Subperiosteal hematoma of the head. A Clinical Guide to Traumatic Brain Injury

01.04.2020

Head injuries at birth result from mechanical forces during labor and / or normal or assisted vaginal delivery. Incorrect presentation, cephalo-pelvic imbalance, high fetal weight, use of forceps or a vacuum extractor, and the need for rapid delivery are major risk factors.

Head injuries at birth include brain injury (cerebral contusion, edema, heart attack, hemorrhage), intracranial accumulations of blood (epidural, subdural hematomas, and subarachnoid hemorrhage), skull fracture, and scalp injuries.

and) Subcutaneous hematoma... Subcutaneous hematoma (PC) is a diffuse, subcutaneous, extraperiosteal accumulation of fluid consisting of lymph and blood. It occurs when the scalp is compressed by the narrowed cervix, and is often associated with either premature discharge of amniotic fluid or oligohydramnios. The PC extends to the midline and beyond the suture lines, usually over several bones of the skull. The first segment of the head is usually affected.

Subcutaneous hematoma (PC) looks like superficial soft tissue edema with poorly discernible boundaries, crossing the suture lines. The skin may be discolored due to possible bleeding and bruising. PC is rarely associated with intracranial complications. It resolves completely and spontaneously in the first few days after birth, so imaging studies or treatment are usually not indicated. The skull maintains a normal outline.

b) ( subperiosteal hematoma). Cephalohematoma (CG) is the most common traumatic brain injury in newborns, occurring in 0.2-2.5% of live births. It is caused by bleeding from the periosteal veins (small vessels that cross the periosteum and communicate with the diploitic veins), which can be damaged during childbirth, especially if it is prolonged, or when using forceps or a vacuum extractor.

As a result of bleeding, the periosteum rises with subsequent subperiosteal accumulation of blood. CG is limited to sutures, since in infants between the bones of the skull, the periosteum is tightly adhered to the dura mater, and the diploitic veins of each bone are separate. CG looks like a well-circumscribed, fluctuating formation that increases after birth, becoming hard and tense on the second or third day of life. Parietal localization occurs most often. The scalp can move freely relative to the formation and is not discolored.

Cephalohematoma (CG) can be easily distinguished from PG or subgaleal bleeding because it does not extend beyond the sutures. The absence of pulsation and an increase in pressure with crying makes it possible to differentiate it from meningocele. CG can be associated with linear fractures of the skull (10-25% of cases) or with traumatic intracranial injuries. CGs are reabsorbed completely within 2-4 weeks to 3-4 months in more than three quarters of cases. Otherwise, it can persist and calcify. Calcification appears during the first weeks, sometimes mimicking a depressed skull fracture.

In this case, it is necessary to perform it for a correct diagnosis. With a significant accumulation of blood, CG can be complicated by jaundice due to hyperbilirubinemia arising from blood reabsorption, as well as anemia, especially when using a needle for taking a blood sample. Phototherapy and / or blood transfusion may be required. Percutaneous aspiration should be avoided due to the risk of infection and subsequent meningitis and / or osteomyelitis. The operation is indicated only for cosmetic purposes to correct the deformation of the skull after hematoma calcification.

in) Subgoneurotic hematoma (subgaleal bleeding). Subgaleal hematoma (PAG) is a rare but potentially fatal head injury at birth. It consists in hemorrhage into the space between the periosteum and the aponeurosis. This virtual space extends from the supraorbital rim to the neck, and a significant amount of blood can accumulate in the parotid region. Bleeding usually results from prolonged use of vacuum extraction or forceps.

The presence of coagulopathy significantly increases the risk. PAH looks like a fluctuating, soft mass that gradually develops within a few hours / days after birth. The hematoma can extend to the entire skull, crossing the sutures, but is more often limited to the occipital region. Growth can proceed without symptoms, leading to noticeable blood loss or even mass effect. Calcification is usually absent. Severe PAHs are detected immediately after delivery and can initiate hemorrhagic shock. Treatment for PAH actually consists of careful monitoring, including possible complications: anemia and hyperbilirubinemia. A pressure bandage may be used to limit the spread of the hematoma.

Like other head injuries, PAH is often associated (in 40% of cases) with other injuries, namely skull fracture and intracranial hemorrhage, which require neuroimaging to detect. The prognosis, however, depends on the degree of subsequent hypovolemia, and not on the accompanying traumatic injury.

Localized cranial deformity caused by calcified cephalohematoma (arrow).

A-B. Perinatal head injuries. A. Bilateral parietal cephalohematoma.
CT scan reveals subperiosteal fluid accumulation and concomitant cerebral edema with bruised foci of the occipital lobes.
B, C. X-ray of the skull in the anteroposterior and oblique projections determines the subgaleal accumulation of fluid and the accompanying divergence of the cranial sutures (arrows).

Periosteal injury occurs as a result of trauma. In this case, severe pain occurs, which sometimes has an overly intense character. In some cases, such trauma can lead to loss of consciousness.

This is due to the fact that there are many nerve endings in the periosteum, which lead to the occurrence severe pain... After a while, it can disappear, and after a few hours, it can appear again.

The periosteum of the lower leg is characterized by the following symptoms:

A bruise is formed due to hemorrhage of the injured vessels of the periosteum
A hematoma occurs after damage to large vessels, which leads to the inability to normally relax and contract muscles
The patient is unable to lean normally on the limb
There is swelling and swelling at the site of the impact

The hematoma under the skin gradually changes in color. First it is red, then green, and then it turns yellow. The term for such changes is about a week. A hematoma can be located in muscle tissue or in the shallow layers of the skin. If such a formation appears on the surface of the leg, then it is visible immediately, and deep ones appear gradually, after one to three days.

If a pain do not disappear after a blow for an hour, you should immediately take the victim to a medical facility. Such an injury may indicate that the patient has a cracked bone or a closed one.

First aid

As a first aid for a bruised periosteum, the shin is immobilized to the victim, then the small and large tibia is fixed using a splint made of materials that are at hand. When delivered to the trauma center, the patient must be in the supine position (it is best to deliver him to the medical facility without changing the position of the leg).

If the integrity of the skin has suffered and the patient has a wound, it is necessary to carry out antiseptic treatment. If the wound is not too deep, you can use alcohol, iodine, fucorcin, or brilliant green. If the subcutaneous fat layer is damaged, it is best to use more gentle means so as not to aggravate the injury: chlorhexidine, Mikosist or.

In no case should you use warm lotions and compresses, as well as warming ointments.

It is best to treat cold damage:

Food ice wrapped in plastic
Snow pack (must be clean)
A bottle filled with ice water

Applying cold - first aid for injury

In this case, the ice should not directly contact the skin. Experts recommend wrapping the cold product in a towel. From the cold, the vessels narrow, the pain sensations weaken and the injured place becomes less sensitive. In order to create an outflow of blood from the damaged area, you can elevate the lower leg using a chair, blankets or pillows.

If a fracture is ruled out in the emergency room, you can continue to apply ice at home. In this case, you should take a half-hour break. In addition, if there is a bruise of the periosteum, apply cold for no more than 20 minutes at a time.

After three days, warming manipulations can be performed that will help the hematoma dissolve. To do this, use a warm heating pad, anti-inflammatory and warming ointments, a warm foot bath, and a compress on alcohol.

It is allowed to apply a mesh of iodine, which is carried out along the gastrocnemius muscle and the front of the lower leg. The solution for application is prepared according to the following scheme: (5%) is diluted with alcohol or vodka in a ratio of 50 to 50. On the following days, the victim must comply with bed rest. Also, you can not overload the limb.

Bruise treatment

As the main treatment, a specialist in a medical institution, as a rule, prescribes anti-inflammatory drugs based on herbal ingredients, ibuprofen or heparin. In addition, he can prescribe Finalgon ointments, Troxevasin, etc.

With insufficient observance of hygienic rules by the patient, streptococcal or staphylococcal infection can get into the wound on the periosteum, which will lead to a purulent inflammatory process - phlegmon, without clear outlines. This formation can go to the periosteum itself, ligaments, joints and bone.

The inflammatory process in the bruised limb is distinguished by the following features:

Increased level
Nausea and headaches
Redness, pain and severe swelling in the affected area of \u200b\u200bthe lower leg

If the temperature rises significantly, you should definitely consult a doctor. In some patients, periostitis may appear - an inflammatory process in the periosteum, accompanied by not only high temperature, but also by pulsation in the lower leg.

When periostatitis or phlegmon occurs, anti-inflammatory and antibacterial therapy is performed in a medical institution. If the disease is not treated in time, this condition can develop into sepsis. In some cases, this is fatal. In order to prevent this from happening, it is necessary to thoroughly sanitize the wound surface.

Some situations may require a second visit to the doctor:

Elevated temperature
A burning sensation or heat in the affected area
The hematoma does not change in size for three days
Strong pain persists in the bruised lower leg for more than four days
Pus appears in the wound, it does not heal and gets wet
Pustules have formed on the surface of the lower leg or
The foot becomes numb or numb, its sensitivity becomes less

In the last listed case, there is a high probability that the victim has damaged nerve endings due to soft tissue injury. In this case, the specialist adjusts the course of treatment. In the future, so that such injuries do not appear anymore, the patient is recommended to wear non-slip comfortable shoes, as well as warm up well before sports training.

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Infantile head hemangioma on ultrasound

Infantile hemangioma is the most common vascular tumor of childhood. Absent at birth, becomes visible in the first weeks of life. The skin is the most affected organ, most often in the head and neck (60%) and trunk (25%). On ultrasound, a hypo- or hyperechoic formation is clearly delimited, the blood flow is markedly increased.

Picture. A 1 month old girl with a bump on the scalp, frontal bone on the right. Ultrasound shows a hyperechoic, hypervascular node within the scalp, measuring 2.2 * 2.0 * 0.5 cm.

Picture. A 4-month-old girl with a bump in the supraorbital region on the left. On ultrasound, a well-delineated hypoechoic hypervascular subcutaneous node, size 1.7 * 1.5 * 0.5 cm without bone lesion.

Epidermal cyst of the head ultrasound

Epidermoid cyst - refusal to completely separate the ectodermal surface (3-5 weeks of pregnancy). Less than 5% of head lesions, mild addiction for men and most patients present in the first four decades. Three types: epidermoid, dermoid and teratoid. Usually one-eyed, with slow growth... On ultrasound, a hypoechoic cystic lesion with well-defined limits.

Picture. Boy, 10 months old, a small mass is palpable on the scalp. On ultrasound, a well-limited subcutaneous node with solid and cystic components, blood flow is not detected. MRI reveals an extracranial cystic formation in the midline on the parietal region near the bregmatic fontanelle, resembling an epidermoid cyst without a fatty component.

Lipoma of the head on ultrasound

Lipomas - benign tumorscomposed of mature adipocytes. They are the most common soft tissue tumor seen in ~ 2% of the population. Typically, lipomas are subcutaneously located and present as a soft, painless mass in adulthood. They are likely to have been present for many years and can change size with weight. Benign lipomas are limited soft masses, usually encapsulated and composed almost entirely of fat. Often a small number of non-adipose components are present, which are fibrous septa, areas of fat necrosis, blood vessels and muscle fibers located between them. Any non-adipose components should be carefully assessed to rule out a more aggressive component.

On ultrasound, the lipoma is hyper- (20-52%), iso- (28-60%) and hypoechoic (20%) formations, the capsule is difficult to separate from the surrounding tissues, without an acoustic shadow, minimal internal blood flow is possible. The echo structure is heterogeneous - linear and / or point hyperechoic inclusions.

Picture. A patient with a tumor of the scalp for 8 years. On ultrasound in the soft tissues of the scalp there is a hypoechoic focus, heterogeneous echo structure due to linear structures, ovoid with a clear and even contour, size 38 * 35 * 2 mm, internal blood flow is not detected, a small vein passes nearby.

Pilomatrikoma of the head on ultrasound

Pilomatricoma is a rare tumor that arises from a hair follicle. In 40% of cases, the onset of the disease occurs in the first decade of life, 60% - before the age of twenty. It is a mobile, stony consistency covered with normal skin, without recurrence after removal. Located mainly on the face, neck and upper limbs... On ultrasound, a hyperechoic node, well demarcated, located in the subcutaneous tissue, with appropriate calcifications.

Picture. A 7-year-old male patient with head palpable nodules of hard consistency on the scalp of the frontal region. On ultrasound, two solid, calcified and well-defined nodules, subcutaneous with a discrete flow of peripheral blood in color Doppler, measuring 2.4 * 2.0 * 1.6 cm and 1.5 * 1.0 * 0.4 cm, located in the frontal area of \u200b\u200bthe head. Conclusion based on the results of histology: Pilomatrikoma.

Eosinophilic granuloma of the head on ultrasound

Picture. A 3-year-old girl with a dense bump on her head that appeared 3 weeks ago. On ultrasound, a dense osteolytic formation with uneven borders prolapses into the subgaleal space and into the cranial cavity, blood flow is not detected. X-ray shows an osteolytic formation with uneven borders in the left parietal region. On CT it is seen that the formation violates the outer and inner cortical layer of the bone and prolapse into the subgaleal space and into the cranial cavity.

Miyazis on ultrasound

Miyazis - various two-winged animals use humans and animals for the development of larvae. In Latin America, the most common cause is Dermatobia hominis. On ultrasound, a hyperechoic node, representing the larvae surrounded by a hypoechoic halo (cavity), followed by acoustic shading, with CDC, the flow of fluid inside the larvae can be seen.

Picture... Girl with nodules of the scalp. On ultrasound, small hard nodules in the scalp, clearly defined, with a hyperechoic center and a hypoechoic peripheral rim of the halo, posterior acoustic shading, and central blood flow.

Take care of yourself, your Diagnostician!

Subcutaneous hematoma

The formation of a subcutaneous hematoma occurs in a limited space filled with subcutaneous tissue. The dimensions of the space are quite constant due to rigid fixation with connective tissue bridges running vertically from the skin to the tendon helmet (aponeurosis epicranialis). The formation of a subcutaneous hematoma is possible if damage occurs not only to the blood vessel, but also to the bridges. The rupture of the connective tissue bridges occurs directly as a result of injury or as a result of excessive blood pressure in the damaged vessel, which is most often observed in people with high blood pressure. With closed trauma to the cranial vault, these fascial bridges contribute to a significant restriction of bleeding and the formation of subcutaneous hematomas, sometimes of a clearly rounded shape.

Subgoneurotic hematoma

The formation of a hematoma is associated with the accumulation of blood in the subaponeurotic space and the detachment of the supracranial aponeurosis (Fig. 3). Due to the extremely weak connection of the aponeurosis with the underlying layers due to the presence of a layer of loose subgaleal fatty tissue, detachment can occur over a significant area with the formation of a massive hematoma. It should be remembered that subgaleal hematomas are frequent companions of skull fractures, especially in children. If the source of bleeding is the vessels of the subcutaneous fat layer, then this is associated with a violation of the anatomical integrity of the aponeurosis. Subcutaneous hemorrhages are prone to suppuration and can simulate a depressed fracture. Abrasion - superficial skin damage that does not extend deeper than its papillary layer. Abrasions can form on any part of the scalp, but most often they are found on the face. Due to the protective properties of hair and headgear, abrasions occur less frequently on the scalp. The number of abrasions usually indicates the amount of trauma. With dynamic contact, the greatest depth and severity of the scratch is noted in the initial area, whitish patches of the exfoliated epidermis are noticeable at the opposite end of the abrasion. These morphological features make it possible to establish the direction of the force vector. Immediately after an injury, an abrasion is a defect in the surface layers of the skin with a sinking moist, shiny surface. After a few hours, the bottom of the abrasion dries up and takes on a matte shade. Gradually, the damaged tissue necrotic and, together with coagulated blood, form a dense crust. Within 1 day, the crust reaches the level of the surrounding skin, on the 2nd day it already exceeds it. In parallel with the formation of a crust from the periphery of the abrasion to its center, the processes of spontaneous epithelization of the damaged skin begin. The newly formed epithelium gradually exfoliates the edges of the crust from 3-4 days. By the 4-8th day, the crust disappears, exposing the surface of the pinkish epidermis, which easily collects when the skin is squeezed into multiple small superficial folds. By the end of the 2nd week, the area does not differ in color and consistency from the surrounding skin. Wound - damage to soft tissues deeper than the papillary layer of the skin. Distinguish between stabbed, bruised, torn, bruised-torn, cut, scalped and gunshot. Most often, with traumatic brain injury, bruised, lacerated and bruised-lacerated wounds are observed. Bruised wounds are formed from shock. Their morphological features are uneven, bruising, crushed and squeezed edges, connective tissue bridges between the opposing edges of the wound. Torn wounds arise by the stretching mechanism. The most typical laceration is caused by an action from the inside by the end or edge of a fracture of the bones of the cranial vault. Lacerations most often rectilinear or arcuate, sometimes with additional breaks, giving them a complex configuration. The edges of the wound are uneven and never hardened. There are no connective tissue jumpers. The bottom of the wound is usually the damaged bone. Bruised and torn wounds arise from the combined impact and stretching action. The wound is formed most often from the action of a blunt object at an acute angle: at the first stage, a bruised component of the wound is formed with sagging, bruising, sometimes crushed edges, then the skin exfoliates from the subcutaneous fat layer or comes off in the form of flaps (a torn component of the wound). Scalped wounds characterized by detachment of skin and tissue with their complete separation from the underlying tissues. Extensive scalped wounds are dangerous due to the presence of significant blood loss and the possibility of subsequent necrosis of the flap. Chipped wounds occur when exposed to a sharp or limited surface of a wounding object. The general dimensions of such wounds do not go beyond the dimensions of the traumatic surface of the object. Depth of wounds prevails over width and length. The bottom of the wounds is deepened, often reaches the underlying bone, and can be represented by individual fibers of the connective tissue bridges. Firearms wounds can be bullet, shot, fragmentation, with a blind or through wound channel. The entrance wound is characterized by three obligatory signs: a tissue defect, a sludge belt 1-2 mm wide and a rubdown belt (grease, soot). The exit wound may be slit-like. The number of entry and exit wounds may not be the same. Features of injuries in gunshot wounds are associated with the occurrence of a shock head wave and the formation of a "molecular shock zone". Tissues subjected to molecular concussion necrotize, and therefore gunshot wounds always heal secondary tension... According to the dynamics of changes in damaged tissues, it is possible to roughly assume the duration of the impact of external damaging factors. Revision of wounds in some cases makes it possible to judge the nature and severity of neurotrauma (damage to the aponeurosis, bone structure of the skull, the presence foreign bodies, bone fragments, admixture of cerebrospinal fluid, cerebral detritus, etc.). Subgaleal hematomas as companions of fractures have a certain diagnostic value. Isolated staining of the skin with a hematoma in the behind-the-ear region is noted with a fracture in the lateral angle of the posterior cranial fossa with damage to the mastoid graduates. With significant venous bleeding, blood can spread down the sternocleidomastoid muscle sheath, causing muscle irritation and torticollis. Well-known and hemorrhages in the periorbital tissue, manifested in the form of bruises - "glasses" on the upper and lower eyelids. They can form without any local application of force as a sinus hemorrhage from the area of \u200b\u200bthe skull base fracture. However, it should be remembered that their appearance is not a reliable sign of a skull fracture in the anterior fossa. Most often, this symptom occurs due to blood migration with hematomas of the soft tissues of the frontal region or fractures of the nasal bones. The appearance of the "glasses" symptom in the delayed period in the absence of direct trauma to the orbital region is alarming. The fact of a fracture will be irrefutable in the presence of nasal liquorrhea. When examining the victim's head, it is imperative to inspect the external auditory canals for the flow of cerebrospinal fluid. Otolikvorrhea indicates a fracture of the base of the skull in the region of the middle cranial fossa, passing through the pyramid temporal bone... Sometimes these lesions are accompanied by nasal liquorrhea, since cerebrospinal fluid flows into the nasopharynx through the auditory tube. In the acute period, the cerebrospinal fluid flowing from the ear canal usually contains a significant admixture of blood, and to differentiate isolated damage to the ear canal, tympanic membrane and even blood flow from an external wound is often not possible. In such situations, it is preferable to follow the path of overdiagnosis and exclude otoliquorrhea only after a comprehensive ENT examination (tests for glucotest, examination of hearing acuity, air and bone conduction, nystagmus, etc.).

When examining a wound, in addition to determining the type of wound, it is necessary to take into account damage to the aponeurosis of the fronosoccipital muscle, since given sign allows to differentiate between closed and open head injury. It is extremely important to identify possible damage to the underlying bone and medulla. Visual or digital examination of the bottom of the wound can determine the deformation of the cortical bone or the presence of free bone fragments, indicating the presence of a depressed fracture. The leakage of cerebrospinal fluid or cerebral detritus from the wound reliably indicates the penetrating nature of TBI. Features: currents wound process on the head and high probability development formidable complications, down to before lethal outcome, conditioned necessity final processing wounds only in conditions branches neurosurgical profile. When treating wounds and planning tactics to help victims with TBI, the anatomical and topographic features of the soft integument of the head should always be taken into account. Even from small-sized wounds, profuse bleeding is observed, which leads to significant blood loss, up to hemorrhagic shock, which sharply aggravates the course of TBI. This is largely due to the unusually abundant blood supply to the soft tissues of the head and numerous vascular anastomoses. It must be borne in mind that Adventitia blood vessels firmly grows together with the fascial bridges, as a result of which the vessels do not collapse during injury. The most effective and affordable way to stop bleeding at the prehospital stage is the imposition of a pressure aseptic dressing, with which you can squeeze the lumen of the bleeding vessel by pressing the soft tissues of the head against the bones of the skull. A similar effect can be obtained with finger compression of the vessel (Fig. 4). To enhance the compression effect of the bandage, it is possible to use gauze rollers, which are placed on the edges of the wound. The adequacy of the applied bandage is determined by the intensity of bleeding from the wound. With a properly applied bandage, bleeding stops. In addition to stopping bleeding from a wound, the need for a pressure bandage is due to a number of anatomical and topographic features. The layer of adipose tissue located under the aponeurotic skin flap prevents a firm fixation of the flap with the underlying tissues (periosteum) and, even with minor trauma, leads to detachment or detachment of the flap with the formation of extensive subaponeurotic hematomas and streaks. Timely applied pressure bandage will prevent the accumulation of blood under the aponeurosis. A contraindication to the imposition of a pressure bandage is the presence of a depressed comminuted fracture of the skull bones in order to avoid immersion of bone fragments into the medulla. The most convenient hemostatic dressings are knot and cap.

A nodular dressing is a pressure bandage and is usually used to stop arterial bleeding. When assisting the victim, bleeding from the damaged vessel is temporarily stopped by finger pressure, after which a sterile gauze napkin is covered with a sterile gauze cloth and a bandage is applied with a two-headed bandage. It is recommended to start bandaging from the temporal region of the healthy side, wrapping the bandage heads around the head. In the area of \u200b\u200bdamage, a bandage cross is made, for which the right head of the bandage is taken in the left hand, and the left head in the right hand. Further, the head of the bandage is led to the temporal region of the healthy side, then they are carried out to the area of \u200b\u200bdamage, where they make a cross again and lead the bandage around the forehead and back of the head. Further moves of the bandage are repeated. The cross bandage is placed each time over the area of \u200b\u200bdamage.

The bandage "cap" (Fig. 6) allows you to comfortably and firmly fix the aseptic material to the scalp of the victim. Requires the presence of an assistant, the role of which can be performed by the patient himself. The bandage is formed as follows: a separate piece of bandage (tie), about 1 meter long, is placed on the parietal-temporal region in front of the auricles, and the assistant (or patient) keeps the ends of the tie taut. A horizontal round is made around the head and, having reached the tie, they throw a bandage over it, bring it under the eyeballs and lead back, covering the back of the head. On the other side, the bandage is again wrapped around the tie and led to the front, covering the forehead and part of the crown to the tie on the opposite side. Subsequent rounds of bandage repeat the moves of the previous ones, but with each move they are shifted more and more towards the tie. The end of the bandage is reinforced with a circular round or fixed under one of the ties. The ends of the string are tied under the lower jaw. In case of extensive damage to the cranial vault, it is common to apply a “returning” bandage (Fig. 7). To apply this bandage, first, fixing tours (1) are carried out around the head, the bandage is folded in the frontal region (2) as low as possible and it is led along the lateral surface of the head above the previous one. A second fold is formed on the back of the head and the lateral surface of the head is covered with a bandage from the opposite side (3). Fix the returning passages in a circular round (4). Subsequent returning rounds (5, 6, 8, 9, 11, 12, 14) cover the lateral surface of the head, making moves higher and higher until the whole head is bandaged. Returning tours are fixed with circular bandages (7, 10). It should be noted that the returning bandage is fragile, slips off the head easily and therefore is used only for temporary fixation of the dressing material. More durable bandage is the "cap of Hippocrates" (Fig. 8).

The "Hippocratic hat" bandage (Fig. 8) is applied using a two-headed bandage, which is easy to make from a regular bandage, partially rewinding it, or with two bandages. A circular path is made around the head (1) below the external occipital protuberance. After crossing the bandage in the occipital region with the right hand, pass the head of the bandage through the vault of the skull to the forehead (2), where it is strengthened in a circular round (3). After crossing with a circular round, the bandage is returned to the back of the head (4) through the vault of the skull, covering the previous round on the left by half the width of the bandage. After crossing in the occipital region with this bandage head, the next round is made in the sagittal direction, placing it to the right of the previous ones (6). The number of returning moves of the bandage on the right (10, 14 ...) and on the left (8, 12 ...) should be the same. With the head of the bandage in the left hand, circular rounds (5, 7, 9, 11 ...) are always applied across the forehead and back of the head. The circular passages of the bandage, tightly superimposed below the frontal tubercles, above the auricles and under the occipital protuberance, have a smaller perimeter than the head circumference in the widest part. Thanks to this, the bandage is firmly held on the head.

In the presence of pronounced psychomotor agitation, inadequacy of the victim's behavior, the bandage "Hippocrates' cap" is additionally strengthened: in the frontal plane through the cranial vault in front of the auricles, 2-3 circular bandages are carried out under the lower jaw. On the parietal, parietal-temporal areas, the lower jaw, a bandage is usually applied in the form of a "bridle". A simplified version of this bandage (Fig.9a) is applied as follows: fixing rounds are made around the head. Having reached the temporal region, the bandage is bent and led vertically up along the parietal region to the opposite side down the cheek, under the lower jaw on the cheek of the other side and fix the place of bend. The number of vertical rounds is arbitrary, usually up to complete closure of the parietal region. At the end of the bandage, a bend is made in the temporal region, the bandage is given a horizontal direction and the bandage is strengthened in a circular round. A similar bandage can be applied without kinking the bandage (Fig.9b). After two obligatory fixing horizontal rounds, the bandage is carried over the left ear along the occipital region to the right lateral surface of the neck and from there - under the lower jaw. On the left side lower jaw the rounds of the bandage take a vertical direction and pass in front of the auricle. The entire parietal and temporal region is bandaged with vertical moves, and then from under the chin a bandage along the left lateral surface of the neck is led to the back of the head and transferred to horizontal tours. The bandage is strengthened with circular, securing horizontal strokes. To close the lower jaw, after fixing rounds around the head, the bandage is led obliquely, closing the back of the head, on the right surface of the neck and bypassing the lower jaw in front with horizontal moves of the bandage, and then closing the parieto-temporal region with vertical rounds. The bandage is finished with circular horizontal bandage moves, which are projected onto the first fixing ones.

It is necessary remember, what imposition circular frontal moves bandage under bottom jaw makes it difficult opening oral cavities and creates objective difficulties at holding reani mational activities. Using bandages from similar fixation special undesirable at affected from TBI in connections from high risk aspiration at vomit and possible sinking language. Bandage on the right eye (Fig.10a). The bandage is strengthened with two horizontal circular moves around the head. Then, along the occipital region, it is lowered down under the right ear and carried obliquely up the lateral surface of the cheek, closing the sore eye and the inside of the orbit. With a circular round, the ascending course of the bandage is fixed. After that, the bandage is again led obliquely under the right ear and the eye is closed, slightly shifting the bandage outward. The oblique course of the bandage is fixed in a circular manner. Alternating circular and ascending rounds of the bandage, close the eye area. Usually, after three returning rounds, the bandage can be finished by securing the bandage in a circular motion. Bandage on the left eye (fig.10b). It is more convenient to bandage from right to left clockwise, holding the head of the bandage with your left hand. The alternation of rounds of the bandage is the same as when applying a bandage to the right eye. Bandage on the both eyes (fig.10c). The bandage is fixed in circular horizontal rounds around the head. The third round is carried out obliquely over the left ear along the occipital region under the right ear, under the right eye, then on the back of the head, over the right ear on the right temporal, frontal region, and then from top to bottom on the left eye. The bandage is directed under the left ear, along the occipital region under the right ear, along the right cheek and carried over the right eye, shifting the bandage by a third of its width downward and inwardly from the previous round, lead over the bridge of the nose along the left lastotemporal region to the back of the head, along the right lateral surface of the head , slightly higher than the previous round to the area of \u200b\u200bthe left eye, moving inward from the previous round. The bandage is finished with a circular horizontal tour through the forehead and back of the head. By applying a bandage over both eyes, each round of bandage covering the right or left eye can be strengthened in a circular motion. When applying a bandage to one or both eyes, do not apply tours to the auricles.

Neapolitan bandage applied to the ear and mastoid process. Bandage moves resemble those of an eye patch. Bandage rounds after securing moves are conducted above the eye on the side of the injury without engaging the neck. At the end of the bandaging, the bandage is strengthened in a circular round. For minor injuries in the frontal, temporal, or occipital region, a circular or sling-like dressing can be used. It should be noted that if it is necessary to close the area of \u200b\u200bthe nose, the lower jaw, it is more rational to apply a sling-like bandage, since it is simpler, reliably fixes the dressing, does not require significant time for manufacturing, and is economical. The dynamics of the wound process on the head is also largely due to the anatomical and topographic features. The presence of numerous anastomoses passing through the bones of the skull and connecting the veins of the integument of the head with the intracranial venous sinuses implies, when the wound is suppurating, the rapid development of such formidable complications as meningoencephalitis, brain abscess, thrombosis of the venous sinuses, osteomyelitis of the skull bones. Demand to asepticity bandages related from prevention secondary infection. When assisting patients with infected and purulent wounds without signs of bleeding, the use of kerchiefs is quite acceptable (Fig. 12). A headscarf is understood as a triangular piece of some kind of fabric (better coarse calico), which is obtained after cutting a square of fabric about 100 x 100 cm diagonally. An improvised headscarf can be made from a woman's headscarf folded diagonally. The base of the scarf is placed in the back of the head, and the top is lowered onto the face. The ends of the scarf are held over the auricles on the forehead, where they are tied. The top is wrapped up over the tied ends and secured with a safety pin or stitched. If the wound is located in the forehead, then the aseptic material is covered with the base of the headscarf, the top is placed on the back of the head, the ends of the headscarf are tied at the back and somewhat on the side, the top is wrapped on them and strengthened. At the prehospital stage, in the absence of violations of vital functions of the body, it is permissible to limit medical care by stopping bleeding from the damaged outer cover of the head, respiratory support, prevention of aspiration, and drug therapy (symptomatic and specific). Prevention aspiration is carried out by the correct placement of victims with TBI (Fig. 13), which should prevent secondary injuries during transportation, the development of hemodynamic and respiratory complications and ensure maximum rest of the victims. In case of gross impairment of consciousness (at the coma level - GCS less than 7 points), tracheal intubation is indicated to adequately ensure airway patency and prevent aspiration.

Respiratory support carried out by inhalation of humidified oxygen in order to eliminate respiratory failure and prevent hypoxia. You should refrain from inhaling humidified oxygen through a mask if active or passive regurgitation is suspected. With a full stomach, pregnancy, obesity, inhalation of humidified oxygen is preferably carried out through a nasal catheter.

Medication therapy In severe TBI against the background of stable hemodynamics, a low-volume infusion of solutions of low molecular weight colloids (with a rheological effect) is performed, then saline solutions in a 1: 1 ratio. Glucose solution is not used. Infusion is carried out under the control of hemodynamic parameters. When signs of hemodynamic instability appear, the volume and rate of intravenous infusion of plasma-replacing solutions increase up to 12-15 ml / kg / hour. It is advisable to bolus 200 ml of hypertonic sodium chloride solution and corticosteroids. If there is no effect within 10-15 minutes, the administration of adrenomimetics is indicated. Decrease in systolic blood pressure less than 90 mm Hg. does not provide adequate cerebral perfusion pressure. It is advisable to keep the upper values \u200b\u200bof systolic blood pressure within no more than + 15-20% of the working blood pressure (in the presence of anamnesis data) or no more than 160 mm Hg.

Symptomatic therapy -- Emetic syndrome - for the prevention of vomiting, the introduction of metoclopramide is sufficient; in case of repeated vomiting or lack of effect after administration of metoclopramide, the appointment of ondansetron is indicated. - Convulsive syndrome, psychomotor excitation - in the case of severe psychomotor agitation or the development of a convulsive attack, the administration of tranquilizers (sibazon) is indicated, the drugs of choice for arresting a convulsive attack may be agents for general anesthesia (sodium thiopental, etc.). - Painful syndrome - preference is given to non-narcotic analgesics due to the minimal depressing effect on the respiratory center; with persistent pain syndrome and the lack of effect from the introduction of NSAIDs, the introduction of narcotic analgesics is indicated; if necessary, short-term elimination of pain during the manipulation period (intubation, immobilization, etc.), it is optimal to use funds for general anesthesia (ketamine).

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Features of damage to the soft tissues of the head are determined by the direction and strength of the mechanical impact, as well as the area of \u200b\u200bcontact between the wounding object and the integument of the head. The soft tissues of the head contain several layers: - Skin (Skin), a layer of dense connective tissue (textus Cormectivus), an aponeurosis (Aponeurosis), a layer of loose connective tissue (Loose connectiv tissue) and a periosteum (Pericranium). Union initial letters the names of these layers gives the generally accepted abbreviation of the soft tissues of the head - "SCALP". The first three layers of the scalp are tightly accreted to each other, and the periosteum to the outer surface of the bone.

The severity of a scalp injury is determined by the area and depth of damage, varying over a wide range - from superficial injuries (abrasions) to extensive wounds with detachment of soft tissues from the entire scalp (scalped wounds).

Bruisesand scalp abrasions -the most common injuries from head trauma are characterized by swelling of soft tissues in the area of \u200b\u200bimpact and / or damage to the dermal layer of the skin. If the latter is not significantly damaged, the dirt is removed and local treatment is carried out. Extensive abrasions to the forehead can lead to cosmetic defects. The main clinical significance of abrasions and bruises is in determining the place of impact, it is in this zone in children in the overwhelming majority of cases there are injuries to the bones of the skull and intracranial changes (hematomas, bruises).

Scalp hematomas- limited extracranial blood accumulations, usually occurring immediately after injury and characterized by protrusion and cyanosis of the skin in the area of \u200b\u200bthe hematoma. There are hematomas of the scalp, subgaponeurotic and under periosteal hematomas.

Scalp hematomas are hemorrhagic edema of the scalp area, are observed more often in newborns and occur as a result of infringement of the fetal head segment in the birth canal (caput saccedaneum, edematous head). Localization - the arch of the head. The swelling goes away on its own after a few days.

A subgoneurotic hematoma is an accumulation of blood in the space between the aponeurosis and the periosteum. Given the loose connection of these two layers, such hematomas are usually quite large in size and extend beyond one bone. Their predominant localization is in the fronto-parietal region. The greatest danger of these hematomas is associated with acute blood loss syndrome in infants. Children with extensive hematomas are hospitalized. The scope of the examination - to control the significance of blood loss, hemoglobin and hematocrit are re-determined, craniography and ultrasonography are performed, and if pathology (fractures of the skull bones, traumatic intracranial injuries) and the need to clarify the diagnosis, CT is detected. Surgical treatment these hematomas are not subject, sometimes blood transfusion is carried out.

Subperiosteal hematomas (PG) are an accumulation of blood between the periosteum and the bone, and the borders of the hematoma exactly correspond to the edges of the bone and very rarely extend over another adjacent bone. This is due to the fact that in infants, between the bones of the skull (in the area of \u200b\u200bthe sutures), the periosteum is very densely accreted to the dura mater and the potential subperiosteal space is clearly limited by the cranial sutures that surround the bone. PG are usually found in newborns and children under 1 year of age, located mainly above the parietal and, less often, above the frontal bones in the form of a tense swelling. In uncomplicated PG, infants usually only need observation, since hematomas almost always resolve spontaneously within 1–2 months. In rare cases, a narrow petrification lamina is formed along the periphery of the PG (“eggshell” stage). In the future, ossification of the hematoma occurs with a more or less pronounced asymmetry of the head. After 2-5 years, this asymmetry is usually smoothed out and only very rarely there is a need for cosmetic surgery. In some cases, when the contents of the hematoma become liquid and its volume gradually decreases, a dense roller is palpated along the perimeter of the hematoma, creating a false impression of the presence of a depressed fracture. To exclude it, X-ray of the skull is performed in 2 projections. However, preference in these cases should undoubtedly be given to US-craniography.

It should be borne in mind that in 10-25% of children with PG, skull fractures are found, which can be accompanied by both extra and intracranial bleeding, forming a "subperiosteal-epidural hematoma". Therefore, it is advisable for children with subperiosteal hematoma to undergo US with an assessment of the intracranial state and the integrity of the skull bones in the area of \u200b\u200bthe hematoma.

The need for puncture removal of extensive PGs that do not tend to dissolve is controversial. We prefer to puncture them after blood clots liquefy (10-12 days after their occurrence). This tactic is dictated by the risk of infection, the occurrence of a sharp thickening of the bone (traumatic osteitis) or fibrous degeneration (fibrous osteitis) with a gradual increase in local protrusion. The peculiarities of the technique of performing a puncture of the PG are outlined earlier (see section "Birth trauma to the head"),

In the subgaponeurotic or subperiosteal spaces, not only blood, but also CSF \u200b\u200bcan accumulate. In these cases, the swelling does not have a bluish color and does not appear immediately after injury (like a hematoma), but usually after 1-3 days. These are extracranial hygromas, and their presence indicates a more serious injury, accompanied not only by damage to the scalp and / or skull bone, but also by rupture of the hard and arachnoid membranes of the brain with the outflow of cerebrospinal fluid into the soft tissues of the head. Such children are subject to hospitalization, examination in order to clarify the state of the skull bones (X-ray of the skull, US-craniography) and exclude intracranial meningeal accumulations (US, CT). In most cases, ekracranial liquor accumulations disappear on their own within 1-2 weeks. In rare cases, a tight head bandage is necessary. The presence of a linear fracture with an extracranial hygroma requires repeated US-craniography to exclude a growing fracture (see below).

Scalp wounds- mechanical damage to the soft tissues of the cerebral skull, accompanied by violations of the integrity of the skin. The depth of scalp injury is important in characterizing the injury (open or closed). Open injuries include cases of TBI, accompanied by wounds, including damage to the aponeurosis. In addition, cases accompanied by cerebrospinal fluid also belong to open TBI. Open trauma occurs in 16.5% of cases.

According to the mechanism of damage, wounds are divided into: cut, stabbed, chopped, torn, bruised, crushed, bitten, gunshot. In shape - linear, perforated, stellate, patchwork, scalped. Contaminated wounds (in the presence of clearly bacterially contaminated foreign bodies) and infected (wounds with objective signs of inflammation) should be isolated.

A feature of the blood supply to the head is that about 20% of the cardiac output is directed to it, and the vessels of the scalp have many anastomoses. Therefore, bleeding from scalp wounds can be massive.

The main tasks in the treatment of scalp wounds are as follows: a) hemostasis; b) assessment of the condition of the bones of the skull; c) removal of crushed areas of the scalp; d) suturing the wound without tensioning its edges; e) antibacterial therapy; f) prevention of tetanus.

Given the abundance of blood supply to the scalp in children and their special sensitivity to blood loss, it is necessary to provide hemostasis in the early stages (pressure bandage, compression of the wound edges in the area of \u200b\u200bthe bleeding vessel, etc.). The optimal treatment of wounds is early (within the first 24 hours after injury) primary surgical debridement with final hemostasis, excision of necrotic margins and suturing. B two layers in children, the wound is sutured only in the forehead, where the skin sutures must be removed as early as possible. In this case, the sutures on the aponeurosis are superimposed with unpainted material, otherwise in infants they may be seen through the skin. Most wounds are treated under local anesthesia. General anesthesia is used for extensive damage to the scalp.

In modern conditions of immunization, children under 10 years of age have adequate protection against tetanus. In older children, vaccinations are necessary for contaminated wounds. Antibiotics are prescribed only for contaminated and bitten wounds.

Contaminated scalp woundsrequire consideration of delayed secondary closure. These are animal and human bites or contaminated wounds. In these situations, the wound is repeatedly processed within 48 hours and after sufficient cleaning (bacterial index less than 10 5 per gram of tissue) the wound is closed.

Scalp injuries with tissue defect require mobilization of the scalp fragment that carries the hair. The basic principles of treatment are as follows:

Any mobilization of tissue must take into account the cosmetic consequences;

If possible, areas of the scalp in the hair growth zone should be mobilized;

The skin flap becomes mobile when the scalp is dissected to the periosteum, and it should also be placed on the periosteum;

It is especially important to maintain good blood circulation in the flap being moved (when moving a large flap, it must contain a large vessel);

The use of electrocoagulation can lead to damage to the hair follicles and local baldness.

Wounds with minor scalp defects can usually be closed without difficulty. For more severe injuries, methods of stretching, moving and rotating the flap, as well as tissue augmentation are mainly used.

The flap is stretched when the tissue breaks to form a scalp flap. It is necessary to lift the scalp flap and make several incisions on the inside of the flap, dissecting only the aponeurosis. The incisions made should be parallel to the base of the flap. Following these “internal laxative incisions”, the flap can be enlarged to close the defect.

The flap is moved and rotated after the formation of laxative incisions parallel to the edges of the wound on one or both sides of it. This is followed by subgaleal mobilization of the scalp in the wound area and the closure of the defect with slight tension on the edges of the skin.

With extensive scalp defects, the tissue augmentation method has the greatest potential, which revolutionized reconstructive scalp surgery. On the side of the wound, a subgaleal pocket is formed and a silicone prosthesis is placed into it, the volume of which gradually increases. This method provides a full-thickness flap with good vascularity and hair. With this technique, the normal scalp can be enlarged at least twice within a few months.

Surgical interventions for large scalp defects using flap rotation, skin grafting or tissue augmentation are performed with the participation of plastic surgeons. This provides a significantly greater cosmetic effect of reconstructive surgery.

A.A. Artarian, A.S. Iova, Yu.A. Garmashov, A.V. Banin