnosis of TBI, methods of magnetic resonance imaging, computed tomography, and radiography are used.

Treatment of TBI and consequences of brain injuries

In the acute period, decongestant, neurometabolic, neuroprotective, symptomatic therapy is carried out, which consists in the selection of several drugs offered both in the form of tablets and in the form of injections (drip and intramuscular).

This treatment is carried out for about a month. After that, the patient remains under the supervision of his attending physician, depending on the severity of TBI, from six months to several years.

For at least three months after a TBI, the intake of alcoholic beverages and heavy physical exertion is strictly prohibited.

In addition to traditional methods of treating TBI, there are no less effective methods:

In combination with drug therapy and physiotherapy, these techniques can have a more pronounced and faster effect. However, in some cases they are contraindicated for use.

Everyone knows the fact that treatment should be complex, and the more techniques will be used during treatment, the better.

After the end of the course of treatment, the patient must be under the supervision of a doctor, and in the future he may need repeated courses, as a rule, once every half a year.

Possible Complications

If left untreated, brain injury often leads to complications. The most dangerous consequences are remote, which are initially formed hidden. When, against the background of general well-being, without visible symptoms, a complex pathology is formed. And only after a few months, or even years, an old brain injury can make itself felt.

The most common among them are:

• headaches, often with nausea and vomiting,
• dizziness,
• memory impairment,
• the formation of mental pathology, etc.

Traumatic brain injuries are a danger that the patient may not be aware of.

After hitting the head, various kinds of problems can occur, even when there are no visible symptoms of a concussion (headache, dizziness, vomiting, pressure on the eyes, feeling overtired, drowsiness, a veil before the eyes).

In many cases, the consequences of a brain injury can be accompanied by a displacement of the cervical vertebrae, which can also lead to:

• headaches,
• pain in the neck
• memory impairment,
• increased fatigue afterwards.

Brain injury is often the "trigger" of diseases such as:

• facial neuritis,
• pathology of the trigeminal and other facial nerves.

this may be accompanied by pain on one side of the face or muscle weakness on one side of the face.

The clinic "Brain Clinic" conducts all types of research and complex treatment of the consequences of brain injuries.