With the development of modern technology and advanced transportation, the morbidity of trauma is increasing, especially brain trauma has become the primary cause of death in adolescents, and its morbidity and mortality rate accounts for 85% of the whole trauma patients. Therefore, the treatment of heavy craniocerebral injury has become a difficult problem that neurosurgeons must face. To improve the level of craniocerebral injury treatment and reduce the morbidity and mortality rate, there are three important links:
Pre-hospital emergency, emergency room emergency and in-hospital treatment.
First, pre-hospital emergency
For patients with severe craniocerebral trauma, 1 h after the injury is the “golden hour” for rescue treatment. Whether the on-site resuscitation of craniocerebral injury patients is timely and correct is the key to the success or failure of resuscitating patients. First of all, to strengthen the construction of emergency stations and emergency centers, to minimize the response time and rescue radius. Today in the United States, Japan and other developed countries, pre-hospital emergency care belongs to the fire system, by trained firefighters to undertake pre-hospital emergency care, while equipped with modern transfer equipment, pre-hospital emergency response time of 4 ~ 5min, to save the lives of patients to buy time. The current pre-hospital emergency organization in China is still very unsound and lacks a clear and unified understanding and practice. After the ambulance and medical personnel arrive at the scene, the basic trauma life maintenance should be carried out immediately, and the most priority treatment is rapid and thorough physiological resuscitation, and the treatment of high cranial pressure must be based on this. In the absence of evidence of brain herniation or significant increased intracranial pressure, any hypothetical or prophylactic treatment must not be inconsistent with optimal systemic resuscitation. In this process, special attention is paid to two points: first, to keep the airway open to prevent asphyxia. Specific measures include: clearing the oropharynx, maintaining the correct head position, establishing an artificial airway, and the use of a simple respirator. Second, correct hypotension. This includes immediate treatment of active wounds, rapid intravenous infusion of fluids, replenishment of blood volume, and maintenance of mean arterial pressure above 80 mm Hg (1 mm Hg = 0.133 kPa). If necessary, the use of antihypertensive drugs (dopamine or dobutamine), because early post-injury hypotension and hypoxia can significantly increase the morbidity and mortality of craniocerebral injury.
Second, emergency room first aid
Modern craniocerebral injury treatment requires a high level of craniocerebral trauma professional skills of the emergency room medical staff, at the same time, because of the modern craniocerebral injury more combined injuries, the emergency room should also have the ability to deal with thoracic, abdominal, bone, vascular and hand surgery patients. Patients come to the emergency department for emergency treatment so that the airway (A), breathing (B) and circulation (C) of critically ill patients can reach a stable state as soon as possible. Once the patient is contacted, the patient is immediately put into rescue without conditions. The first step is to immediately determine whether the patient is breathing and heartbeat, and after it is clear that there is no heartbeat and breathing, immediately perform emergency cardiopulmonary resuscitation, including opening and clearing the airway, skin-bag assisted breathing until tracheal intubation and ventilator, chest cardiac compressions, early injection of epinephrine and other resuscitation drugs, and strive to establish artificial respiration and artificial circulation in the shortest possible time, and establish open intravenous access. If the patient’s heartbeat and respiration still exist, immediately improve respiration, open the channel, on the monitoring equipment, according to the situation to give the necessary resuscitation measures. Specific measures include
①General measures: oxygen inhalation, keep the respiratory tract unobstructed, establish intravenous infusion channels, monitor vital signs and neurological functions, closely observe the condition of consciousness, pupils, changes in vital signs can reflect the degree of cranio-cerebral injury, the formation of intracranial pressure and encephalopathy and the evolution of the condition, therefore, observation of the condition should be carried out simultaneously with resuscitation. These include
1.Consciousness monitoring: the change of patient’s consciousness is to judge the degree of craniocerebral injury and reflect the trend of disease development. In patients with severe craniocerebral trauma, the impairment of consciousness is heavy and fast due to the impairment of cerebral cortex or brainstem reticular structure, so the change of consciousness indicates the change of condition, such as progressive impairment of consciousness is one of the main symptoms of the aggravation of cerebral edema or intracranial hemorrhage, if it is not detected early and treated timely, it will delay the time of rescue.
2, the pupil observation: pupil changes with the emergence of impaired consciousness, is a reliable basis for the diagnosis of encephalopathy, and has localization significance, should pay attention to continuous observation of bilateral pupils are equal in size, equal round and sensitive to light reflex. If one side of the pupil is progressively dilated, the response to light is blunted or disappears, and is accompanied by coma and contralateral hemiparesis, it indicates cerebellar curtain notch disease; if both pupils are large and small, unequal or extremely narrow, the response to light disappears, and the eye is fixed or in an abnormal position, it is often a sign of brainstem injury; bilateral pupils are dilated, the light reflex disappears, the eye is fixed, and the patient is in deep coma, which is an advanced stage of encephalopathy or in an endangered state; however, due to extensive However, due to the extensive skull base fracture, the optic nerve and ophthalmic nerve are directly damaged, which can also cause the pupil to dilate and the light reflex to disappear on one side, so it should be analyzed and judged in relation to the patient’s general condition and state of consciousness.
3.Close observation of pulse, respiration, blood pressure, body temperature, etc.: If blood pressure is found to rise progressively, respiration becomes slow and deep, and pulse becomes slow and strong, it often indicates increased intracranial pressure; when blood pressure drops, pulse is fine and fast, and respiration is irregular, it is a manifestation of critical condition and should be dealt with in time.
4, pay attention to the patient’s headache, vomiting and limb activity: rapid aggravation of limb paralysis indicates deterioration of the condition. In addition, when the patient has severe headache and frequent jet vomiting, it means that the intracranial pressure is increased.
Pre-operative preparation should be done if necessary. Patients with combined shock should promptly replenish blood volume, establish double intravenous infusion channels, use intravenous indwelling needle puncture, apply pressure-raising drugs, and perform deep venous puncture placement if necessary, in order to monitor central venous pressure, provide a basis for treatment, and prevent complications such as cardiac failure and cerebral edema.
If there is a wound with active bleeding, timely hemostasis should be performed, and hemostatic drugs should be used as appropriate to effectively prevent or reduce external bleeding or secondary intracranial bleeding. Combined rib, femoral, and pelvic fractures are common, and for non-life-threatening fractures can be performed after resuscitation of fatal injuries. Care should be taken to rule out paraplegia at high level in patients presenting with tetraplegia.
For open cranial injuries, bandage to stop bleeding first; debridement and suturing of small head or other wounds is feasible after stabilization. Attention should be paid to monitoring blood glucose and differentiating it from diabetes mellitus and treating it accordingly.
③Lowering intracranial pressure: Mannitol is the most effective drug for lowering cranial pressure by dehydration, and is considered the cornerstone of treatment for traumatic brain injury. However, its use should have clear indications: such as evidence of elevated cranial pressure and signs of brain herniation. At the same time, the blood volume should be replenished and the plasma osmolality should be <320 mOsm/L. Preferably, 20% mannitol, 125~250ml for adults and 1-2g/kg for children, should be administered rapidly and repeated once in 4~6h if necessary.
Glucocorticoid: small dose is ineffective, apply large dose for a short time, commonly used dexamethasone, glucocorticoid is effective in reducing cerebral edema, but at the same time may cause the spread of intracranial infection, stress gastrointestinal ulcer bleeding side effects. The use of hormones in the pharmacological treatment of traumatic brain injury is still inconclusive. Inpatient units sometimes use hormones for short periods of time as appropriate in the treatment of traumatic brain injury. Whether or not to apply them should be weighed as a whole.
(5) Ice cap and artificial hibernation therapy: For patients with high fever, irritability, convulsions, and increased muscle tone, use an ice cap on the head and a hibernator.
⑥Other measures: for patients with combined shock, we should supplement the blood volume in time, usually by double tube infusion, using intravenous indwelling needle puncture, applying pressure-boosting drugs and, if necessary, deep venous puncture placement, so as to monitor the central venous pressure and provide a basis for treatment, and prevent the occurrence of heart failure, cerebral edema and other complications. For patients with combined hemopneumothorax, thoracic puncture and blood extraction, and for those with fractures, fracture fixation are performed.
(7) On the basis of the patient’s stability, the necessary tests, such as cranial CT and X-ray, should be performed quickly to make a diagnosis and further treatment. In this period, the most important thing is to quickly determine the type, scope and degree of trauma, to find out the most fatal injury to the patient, to formulate a rescue plan, and to create conditions for the next step of treatment. The development of modern imaging technology has provided strong technical support for craniocerebral trauma doctors, so that doctors no longer rely on physical examination and experience to estimate the injury situation. We should avoid pushing, dragging, pulling and other actions in the process of transportation, and add restraint belt for patients with faint consciousness and restlessness to prevent fall injury. If necessary, sedation can be used for agitated patients, without worrying about covering up the patient’s condition. Adequate sedation, on the one hand, allows the necessary examinations to proceed smoothly and, on the other hand, reduces oxygen consumption and the adverse effects on intracranial pressure.
When dealing with patients in the emergency room, we should pay attention to the detection and management of combined injuries, overcome the time delay and procedural conflicts caused by the existing division of trauma patients into different departments, and coordinate with related departments to timely deal with combined injuries that seriously threaten patients’ lives, such as hemopneumothorax, rupture and bleeding of thoracoabdominal organs. Even for patients with negative CT, we should choose whether to observe or admit them to the hospital, taking into account their medical history and signs. For example, frontotemporal lobe brain contusion, “panda eye” sign, bleeding or fluid outflow from the mouth, nose and ears, bruising of the mastoid behind the ear, etc. are mostly suggestive of skull base fracture.
Third, in-hospital treatment
In-hospital treatment of craniocerebral injury is actually the treatment process of professional ICU and ward. The establishment of neurology ICU (NICU) has greatly improved the success rate of neurology critical care resuscitation and won time for nerve regeneration and remodeling through the functional support of organs.