Combined craniocerebral and maxillofacial trauma. Chapter vi combined injuries of the bones of the facial skeleton

Traumatic brain injury is combined (CTBI) if it is accompanied by damage to the skeleton and internal organs. This is a special type of traumatic pathology in which the organ that regulates all life activity - the brain - and the executive system suffer. According to our data, TBI occurs in 10% of victims.

The presence of extracerebral injuries accompanying traumatic brain injury not only significantly aggravates the patient’s condition, but also creates additional difficulties in diagnosis and surgical tactics. This is due to the emergence of mutual aggravation syndromes, severe pathological reactions in response to combined trauma, which have their own specifics, often manifest atypically, are difficult to correct and act as factors of secondary brain injury.

The situation is aggravated by the fact that all problems of the acute period often have to be solved against the background of impaired consciousness and vital functions, and within a short period of time.

This report will present the features of the clinical manifestations of TBI, diagnostic and tactical algorithms for various combinations of injuries. We consider this especially important for practicing doctors, since until now, even in large cities, assistance to such victims is not always properly organized.

In particular, teams of doctors on duty are not always staffed with all the necessary specialists: there is no neurosurgeon, general or maxillofacial surgeon, conditions are not created everywhere for round-the-clock operation of a computer or magnetic resonance imaging (CT, MRI) scanner, which entails the loss of precious time on calling consultants , clarification of the diagnosis.

The number of adverse outcomes remains high, reaching 60-70% for severe injuries. The situation may change for the better with the implementation of the federal program “Assistance to Victims of Road Traffic Accidents,” which provides for the organization of large, well-equipped and staffed trauma centers. But, firstly, this work is just beginning, and secondly, the causes of combined injury, in addition to road accidents, are falls from a height (about 30%) and household injuries (about 20%).

Our analysis of fatalities from traumatic brain injury showed that in almost half of the victims the injury was incompatible with life: severe, extensive contusions of the brain stem, massive crush injuries to brain tissue, ruptures of large vessels, parenchymal and hollow organs. The patients died in the first hours after the injury. In other cases, the causes of death were traumatic shock and blood loss, dislocation and infringement of the brain stem, fat embolism, purulent-septic complications of the lungs, brain and its membranes, and trophic disorders.

Diagnostic and tactical errors occur in large numbers not only at the prehospital stage, but also in surgical hospitals. The main mistakes at the prehospital stage: injuries to the organs of the chest and abdominal cavities, compression of the brain, fractures of the ribs, pelvis, and spine are not recognized; tracheal intubation and infusion therapy are not carried out according to indications.

In hospital settings, compression of the brain and intracavitary bleeding are often diagnosed with a delay, and therefore a decision on surgery is made belatedly. Intensive therapy in the postoperative period is not always adequate; this group of patients is the most promising in terms of optimizing the outcomes of severe TBI.

In accordance with the classification of TBI developed by us, which has become generally accepted, all patients can be divided into four groups depending on the ratio of the severity of the cranial and extracranial components of the injury. It is this factor that determines the characteristics of the clinical picture, diagnosis and surgical tactics.

• Group I- severe traumatic brain injury (moderate and severe brain contusion, brain compression, diffuse axonal damage) and severe extracranial injuries (fractures of the hip, pelvis, shoulder, both leg bones, spine, multiple fractures of the ribs, jaws, injuries to the thoracic and abdominal organs cavities, multiple extracranial injuries).
• Group II- severe traumatic brain injury and minor extracranial injuries (fractures of the bones of the hand, foot, nose, one of the bones of the forearm).
• III group- mild traumatic brain injury (concussion, mild brain contusion) and severe extracranial injuries.
• IV group- mild traumatic brain injury and mild extracranial injuries.

We emphasize that the concept of “minor injury” is very relative, since in combination with other injuries a mutual aggravation syndrome may appear, causing the general serious condition of the victim.

General reactions of the body to combined injury

Traumatic shock

According to our data, traumatic shock develops in a third of victims with TBI. It is most often recorded in patients of group I - 75% of cases, in patients of group III - 45% of cases. It is noteworthy that 15% of patients in group II with mild extracranial injuries experience shock reactions. If we consider that isolated traumatic brain injury is rarely accompanied by shock (1% of cases), a certain influence of even mild extracranial injuries, which in themselves are not shockogenic, becomes obvious. This is one of the manifestations of mutual aggravation of damage in combined trauma.

In the pathogenesis of traumatic shock, it is necessary to take into account several leading mechanisms.

• Acute blood loss- directly causes a decrease in the volume of circulating blood, which is realized in a decrease in minute volume of blood circulation, hypotension and a decrease in tissue perfusion, accompanied by their increasing hypoxia.
• Insufficient pumping efficiency of the heart- additionally helps reduce blood pressure. The causes are circulatory hypoxia of the heart muscle, cardiac contusions, as well as early post-traumatic endotoxemia. Often these reasons are combined. A decrease in blood pressure during traumatic shock can be caused by a circulatory, vascular factor.
• Pathological afferentation and the systemic action of inflammatory mediators formed in damaged cells become important in cases of extensive damage to soft tissues and bones. We emphasize that coma is not equivalent to anesthesia and does not prevent reactions to pain.
• Functional disorders, associated with a specific localization of damage (in particular, regulatory disorders, including vascular tone, brain function, damage to its stem sections, etc.) - make a significant contribution to the pathogenesis of traumatic shock.

It is acceptable to assume that direct damage to the nerve centers not only causes qualitatively new features in the manifestation of shock, but, apparently, creates additional prerequisites for its development due to disruption of the processes of functional regulation - adaptation and compensation in severe combined injuries.

They turn on almost simultaneously compensatory mechanisms, which for some time can support the vital functions of organs and systems.

These include:

• an increase in minute volume of blood circulation against the background of a decrease in circulating blood volume (CBV) due to an increase in heart rate;
• centralization of blood circulation by increasing the tone of peripheral vessels and internal redistribution of limited blood volume in the interests of organs experiencing the greatest functional load in an extreme situation;
• increasing the depth and frequency of external respiration as a mechanism to compensate for developing hypoxia;
• intensification of tissue metabolism in order to mobilize additional energy resources.

The actions of damaging and compensatory factors are complexly intertwined, and their ratio changes. At the same time, initially compensatory mechanisms, in the absence of early adequate treatment, acquire the opposite pathological direction, closing the “vicious circle” of pathogenesis.

A comparison of the known clinical picture of shock in injuries of internal organs and skeleton and in cases of traumatic brain injury allows us to assert that with combined trauma, the core of the clinical picture of classical traumatic shock is preserved, but it is often accompanied by atypical features caused by the craniocerebral component.

• Pale skin is a characteristic sign of traumatic shock. This is also typical for shock during traumatic brain injury, especially when there is blood loss. In other cases, the color of the skin may not change or there may be facial hyperemia, especially if the diencephalic parts of the brain stem are involved.
• Classic traumatic shock is accompanied by disturbances of consciousness, but it is preserved, the patient is only inhibited; with massive blood loss, there may be disturbances of consciousness up to stupor. The critical level of blood pressure at which consciousness is lost is 60-70 mm Hg. Art. With concomitant severe and moderate traumatic brain injury, there is necessarily a disturbance of consciousness up to coma, not associated with blood loss.
• Tachycardia and a drop in systemic blood pressure are characteristic signs of classic traumatic shock: the faster the pulse and the lower the blood pressure, the more severe the degree of shock. With traumatic brain injury, this situation is not so clear.

Let's consider what adjustments a traumatic brain injury makes to the picture of traumatic shock.

• With TBI, shock occurs with less severity of extracranial injuries.
• The erectile phase of shock during TBI is prolonged in time and therefore can be recorded more often in the hospital.
• Shock during TBI may be accompanied by a normal pulse rate or even bradycardia. In the first hours after injury, arterial hypotension, a cardinal sign of traumatic shock, may not be detected.

Apparently, different degrees of interest in certain parts of the brain sometimes explain the peculiar relationships between pulse rate and maximum blood pressure. Low pressure may correspond to a rare weak pulse or, on the contrary, to relatively normal or even elevated blood pressure - tachycardia. Therefore, the classification of traumatic shock based on the values ​​of maximum blood pressure and pulse rate (the lower the blood pressure and the faster the pulse, the more severe the degree of shock) is not fully acceptable for TBI.

• In contrast to classic traumatic shock, shock due to TBI may not result in a decrease in body temperature - it can be either normal or even elevated.
• Shock during TBI can be accompanied by various focal neurological symptoms caused by damage to the cranial nerves, brainstem, cortex and subcortical areas.

The stated differences in shock during TBI emphasize the practical importance of the concept of “shockogenic injury”, showing that there are no typical signs of shock, however, the nature of the injury (fractures of long tubular bones, pelvis, damage to internal organs) may indicate the possibility of its development. The absence of any one or even two typical signs of classic traumatic shock is not a basis for its exclusion.

Blood loss and anemia

Blood loss and anemia are the second important factor in the chain of life-threatening pathological reactions in TBI. Of course, shock and blood loss cannot be considered in isolation; they are inextricably linked with each other. The magnitude and rate of blood loss determine the degree, persistence and duration of shock reactions, and the effectiveness of intensive care. It is known that with first degree shock, blood loss is about 0.5 l, second degree - 1 l, third degree - 2 l or more.

With TBI, blood loss is observed in almost all patients: intracavitary with injuries to internal organs, interstitial with fractures of skeletal bones, and also external with injuries to the soft tissues of the torso and the integument of the skull. Approximate estimate of blood loss in skeletal trauma: fracture of the bones of the forearm - 0.3-0.6 l, shoulder - 0.6 l, lower leg - 0.8-1 l, hip - 1.8 l, pelvis - 1.5-3 l.

According to our observations, hemoglobin (Hb) upon admission of the patient to the hospital is below normal values ​​in only 10% of victims, and even then, half of them have grade I anemia (Hb - 90-100 g/l). Only with a dynamic examination, most often after a day, and in some patients - after 5-7 days, a progressive drop in Hb is noted.

The increase in anemia during dynamic observation is due to a number of circumstances:

• firstly, sometimes a delayed reaction of red blood to bleeding;
• secondly, the relatively slow rate of interstitial blood loss during fractures of skeletal bones and internal bleeding during small tears of parenchymal organs;
• thirdly, surgical interventions performed on the chest, abdominal cavities, and skull are sometimes accompanied by additional blood loss.

This must be taken into account when assessing the severity of injuries and planning intensive care.

Fat embolism

In case of traumatic brain injury, one should keep in mind the possibility of fat embolism, which significantly aggravates the condition of the victim, creates additional difficulties in assessing the severity of the traumatic brain injury, and can lead to pulmonary complications and cerebrovascular accidents. The causes of fat embolism are most often fractures of the pelvic bones, hips, and multiple injuries to the musculoskeletal system.

Fat embolism is more common than diagnosed. To one degree or another, it is present in all fractures, but clinically significant fat embolism is found in only 1% of cases. Motor agitation and inadequate immobilization during fractures of the limbs contribute to its development. More often it occurs on the 3rd-5th day after the injury, and then it is necessary to differentiate it from traumatic brain injury, in particular with brain compression, due to the similarity of some clinical signs of these conditions.

Our analysis showed that the following factors can serve as the leading demarcation points between fat embolism of cerebral vessels and traumatic compression of the brain.

• Persistence of headache and vomiting with compression of the brain and their frequent absence with fat embolism of cerebral vessels.
• Relatively gradual secondary shutdown of consciousness after a light interval with compression of the brain and sudden shutdown with fat embolism of cerebral vessels.
• Tendency to bradycardia, arterial hypertension, low-grade fever, predominance of rhythm disturbances in breathing disorders due to compression of the brain and tachycardia, fluctuations in blood pressure, hyperthermia, tachypnea without rhythm disturbance in fat embolism of cerebral vessels.
• Frequent increase in cerebrospinal fluid pressure and blood in the cerebrospinal fluid during traumatic brain injury; normotension and colorless cerebrospinal fluid in case of fat embolism of cerebral vessels.
• X-ray of the lungs with fat embolism reveals diffuse small- and medium-spotted merging opacities.

The detection of petechiae on the skin, fat in the urine, and retinopathy in the fundus makes the diagnosis of fat embolism undeniable. However, it should be taken into account that they appear only 1-3 days after the disaster.

Clinical picture of combined traumatic brain injury

Features of clinical manifestations, diagnostic and surgical tactics largely depend on the location of extracranial injuries. Features of the clinical picture of traumatic brain injury combined with damage to the facial skeleton include:

• the possibility of severe external respiration disorders caused by occlusion of the respiratory tract;
• frequent severity of traumatic edema and facial deformation, making it difficult to adequately assess the function of the cranial nerves;
• frequent expression of frontobasal syndrome due to selective contusion of this area;
• predominant localization of intracranial hematomas and hydromas in the anterior hemispheres;
• predominant localization of depressed fractures in the frontal bone with frequent damage to the frontal sinuses;
• relatively common possibility of pneumocephalus; frequent damage to the eye, ear, tongue, as well as peripheral branches of the trigeminal and facial nerves;
• the possibility of massive blood loss due to damage to the branches of the external carotid artery;
• constant threat of liquorrhea and meningoencephalitis due to direct communication of the paranasal sinuses with intracranial contents in fractures of the base of the skull, frequent development of traumatic sinusitis;
• peculiar long-term asthenohypochondriacal and asthenoapathic conditions in the long-term period of craniofacial trauma, caused by cosmetic facial defects.

Craniofacial trauma occurs in 7% of patients with traumatic brain injury, and according to dental authors, brain injury of varying severity is recorded in almost all patients with fractures of the facial skeleton.

When compression of the brain is combined with severe chest trauma, breathing disorders dominate the clinical picture. Against the background of a deep disorder of consciousness, recognition of rib fractures is difficult. Even with a targeted examination, they cannot always be identified. Lung damage is determined when subcutaneous emphysema or blood is detected during pleural puncture. Craniothoracic trauma occurs in 22% of victims.

In case of severe traumatic brain injury combined with trauma to the abdominal organs, in unconscious patients, the main clinical signs of damage in the abdominal cavity are obscured: the pain reaction on palpation of the abdominal wall disappears or is significantly weakened, and symptoms of peritoneal irritation during peritonitis are not detected. The pulse rate and blood pressure may not correspond to the degree of blood loss and shock. In turn, against the background of blood loss and shock, it can be difficult to assess the severity of the traumatic brain injury.

In a stuporous state of consciousness or stupor, deep palpation of the abdomen can cause a facial reaction to pain or motor restlessness in the victim.

When assessing abdominal symptoms, it should be borne in mind that a number of diseases, as well as brain injury, can simulate the picture of an “acute abdomen.” Dynamic observation allows to exclude damage to the abdominal organs. Typically, the “acute abdomen” syndrome in the absence of damage to the abdominal organs is short-lived. Cranioabdominal trauma occurs in 12% of victims.

With combined injuries to the brain and spinal cord, it is extremely difficult to distinguish between cerebral and spinal symptoms, which are intertwined and layered on top of each other. Paresis of the limbs, asymmetry of tendon and skin reflexes, sensitivity disorders, anisocoria, nystagmus, bradycardia, breathing disorders, etc. lose their uniqueness.

Meningeal symptoms in craniovertebral injury are the result not only of irritation of the meninges, but also of reflexive, antalgic sparing of the injured areas of the spine. Even such a reliable sign of traumatic brain injury as the presence of blood in the cerebrospinal fluid, with simultaneous injuries to the spine, can be a consequence of spinal subarachnoid hemorrhage.

Differential diagnostic difficulties with craniovertebral injuries are often aggravated by traumatic shock. Its course in this case is especially severe. Along with the pain factor and pronounced cerebral disorders, it is aggravated by spinal shock, early development of trophic disorders, additional intoxication, as well as segmental damage to the function of internal organs.

With craniovertebral injuries, there are few symptoms that allow one to confidently identify a traumatic brain pathology. Essentially, only long-term deep loss of consciousness, disturbances of speech and other higher cortical functions, a characteristic set of craniobasal symptoms, liquorrhea and skull fractures detected on radiographs with high accuracy indicate brain damage.

Spinal cord injuries with impaired consciousness are even more difficult to recognize. The following signs can serve as more or less reliable criteria:

• participation of only the diaphragm in the act of breathing, even in patients in a comatose state, is a criterion for damage to the cervical spinal cord;
• the presence of tetra- or paraparesis with low tone with preservation of brainstem reflexes (pupillary, corneal, swallowing, etc.) indicates spinal pathology;
• the fact of damage to the thoracic spinal cord becomes very likely when muscle tone is dissociated, when it has an extrapyramidal color in the upper extremities, and in the lower, against the background of paraparesis, is sharply reduced.

Non-participation in motor excitation or a generalized convulsive seizure of certain limbs can be regarded as an indication of the spinal or radicular genesis of paresis. When hemiparesis is combined with Horner's symptom, damage to the cervical spinal cord is very likely.

After a patient with craniovertebral injury emerges from a comatose state, the possibilities for distinguishing between cerebral and spinal traumatic pathologies expand. Sometimes radicular pain syndrome is detected, as well as conductive and segmental sensory disturbances, reflex and motor disorders characteristic of spinal cord lesions. Disturbances of urination and defecation of the spinal type are noted. With parasagittal localization of a contusion or compression substrates, urinary retention is also sometimes observed, but unlike a spinal lesion, it is shorter (usually no more than 2-3 days).

With severe damage to the substance of the spinal cord, trophic disorders appear early in the form of bedsores, “cold” edema, etc.

Let us emphasize one more, albeit variable, difference between spinal disorders and cerebral ones - the frequent symmetry of the former with a clear level of transverse damage to the spinal cord and the frequent asymmetry of the latter. Craniovertebral injury occurs in 6% of victims.

In cases of severe traumatic brain injury and fractures of the extremities and pelvis, examination of patients and recognition of fractures in their extremity bones is difficult due to profound impairment of consciousness and motor agitation. The leading principle for recognizing lateralized focal brain lesions is violated - the principle of comparing the states of the motor, reflex, and coordination spheres in symmetrical areas of the limbs. Therefore, lesions of the cranial nerves and higher cortical functions are of decisive importance for the clinical diagnosis of the cranial component. Fractures of the bones of the limbs and pelvis occur in 46% of patients with TBI.

The main cause of diagnostic difficulties in combined traumatic brain injury (CTBI) is the polyetiology of disorders of consciousness: traumatic brain injury, shock and blood loss, fat embolism, multiple organ failure, etc., therefore, a thorough dynamic clinical examination should be supplemented by the use of hardware, instrumental and laboratory methods . The ideal method for diagnosing all existing injuries is Whole Body CT.

Emergency care for combined traumatic brain injuries

Based on the results of our own research and literature data, we have developed an algorithm for primary measures for severe TBI (see figure). Let's decipher some provisions of the algorithm.

When assessing the severity of the patient’s condition and injury, it should be taken into account that they are not always identical at the time of examination of the victim. For example, with intracranial hematomas formed against the background of a mild brain contusion, the patient’s consciousness and other vital functions can be preserved (“light gap”), and with small tears of parenchymal organs or with subcapsular damage, there may be no symptoms of internal bleeding.

A patient with a severe combined injury should be examined in the first minutes, preferably directly in the operating room, by several specialists: a resuscitator-anesthesiologist, a neurosurgeon, a traumatologist, a general surgeon, and, if necessary, a dentist.

It is important to quickly and simultaneously diagnose all existing injuries and identify the most life-threatening ones at a given moment. Doctors' attention is often focused on obvious, conspicuous injuries, such as severed limbs, and other equally serious injuries are missed.

In addition to a general clinical examination (level of consciousness, color of the skin and mucous membranes, state of external respiration, pulse rate and completeness, blood pressure, condition of the pupils, examination and palpation of the torso, abdomen, pelvis, limbs), direct visualization methods are used - CT, MRI, ultrasound, radiography, as well as ECG, catheterization of the bladder, puncture of cavities.

The recommendations of some surgeons and traumatologists to perform a lumbar puncture for diagnostic purposes should be considered erroneous. It is contraindicated until compression of the brain is excluded, as well as in shock and multiple injuries, especially since its implementation does not solve diagnostic problems, unless it confirms the presence of subarachnoid hemorrhage. The results of a blood test are extremely important, especially the hemoglobin content and hematocrit.

An assessment of the patient's condition and the severity of the injury, diagnosis of its localization should be carried out simultaneously with emergency treatment measures. These activities are carried out in the following sequence.

• The central vein or two large veins are catheterized, blood is taken for the necessary tests: hemoglobin, hematocrit, biochemical tests, coagulation and fibrinolytic systems. Anesthetizes the sites of fractures of the limbs.
• Adequate breathing is ensured by sanitation of the oral cavity and nasopharynx, an air duct is placed, the head (if the cervical spine is not damaged) is turned to one side, oxygenation is carried out with humidified oxygen, the head end is raised by 10-15°, a gastric tube is installed.
• If spontaneous breathing is inadequate, tracheal intubation is performed followed by mechanical ventilation. If it is impossible to intubate the trachea or occlusion of the respiratory tract, especially with concomitant maxillofacial and thoracic injuries, tracheostomy or conicotomy is indicated.
• At the same time, vigorous measures are taken to bring the victim out of shock, compensate for blood loss, and restore circulating blood volume (CBV). Prolonged arterial hypotension and anemia negatively affect the functioning of all organs and systems; the brain is especially sensitive to these pathological factors: cerebral circulation disorders and cerebral edema due to contusion and compression are aggravated many times over, which contributes to the development of ischemia, which is extremely difficult to treat. The quantitative and qualitative composition of infusion-transfusion therapy depends on the amount of blood loss.

The question of the volume of infusion-transfusion therapy for severe injuries and critical conditions continues to be discussed in the literature: what media should be transfused, in what quantity and pace, etc.? All transfusion media are divided into three groups: blood and its components, colloids, crystalloids.

Compensation for blood loss must be carried out based on the following principles:

• for blood loss of up to 1 liter, use crystalloid and colloid blood replacement solutions with a total volume of 2-2.5 liters per day;
• in case of blood loss up to 2 liters - replace the bcc with red blood cells and blood substitutes in a 1:1 ratio with a total volume of up to 3.5-4 liters per day;
• with blood loss exceeding 2 liters, the volume of blood volume is replaced mainly by red blood cells with blood substitutes in a ratio of 2:1, and the total volume of injected fluid exceeds 4 liters;
• when blood loss exceeds 3 liters, replenishment of bcc is carried out using large doses of red blood cells (in terms of blood - 3 liters or more), blood transfusion is carried out at a rapid pace into two large veins or into the aorta through the femoral artery.

Replacement of lost blood is most effective in the first two days. Adequate compensation of blood loss is combined with the use of drugs that stimulate peripheral vascular tone - dopamine 1.0-2.0 ml of 0.2% solution in 400 ml of 5% glucose solution at a rate of 40-50 drops per minute. Along with this, in order to stabilize hemodynamics, glucocorticoids, disaggregants and rheologically active drugs are used.

If heart failure develops, limit infusion and transfusion therapy to 2-2.5 l/day. Polarizing mixtures are used (400 ml of 10% glucose solution with the addition of 16 units of insulin, 50 ml of 10% potassium chloride solution, 10 ml of 25% magnesium sulfate solution). For progressive heart failure, inotropic support with dopamine (5-15 mcg/kg/min) is carried out, if necessary, in combination with nitroglycerin or isoket.

In case of concomitant severe traumatic brain injury and after eliminating compression of the brain, the following intensive care measures are carried out:

• infusion therapy in the mode of moderate hydration with a total volume of up to 3 l/day using crystalloid solutions, 30% glucose solution (38 units of insulin per 250 ml with a total volume of 500-1000 ml), reopolyglucin or reogluman; with the development of cerebral edema, dehydration is carried out using saluretics (Lasix - 60-100 mg), osmodiuretics (mannitol - 1 g/kg body weight in the form of a 6-7% solution), oncodiuretics (albumin - 1 ml/kg).
• complete central analgesia by intramuscular administration of fentanyl - 0.1 mg 4-6 times a day, droperidol - 5.0 mg 3-4 times a day, intravenous administration of sodium hydroxybutyrate - 2.0 g 4 times a day.

The goal of infusion-transfusion therapy for severe traumatic brain injury is not only to replenish blood loss, blood volume, and remove the victim from shock, but also to prevent and relieve cerebral edema, cerebral circulatory disorders, and secondary trauma with the development of ischemia.

At the institutes named after N.N. Burdenko and N.V. Sklifosovsky in recent years has specifically studied the effect of both traditionally used and new solutions for infusion therapy in patients with brain damage. Interesting and practically important data were obtained that will help more adequately plan intensive care in the acute period.

It has been established that in the absence of occlusion of the cerebrospinal fluid pathways or after eliminating compression of the brain, most of the infusion solutions discussed above can be successfully used in the acute period to relieve arterial hypotension and intracranial hypertension; the rate of their administration is not of fundamental importance. You should only limit the use of a 5% glucose solution, which can contribute to an increase in intracranial hypertension, as well as saluretics that do not significantly reduce intracranial pressure.

For the purpose of dehydration, it is advisable to prescribe mannitol - 1 g/kg for 2-3 days; long-term use can lead to hypovolemia, which is especially dangerous in case of combined injury.

In the presence of occlusive hydrocephalus, ventricular drainage, infusion of hyperosmolar saline solutions, and mannitol are effective. In the absence of ventricular drainage, active infusion therapy contributes to the progression of intracranial hypertension.

Israelyan (2006), studying the effect of new infusion solutions in neurosurgical patients, came to the conclusion that voluven and especially gelofusin are able to quickly increase blood volume and effectively correct hypovolemia. The hyper-HAES solution at the beginning of the infusion can aggravate the increase in intracranial pressure and also lead to a drop in blood pressure, so its use in severe combined trauma in the acute period is ineffective.

The most important place in the treatment of severe TBI belongs to surgical interventions. Despite all the correctness and indisputability of the generally accepted statement that surgical interventions to stop bleeding, eliminate respiratory disorders, prevent dislocation and infringement of the brain stem, and the development of peritonitis are anti-shock and vital measures, and therefore must be carried out urgently, their use should always be specified according to attitude towards each patient.

Very difficult questions arise about the timing, sequence and scope of interventions. There can be no template or standard approaches here. We should agree with V.A. Sokolov (2006) is that any additional aggression, in this case surgical trauma, can be fatal in a weakened, bleeding patient, so everything must be carefully weighed and thought out. For example, external bleeding from wounds, including when limbs are torn off, can be temporarily stopped with a tourniquet or clamp in the wound or by suturing it, and final surgical treatment is performed after stabilization of hemodynamics.

Trepanation of the skull for depressed fractures, small intracranial hematomas, areas of crushing of the brain can be delayed for several hours or even days, if there are no increasing signs of intracranial hypertension, dislocation of the trunk, and according to CT data - a significant displacement (more than 5 mm) of the midline structures, rough deformations of the basal cisterns.

If the lung is damaged, there is also usually a reserve of time, during which the patient is treated conservatively and which is used to replenish blood loss and blood volume.

A situation where the slightest delay in intervention is really fraught with the rapid death of the patient occurs, as a rule, in two cases: with massive intra-abdominal bleeding and with a rapidly growing clinical picture of compression and dislocation of the brain. In these situations, under the cover of infusion-transfusion therapy, a laparotomy is performed, hemostasis is achieved, then a craniotomy is performed, the compression substrate is removed and the wounds on the skull and abdominal wall are sequentially sutured.

Such tactics are consistent with modern views, in particular those promoted by the Hanover School (1990). This step-by-step surgical tactics for polytraumas is called “damage control”.

There are three main components in the treatment of severe TBI:

• combating disturbances in vital functions and severe pathological reactions in response to injury;
• treatment of direct cranial and extracranial local injuries, prevention of complications;
• restorative treatment, labor and social rehabilitation.

The division of therapeutic measures into the indicated stages is purely conditional. They are closely intertwined, and, for example, surgical interventions on the skull and brain, chest and abdominal cavities, and limbs, carried out at the first stage, are the beginning of subsequent rehabilitation.

Once the diagnosis is made, surgery is usually performed. In this case, additional blood loss occurs (intraoperative), to which a victim with a long history of previous bleeding is especially sensitive.

Treatment of victims with acute blood loss, especially those in a state of shock, includes surgery and urgent restoration of the optimal volume of blood volume. The choice of treatment tactics depends on the specific disorders and severity of the victim’s condition, the duration of bleeding and the amount of blood loss, and the effectiveness of the body’s compensatory defense mechanisms.

When providing emergency care to patients with combined trauma, it is necessary to adhere to a number of fundamental principles:

• Early start of treatment measures at the prehospital stage - during the first “golden hour”.
• Simultaneous diagnosis of all injuries at the hospital stage using instrumental methods: radiography, including cisternography, excretory urography, echoEG, ECG, puncture of cavities, laparocentesis, laparoscopy, cystoscopy, CT, MRI, biochemical tests.
• Combination of diagnostic measures with emergency treatment. Examination of the patient simultaneously by several specialists directly on the operating table. Surgical interventions, minimal in scope, with the sole purpose of saving the life of the victim.
• Early implementation of delayed operations aimed at eliminating the syndrome of mutual aggravation of injuries - this means osteosynthesis for fractures of long tubular bones, stabilization of the spine, etc.
• Proactive treatment of disability and complications. Generalized wound infection is prevented by actively searching for and eliminating unsanitized foci of destruction, using modern detoxification methods (hemosorption, plasmapheresis, enteral lavage with enterosgel, mufosal, etc.).
• Step-by-step implementation of reconstructive surgical interventions and rehabilitation. At the first stage, measures aimed at normalizing external respiration and blood circulation are paramount.

Correction of external respiration and gas exchange

TBI is always accompanied by disturbances in the function of external respiration due to a violation of central regulation, as well as obstruction of the upper respiratory tract with mucus, blood, gastric contents, retraction of the root of the tongue and lower jaw, which are the reasons for the aggravation of primary brain hypoxia and the development of intracranial hypertension.

Early tracheostomy is indicated for combined maxillofacial trauma and the impossibility of tracheal intubation. In some cases, conicotomy followed by high-frequency mechanical ventilation is recommended. However, it should be remembered that such mechanical ventilation is possible with preserved spontaneous breathing (RR of at least 12 per minute) and the absence of obstruction of the trachea and main bronchi.

In cases of laryngo- and bronchospasm and inadequate breathing under anesthesia, tracheal intubation is performed, followed by mechanical ventilation, aimed at maintaining adequate gas exchange, eliminating hypoxia and hypercapnia.

Indications for pulmonary ventilation are:

• deep coma (Glasgow Coma Scale - 8 points or less);
• apnea or ineffective breathing (breathing rate less than 12 or greater than 35 per minute);
• pathological types of breathing (Kussmaul, Biot, Cheyne-Stokes);
• CTBI (with injury to the facial skeleton and/or chest);
• single or multiple seizures accompanied by periods of apnea;
• hypoxia and/or hypercapnia (pO2<75 мм рт. ст., рСО2>45 mmHg Art.).

Mechanical ventilation is carried out in the mode of normoventilation or moderate hyperventilation (pCO2 - 30-35 mm Hg), first with liquid oxygen, and then with an air-oxygen mixture of 30-50%. In recent years, it has been established that long-term use of severe hyperventilation (pCO2 25 mm Hg) to relieve the rise in intracranial pressure worsens the outcomes of brain contusion.

Correction of circulatory disorders

The fight against circulatory disorders includes the transfusion of anti-shock fluids and stopping external and internal bleeding. It is advisable to start with an intravenous drip infusion of polyglucin. At this time, the diagnosis is clarified, external bleeding is stopped and the issue of laparotomy, thoracotomy, craniotomy is decided to stop internal bleeding and eliminate compression of the brain.

A practically feasible scheme for the initial replacement of intravascular volume in case of blood loss is the rapid intravenous administration of 2 liters of crystalloid solution (lactasol, isotonic sodium chloride solution) through 2-3 veins in 20-30 minutes. This completely corrects hypovolemia with a blood loss of 10% of the bcc, if no further blood loss occurs, and will also significantly reduce the degree of hypovolemia with a blood loss of 20% of the bcc (1 l) and improve the patient’s condition.

More severe blood loss is not completely amenable to such treatment, but the need for it is obvious. Absence or insufficient response to an infusion of 2 L of crystalloid solution indicates blood loss reaching or exceeding 1 L, and usually requires transfusion of donor blood and continued administration of plasma expanders. In a person with a body weight of 70 kg and an initial hematocrit of 40%, a loss of 1400 ml of blood requires the administration of 4.2 liters of crystalloid solution. At the same time, by the end of infusion therapy, the hematocrit decreases to 30%.

Basic provisions that determine surgical tactics

In case of traumatic brain injury, regardless of the severity of brain damage, transfusion of blood and anti-shock solutions is indicated in the amount necessary to fully compensate for blood loss and stable normalization of hemodynamic parameters.

The previously existing opinion that blood transfusion and the introduction of fluids into the body are contraindicated in cases of severe traumatic brain injury is outdated and requires revision. Naturally, this means timely elimination of cerebral compression and infusion-transfusion therapy against the background of dehydration.

Surgical interventions to normalize breathing (tracheostomy), stop bleeding (laparotomy, thoracotomy, amputation of crushed limbs), and eliminate increasing compression of the brain are necessary in the complex of anti-shock therapy and are carried out urgently.

Severe clinical decompensation is caused by impaired airway patency, ongoing intracavitary bleeding or peritonitis, and increasing compression of the brain. Therefore, along with transfusion and infusion therapy, surgical intervention is indicated. Only in these cases can it interrupt the deepening of decompensation and prevent a complete breakdown of compensatory mechanisms.

The order of surgical interventions is determined depending on the degree of danger of the injury to the life of the victim. In case of compression of the brain and intra-abdominal bleeding, laparotomy is first performed, then craniotomy. In case of open fractures of the limbs, hemothorax without its noticeable increase, first of all, craniotomy is performed, and then operations on the limbs and treatment of hemothorax.

At the second stage of treatment, more attention is paid to the elimination of local damage itself and the prevention of cranial and extracranial complications. As for the craniocerebral component of the injury, during this period drugs are prescribed aimed at reducing intracranial pressure, or therapy for brain collapse is carried out. Drugs are administered that improve cerebral circulation and prevent inflammatory complications.

They decide on the method of final fixation for fractures of the jaws, limbs, and spine. We give preference to methods of strong and at the same time less traumatic immobilization, which make it possible for early and definitive treatment of fractures (craniomandibular or craniomaxillary fixation for fractures of the upper and lower jaws, the Ilizarov apparatus for fractures of the tibia, metal osteosynthesis for transverse fractures of the femur, tibia, etc. ). At the second stage of treatment, infusion-transfusion therapy is continued to compensate for blood loss and detoxification.

The third stage includes a full range of rehabilitation treatment: medication, physiotherapy and sanatorium-resort.

In case of craniofacial trauma, due to the predominant localization of hematomas, hydromas and crush areas in the frontal lobes, craniotomy should be performed in such a way that it is possible to revise the anterior parts of the hemispheres, including the poles of the frontal lobe. When applying search burr holes in order to exclude intracranial hematoma, one should begin with trepanation in the anterior frontal-basal region.

When developing a treatment plan for a victim with a craniofacial injury, it is necessary from the first hours to resolve issues related not only to the craniocerebral component, but also to the maxillofacial component. The basic principle regarding injuries to the facial skeleton is early splinting of the jaws, and, if indicated, early surgical intervention.

At the first stage of treatment, the primary tasks are normalization of external respiration, recovery from shock, and stopping bleeding. During this period, in case of jaw fractures, only temporary immobilization is carried out using a sling bandage or Ivey ligature. Solve diagnostic and surgical problems in connection with brain compression.

Splinting of the jaws and intermaxillary fastening is carried out after the compression of the brain has been eliminated, breathing and hemodynamics have normalized (usually after 3-5 days). For fractures of the lower jaw, dental splints made of aluminum wire with hooking loops are applied; for bilateral and multiple fractures, intermaxillary fastening is carried out. For jaw osteosynthesis, the use of titanium miniplates is effective.

The most severe contingent are victims with brain compression and brain contusion of the third degree, combined with multiple injuries to the facial skeleton. After normalization of breathing and blood circulation, elimination of compression of the brain, the issue of final fixation of the jaws is resolved. For fractures of the lower jaw, dental splints are applied. In case of simultaneous fracture of the upper and lower jaws, surgical methods of fixation are preferable.

Among the existing methods of surgical fixation for fractures of the upper jaw combined with traumatic brain injury, the method of Vigneui and Billet (1963, 1970), modified at the Nizhny Novgorod Neurosurgical Center, has undoubted advantages, in which the upper jaw is fixed to the cranial vault - craniomaxillary fixation. After applying diagnostic burr holes or craniotomy for depressed fractures or intracranial hematomas, an additional small hole is placed below the edge of the bone defect using a dental bur. A stainless steel wire with a cross-section of 1-2 mm is inserted epidurally and its proximal end is twisted between the edge of the trepanation window and the additional hole.

Using a long hollow needle with a straight cut, the distal end of the ligature wire is brought down under the temporal muscle, zygomatic arch into the oral cavity in the area of ​​the transitional fold of the mucous membrane. The assistant “meets” the needle in the oral cavity and pulls it out, pulling it off the ligature wire. The distal end of the wire is attached to a dental splint, which is applied before or after craniotomy. A similar operation is performed on the other side.

With a simultaneous fracture of the lower jaw, a dental splint is used to apply an intermaxillary rubber traction, carried out after the patient recovers from a serious condition (on the 2-5th day). The ligature wire is removed after 4-5 weeks. To do this, the place where the wire is fixed to the bones of the skull is exposed, the wire is cut, and its cranial end is removed. The rest of the ligature wire is pulled out and removed through the oral cavity.

This method is technically simple, provides sealing of the brain skull, and has advantages over other methods in cosmetic terms. And most importantly, with its help, the problems of eliminating brain compression and treating fractures of the facial skeleton are simultaneously solved.

We have also developed a fundamentally new type of jaw fixation for traumatic brain injury, protected by an author’s certificate - craniomandibular fixation. The indications for this operation are the same as for craniomaxillary fixation. After craniotomy, a wire with a damper spring is lowered into the oral cavity and attached to a dental splint previously placed on the lower jaw.

Craniomandibular fixation eliminates the need for bimaxillary splinting using rubber traction - this is more hygienic and less traumatic, as well as a more functionally adequate method. Craniomandibular fixation ensures simultaneous fixation of the lower and upper jaws, sealing of the brain skull, and correct bite in central occlusion.

To identify a chest injury, it is necessary to pay attention to the presence of the following signs: increasing shortness of breath, cyanosis, increasing tachycardia, the presence of subcutaneous emphysema, swelling of the neck veins, puffiness of the face, asymmetry and limitation of respiratory excursions of the chest, hemoptysis, bloody sputum, tympanitis and dullness of percussion sound on the side of injury, the absence or sharp weakening of respiratory sounds, dullness of heart sounds, the presence of flotation of sections of the chest wall and paradoxical breathing, deformation and severe pain in places of fractures of the chest (crepitation of bone fragments is possible).

Deformation of the chest is characteristic of multiple double rib fractures. With fenestrated fractures, paradoxical movements of a section of the chest wall occur in the area of ​​damage. When the sternum is fractured, its bayonet-shaped deformation is visually and palpated; these changes are also visible on lateral radiographs of the chest.

The most important in diagnosing breast injuries are x-ray examination, ultrasound examination, pleural puncture, and thoracoscopy. Bronchoscopy, bronchography, and esophagoscopy are less commonly used.

An X-ray examination of the chest should be performed for all victims with concomitant trauma: they identify fractures of the chest bones, the presence of fluid and air in the pleural cavity, the degree of collapse of the lungs, pulmonary atelectasis, expansion of the boundaries and changes in the configuration of the cardiac shadow, expansion of the boundaries of the mediastinum, the presence of subcutaneous emphysema and emphysema mediastinum. It should be remembered that rib fractures in the cartilaginous part (and in some projections in the bone part) may not be detected.

The X-ray picture is more informative when the study is performed in an upright position of the patient. However, this is not always possible, especially in patients with severe traumatic brain injury. In this situation, pleural puncture becomes important.

Recently, ultrasound has become increasingly popular in chest trauma. This method allows you to identify foreign bodies (including radiopaque ones), the presence of gas and liquid in the cavities, assess the functional state of the heart, its valve apparatus, and the condition of the aorta.

Bronchoscopy is indicated for suspected bronchial rupture, foreign body entry, or aspiration of vomit. In addition to diagnostics, sanitation of the tracheobronchial tree is achieved. Nevertheless, bronchoscopy in an emergency situation is performed quite rarely (airway obstruction is dealt with by an anesthesiologist-resuscitator or a tracheostomy is applied), and is more often used in a delayed period.

In specialized departments, thoracoscopy is performed to diagnose breast injuries. In patients with concomitant trauma (especially in a state of shock), it is done only in cases of unclear diagnosis after other examination methods. Thoracoscopy is possible when the patient’s hemodynamics and breathing are relatively stable. It is of great importance in case of diaphragm injury, hemopneumothorax, suspected bronchial rupture, and for removing clotted blood from the pleural cavity. Thoracoscopy is especially widely used in the treatment of various post-traumatic complications and, first of all, coagulated hemothorax and pleural empyema.

Massive hemothorax - the rapid accumulation of a significant volume of blood in the pleural cavity - is accompanied by hypovolemic shock and impaired ventilation of the lungs due to compression of the organs of the chest cavity. The main sources of bleeding can be the heart, mediastinal vessels (aorta, inferior vena cava, paired and semi-gyzygos veins, vessels of the root of the lung), subclavian artery and vein, internal mammary artery, intercostal arteries and veins.

Indications for surgical treatment are large and total hemothorax with signs of ongoing bleeding, according to clinical data and pleural puncture. The classic radiological sign - fluid level above the fifth intercostal space (middle of the scapula) with the clinical picture of intrapleural bleeding - should guide the surgeon to perform a thoracotomy.

Small and medium hemothorax should be treated conservatively - remove the blood by pleural puncture and establish dynamic monitoring of the patient. If clinical signs and control radiographic data indicate re-accumulation of blood in the pleural cavity, it is necessary to perform drainage of the pleural cavity.

If an abdominal injury is suspected, radiography of the abdominal cavity is advisable; it can be performed with the patient standing and lying on his back or healthy side (laterogram). This reveals free gas in the abdominal cavity, which indicates damage to the hollow organ. The detection of retroperitoneal “emphysema” (retroperitoneum) on radiographs indicates a retroperitoneal rupture of the duodenum. The absence of clear contours of the kidney may indicate a retroperitoneal hematoma. In addition, displacement of the shadows of the abdominal organs into the pleural cavity may be detected when the diaphragm ruptures.

Ultrasound examination of the abdominal and thoracic cavities in case of abdominal trauma should be a screening method; this non-invasive examination takes little time, is highly informative, and can be performed without additional transportation of the patient. This reveals free fluid in the abdominal cavity, hematomas of parenchymal organs and retroperitoneal space.

An abdominal ultrasound can be performed in almost any setting and for any condition of the patient. In some cases, this study is carried out in an operating room with simultaneous intensive care. However, this study must always be performed before laparocentesis, because air or fluid introduced for diagnostic purposes distorts the data.

The simplest, most accessible method for examining the abdominal cavity is laparocentesis. Its use is considered mandatory in patients with TBI in a state of shock, cerebral coma, when the mechanism of injury does not exclude damage to the abdominal organs, with an unexplained decrease in blood pressure and progressive anemia, multiple fractures of the pelvic bones, and suspected thoracoabdominal injury.

Laparoscopy is a more complex study, but its informativeness reaches 98%. There are reports of a reduction in the number of unnecessary laparotomies for penetrating injuries of the abdominal organs and closed injuries when using laparoscopy. Sometimes diagnostic laparoscopy can become therapeutic, which eliminates the need to perform an “open” laparotomy. In some cases, laparoscopy is complicated by the inability, due to the severity of the patient’s condition, to insufflate a large amount of air and perform torso rotations with concomitant injuries to the ribs, spine, and hips. The value of the method is undeniable for subcapsular hematomas of the liver and spleen, for the diagnosis of hematomas in pelvic fractures. Difficulties arise when interpreting the causes of retroperitoneal hematoma (damage to the duodenum, kidneys, and pancreas may be missed).

One of the important aspects of the clinical examination of patients with craniovertebral injury is the dynamics of neurological spinal disorders, determined according to the ASIA scale (1996), where a score of neurological disorders is given every day - this can determine the form of spinal cord damage and its dynamics.

In case of spinal injuries, precautions should be taken during intrahospital transportation, when transferring the patient, and positioning him on the operating table. Particular care is needed when the fracture is located in the cervical spine. Avoid turning the head or throwing it back during tracheal intubation. When severe traumatic brain injury is combined with injuries to the spine and spinal cord at the cervical level, tracheostomy is preferable.

It should be noted that with fractures of the bodies and dislocations of the vertebrae, mainly anterior compression of the spinal cord occurs (in 90-95% of cases) and only in 5-10% of patients the compression of the spinal sac occurs by elements of the posterior semi-ring due to fracture of the arches, articular processes and their displacement towards the spinal canal. It is in this situation that laminectomy is indicated. MRI and CT myelography allow determining the location of the compressing substrate.

In case of anterior compression of the spinal cord at the cervical level by a broken vertebral body or a prolapsed intervertebral disc, the operation is performed using an anterior approach with removal of the vertebral body and adjacent discs. Anterior wedging spondylodesis is performed using an auto- or allograft, which must be supplemented by fixation of the spine with anterior locking plates.

When injuries are localized in the thoracic or lumbar spine, surgical tactics should be based on the need to decompress the spinal cord and restore stability and supportability of the spinal motion segment.

At the first stage of treatment of traumatic brain injury combined with fractures of the limbs and pelvis, the primary procedures are the elimination of airway occlusion and bringing the patient out of shock. Along with stopping bleeding and transfusion therapy, pain relief and immobilization are of great importance. During this period, the method of choice for fractures of the leg, femur, and shoulder is the application of a deep plaster splint, which ensures the patient’s mobility and the ability to perform additional instrumental diagnostic methods, as well as surgical interventions for depressed skull fractures and intracranial hematomas.

Other methods of fixation, in particular skeletal traction, are often unacceptable, since proper immobilization of the fracture is not achieved, especially in patients with motor agitation, and intrahospital transportation becomes impossible.

However, a plaster splint applied in the first hours after injury does not solve the problem of treating fractures, so reposition and final fixation of the injured limb must be performed in a timely manner. In some cases, after eliminating compression of the brain, while the patient is under anesthesia, an attempt may be made to reposition the fracture by fixing the limb with a plaster cast or performing osteosynthesis.

The success of treatment is associated not only with the elimination of compression of the brain, but also largely depends on the timing of fixation of fractures of the extremity bones. Operative stabilization eliminates endotoxicosis, eliminates excess afferent impulses, and ensures mobility of the victims. The method of fixing fractures must be simple, reliable and atraumatic. Extrafocal osteosynthesis fully meets these requirements - it is the most rational for combined trauma.

Of course, eliminating brain compression is a vital and emergency measure. However, it should be remembered that untimely treatment of limb fractures can cause various complications, significantly lengthen the treatment period, and sometimes lead to disability. Choosing the optimal period of active action regarding limb fractures is not always easy.

There are different opinions on this issue in the literature. Proponents of early (in the first hours and days) osteosynthesis for fractures of long bones combined with severe traumatic brain injury justify their tactics by the need for reliable fixation, allowing for patient care, effectively preventing respiratory distress syndrome, inflammatory, trophic, thromboembolic complications and simultaneously solve the problems of treating fractures, which ultimately reduces the period of disability. Other surgeons prefer to perform osteosynthesis delayed by 2-3 weeks.

We believe that both long-term postponement of surgical treatment of fractures of long tubular bones without sufficient grounds and the desire for too early osteosynthesis are equally unjustified. In this regard, criteria for the state of brain functions have been developed to determine the possibility of osteosynthesis for fractures of long bones combined with traumatic brain injury.

• Consciousness: its progressive restoration, including after elimination of cerebral compression, to moderate stupor or clarity.
• Breathing: free patency of the airways, no rhythm disturbances, severe tachypnea (more than 26 per minute) or bradypnea (less than 16 per minute).
• Pulse: no rhythm disturbances and severe tachycardia (over 100 per minute) or bradycardia (less than 60 per minute).
• Blood pressure: stability of systolic pressure (not lower than 110 mm Hg).
• Body temperature: no hyperthermia; low-grade fever not associated with inflammatory complications is not a contraindication to osteosynthesis.
• Blood parameters: accelerated ESR and increased levels of leukocytes in the blood, caused by disturbances in the central regulation of the blood system, do not serve as contraindications to osteosynthesis; Severe anemia is a temporary contraindication to surgery.
• Focal neurological symptoms: any, even severely expressed focal hemispheric and craniobasal symptoms that persist after elimination of compression of the brain or are caused by a contusion, are not in themselves a contraindication to osteosynthesis.
• Psyche: disorientation in place, time and situation, memory impairment, apathetic disorders, euphoria, decreased criticism of one’s condition, impaired control over the functions of the pelvic organs and other manifestations of frontal syndrome, psychomotor agitation in themselves are not contraindications to osteosynthesis. Traumatic delirium, amental twilight and oneiric states, developing like acute psychosis, can serve as a basis for postponing surgical intervention on the extremities.
• Fundus of the eye: congestive papillae of the optic nerves, which existed before the removal of brain compression and persisted after it, are not a contraindication to osteosynthesis.
• Lumbar puncture: cerebrospinal fluid pressure is not higher than 250-300 mm of water. Art., a small admixture of blood in the cerebrospinal fluid are not contraindications to osteosynthesis.
• Echoencephalography: tendency to redislocation of midline structures; M-echo displacement not exceeding 5 mm is not a contraindication to osteosynthesis.
• Electroencephalography: absence of gross cerebral and brainstem changes (dominance of slow activity, frequent, prolonged brainstem discharges), low-voltage dysrhythmia, desynchronization of cortical rhythms, individual brainstem discharges, focal changes caused by concomitant brain contusion or remaining after removal of intracranial hematoma are not contraindications to osteosynthesis .
• Computed tomography: the absence of substrates for brain compression, a tendency to redislocation of midline structures, and a decrease in the dynamics of cerebral edema confirm the possibility of performing osteosynthesis.

The optimal period for performing osteosynthesis is during the period of primary or short-term compensation (1-2 days after injury), transosseous is more often used. During the period of primary decompensation (3-8 days), it is better to abstain from osteosynthesis; it is performed in exceptional cases, more often - transosseous. During the period of stable compensation (9-21 days), osteosynthesis is used most often, both transosseous and submersible.

Taking into account the above criteria, the vast majority of patients with TBI can undergo osteosynthesis in the first hours/day. This applies to victims with a concussion, mild to moderate bruise. Indications for surgical treatment of fractures of long tubular bones, combined with severe contusion of the brain or its compression against the background of severe contusion, should be made with great caution. However, even in these cases, the desire for early stabilization of fragments is justified, which can be accomplished within an acceptable time frame - 1-3 days after injury.

In recent years, the tactic of operating simultaneously with two teams on different organs and systems has become increasingly widespread. There are arguments for and against this. In particular, V.A. Sokolov (2006) believes that the recommendations of some specialists to perform operations in two and three teams should be abandoned.

We have some experience in operating with two teams for severe traumatic brain injury combined with fractures of the limbs. We believe that in each specific case the issue should be resolved individually. Of course, simultaneous interventions have an advantage: the patient gets rid of repeated operations, treatment time is reduced, and complications are prevented. It is only important to carefully weigh everything: whether the risk of operations is justified, how vital they are at the moment, whether the patient will suffer additional trauma and blood loss.

In addition, operating simultaneously with two teams should not be taken in a literal sense. It is more expedient to somewhat separate the beginning of interventions, for example, craniotomy and osteosynthesis: an intracranial hematoma is removed or a depressed fracture is eliminated, hemostasis is achieved and at this time surgery on the extremities begins. “Exit” from operations, i.e. suturing of soft tissues can be carried out simultaneously.

A.P. Fraerman, N.V. Syrkina, O.V. Zhelezin

In 5% of deaths, the cause of mortality in the first 3 hours was swelling and dislocation of the brain. The severity of their condition on the Glasgow scale was 4-5. This indicates that for the development of not only cerebral edema, but also its dislocation, a long period of time (for many hours or days) is not necessary. These phenomena in the first 3 hours after injury usually developed in victims with intracranial traumatic hematomas in combination with foci of brain contusion, i.e. for very severe TBI (Fig. 25-10). Among the deceased, intracranial hematomas occur in 50-60% of cases (epidural - 10%, subdural - 77.5%, intracerebral - 15%). Hematomas of the posterior cranial fossa occur in 1.2% of victims, and hydromas in 5%. In 3.7% of such victims, intracranial hematomas are unfortunately not recognized. Only about 50% of victims usually undergo surgical removal of intracranial hematomas. This is explained either by the extremely severe condition (3-5 points on the Glasgow scale) of the victims, or by the small volume of the hematoma (up to 40 ml) not accompanied by symptoms of increasing compression of the brain, or by the fact that the victims are primarily operated on for ongoing bleeding from internal organs of the chest or abdomen.

Rice. 25-10. CT scan of the head 4 hours after injury. A subdural hematoma with a volume of 120 ml is determined in the right frontotemporo-commonal region. Displacement of the midline brain structures to the left by 14 mm. The right ventricle is compressed and grossly deformed. The left one is hydrocephalic. Signs of axial mixing in the form of a focus of edema in the right parietal-occipital region, which arose as a result of circulatory disorders in the vertebro- basilar pool with subsequent ischemia.

After 3 hours from the moment of injury, the severity of cerebral edema and its dislocation increases, which leads to an increase in mortality from 16.1% on the first day to 34.4% on the third.

Among patients with brain dislocation who died on the first day after injury, the lethal outcome depends on the magnitude of the displacement of the midline structures of the brain - the greater it is, the greater the likelihood of death. When the midline structures are displaced by more than 10 mm, mortality increases significantly. Thus, in acute subdural hematomas with a volume of more than 100 ml with lateral dislocation of the midline structures of the brain up to 10 mm, the mortality rate is about 16%. With lateral dislocation up to 15 mm, mortality increases to 80%, and with displacement from 16 to 27 mm, it reaches 90-95%. Mortality also depends on the type of hematoma - the greatest with subdural ones.

It is therefore obvious that the prevention and treatment of cerebral edema and dislocation must begin immediately upon admission of the patient. The main treatment measure is early, preferably before the development of dislocation, removal of a traumatic intracranial hematoma or a focus of brain contusion (if it behaves “aggressively”).

25.11.1. Diagnosis of craniocerebral injuries in combined trauma

It is especially difficult for fractures of the limbs, damage to the organs of the thoracic and abdominal cavities. In this case, paralysis and paresis can simulate fractures of long bones, and vice versa - bone fractures - paresis or paralysis. Transport or stationary immobilization in the form of plaster casts or skeletal traction also complicates diagnosis. Damage to the internal organs of the abdominal or thoracic cavities, rib fractures can distort abdominal reflexes and skin sensitivity. Damage to the heart and lungs can simulate damage to the brain stem. However, difficulties in establishing an early diagnosis of brain compression by intracranial traumatic hematoma are not an excuse for delaying surgical intervention. At the same time, when analyzing mortality due to combined TBI treated in a non-neurosurgery department and without involving a neurosurgeon in treatment, it turned out that in 44% of patients intracranial hematomas were not recognized and the victims were not operated on. Difficulties in diagnosing in-

^ Combined traumatic brain injury

We explain tracranial hematomas by the change in their clinical picture (compared to the “classical”) at the present time, especially in victims with combined TBI. This is due to an increase in the kinetic energy of the traumatic factor in the majority of victims (car injury, fall from a height, road accidents, weapon wounds, etc.).

Each patient with combined TBI, regardless of the existing neurological pathology (with the exception of patients who need to be operated on immediately, for health reasons, regardless of intracranial hematoma or damage to internal organs), must have a craniogram in two mutually perpendicular projections, as well as a spondylogram cervical spine.

Of course, echoEg is a mandatory method of instrumental research. If the clinical picture is unclear or EchoEg indicators are unclear, ultrasound location of the skull should be carried out dynamically. At the slightest suspicion of intracranial hematoma, the patient must undergo a CT scan of the head or, if this is not possible, angiography of the cerebral vessels. In the absence of serial angiographic devices, the study can be performed with a single image on a conventional X-ray machine in two projections by moving the X-ray tube and cassette (it is advisable to equip the cassette with a scattering grating).

In the absence of the specified diagnostic equipment, if a possible intraranial traumatic hematoma is suspected, they resort to the application of search burr holes, which are the last diagnostic and first surgical method for diagnosing and treating these hematomas. The scope of surgical intervention and its technical implementation do not differ from those adopted for isolated TBI.

When the lateral displacement of the midline structures of the brain is more than 10 mm, it is advisable not to limit the operation only to the removal of one hematoma, but also to remove the accompanying foci of brain crushing, brain detritus, i.e. carry out radical external decompression. It is advisable to add internal decompression in the form of expellation, tentoriotomy or falxotomy. Expedition is carried out in case of axial (most severe) displacement, confirmed by CT scan, and only if the pathological focus is completely removed (intracranial hematoma and the “aggressive” focus of brain contusion). For this-

Through a lumbar puncture, 80 to 120 ml of warm (36-37°C) Ringsr-Lokka solution or isotonic sodium chloride solution is injected into the spinal sac. Many people have observed a good clinical effect from exploitation. Exploration cannot be carried out BEFORE removing the pathological focus! According to our department (I.V. Kory-paev), in very serious condition of the patient, with a transverse displacement of the midline structures of the brain by more than 15 mm, after removal of acute intracranial hematomas, mortality ranged from 95.2 to 73.9% . When the hematoma was removed with subsequent expulsion in similar victims, the mortality rate decreased to 50%.

^ 25.12. DIAGNOSIS AND TREATMENT OF CRANIOFACIAL INJURIES

The frequency of combination of TBI with injuries to the facial skeleton is about 6-7% of all types of injuries and 34% among combined TBI, i.e. such injuries are quite common, which is due to the anatomical proximity of the brain and facial skull. The overwhelming cause of craniofacial injuries is road traffic trauma (59%). The most severe and frequent are fronto-facial injuries. Both a neurosurgeon and a dentist should be involved in the treatment of such patients.

Fronto-facial trauma refers to injuries accompanied by fractures of the frontal bone, bones of the anterior cranial fossa, ethmoid bone, nasal bones, upper surface of the orbit and various fractures of the upper jaw and nasal bones. As a rule, fractures of the skull bones occur at the site of application of traumatic force. The vast majority of fronto-facial injuries also occur when force is applied to this area. According to our observations, in approximately 1.5% of cases, fractures of the ethmoid bone or the upper surface of the orbit occur with a blow to the crown, and in 0.3-0.5% - to the back of the head. With gunshot wounds of the skull, when a bullet passes through the facial skeleton, in the area of ​​the maxillary sinuses, and nose, extensive damage to the roof of the orbit can occur both on the side of the wound and on the opposite side. In this case, a significant retrobulbar hematoma may occur, which is clinically accompanied by exophthalmos and often decreased vision or even atrophy of the eye. Cracks in the ethmoid bone may

^ Clinical guidelines for cranial injury

also occur in case of explosion injuries, due to a sharp drop in atmospheric pressure in the explosion zone.

The clinical picture of craniofacial wounds has a number of features. Thus, with fractures of the frontal bone and upper jaw, extensive swelling of the face and head usually occurs. This swelling can be so pronounced that it becomes really difficult or even impossible to examine the victim’s eyes. And such an examination is necessary to establish an eye injury and identify neurological symptoms of damage to the brain stem or cerebellum (nystagmus, exophthalmos, anisocoria, etc.).

Fractures of the nasal bones, ethmoid bone, and upper jaw bones may be accompanied by bleeding that is difficult to stop, in particular from the nose. In some cases, neither anterior nor posterior nasal tamponade is able to stop such bleeding. Then you have to resort to endovasal intervention - embolism of the branches of the external carotid artery supplying the nose with evalon or other microemboli. The operation is performed on both sides. However, this method may not be effective in some cases. In 1996, we observed a patient who eventually died from ongoing bleeding from the nose (due to a fracture of the nasal bones). Ligation of the internal carotid artery on one side in such cases is practically ineffective and extremely dangerous. Ligation of the internal carotid arteries on both sides almost always ends in the death of the victim.

Common fractures of the upper jaw bones (For-2, For-3) cause shock in almost 50% of victims. And with a fracture of the frontal bone, its arch and base in combination with fractures of the bones of the upper jaw and nose, macro- or microcerebrospinal fluid leakage occurs in 31% of patients. The development of facial rhea indicates that the existing damage to the skull is related to penetrating. In this case, there is a real threat of purulent meningitis.

Currently, with the use of the latest generation of antibiotics, the number of meningitis in acute liquorrhea, compared with the 70s, has decreased and amounts to 53.1%. At the same time, in 23.2% meningitis develops once, and in 76.8% - repeatedly. Curing meningitis does not indicate that the cause of its occurrence has been eliminated. There continues to be a real threat of its re-development. Moreover, the longer liquorrhea exists, the more often recurrent meningitis occurs. Features of the course and treatment

Nia liquorsi, prevention and treatment of purulent meningitis will be presented separately.

According to the degree of increase in the risk of liquorrhea, fractures are arranged as follows: fractures of the ethmoid bone, fractures of the upper jaw of type For-3, For-2, fractures of the nasal bones, fracture of type For-1. In a For-1 fracture, the fracture line runs horizontally over the alveolar processes, crosses the maxillary (maxillary) sinuses, the nasal septum and the ends of the pterygoid processes (Fig. 25-11). With a complete fracture, this entire conglomerate of processes descends downwards.

Rice. 25- 11. Lines (types) of fractures of the upper jaw. Explanation in the text.

In a For-2 fracture, the fracture line passes through the base of the nose, crosses the medial wall of the orbit, and then descends downward between the zygomatic bone and the zygomatic flap. Posteriorly, the fracture passes through the nasal septum and at the base of the pterygoid processes.

In a For-3 fracture, the fracture line passes through the root of the nose, transversely through both orbits, the edges of the orbits and through the arches of the zygomatic bones. With such a fracture, mobility of the broken fragment of the upper jaw along with the zygomatic bones is noted. Following the movement of this fragment, the eyeballs also move, which is not the case with a For-2 type fracture.

546

^

Patients with severe TBI and facial trauma are usually admitted in severe or extremely serious condition. Therefore, a detailed X-ray examination of them in the first days is impossible. Only craniograms are produced in 2 mutually perpendicular projections. After the elimination of a serious condition, usually on days 10-15 of TBI, clarifying x-ray studies are performed (if indicated, contact photographs of the skull, photographs in oblique projections, tomography of the anterior cranial fossa, etc.)

Treatment. First aid consists of eliminating or preventing breathing disorders, stopping bleeding, and carrying out anti-shock measures. Anti-shock measures also include fixation of a broken lower and upper jaw, which is achieved by applying Limberg or Zbarzh splints. Before the victim is brought out of shock, primary surgical treatment of wounds is unacceptable. Only resuscitation operations can be performed. Therefore, if the patient’s condition is serious, in the first 1-3 days the upper jaw is fixed using splints. Once the patient recovers from a serious condition, its final fixation is performed.

If the patient has not been operated on for a head injury and such an operation is excluded, then fixation of the jaw can be achieved by extraoral traction using a plaster cap or using metal structures. If the patient has been operated on, or surgery on the skull is not excluded, then such fixation cannot be used, because it will interfere with both the upcoming operation and dressings. Then fixation is carried out using the craniomaxillary method. To do this, 2 burr holes are placed in the frontotemporal region, located at a distance of 0.5-1.0 cm from each other. The “bridge” between these holes serves as a support for the ligature wire passed under it. The distal end of the wire is passed under the temporal muscle and zygomatic arch into the victim’s mouth at the level of the 7th tooth. A wire splint is placed on the teeth, to which the ligature inserted into the mouth is fixed. For For-3 type fractures, such manipulation is performed on both sides.

Frontofacial injuries may be accompanied by damage to the optic nerve. According to the literature, the frequency of such injuries ranges from 0.5 to 5% of all cases of TBI. According to our data, more than 30,000 observations of victims with TBI, damage to the optic nerve is much less common and amounts to hundredths of a percent. In case of damage to the visual

Nerve vision impairment usually occurs immediately. With the development of rstrobulbar hematoma, visual impairment can occur gradually, increasing, and then either regress to some extent, or completely, or vision is completely lost.

The difficulties in establishing the degree of vision loss, and even more so in studying the visual fields of a victim in the acute period of TBI, are determined by his unconscious state, inappropriate behavior, and inability to contact the patient. Due to these circumstances, the diagnosis of optic nerve damage is delayed until the patient’s condition stabilizes. At this time, surgical intervention to decompress the optic nerve is already overdue. However, even in those isolated cases when we were able to extract a fragment of the orbital wall from the wounded optic nerve 1-2 days after the injury, the operation was ineffective.

It is believed that at various times after TBI, the use of transcutaneous electrical stimulation of damaged optic nerves can improve visual function in 65% of patients. We used transcutaneous stimulation of the optic nerves in more than 100 patients operated on for optochiasmal arachnoiditis and in a few patients after damage to the optic nerves. We cannot say anything definite about the effectiveness of this technique.

When the walls of the air cavities (main sinus, ethmoidal labyrinth, frontal sinus, pyramidal cells of the temporal bones) are fractured, traumatic pneumocephalus may occur, which is an absolute sign of penetrating injury to the skull.

Bleeding from damaged bones and wounds of soft tissues of the face and skull, liquorrhea, increased secretion of mucus and saliva in the oropharynx and nasopharynx, vomiting pose a threat to aspiration or are accompanied by it. This requires immediate preventive and therapeutic measures. Intubation in such patients is difficult and sometimes impossible. Stopping bleeding from the nose, upper jaw and base of the skull can be quite difficult (see above).

The uniqueness of the clinical picture is complemented by injury to the poles of the frontal lobes of the brain that often occurs with such injuries. This leaves its mark on the patient’s behavior and makes it very difficult to treat and care for him. In the future, this can lead to asthenohypochondriacal or asthenoapathic personality changes.

^

To exclude acute traumatic intracranial hematoma, a patient with a combined craniofacial injury should be examined in the same way as a patient with an isolated TBI.

^ 25.13. DIAGNOSIS AND TREATMENT OF CRANIOBRAIN INJURY COMBINED WITH FRACTURES OF THE LIMB AND PELVIS

25.13.1. General provisions

In case of TBI combined with trauma to the organs of the chest, abdomen or retroperitoneal space, the timing of surgical intervention is determined by vital disturbances (bleeding, rupture of the hollow intestinal organ or stomach, lung damage followed by hemo or pneumothorax, etc.) and does not raise any doubts. Fractures of large tubular bones (femur, tibia), as a rule, are not accompanied by massive ongoing bleeding. By the time you arrive at the hospital, bleeding at the fracture site usually stops spontaneously. Removing such victims from shock is easier than when a TBI is combined with damage to internal organs against the background of ongoing bleeding. Therefore, it would seem that surgical intervention on broken bones of the extremities can be postponed for a long time (2-3-4 weeks). However, early (within the first 3 days) surgical interventions on broken limbs (osteosynthesis using various methods) are of great importance for the treatment outcomes of such victims. This is due to the fact that after 3 days from the moment of injury, among the causes of mortality (except for swelling and dislocation of the brain), such as pneumonia (37.9%) and cardiovascular failure (13.7%) increase, which later 3- x days from the moment of injury, the cause of mortality is already in 72.7% of patients (of all deaths).

For the prevention and treatment of TBI, trophic disorders, cardiovascular failure and, especially, pneumonia, the patient’s mobility within the bed is of great importance. Pneumonia in such patients mainly develops as a result of mechanical ventilation, preceding aspiration, or has a hypostatic genesis. The influence of aspirated masses on the development of the inflammatory process remains even with timely and

Complete sanitation of the tracheobronchial tree. A powerful factor in the prevention and treatment of trophic disorders, cardiovascular failure (except for drug treatment) in such patients is manual and vibration massage, physical therapy (active and passive). A complex of physical therapy can reduce the number of victims whose TBI was complicated by pneumonia by 10 percent or more.

To carry out bronchoscopy, intensive therapeutic exercises, lumbar punctures, vibration massage of the chest and back, the victim's lability in bed is necessary. Massive plaster casts, especially with various “spacers” in the form of plaster-plastered horizontal beams, especially skeletal traction, which is applied for fractures of the femur or tibia, sharply limit the freedom of the victim in bed, preventing him from turning on his sides. All this makes it difficult to carry out a number of therapeutic and preventive measures and routine hygienic care.

This also affects the development of pneumonia. Thus, in the group of patients (102 people) who were treated conservatively (skeletal traction) and whose mobility was severely limited, pneumonia developed in 23 (22.5%). In the group of patients who underwent early osteosynthesis (15 people), pneumonia did not occur in any of them (reliability P
The combination of TBI with fractures of the extremity bones complicates the course and prevents active treatment of both the TBI itself and the fractures of the extremity bones. Thus, motor excitation as a consequence of TBI not only increases brain hypoxia and increases its swelling, but can lead to the transition of a closed fracture to an open one, an uncomplicated fracture to a complicated one (secondary injury to the peripheral nerve, injury from bone fragments of blood vessels, the occurrence of muscle interposition, etc. ). Thus, one damage affects another, complicating its course.

Combination traumatic brain injury

25.13.2. Choosing a method

Fixation of limb fractures

The doctor is faced with the problem of rational fixation of the fracture in order to make the patient mobile. The solution to this problem is associated with determining the timing, volume and indications for surgical treatment (fixation) of fractures. If, with an isolated injury, local factors (type of fracture, its location, etc.) and the general condition of the body play a role in determining the indications for surgical treatment of broken limbs, then with a combined injury, the indications for surgery are also influenced by TBI - its nature, the severity of the patient’s condition, the condition of the patient. vital functions of the victim. In addition, certain requirements are also imposed on the fixation itself: such fixation must be very strong and not be disturbed by motor restlessness of the victim (motor restlessness itself is an indication, not a contraindication, to osteosynthesis surgery).

Intramedullary fixation of tubular bones with a metal rod is rational. Intramedullary osteosynthesis after corrected hypovolemic shock causes only temporary pulmonary stress. Therefore, primary intramedullary osteosynthesis of long tubular bones in patients with multiple trauma without lung damage can be used without fear of severe pulmonary disorders. However, such osteosynthesis is possible only for closed fractures of the femur and tibia, localized in the middle third and having a transverse or oblique fracture line. The number of such patients in the total number of victims with combined TBI is about 15%.

Mostly, the victims have complex comminuted fractures of long tubular bones, periarticular and intra-articular fractures. Here, in order to compare and firmly fix the fragments, a wide range of different plates, screws and pins and, of course, a highly qualified traumatologist are required. For such patients, it is better to use “surgical immobilization” of both closed and open fractures of any location using rod-based external fixation devices, which sufficiently firmly fixes complex comminuted fractures of long tubular bones (Fig. 25-12). To do this, through a puncture of the skin, at least two screw rods are inserted into the bone, above and below the fracture site.

Nei, the ends of which remain above the skin. By pulling along the length of the limb, displacement along the length and angular, and possibly also in width, is eliminated. The rods are then connected with a metal tube. Less desirable is compression-distraction osteosynthesis according to Ilizarov.

Rice. 25-12. External fixation rod device for comminuted femoral fracture.

With early fixation operations of long tubular bones, in addition to the prevention and adequate treatment of severe complications (bedsores, meningitis, pneumonia, etc.), treatment is significantly cheaper, its duration is reduced by at least a month, and disability payments are reduced.

Taking into account the characteristics of the patient’s condition with combined TBI (tendency to breathing problems or existing breathing problems, the special sensitivity of the damaged brain to hypoxia, motor agitation, lack of communication of the patient), osteosynthesis surgery is recommended to be performed only under anesthesia. Osteosynthesis must be early, durable and non-traumatic. In this case, hemostasis must be perfect, because Postoperative hematomas that arise in such patients, due to their decreased immunity, are prone to suppuration.

There are primary, early-delayed and late-delayed osteosynthesis.

Primary osteosynthesis includes osteosynthesis performed in the first 3 days after the injury.

Early-delayed - osteosynthesis, carried out within a period of up to 3 weeks, i.e. during the formation of fibro-osseous callus.

Late-delayed - osteosynthesis performed later than 3 weeks from the moment of injury.

^ Clinical Guidelines for Traumatic Brain Injury

Technically, performing primary osteosynthesis is less traumatic than early or delayed osteosynthesis. With the formation and development of fibro-osseous callus, osteosynthesis becomes more and more traumatic and is accompanied by large bleeding and soft tissue injury, which is associated with the release of bones from adhesions and destruction of fibro-osseous tissue in the fracture area. In this case, there may be significant bleeding and the operation requires blood transfusion.

Carrying out osteosynthesis on the first or second day is also favorable in that the operation is performed when the immunological background, protein and mineral metabolism, and trophic and inflammatory changes (bedsores, pneumonia, etc.) have not yet arisen. The most unfavorable time for osteosynthesis is 3-7 days after injury, because It is at this time that there is an increase in cerebral edema, its dislocation, instability of the general condition, a decrease in immunity, hemoglobin, etc.

During the same period, in patients with combined TBI, the so-called translocation (movement of bacteria from the intestinal contents to other environments of the body - blood, sputum, urine, etc.) is most pronounced. Normally, the preservation of the intestinal barrier function is carried out by lymphocytes, macrophages of the intestinal wall, Peyer's patches and Cooper cells of the liver. Various stress conditions and systemic disturbances of homeostasis, which is observed in victims with combined TBI, lead to damage to this barrier and increased permeability of the intestinal wall to bacteria and other toxic substances. Bacteriological studies of sputum, feces, urine, throat and stomach contents reveal microbiocetosis disorders, which are associated with a decrease in the body's resistance to the infectious agent. Under certain conditions, bacteremia observed in the blood can cause purulent complications in various organs (including the brain) and even the development of sepsis.

We analyzed 450 case histories of victims with TBI. Of these, 228 victims were treated conservatively and 252 surgically. The average number of days of hospital stay for primary and early-delayed osteosynthesis was 67.9, for late-delayed osteosynthesis - 117.4. The period of incapacity for work is respectively 200 and 315 days.

Disability due to limb injury with primary and early-delayed osteosynthesis was 8.6%, with late-delayed osteosynthesis - 11%, with

Conservative treatment - 13.8%. The severity of TBI was approximately the same in all groups.

^ 25.14. CRANIOVERTEBRAL TRAUMA

Simultaneous injuries to the skull and brain and the spine and spinal cord (craniovertebral trauma) are uncommon. However, victims with this type of combined injury are characterized by the particular severity of their condition, difficulties in diagnosis and development of surgical tactics.

Injuries to the spine and spinal cord are diagnosed in 5-6% of victims with traumatic brain injury. At the same time, TBI due to spinal trauma is observed in 25% of cases, ranking first among other combinations.

The causes of craniovertebral injury are most often motor vehicle accidents, falls from great heights, natural and industrial disasters accompanied by destruction and rubble.

Craniovertebral injury can be caused not only by separate direct effects of mechanical energy on the skull and spine, but also often when a traumatic agent is applied only to the head.

If you sharply straighten your head after a blow to the face or fall face down, a fracture of the cervical spine may occur simultaneously with a skull injury. When diving and hitting your head on the bottom, along with a brain injury (usually not severe), compression fractures and dislocations occur, most often of the C5-C7 vertebrae. Similar damage occurs when the head hits the ceiling of the cabin of a car moving on a bumpy road.

When large weights fall on the head, which is in a state of extension, along with severe traumatic brain injury, “traumatic spondylolisthesis” of the 1st cervical vertebra can occur. With direct blows to the parietal region, hemorrhages appear in the upper cervical part of the spinal cord, explained by the influence of acceleration forces. Motor vehicle accidents and rubble usually result in multiple injuries: along with head and spine trauma, fractures of the ribs, limbs and pelvis, and damage to internal organs are detected.

Determining the causes and mechanism of damage greatly facilitates diagnostic tasks.

Combined traumatic brain injury

25.14.1. Classification

The classification of cranial trauma is based on 3 principles: the localization and nature of the traumatic brain injury, the localization and nature of damage to the spine, spinal cord and its roots, the ratio of the severity of the craniocerebral and spinal cord components of the injury.

The classification of traumatic brain injury is well known, the classification of spinal cord injury is also generally accepted

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2015

Multiple fractures of the skull and facial bones (S02.7), Fracture of an unspecified part of the skull and facial bones (S02.9), Fracture of the lower jaw (S02.6), Fracture of the zygomatic bone and upper jaw (S02.4), Fractures of other facial bones bones and skull bones (S02.8)

Traumatology and orthopedics, Maxillofacial surgery

General information

Brief description

Recommended
Expert advice
RSE at the RVC "Republican Center"
healthcare development"
Ministry of Health
and social development
Republic of Kazakhstan
dated September 15, 2015
Protocol No. 9

Definition .

Combined craniofacial trauma (SCHLT). Concussion (CHM), Contusion (UGM) of the brain.

Combined injuries- is simultaneous damage to tissues or organs of several anatomical areas of the body by one damaging factor. Combined injuries of the maxillofacial area include trauma to the soft tissues or bones of the face, combined with traumatic brain injury.

Combined damage may be single, if it was caused by one wounding agent, or multiple, if there were two or more wounding agents. In turn, multiple injuries can be isolated, when damage caused by several wounding agents is observed in one anatomical area, and combined, when two or more anatomical areas are simultaneously affected by several wounding agents.

There is a relationship between the nature of facial bone fractures and the severity of damage to other areas of the body, primarily the severity of traumatic brain injury.

A feature of facial bone fractures is possibility of simultaneous injuries brain, peripheral branches of the nervous system, blood vessels, mandibular joint, tooth, soft tissues of the face and oral cavity. It has been established that injuries to the maxillofacial area are accompanied by changes in intracranial hemodynamics and functional shifts in the central nervous system, therefore this type of injury should be considered combined (UD - C).

Protocol name: Multiple (combined) fractures of the facial bones and skull bones. Combined craniofacial trauma.

Protocol code:

ICD-10 code(s):
S02.40 Fracture of the zygomatic bone and upper jaw - closed
S02.41 Fracture of the zygomatic bone and upper jaw - open
S02.60 Fracture of the lower jaw - closed
S02.61 Fracture of the lower jaw - open
S02.70 Multiple fractures of the skull and facial bones - closed
S02.71 Multiple fractures of the skull and facial bones - open
S02.80 Fractures of other facial bones and skull bones - closed
S02.81 Fractures of other facial bones and skull bones - open
S02.90 Fracture of an unspecified part of the skull and facial bones - closed
S02.91 Fracture of unspecified part of the skull and facial bones - open

Abbreviations used in the protocol:

ACT- aspartate aminotransferase;
ALT - alanine aminotransferase;
HIV - human immunodeficiency virus.
TMJ - temporomandibular joint;
MRI - magnetic resonance imaging;
CT - computed tomography;
Exercise therapy - physical therapy;
UAC - general blood test;
OAM - general urine test
ESR - erythrocyte sedimentation rate;
UHF - ultra high frequencies;
Ultrasound - ultrasound examination;
Ural Federal District - ultraviolet irradiation;
ECG - electrocardiogram;
ECHOCG - echocardiogram.

Date of development of the protocol: 2015

Protocol users: maxillofacial surgeons, emergency doctors, traumatologists, neurosurgeons .

Assessment of the degree of evidence of the recommendations provided.
Level of evidence scale:

A	High-quality meta-analysis, systematic review of RCTs or large RCTs with very low probability (++) of bias results.
IN	High-quality (++) systematic review of cohort or case-control studies or high-quality (++) cohort or case-control studies with very low risk of bias or RCTs with low (+) risk of bias.
WITH	Cohort or case-control study or controlled trial without randomization with low risk of bias (+).
D	Case series or uncontrolled study or expert opinion.
GPP	Best Pharmaceutical Practices

Classification

Clinical classification.
Multiple (combined) fractures of the facial bones and skull bones.Combined craniofacial trauma (CCFT).
A. Fracture of the zygomatic bone and upper jaw:
- Fracture of the zygomatic bone and arch.
- Fracture of the alveolar process of the upper jaw.
- Fracture of the upper jaw according to Le Fort - III.
- Fracture of the upper jaw according to Le Fort - II.
B. Fractures of the lower jaw:
- Fractures of the body of the lower jaw.
- Fractures of the lower jaw branch.
- Multiple fractures (body and branches) of the lower jaw.
B. Multiple fractures of the skull and facial bones:
- Fracture of the upper jaw according to Le Fort - I.
- Multiple fractures of the skull and facial bones with mention
intracranial injury.
D. Fractures of other facial bones and skull bones:
- Fracture of the alveolar process of the lower and upper jaws.
- Fracture of the palatine bone.
- Fracture of the anterior wall of the maxillary sinus.

Diagnostics

List of basic and additional diagnostic measures
Basic (mandatory) diagnostic examinations at the outpatient level when visiting a trauma center:
· radiography of the bones of the facial skeleton.
· UAC;

Minimum list of examinations that must be carried out when referring for planned hospitalization: none.

Basic (mandatory) diagnostic examinations carried out at the hospital level(in case of emergency hospitalization, diagnostic examinations not carried out at the outpatient level are carried out :
· UAC;
· OAM;
· Determination of blood group using the ABO system;
· Determination of the Rh factor of blood;
· biochemical blood test (protein, bilirubin, ALT, AST, glucose, thymol test, urea, creatinine, residual nitrogen)
· coagulogram (PTI, prothrombin time, INR, fibrinogen, APTT, thrombin time, ethanol test, thrombotest);
· CT scan of the bones of the facial skeleton;
· ECG.

Diagnostic measures carried out at the stage of emergency care:
· ECG.

Diagnostic criteria for diagnosis :
Complaints and anamnesis:
Complaints:
Pain and swelling in the soft tissue area;
· bleeding from the mouth and/or nose;
· dizziness, nausea, vomiting;
· dysfunction of chewing, swallowing, breathing, speech, vision.
Anamnesis:
· time and circumstances of injury;
Mechanism of injury:
· type of damaging agent;

Physical examination:
General inspection:
· asymmetry of the face due to swelling of soft tissues;
· abrasions, wounds, hematomas;
· symptom of “glasses” - hemorrhages in the conjunctiva, bruising and hematoma around the eye;
· symptom 3 “U” - (“lengthening”, “flattening” of the face, “surprised” appearance of the patient);
Bleeding from the mouth and nose;
· leakage of cerebrospinal fluid from the nose and ears due to a fracture of the base of the skull;
Limited and painful mouth opening;
· disturbance of sensitivity along the branches of the trigeminal nerve;
· malocclusion;
· violation of the integrity of the oral mucosa;
· profuse salivation.
Palpation:
pain in the area of ​​the fracture;
· mobility of fragments;
· positive symptom of “load”;
· positive “step” symptom, crepitus.

Laboratory research:
· CBC: low hematocrit due to blood loss, increased number of blood leukocytes - indicates an inflammatory process.
Taking into account the coagulogram

Instrumental studies:
· X-ray of the bones of the facial skeleton: violation of the integrity of the bones of the facial skeleton, changes in the proportions of the orbits, maxillary sinuses. Reduced pneumatization of the maxillary and frontal sinuses.
· CT scan of the bones of the facial skeleton: damage to the bone tissue of the face.

Indications for specialist consultation:
neurosurgeon - if there are symptoms of brain damage
· otorhinolaryngologist - in case of combined damage to the ENT organs;
· ophthalmologist - in case of damage to the walls of the orbit;
· traumatologist - for combined damage to skeletal bones;
· an anesthesiologist - resuscitator - in order to determine the tactics of anesthesiological care.
· consultations with other specialists if there is a concomitant
pathology.

Differential diagnosis

Differential diagnosis.

№	Nosology	Differential diagnostic signs
		Clinical	X-ray
1	Maxillary fracture	Facial asymmetry: lengthening of the midface, swelling in the middle third of the face and under the orbit. Symptom 3 "U" - (“lengthening, flattening of the face, surprised” appearance of the patient). The patient sometimes notes diplopia. Headache and local pain. Hemorrhage into the conjunctiva, bruises on both sides, “spectacles” symptom. Impaired function of chewing, breathing, vision. Possible leakage of cerebrospinal fluid from the nose (rhinorrhea, from the ears-otorrhea). Nosebleeds (very common) Pathological mobility of the entire middle third of the face. Exophthalmos, often enophthalmos, due to damage to the bones of the orbit. Loss of sensitivity in the zygomatic and maxillary areas. Pathological bite.	Violation of the integrity of the upper jaw, most often along the middle and lower line of the upper jaw LEFOR-1 and LEFOR-2, sometimes on one side of the face a fracture of the LEFOR-GUERIN type, as a rule, is determined by the dislocation of fragments down and back. In case of a fracture, according to LEFOR-1, broken tooth roots are often detected in the fracture gap. In case of fractures according to LEFOR-2 and LEFOR-3, fractures of other bones are determined (zygomatic bone, nose, bones forming the walls of the orbit, and sometimes the base of the skull). X-rays can detect hemosinus
2	Multiple (combined) fractures of the zygomatic bone and upper jaw. Fracture of the floor of the orbit. Fractures of other facial bones and skull bones	Facial asymmetry (smoothness of the zygomatic arch and nasolabial fold on the affected side). It is necessary to pay attention to the location of the zygomatic (bone) arch and the limitation of the range of movements of the lower jaw. Headache and local pain, nosebleeds, contusion of the eye on the affected side Loss of sensation in the area of ​​the nose, upper lip or zygomatic area is characteristic of a displaced fracture. Impaired chewing function due to difficulty moving the lower jaw. Symptom of “steps” on the affected side. Sometimes trauma leads to exophthalmos, enophthalmos, diplopia, and loss of vision. Bleeding into the conjunctiva, bruising and hematoma around the eye	A violation of the integrity of the zygomatic bone (arch) and the edge of the orbit is determined. In the “lunar” projection of the x-ray of the zygomatic bone, fracture lines, dislocation and violation of the lower edge of the orbit are determined. Recession of the zygomatic arch and limited movement of the lower jaw, confirmation of x-ray images, the main guidelines for differential diagnosis
3	Multiple (combined) fractures of the lower jaw	Facial asymmetry, soft tissue swelling, half-open mouth, hematomas of the floor of the mouth. Palpation: local pain, the fracture line can be palpated before swelling develops. Chewing, swallowing, breathing, speech dysfunction, change or loss sensitivity in the lower jaw area. Pathological occlusion (“stepped” dentition), a state of mobility or traumatic tooth extraction. Displacement of jaw fragments is often observed, which increases pain, bleeding, discomfort, and with significant displacement of fragments, the phenomenon of difficulty breathing. The saliva is often stained with blood (open fracture). Bleeding from the mouth, bleeding from the gums when trying to move the lower jaw.	A violation of the integrity of the lower jaw is determined, most often by the angle on the left or along the body; as a rule, the dislocation of fragments is determined. Often a broken or intact tooth (root) is identified in the fracture gap and double and triple lines of fractures are identified, sometimes dislocation of the broken articular head

Treatment abroad

Get treatment in Korea, Israel, Germany, USA

Get advice on medical tourism

Treatment

Treatment goals:
· final stabilization of the victim’s condition (elimination of pain, bleeding, absence and prevention of asphyxia, shock).
· elimination of dysfunction (reposition, immobilization, fixation of bone fragments).
· normalization of function (prevention of inflammatory complications).

Treatment tactics (UD-T).

PRINCIPLES OF TREATMENT OF FACIAL BONE FRACTURES WITH CTBI

Surgical methods are delayed until normal general condition is restored 10-12 days.
- If there is no progression of intracranial damage on days 5-7, you can use minimally invasive methods for fixing fragments of bones of the facial skeleton.
- For the first three days, temporary types of immobilization of facial bone fragments are used.
- Early immediate elimination of fractures (osteosynthesis) in patients with complex craniofascial injuries in the acute period.
- Open reduction and internal fixation of facial fracture fragments are important anti-shock measures.
- Creating an algorithm for the treatment of patients with combined injuries due to the diversity of the clinical picture, the general condition of the patients and local manifestations of injuries to the midface area, unfortunately, is practically impossible.

With regard to the adequate organization of emergency care and the participation of various medical specialists in the process of diagnosis and treatment of combined trauma of the maxillofacial area, we have developed an adequate working classification. Taking into account the complexity of organizing medical care for combined maxillofacial and craniocerebral injuries and, supplementing with abbreviations (OROT-orofacial trauma, OTOT-otolaryngological trauma, OFTAT-ophthalmological trauma), we propose an algorithm, a single-type classification system with an abbreviated form for filling out telemedicine documentation : We suggest marking a mild degree of injury in the documentation with the letter “L” and the sign “+” (“L +”). Average degree - (“C++”). Severe degree - (“T+++”).
And then, with combined maxillofacial trauma of varying severity and traumatic brain injury of mild severity (TBI-1), the proposed working modification of the CCLT classification will help determine the “addresses” of telemedicine diagnostics and assistance (see Appendix 04).

Non-drug treatment:
· The regimen for conservative treatment is general, in the early postoperative period - half-bed, with subsequent transition to general;
Diet taking into account the characteristics of childhood:
· For children under 3 years of age, a dairy diet.
· for children from 3 years of age and teenagers jaw diet.
· adults table No. 1, followed by transition to table No. 15.
· Patients with maxillofacial trauma are fed 5 times a day.
Special oral care.
· It is necessary to wipe the teeth and oral mucosa at least 3 times a day with a solution of furatsilin, potassium permanganate.
To clean your mouth, you should use toothbrushes with tufts cut alternately.
After splinting, you should thoroughly irrigate the oral cavity at least 6 times a day.
· rational psychotherapy from the moment the patient contacts until complete rehabilitation.

Drug treatment:
Drug treatment provided on an outpatient basis: No;

Drug treatment provided at the inpatient level:

№	Drug, release forms	Dosing	Duration and purpose of use
	Antibiotic prophylaxis
1	Cefazolin powder for solution for injection 500 mg and 1000 mg	1 g IV (children at the rate of 50 mg/kg once)	1 time 30-60 minutes before the skin incision; for surgical operations lasting 2 hours or more - an additional 0.5-1 g during surgery and 0.5-1 g every 6-8 hours during the day after surgery to prevent inflammatory reactions
2	Cefuroxime + Metronidazole Cefuroxime powder for solution for injection 750 mg and 1500 mg Metronidazole solution for infusion 0.5% - 100 ml	Cefuroxime 1.5-2.5 g, IV (children at the rate of 30 mg/kg once) + Metronidazole (for children at the rate of 20-30 mg/kg once) 500 mg IV	in 1 hour to the cut. If the operation lasts more than 3 hours again after 6 and 12 hours similar doses, in order to prevent inflammatory reactions
	If you are allergic to β-lactam antibiotics
3	Vancomycin powder for solution for infusion 500 mg and 1000 mg	1 g IV (for children at the rate of 10-15 mg/kg once)	1 time 2 hours before the skin incision. No more than 10 mg/min is administered; the duration of infusion should be at least 60 minutes in order to prevent inflammatory reactions
	Opioid analgesics
4	Tramadol injection solution 100mg/2ml, 2 ml in ampoules 50 mg in capsules, tablets	Adults and children over 12 years of age are administered intravenously (slow drip), intramuscularly at 50-100 mg (1-2 ml of solution). If there is no satisfactory effect, an additional administration of 50 mg (1 ml) of the drug is possible after 30-60 minutes. The frequency of administration is 1-4 times a day, depending on the severity of the pain syndrome and the effectiveness of therapy. The maximum daily dose is 600 mg. Contraindicated in children under 12 years of age.
5	Trimeperidine injection solution 1% in ampoules of 1 ml	1 ml of 1% solution is administered intravenously, intramuscularly, subcutaneously; if necessary, it can be repeated after 12-24 hours. Dosage for children over 2 years of age is 0.1 - 0.5 mg/kg body weight, if necessary, repeated administration of the drug is possible.	for pain relief in the postoperative period, 1-3 days
	Nonsteroidal anti-inflammatory drugs
6	Ketoprofen injection solution 100 mg/2ml in ampoules of 2 ml 150 mg extended-release in capsules 100 mg per tab. and cap.	The daily dose for intravenous injection is 200-300 mg (should not exceed 300 mg), followed by oral administration of prolonged capsules 150 mg 1 time per day, caps. tab. 100 mg twice a day	The duration of IV treatment should not exceed 48 hours. The duration of general use should not exceed 5-7 days, for anti-inflammatory, antipyretic and analgesic purposes.
7	Ibuprofen suspension for oral administration 100 mg/5 ml100ml; capsules, tablets 200 mg; granules for solution for oral administration 600 mg	For adults and children over 12 years of age, ibuprofen is prescribed 200 mg 3-4 times a day. To achieve a rapid therapeutic effect in adults, the dose can be increased to 400 mg 3 times a day. Suspension - a single dose is 5-10 mg/kg of the child’s body weight 3-4 times a day. The maximum daily dose should not exceed 30 mg per kg of body weight of the child per day.	No more than 3 days as an antipyretic No more than 5 days as an anesthetic with anti-inflammatory, antipyretic and analgesic purposes.
8	Paracetamol tablets 200 mg, 500mg; oral suspension 120 mg/5 ml; rectal suppositories 125 mg, 250 mg, 0.1 g	Adults and children over 12 years of age weighing more than 40 kg: single dose - 500 mg - 1.0 g (1-2 tablets) up to 4 times a day. The maximum single dose is 1.0 g. The interval between doses is at least 4 hours. The maximum daily dose is 4.0 g. Children from 6 to 12 years old: single dose - 250 mg - 500 mg (1/2 - 1 tablet) up to 3-4 times a day. The interval between doses is at least 4 hours. The maximum daily dose is 1.5 g - 2.0 g.	The duration of treatment when used as an analgesic and as an antipyretic is no more than 3 days.
	Hemostatic agents
9	Etamzilat injection solution 12.5% ​​- 2 ml	4-6 ml of 12.5% ​​solution per day. For children, a single dose of 0.5-2 ml is administered intravenously or intramuscularly, taking into account body weight (10-15 mg/kg).	If there is a risk of postoperative bleeding, it is administered for prophylactic purposes.
	Antibacterial drugs
10	Amoxicillin clavulanic acid(drug of choice)	Intravenously Adults: 1.2 g every 6-8 hours. Children: 40-60 mg/kg/day (for amoxicillin) in 3 doses.
11	Lincomycin(alternative drug)	Use intramuscularly, intravenously (drip only). It cannot be administered intravenously without prior dilution. Adults: 0.6-1.2 every 12 hours. Children: 10-20 mg/kg/day in 2 administrations.	With the development of odontogenic periostitis and osteomyelitis, the course of treatment is 7-10 days
12	Ceftazidime(when P.aeruginosa is isolated) or	Intravenously and intramuscularly Adults: 3.0 - 6.0 g/day in 2-3 injections (for Pseudomonas aeruginosa infections - 3 times a day) Children: 30-100 mg/kg/day 2-3 injections;	With the development of odontogenic periostitis and osteomyelitis, the course of treatment is 7-10 days
13	Ciprofloxacin(when P.aeruginosa is isolated)	Intravenously Adults: 0.4-0.6 g every 12 hours. Administer by slow infusion over 1 hour. Contraindicated for children.	With the development of odontogenic periostitis and osteomyelitis, the course of treatment is 7-10 days

Other types of treatment:
Other types of treatment provided on an outpatient basis: No.

Other types of treatment provided at the hospital level:
According to indications:
· antishock therapy according to the scheme, tracheal intubation with IVA.
· operation of manual reposition and immobilization of jaw fragments using dental splints;
· Physiotherapy;
· Magnetotherapy;
· Mechanotherapy;
· Exercise therapy.

Other types of treatment provided at the emergency medical care stage:
According to indications: - tracheal intubation with IVA, catheterization of central veins with infusion therapy, improvement of means of transport immobilization (see Appendix 01-03).

Surgical intervention:
Surgical intervention provided on an outpatient basis: is not carried out.

Surgical intervention provided in an inpatient setting:
· Open bone grafting [osteotomy] of the branches of the lower jaw - with an open fracture of the branch of the lower jaw.
· Closed bone grafting [osteotomy] of the branches of the lower jaw with a closed fracture of the branch of the lower jaw.
· Local excision or destruction of the affected area of ​​the facial skull bone - in case of small-fragmented fractures, when removing a tooth from the fracture line, excision of destructive areas of the bone.
· Excision and reconstruction of the bones of the facial skull - in case of displacement of fragments of a broken bone, in the formation of a defect and deformation.
· Other types of dissection of the bones of the facial skull - for impacted fractures of the bones of the facial skeleton.
· Open reduction of temporomandibular dislocation - for intra-articular dislocation fractures with displacement of fragments.
· Introduction of a synthetic implant into the bone of the facial skull - in case of displacement of fragments and in the formation of a defect in bone continuity.
· Bone graft into the facial skull bone - when a large defect is formed that cannot be repaired by conventional osteosynthesis.

Prevention of complications:
1. Coordinated work is needed teams of specialists:
maxillofacial surgeon, neurologist, neurosurgeon,
ophthalmologist, otorhinolaryngologist, dentist.
2. Surgical treatment should be carried out as early as possible, taking into account the patient’s condition. Timeliness of treatment.
3. Prevention of functional overload of the periodontium and masticatory apparatus.
4. Exercise therapy, physiotherapy, special hygiene, sanitation and prosthetics of the oral cavity.

Further management(see Appendix 05):
· dispensary observation by a maxillofacial surgeon - 2 times a year;
· control examination after 1-3,6,12 months;
· rational prosthetics after 6-8 months;

Indicators of treatment effectiveness:
· restoration of the integrity of the bone tissue of the facial skeleton;
· restoration of the patient’s physiological bite;
· restoration of jaw function;

Drugs (active ingredients) used in treatment

Hospitalization

Indications for hospitalization.
Indications for emergency hospitalization:
· Violation of the patient’s general condition (shock, coma, asphyxia, bleeding).
· Violation of the integrity of the jaw and facial bones as a result of injury;

Indications for planned hospitalization: No.

Information

Sources and literature

1. Minutes of meetings of the Expert Council of the RCHR of the Ministry of Health of the Republic of Kazakhstan, 2015
   1. List of used literature: 1. Denisov I.N., Shevchenko Yu.L., Kulakov V.I., Khaitov R.M. Clinical recommendations for practitioners based on evidence-based medicine. Geotar-Med, 2002. P.541-545. 2. Kurmangaliev Zulkazha Clinic and treatment of combined craniofacial injuries. Author's abstract. dissertation Candidate of Medical Sciences Kyiv, 1988, 15 p. 3. Kalinovsky D.K., Matros-Taranets I.N., Khaheleva T.N. Prospects for the use of digital computer technology and telemedicine in maxillofacial surgery // Ukrainian Journal of Telemedicine and Medical Telematics - No. 1, 2004, pp. 88-93. 4. Afanasyev V.V. Traumatology of the maxillofacial region Geotar-Med, 2010.-256 p.. 5. Batyrov T.U., Batpenov N.Zh., Urazalin Zh.B. Methodological recommendations. “Periodic protocols for the diagnosis and treatment of injuries of the facial bones” - Astana, 2006. , Valeev E.K., Grishin P.O., Ibatullin I.A., Dubeley O.V., Kreshetov E.V. The influence of complex pathogenetic therapy on the state of microcirculation in combined maxillo-cerebral trauma // Journal of Neurosurgery named after. N.N.Burdenko 1998.-N 1.-P.26-29 7. Kharitonova K.I., Rodyukova E.N. Immunological reactions of the body in traumatic brain injury, Novosibirsk, 1983, p.98-100. 8. Bernadsky Yu.I. Traumatology and reconstructive surgery of the cranial-maxillofacial region. - M.: Medical literature, 1999. - 456 pp.: ill. 9. Kulakov A.A., Robustova T.G., Nerobeev A. AND. Surgical dentistry and maxillofacial surgery. National leadership // A.A. Kulakov, T.G. Robustova, A.I. Nerobeev - M.: GEOTAR-MED, 2010. – 928 p.: ill. 10. Kharkov L.V., Yakovenko L.N., Chekhova I.L. Surgical dentistry and maxillofacial surgery of children / Under the editorship of L.V. Kharkov. - M.: “Book Plus”. 2005- 470 p. 11. Supiev T.K., Zykeeva S.K. Lectures on pediatric dentistry: textbook. manual – Almaty: Stomlit, 2006. – 616 p. 12. Zelensky V.A., Mukhoramov F.S., Pediatric surgical dentistry and maxillofacial surgery: textbook. – M.: GEOTAR-Media, 2009. – 216 p. 13. Pediatric dentistry. Surgery: textbook / ed. S. V. Dyakova. - M.: Medicine, 2009. -384 p. 14. Afanasyev V.V. Surgical dentistry - M., GEOTAR-Media., 2011, - P.468-479. 15. Clinical protocol for medical care for acute tissue trauma of the face, head and neck. Moscow 2013 16. Trunin D.A. Optimization of treatment of patients with acute trauma of the midface and prevention of post-traumatic deformities. dis. ... doc. honey. Sci. M., 1998. 17. REPORT “On research work

> Arterial hypotension and tachycardia are typical for shockogenic trauma.

> For TBI, on the contrary, there is arterial hypertension and bradycardia.

> Due to the multidirectional nature of the processes leading to the development of these symptoms, a victim with TBI often experiences the development of a syndrome of “imaginary well-being.”

In patients with mild TBI, in the vast majority of cases, there are no neurological complaints against the background of traumatic shock, which is explained by the later development of intracranial hypertension due to shock, compared with isolated TBI. At the same time, due to severe systemic disorders leading to hypoxia, neurological symptoms, primarily the depth of consciousness disorders, can simulate a more severe TBI than in reality. The degree and duration of disorders of consciousness are directly related to the severity of TBI and, therefore, can serve as a reliable diagnostic criterion in victims with systolic blood pressure from 80 to 160 mm Hg. Art. A quick and easy way to assess a victim's level of consciousness is the Glasgow scale. The nature of shockogenic TBI can be reliably assessed only at the end of the acute period of TB. This makes it necessary at the prehospital stage to evaluate all victims with signs of neurological disorders, as well as based on information about the mechanism of injury, as patients with acute traumatic brain injury. Pronounced external signs of TBI include:

Signs of a fracture of the base of the skull (ear or nasal liquorrhea or hemolysinic liquorrhea, postauricular hematomas, bleeding from the ear in combination with facial asymmetry, the symptom of “glasses”);

Multiple fractures of the facial skeleton or fractures of the upper jaw;

Extensive (more than 30 cm2) subgaleal hematomas;

Extensive scalp wounds of the scalp;

Nosebleeds in the absence of external signs of damage to the skull or when hematomas (wounds) are localized in the occipital region.

There are two variants of traumatogenesis in road accidents, in which severe TBI may not be accompanied by external signs: an injury received by a person sitting in the car, subject to fixation with a seat belt; injury sustained by a motorcyclist wearing a helmet.

The main task of the prehospital stage for TBI is not an accurate assessment of the nature of the neurotrauma, but the identification of life-threatening syndromes and their immediate elimination. Most often, with TBI, emergency intervention is required by disorders of the external respiratory function, including due to aspiration of blood and vomit, bleeding from head wounds, and much less often - uncontrolled hypotension due to direct damage to the brain stem or cervical spine and spinal cord.

The primary measure for traumatic brain injury is fixation of the cervical spine with a transport splint. The fact that aspiration has already occurred is an indication for tracheal intubation, regardless of the indicators of external respiration function. When transporting patients with traumatic brain injury while breathing spontaneously, aspiration of vomit should be prevented by raising the head of the stretcher by 30°.

Stopping bleeding from head wounds in the prehospital stage is usually achieved by applying a pressure bandage. Treatment of TBI at the prehospital stage, as a rule, is nonspecific. Treatment of traumatic shock is a priority. The severity of TBI, including cerebral compression, is not an indication for limiting the volume of infusion therapy. On the contrary, elimination of hypoxia and improvement of hemodynamics prevent secondary aggravation of the severity of TBI. In severe TBI, intravenous administration of glucocorticoids (prednisolone up to 250 mg or dexamethasone 12-16 mg) is advisable. With regard to spinal injury, the most important thing is to suspect the possibility of damage to the spine, while the absence of paresis is not an exclusive criterion.

With a spinal cord injury, the victim may develop spinal shock, which is a redistribution type of shock. Peripheral vascular tone decreases approximately by half, and blood pressure decreases sharply. These patients have pink, dry, warm skin and may not have tachycardia. Providing assistance according to the traumatic shock protocol.

If damage to the thoracic spine is suspected, transportation is carried out in the supine position. If a fracture of the lumbosacral spine is suspected, the patient is transported in a supine position on a backboard or in a prone position. The main task during transportation of a victim with a clinical picture of a spinal fracture is to prevent damage to the spinal cord from a displaced vertebra or its fragments. It is advisable to use vacuum mattresses in victims with spinal injuries.

• | Email |
• | Seal

Combined traumatic brain injury (CTBI). Traumatic brain injury is combined if mechanical energy simultaneously causes extracranial damage.

The classification of combined traumatic brain injury is based on two principles:

1. localization of extracranial injuries (facial skeleton, chest and its organs, abdominal and retroperitoneal organs, spine and spinal cord, limbs and pelvis, multiple extracranial injuries;
2. the ratio of cranial and extracranial injuries according to their severity.

In case of TBI, systems that regulate body functions and executive functions are simultaneously affected. The pathogenesis of pathological reactions is based on the mutually aggravating influence of direct damage to the brain stem sections and factors such as pain afferentation, blood loss, fat embolism of the vessels of the lungs and brain, respiratory hypoxia, and intoxication.

Combined traumatic brain injury is complicated by shock in more than a third of cases. The erectile phase can be lengthened in time, so it is often recorded in a hospital. Shock due to TBI, in contrast to classic traumatic shock, can occur against a background of impaired consciousness, accompanied by bradycardia, severe disturbances in external respiration, hyperthermia, as well as focal neurological symptoms and meningeal signs.

In the diagnosis of all components of combined trauma, in addition to analyzing the dynamics of clinical symptoms, a modern instrumental complex is used: to recognize compression of the brain - EchoES, CT, carotid hypertension, etc., injuries to the abdominal organs - laparocentesis, laparoscopy, chest organs - radiography, ultrasound location, thermal imaging, etc.

In doubtful cases or in the absence of special equipment, it is necessary to resort to the application of search burr holes to exclude intracranial hematomas and diagnostic laparotomy if damage to the abdominal organs is suspected.

Treatment of combined traumatic brain injury.

Conventionally, it includes three main links.

1. Combating threatening disturbances of vital functions, bleeding, traumatic shock, compression and swelling of the brain. It is carried out urgently with all available measures, including surgical interventions. First of all, treatment is undertaken for those injuries and disorders of those functions that pose the greatest immediate danger to the patient’s life or interfere with the treatment of other injuries (intubation, tracheostomy, mechanical ventilation, blood transfusion and blood substitutes, stopping external and internal bleeding, craniotomy, laparotomy, thoracotomy, amputation of a crushed limb, etc.).

2. Treatment of local cranial and extracranial injuries and prevention of complications. It begins immediately after diagnosis with radical surgical interventions (osteosynthesis, laminectomy, plastic surgery, etc.) at various times - taking into account the tolerability of the operation depending on the general condition of the patient, the severity of brain damage and taking into account the permissible time limits for the operation in depending on the location and nature of the traumatic pathology (bone fractures of the upper and lower extremities, fractures of the vertebral bodies with and without compression of the spinal cord, jaw fractures, soft tissue defects of the face, etc.). A set of measures is being carried out aimed at preventing cerebral arachnoiditis and other consequences of TBI.

For craniofacial trauma, effective operations are craniomaxillary and craniomandibular fixation, which allow simultaneously removing the substrates of brain compression and ensuring sealing of the brain skull and stable fixation of fractures of the upper and lower jaw.

The treatment method for fractures of long tubular bones is selected taking into account the severity of brain injury and the location and nature of limb fractures. Preference is given to extrafocal compression-distraction osteosynthesis or metal osteosynthesis, which provides the possibility of adequate reposition and stabilization of fragments in the early stages, the patient’s mobility necessary for treatment (including surgical) damage to the skull and brain.

In case of severe brain contusion with disturbances in vital functions, operations on the extremities must be postponed for 2-3 weeks.

3. Medical and social and labor rehabilitation of victims with an emphasis on impaired functions. They begin to implement after the acute period of combined traumatic brain injury has passed and continue in outpatient conditions.