What Happens During a Debridement Procedure?

Craniocerebral rebound injury debridement is suitable for projectiles hitting the head, which cause craniocerebral penetrating injuries after colliding with the skull, and metal foreign bodies are rebounded and returned to escape. There is only one wound on the head, which is both the entrance and the exit. The skull is fractured in a cave shape, and the fragmented bone penetrates the dura mater and enters the brain in different depths. This type of injury accounts for about 5% of craniocerebral penetrating injuries. Injuries are generally mild, but you need to be alert to emergencies caused by intracranial hematomas to avoid delays in treatment.

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Craniocerebral rebound injury debridement is suitable for projectiles hitting the head, which cause craniocerebral penetrating injuries after colliding with the skull, and metal foreign bodies are rebounded and returned to escape. There is only one wound on the head, which is both the entrance and the exit, and the skull is cave-shaped

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Neurosurgery / Craniocerebral Injury Surgery / Craniocerebral Firearm Injury

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Craniocerebral rebound debridement is suitable for:

1. The wounded are generally in good condition. Debridement should be prepared after the wound examination and skull radiographs are taken to understand the distribution of foreign bodies.

2. The wounded are in a coma, and those with intracranial hypertension and cerebral hernia should be debrided immediately.

3. The wounded had been debrided in the first-line hospital. After coming to the hospital, a cranial radiograph showed that multiple fragments of bone or large shrapnel above 1 cm were left in the brain. They should be prepared for surgery again.

1. Severe injury, manifested as deep coma, pathological respiration, decreased blood pressure, and weak pulse frequency, suggesting brain stem failure, not suitable for brain debridement, supportive therapy should be performed.

2. Shock manifestations such as multiple injuries, pale complexion, weak pulse, and decreased blood pressure accompanied by thoracic and abdominal organ injuries are not suitable for brain debridement. Should first resist shock and deal with thoracoabdominal organ injuries, after the condition is stable, then debridement.

3. Coming to the hospital a few days after the injury, the brain wound has purulent secretions. It is not appropriate to perform debridement for the time being. After infection control, late debridement should be performed.

1. For skin preparation, first wash the head with soap and water, and shave before the operation. Fasting before surgery. One hour before surgery, 0.1 g of phenobarbital, 0.4 mg of atropine or 0.3 mg of scopolamine were given intramuscularly.

2. Tetanus antiserum 1500U.

3. Take the orthotopic and lateral radiographs of the skull to understand the number, size and location of intracranial bone fragments and metal foreign bodies.

4. Perform CT scans when necessary to understand the path and extent of the brain trauma. With or without intracranial hematoma, its size and location.

Tracheal intubation is generally used for general anesthesia, and local anesthesia and intravenous anesthesia can also be used when conditions are limited. Position yourself according to the entrance position.

1. During debridement, the number, size and position of the removed bone fragments must be consistent with those shown on the plain skull, to avoid reoperation due to missing bone fragments.

2. Small shrapnel below 1cm deep in the brain is not prone to infection. If there are no symptoms of infection, removal is not recommended, but follow-up observation or periodic CT examination is required within 1 year.

3. The cause of brain swelling should be analyzed during debridement, such as obstructed airway, diffuse brain swelling, hematoma in deep or distant part of the brain, etc., CT examination should be performed to deal with the cause. Missing hematomas can endanger patients' lives.

4. Maximize the protection of brain function. When enlarging the brain incision and removing foreign body in the deep part of the brain, the motor and language area and its conduction beam should be avoided. The surgical approach should be properly designed.

5. There is a large amount of cerebrospinal fluid outflow at the entrance, which is mostly related to ventricular injury or air sinus injury. After debridement, the dura mater should be closely sutured and repaired to prevent leakage after operation.

1. When conditions are available after surgery, postoperative ICU monitoring should be performed. When there is no monitoring condition, the patient's consciousness, pupil, blood pressure, pulse, respiration and body temperature should be closely observed. Measurement and observation should be performed every 15min ~ 1h according to the condition and carefully recorded. If the consciousness is gradually awake, it means that the condition is better; if it is not awake for a long time or it gradually worsens after awake, it often indicates that there are intracranial complications, especially intracranial hemorrhage, a CT scan should be performed if necessary. Once confirmed, it should be sent to the operating room in time. Remove the hematoma and stop the bleeding completely. Those with severe cerebral edema should strengthen dehydration treatment. Those with more bleeding during craniotomy should pay attention to replenish blood volume and maintain normal blood pressure. But blood transfusion and fluid replacement should not be too fast, so as not to aggravate cerebral edema. Respiratory tract should be kept unobstructed, tracheostomy should be performed for those who cannot be awake in a short time. Oxygen should be given after surgery.

2. After debridement, routine radiographs of the skull should be taken routinely. If some fractures remain in the brain, debridement can be performed at an appropriate time according to the whole body of the wounded and the local conditions of the wound.

3. Involvement of brain damage in the sports area, the incidence of epilepsy is very high, antidepileptic drugs can be taken for 3 to 6 months after debridement.

4. After debridement, there are small shrapnel or a small amount of bone fragments in the deep brain. If the operation is not removed due to fear of increased surgery, CT review may be performed at intervals of 6 months to 1 year for the safety of the injured. Very few possibilities.

5. In the process of rehabilitation after debridement, if intracranial hypertension and exacerbations of the lesions appear, CT re-examination should be performed. If infection is found, it should be removed.

6. Skull defect repair without infection wounds, 3 to 6 months after surgery, infected wounds, it is best to carry out 1 year after wound healing.

1. Craniocerebral rebound debridement 1. Traumatic infection

Seen in the time of brain debridement, or inadequate debridement, there are still some broken bone fragments, inactivated brain tissue and blood clots in the brain. Infection should be controlled and local management of the wound should be strengthened, and debridement should be performed again if necessary.

2. Craniocerebral rebound debridement 2. Brain protrusion

It is more common that the brain tissue bulges outward through the bone defect after debridement. The reasons are brain swelling and edema, traumatic hematoma, or local infection of the wound. It should be treated according to the cause. Because the extruded brain tissue is still alive and should not be removed, a cotton ring should be placed around it to protect it with rubber strips.

3. Craniocerebral rebound debridement 3. Meningitis

Mostly due to insufficient debridement of the brain, various foreign bodies, inactivated tissues, and blood clots are left, resulting in good breeding conditions for bacteria. Antibiotic susceptibility to pathogens, including intrathecal injections.

4. Craniocerebral rebound debridement 4. Cranial osteomyelitis

Traumatic infections involve the skull, forming marginal osteomyelitis, and are also seen in infections from frontal sinus injuries. Chronic sinus tracts form locally in the wound, often with dead bone formation and combined with epidural abscess or granulation tissue. After the infection is controlled, the inflammatory damaged bone is extensively excised to the place where the normal dura mater is exposed, and the wound can be cured.

5. Craniocerebral rebound debridement 5. Brain abscess

If there is no debridement of the brain fragments of the skull with firearm injuries, about half of them will develop intracranial infections, which are mainly brain abscesses, especially in dense bone fragments. Large shrapnel above 1cm can also cause brain abscess. CT examination can understand the location, size and formation of the abscess, and its relationship with bone or shrapnel. Treatment depends on the formation of the abscess capsule, using different surgical methods.

6. Craniocerebral rebound debridement 6. Traumatic epilepsy

Epileptic lesions are mostly located in the marginal area of the meningeal brain scar. Antiepileptic drugs should be taken first. If frequent seizures and drug control are not effective, you can look for epileptic focus under the examination of EEG cortical electrodes, and perform subchondral transverse fiber cutting or lesion removal.