Emergency War Surgery NATO Handbook: Part IV: Regional Wounds
and Injuries: Chapter XXII: Craniocerebral Injury
Operative Management of Open and Penetrating Wounds
United States Department of Defense
Peer Review Status: Internally Peer
Reviewed
Treatment is carried out in the following order:
- The head is shaved and the wound inspected. X-rays are
examined to determine the distribution of bone and metallic
fragments.
- Endotracheal intubation and general anesthesia are preferable
in most cases. Adequate blood is made available for wounds near
major dural venous sinuses.
- The scalp is scrubbed with an antiseptic solution, preferably
an iodophor. The wound is copiously irrigated with 1-2 liters of
sterile saline.
- The patient is positioned and draped so that entry and exit
wounds are accessible and a contralateral burr hole can be made if
needed. The head should be elevated slightly above heart level, to
encourage venous return, but not so high as to risk air
embolism.
- Devitalized scalp and foreign bodies are removed. Incisions
are made along lines that can be utilized to rotate the scalp,
should it become necessary to perform plastic repair of the scalp.
As much scalp as possible is preserved.
Figure 29 A
- Contaminated pericranium is removed. Burr holes are made in
intact bone adjacent to the area of damage. A margin of normal
dura is exposed. Bone is removed with rongeurs toward the area of
contamination.
Figure 29 B
Figure 29 C
- Contaminated dura is removed, preserving as much as possible
for closure.
Figure 29 D
- Damaged brain, blood clots, and foreign bodies are removed
with gentle saline irrigation and suction. Removal of all bone
fragments is of greater importance than removal of all metal
fragments. The use of intraoperative ultrasound facilitates
localization of fragments. The debrided track should remain open
after debridement. Closure of the track suggests the presence of
deeper or adjacent clot or necrotic brain tissue exerting pressure
on the track.
Figure 29 E
With high velocity injuries, there is more destruction at the
wound of exit than the wound of entry, and debridement of the exit
wound initially may provide the most rapid decompression. Complete
hemostasis is accomplished before closure.
The brain is copiously irrigated with normal saline solution
containing 1000u/l bacitracin at body temperature. A concentrated
bacitracin solution (500u/cc) should be used to irrigate the
track.
- Massive swelling of the brain is an uncommon but serious
occurrence during operation that may represent the development of
an intracerebral hematoma or a contralateral subdural hematoma. It
may also represent an anesthetic complication or loss of
autoregulation of the cerebral vasculature After determining that
there is no technical difficulty with anesthesia, swelling is
treated in a stepwise fashion by increasing the ventilatory rate
to obtain a PaCO2 of about 25mm Hg, by tapping the
ventricle and draining CSF and by administering barbiturates.
Pentobarbital sodium, 100-300 mg, is given intravenously.
Additional doses of 100 mg may be required hourly. If the brain is
swollen at the time of closure, an intracranial pressure
monitoring catheter is placed, preferably intraventricularly, and
the intracranial pressure is monitored in the post-operative
period.
- The dura is closed without tension. Dural grafts may be
harvested from pericranium, temporalis fascia, or fascia
lata.
- The scalp is closed primarily without tension. Rotation of
scalp flaps with closure of the secondary defect with
split-thickness skin grafts or a myocutaneous pedicle flap may be
necessary.
- Post-operative X-rays or CT scans are obtained to check for
the presence of retained fragments.
- The need for reoperation for retained fragments is a difficult
judgment call that requires much experience. It need not be done
routinely if optimal follow-up neurosurgical and CT scan
capability is anticipated.
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