Etiology and diagnosis of traumatic brain injury
Craniocerebral trauma is extremely common in both civilian and wartime, and the disability and mortality rates rank first among all parts of the body. In the rescue and treatment of craniocerebral injury, time is a very important factor. The earlier the treatment, the higher the survival rate and quality of survival of the injured, the lower the mortality and disability rate.
I. Etiology and pathology
Head injuries are mostly seen in traffic, construction, industrial and mining accidents and natural disasters, and firearm injuries during war. Mainly head impact or impact by objects, including a variety of sharp or blunt objects, so that the head skin, muscle, skull and brain tissue by piercing, cutting, impact, shock, pulling and other physical effects, resulting in contusions, lacerations, bleeding, swelling and skull fractures and other pathological changes in brain tissue. Because the head is rich in blood vessels, brain tissue is the center of life, brittle and soft, and confined to the relatively closed cranial cavity, so traumatic brain injury has the characteristics of high incidence, acute condition, rapid changes in the injury, bleeding fierce, requiring emergency surgery, heavy medical treatment and care tasks, and there are often compound injuries in other parts of the body.
Second, clinical manifestations
1.Disorders of consciousness, due to the different severity of the injury, there can be a variety of performance. From mild to severe can be divided into: (1) drowsiness: can wake up, can barely cooperate with the examination and answer questions, slow response, sleep after the cessation of stimulation; (2) hazy: given strong pain stimulation or language stimulation to wake up, can only make some simple, vague or incorrectly organized answer; (3) shallow coma: dull consciousness, no language response, to strong pain stimulation with escape action, deep and shallow physiological anti-existence; (4) coma (4) coma: loss of consciousness, dull response to strong painful stimuli, loss of superficial reflexes, loss or disappearance of deep reflexes, corneal reflexes and gag reflexes may exist, often urinary incontinence; (5) deep coma: no response to all external stimuli, loss of various reflexes, loss of pupillary light response, loss or extreme increase of muscle tone.
2, headache, vomiting, local pain may be injured. But the head is more continuous swelling pain, often accompanied by nausea and jet vomiting.
3, vital signs change, body temperature, respiration, pulse rate, blood pressure can respond to the degree of cranio-cerebral injury. Normal or slight changes in vital signs indicate that the injury is mild and stable; large changes in vital signs indicate critical condition and urgent treatment, such as increased blood pressure, increased pulse pressure, slow or abnormally fast heart rate, deep and slow breathing and irregular rhythm.
4, eye signs, because of cranio-cerebral injury patients have more coma, observation of the pupil, eye movement and fundus changes can be more objective understanding of the condition. Pupil: normal human diameter is 3-4mm, slightly larger in children, bilateral isotropic circle, if the pupil is dilated, the light response disappears with impaired consciousness more suggests critical condition. Normal eye position is symmetrical, flexible movement in all directions, if there is isotropic gaze or fixed, or the visual axis is scattered, etc. suggests intracranial damage. Fundus observation such as optic papillary edema and hemorrhage suggest intracranial hypertension or intraocular injury.
5, focal symptoms and signs of the nervous system, cranio-cerebral injury can appear one or more symptoms: abnormalities of random movement, speech, mental activity; aphasia, inability to write; poor memory, calculation ability; trunk numbness, limb monoplegia or hemiplegia, dystonia; urinary collapse, high fever, gastrointestinal bleeding; general ankylosis; ataxia; inability to swallow, hoarse voice, crooked corners of the mouth, etc.
Third, examination and diagnosis
The diagnosis of craniocerebral trauma is easier to establish based on the patient’s history of injury and the various manifestations mentioned above found in the physical examination of the whole body and the nervous system. However, there are different treatment plans for different injuries, and the following auxiliary means are needed for careful analysis and judgment.
1.X-ray film: to determine the fracture, cranial suture separation, intracranial gas accumulation, intracranial foreign body.
2, CT scan: very important means, can show the existence and scope of hematoma, contusion, edema, also can see fracture, gas accumulation, etc., if necessary, multiple dynamic scans to track changes in the condition. However, the posterior cranial fossa is often disturbed by artifacts, and the image is not well developed.
3.MRI: Although it is rarely used in the acute stage, it should be considered when the posterior cranial fossa lesion is poorly displayed in CT. It is better than CT for the visualization of intracranial soft tissue structures and can be used to determine the extent of injury and estimate the prognosis after the condition is stabilized.
4, lumbar puncture: can determine intracranial pressure and cerebrospinal fluid assay. Craniocerebral injury with subarachnoid hemorrhage can be released through lumbar puncture of bloody cerebrospinal fluid, and is also an important treatment tool.
5, cerebral angiography: has been less than the diagnosis of craniocerebral injury, but when suspected of vascular lesions should be timely application of the test. Without CT machine can determine the presence of hematoma according to the shape of the blood vessels.
6, other means of examination: ultrasound, electroencephalography, radionuclide imaging, etc. is not significant, rarely used directly in the diagnosis of craniocerebral injury.
Fourth, the principle of treatment
(A), treatment principles, reduce intracranial pressure and control cerebral edema to prevent brain herniation, reduce the increased blood pressure to prevent further bleeding.
(B) Conventional treatment
(1) general treatment; ① keep quiet, absolute bed rest, should be resuscitated locally, should not be transported long distance and too much moving, so as not to aggravate the bleeding; ② keep the respiratory tract unobstructed, suck out oral secretions or vomit at any time.
Give oxygen appropriately, intermittent suction is appropriate;
(3) Maintain nutrition and water-electrolyte balance.
(2) Control cerebral edema and lower intracranial pressure;
(3) Control hypertension, lowering the increased blood pressure is an important measure to prevent further bleeding, but it is not advisable to lower the blood pressure too low to prevent insufficient blood supply. Generally, it is appropriate to maintain the blood pressure at 20.0~21.3/12.0~13.3kpa (150~160/90~100mmhg);
(4) Hemostatic and coagulant drugs are not effective for cerebral hemorrhage, but can be used if combined with gastrointestinal bleeding or coagulation disorders;
(5) Prevention and treatment of complications, critically ill patients should especially strengthen basic care, gently change position at regular intervals, pay attention to dry and clean skin, prevent decubitus ulcers and pulmonary infections, paralyzed limbs should be kept in a functional position, massage and passive movement to prevent joint contracture;
(C), timely surgery, removal of bruises, Chinese medicine, acupuncture, massage therapy with the treatment, the treatment and rehabilitation has a certain effect.
1, for light craniocerebral injury patients should pay attention to the changes in the condition, and can stay in the emergency room, scalp injury debridement, suturing, etc., if necessary, symptomatic treatment and cranial CT examination. Moderate craniocerebral injury should be hospitalized, ready for surgery and ready for surgery. Severe craniocerebral injury, early surgery or take effective drug treatment methods to save brain herniation.
2, craniocerebral injury treatment can be divided into three stages: the acute phase (1 week after the injury), the transition period (1-2 weeks after the injury), the recovery period (3 weeks later). The primary purpose of treatment in the acute phase is to save the patient’s life, and to reduce and avoid secondary cranio-cerebral injury through emergency surgery and early appropriate drug treatment to improve the quality of patient’s survival, for primary brain injury is mainly symptomatic treatment and prevention of complications, but the existing medical measures do not change the primary injury. The transitional period should mainly pay attention to whether new changes in the condition appear, deal with them in time, and start rehabilitation treatment. The rehabilitation period is mainly for the rehabilitation treatment of complications and sequelae of brain injury.
3.The treatment of general craniocerebral trauma includes: surgical removal of hematoma, decompression, debridement, etc., dehydration treatment, application of hormones, subhypothermia treatment, neuroprotective and neurotropic treatment, anti-infection, systemic nutritional support, physical therapy, rehabilitation exercise, anti-seizure, skull repair, etc.
V. Care of cerebral hemorrhage
Cerebral hemorrhage is a common disease among middle-aged and elderly people, which is caused by the sudden increase of blood pressure, resulting in the rupture of microvessels in the brain and bleeding. In the site of the hemorrhage foci, blood can directly compress the brain tissue, causing cerebral edema around it, and in severe cases, secondary brain displacement and brain herniation.
The typical manifestations of cerebral hemorrhage are: sudden numbness, weakness or paralysis of the lateral limbs, when the patient often falls unprepared, or the objects in his hands suddenly fall to the ground; at the same time, the patient will also have distorted corners of the mouth, drooling, slurred speech or aphasia, and some have headache, vomiting, blurred vision, impaired consciousness, incontinence and other phenomena. When a patient has a cerebral hemorrhage, the family should provide emergency care.
1. Keep calm and immediately lay the patient down. Never rush the patient to the hospital to avoid road shock. You can tilt his head to the side to prevent sputum and vomit from being inhaled into the trachea.
2, quickly loosen the patient’s collar and belt, keep indoor air circulation, pay attention to warmth when it is cold and cooling when it is hot.
3.If the patient is unconscious and makes a strong snoring sound, it means that his tongue root has fallen down, use a handkerchief or gauze to wrap the patient’s tongue and gently pull it outward.
4.Cold towel can be used to cover the patient’s head, because the blood vessels contract when they are cold, which can reduce the amount of bleeding.
5.When the patient is incontinent, he/she should be treated in place and not move the patient’s body at will to prevent aggravation of cerebral hemorrhage.
6, the patient’s condition is stable on the way to the hospital, the vehicle should be as smooth as possible to reduce the bumpy vibration; at the same time, the patient’s head slightly elevated, and the ground to maintain an angle of 20 degrees, and always pay attention to changes in the condition
7. Patients need a quiet and comfortable environment, especially within 2 weeks of onset, should minimize visits, maintain a calm and stable mood, avoid various adverse emotional effects. 2. Absolute bed rest for 2 weeks, head can be gently turned to the left and right, should avoid excessive lifting or elevation of the head, limbs can be turned in bed in small increments, once every 2 hours, no need to be overly nervous. Urination and defecation must be carried out in bed, do not get out of bed to relieve themselves, to prevent the occurrence of re-bleeding accidents.
8, some patients will appear irritable, agitated symptoms, for such patients we will take the restraint belt, bed stall and other protective measures, which can prevent the patient to remove the I.V. tube or gastric tube, fall out of bed and other unnecessary accidents. Some family members may not be able to bear it, but we understand their feelings. Once the condition is stable and no longer irritable, we will immediately withdraw the restraint on the torso, but the bed stall still needs extra protection from time to time, especially for patients with air beds, to strictly prevent falling out of bed. We hope you can cooperate with us.
9.During the course of the disease, there will also be different degrees of headache, such as head distension, pins and needles-like pain, severe pain, etc., which are the most common symptoms. We will give reasonable treatment. As the disease improves, the headache will gradually disappear, so you do not need to be overly nervous and learn to distract yourself. If you still feel painful and cannot tolerate it during the treatment, please inform us in time so that the doctor can take a more effective treatment.
10. Elderly patients, with aging and high degree of brittleness of the heart and brain vessels, are prone to induce diseases due to seasonal changes. Long-term bed-ridden patients are prone to lung infections, and sputum is not easily coughed out. Drugs are used to expectorate sputum and strengthen turning and back patting to loosen and cough up sputum and reduce lung infections. Those who are unable to cough up sputum, take sputum aspiration measures and expect to cooperate.
11.Long-term bed rest, skin pressure for more than 2 hours, prone to bedsores, should strengthen turning. Massage the pressurized area to keep the skin clean and dry. Place the limb in a functional position to prevent deformity.
12, diet: to be nutritious, low-fat, light and soft food, such as eggs, soy products, etc.. For those who have difficulty in eating, head can be tilted to the side, feed slowly, avoid talking, prevent choking and suffocation.
13.Keep the stool open, eat banana, honey, more water, strengthen moderate turning, massage the abdomen to reduce constipation. Patients who have not relieved stool for several days or have poor defecation can use slow defecation agent to induce defecation. Do not hold your breath to prevent brain hemorrhage again.
14.Shake the head of the bed 10~15○ during the recovery period according to medical advice, and then gradually shake the head of the bed to semi-recumbent position according to the degree of tolerance and adaptation, ranging from 30 minutes to 1~2 hours per day.
15. Hypertension is a common cause of this disease. Take antihypertensive drugs on time and in quantity, and do not increase or decrease the dosage at will to prevent sudden rise and fall of blood pressure and aggravate the disease.
16.After discharge from the hospital, regular outpatient follow-up, monitoring blood pressure and blood lipids, and appropriate physical activities, such as walking and tai chi, etc.
Sixth, the sequelae of cerebral hemorrhage – recovery has the best trick
After treatment, some of the patients with cerebral hemorrhage saved their lives, but left the sequelae of hemiplegia, especially the patient’s hand, always like a clenched fist can not be broken. Our family ancestral trick, by pressing the nail root of the patient’s fingers, can make the hand stretch out, if pressed once a day, after pressing seven or eight times, even if the recovery is not the original good hand degree, free stretch is not a problem.
The specific method is: the operator, using the thumb nail of both hands, press the nail root of the patient’s affected hand. The requirement is that the pressure must be on the nail root, not on the nail flesh. The position is well found, a gentle force, the patient’s fingers then stretched out on their own, time should not exceed 30 seconds, if coupled with the idea is better. The operator and the patient both recite “the meridians are open, the cerebral blood vessels are open”. The order of pressure is: first press the nail root of the middle finger and thumb (once the finger is stretched out), then press the nail root of the index finger and ring finger, and finally repeat the pressure on the root of the middle nail with the root of the small nail, before and after a total of three times can be pressed.