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

Treatment is carried out in the following order:

1. The head is shaved and the wound inspected. X-rays are examined to determine the distribution of bone and metallic fragments.

2. Endotracheal intubation and general anesthesia are preferable in most cases. Adequate blood is made available for wounds near major dural venous sinuses.

3. The scalp is scrubbed with an antiseptic solution, preferably an iodophor. The wound is copiously irrigated with 1-2 liters of sterile saline.

4. 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.

5. 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

6. 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

7. Contaminated dura is removed, preserving as much as possible for closure.
   
   Figure 29 D

8. 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.

9. 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.

10. The dura is closed without tension. Dural grafts may be harvested from pericranium, temporalis fascia, or fascia lata.

11. 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.

12. Post-operative X-rays or CT scans are obtained to check for the presence of retained fragments.

13. 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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Operational Medicine 2001

Health Care in Military Settings

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