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The clinical data of patients with Chen , male, 40 years old.
1. Chief Complaint: car accident consciousness 2 hours after trauma hospital
2. History of present illness: patients admitted to hospital 2 hours before a car accident, a coma immediately after injury, associated with multiple head wounds bleeding, the head bandage to stop bleeding after the simple 120 ambulance to the hospital, the way a jet vomiting, stomach contents as a dark red . No limbs after injury, convulsions, no urine, incontinence.
3. Physical examination: body temperature 36.9 , pulse 100 beats / min, breathing 20 times / min, blood pressure 90/65 mmHg. Coma, can not sting eyes open, not verbal, physical irritation can locate, Glasgow coma scale (GCS) 7 points. No deformity skull, top of the head, face multiple soft tissue laceration can be seen, the wounds are still active bleeding. Pupil diameter of the left: right = 3.0:5.0 mm, bilateral light reflex. Still visible activities of bilateral nasal bleeding, out of brain tissue associated with the right nostril. Neck soft without resistance. Low lung breath sounds, right lower lung could be heard and small wet rales. Trusted no exception. Right kidney area has a size of an area of about 3 6cm2 of skin bruising, no spinal deformity. Class V limbs, muscle strength, increased muscle tone, knees tendon hyperreflexia, bilateral Pakistan's sign ().
4. Auxiliary examination: more than 2 hours after head injury spiral CT showed: irregular


mixed density can be seen right frontal lobe lesions, low-density area in the more divergent edema patchy high density lesions in the right temporal skull plate strip under the see like high density, density, clear boundary, midline shift to the left, longitudinal pool, Central pool, tentorium, right cistern and local sulcal widening was high density, rough edges, as shown in the right side of the film medial orbital wall, inferior wall, the wall, the right temporal bone, bilateral frontal and right parietal bone density are visible fracture line shadow multiple fracture lines show clearly that some fractures are misplaced, and video film shows bone fragments, two ethmoid and frontal sinuses on the left side of higher density, bilateral frontal, right temporal and the top of the scalp soft tissue swelling significantly, the density increased. Spiral CT chest showed: right lung in the chest wall at the sheet after the step down in recent high density shadow, consider mild pulmonary contusion. Abdominal helical CT showed: right kidney capsule of high density film sheet article, consider the small amount of bleeding may be under the renal capsule.
5. Diagnosis: 1. Acute severe traumatic brain injury Open (sTBI) GCS: 7 minutes2. Lung contusion (right lung)
3. Subcapsular hemorrhage (right kidney)
4. Various skin laceration (head, face and trunk)
Treatment and treatment
1. Treatment: the line in the emergency room bleeding head wound after admission given to expansion, boost and rushed to the operating room, the endotracheal intubation and general anesthesia to the bone (the top of the right frontotemporal about 10 16cm2) decompression , subdural hematoma, ventricular drainage, surgical success. monitoring and cerebrospinal fluid of patients given continuous drainage, tracheotomy, hibernation hypothermia treatment. Ophthalmology consultation, please consider the optic nerve injury and atrophy after giving dehydration, improve microcirculation, nerve nutrition therapy, urology consultation was diagnosed with mild renal injury (I class), given conservative treatment and close observation of patient's condition. Underwent lumbar puncture week released BCSF intracranial pressure was measured, according to intracranial pressure ( 10mmHg) mannitol reduced , proton pump inhibitor, stress ulcer prevention and treatment, antibiotics to prevent brain and lung infection. Calcium antagonists reduce cerebral edema, give magnesium sulfate, estrogen, progesterone, such as citicoline neuroprotective agents. 3 days after CT prompts reprogress cerebral contusion, subarachnoid hemorrhage significantly improved the treatment given to enhance dehydration. CT 3 weeks after the reprompted the formation of mild hydrocephalus, given to promote amide nitrogen, diuretics and other drug treatment.
2. Methods and dosage: monitoring 7 days. Natural hypothermia rewarming after a week. First, 2.5g of magnesium sulfate dissolved in 100ml normal saline intravenously within 15 minutes, then 10 g of magnesium sulfate dissolved in 500ml saline, to maintain 24-hour intravenous drip. Nimodipine 24mg / d, dissolved in 100ml saline, intravenous infusion uniform within 24 hours, 7 days for a course of treatment, the use of two courses.
3. Treatment Results: After 6 days, the patient gradually regained consciousness 25 days after the patient fully awake, able to self-open eyes, the correct answer, Zunzhu activities, right eye, blurred vision, normal hearing and kidney were normal. 60 days after injury, recovered. Than 5 months later cranioplasty surgery, no significant sequelae.
Discussion and Analysis
1. On the diagnosis: acute TBI patients are required to line the head CT scan, fast and accurate display of intracranial situation and provide a basis for surgery. Skull fracture may be due to occipital, mastoid processes, or orbital area produced by the direct impact, the skull base in vulnerable regions such as the sphenoid sinus, the foramen magnum, temporal bone wing rock and the most easily damaged disc, involving the cranial base of skull fractures nerves and skull base vessels. To detect signs of skull fracture, including the tympanic hemorrhage, cerebrospinal fluid otorrhea or rhinorrhea. The injury occurred after the bloody CSF rhinorrhea, pneumocephalus, X-ray showed fracture of the anterior cranial fossa, CT bone window image shows fractures, brain damage, hemorrhage can be diagnosed as a fracture of the anterior cranial fossa. Three-dimensional spiral CT imaging can clearly show the location and extent of skull base fracture, the diagnosis of basal skull fracture has important value, basal skull fracture surgical repair has an important role in guiding.
2. On the treatment of: monitoring in foreign countries has been widely used in clinical, for the GCS: 3 ~ 8 minutes the patients were suitable for use in monitoring, the can understand the state of post-traumatic brain injury in the brain injury diagnosis Treatment and prognosis judgments have great significance. The role of hypothermia treatment is to regulate cerebral blood flow, cerebral metabolic rate of oxygen reduction and improvement of cellular energy metabolism, reduce the release of excitatory amino acids, reducing the generation of oxygen free radicals, reduce intracellular calcium overload, increased neuronal synthesis of ubiquitin, reduced neuronal necrosis and apoptosis, and promote the recovery of signaling between cells, and cerebral edema and lower , while on blood pressure, blood oxygen, carbon dioxide partial pressure, blood pH, and glucose had no effect, no increase in other tissues and organs damage. The current domestic and international animal experiments and clinical studies have shown that brain injury early appropriate use of calcium antagonist nimodipine can improve the cerebral vasospasm and cerebral blood flow, reduce sequelae, is now widely used in clinic. For traumatic brain fluid leak, conservative treatment more than 3 to 4 weeks in bed can be self-healing, and antibiotics to prevent infection, CSF leakage is usually continued for 4 weeks is still not healed, you should consider repairing craniotomy.
Fine points and tips
Should follow the treatment of patients with acute open sTBI norms and principles of treatment. Decompression craniectomy indications including intracranial hematoma, causing brain compression, brain herniation crisis, CT midline shift over 5mm, one or both sides of the pupil to expand. Cerebral contusion (broad or restricted), cerebral edema or intracerebral hematoma combined, causing brain compression, brain herniation. Diffuse brain injury caused by brain compression, brain herniation, and other non-surgical treatment fails. Postoperative care and basic life-giving indications of intracranial pressure monitoring, active management of complications.
For the treatment of brain fluid rhinorrhea: The patient can be taken supine, under the circumstances appropriate to raise the bed 15 ~ 30 , to keep the nose and the ear canal clean, smooth, non-blocking and washing, regular scrubbing with a cotton swab after the release of sterile saline cotton balls in the brain fluid leakage adsorption, while the use of antibiotics to enhance anti-infective treatment.
For the composite mild pulmonary contusion, subcapsular bleeding nor obvious clinical symptoms, and can be no special treatment. May request the relevant department when necessary consultation, with consultation recommended treatment plan.
(Hu Feng Zhang match)


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