RU2119303C1 - Method of curing combined maxilla-cerebrum trauma - Google Patents

Abstract

FIELD: medical technology. SUBSTANCE: this relates to maxilla-facial surgery and to neurotraumatology. According to method, novocaine is introduced into recesses under temples to depth of 4 cm from skin surface. Novocaine is introduced in amount of 0.75 ml per 1 kg of weight of patient at each side. Application of aforesaid method makes easier carrying-out of surgical manipulations. EFFECT: higher efficiency.

Description

 The invention relates to medicine, namely to neurotraumatology and maxillofacial surgery, and is intended for the treatment of combined injuries of the maxillofacial region and the brain.

 A known method of treating traumatic brain injuries using cervical vagosympathetic novocaine blockade according to A. V. Vishnevsky [1]. However, the effect of this blockade is limited by the level of the sympathetic trunk, vagus nerve and sinocarotid zone with no effect on the branches of the trigeminal nerve.

 Closest to the proposed is the prototype method of facial (trigeminosympathetic) novocaine blockade according to MP Zhakov [2], used by the author in the treatment of purulent-inflammatory diseases of the face and neck. When implementing this method, 10-12 ml of a 0.25% solution of novocaine is introduced under the lower edge of the zygomatic arch to a depth of 5-6 cm. However, with this procedure, there is a risk of mechanical damage to the branches of the trigeminal nerve, venous pterygoid plexus and branches of the carotid artery with the development of extensive hematomas, which is fraught with serious complications. In addition, there is no therapeutic effect on the sympathetic trunk, vagus nerve and sinocarotid zone, and the principle of chemical neurotomy lies in the rationale for the treatment method.

 The invention is expressed in the aggregate of essential features sufficient to achieve a technical result, which consists in increasing the effectiveness of treatment and reducing the number of complications. The essence of the invention lies in the fact that the needle is carried out to a depth of 4 cm from the surface of the skin and a 0.5% solution of novocaine is administered on it at the rate of 0.75 ml per 1 kg of patient weight on each side.

 The immersion of the needle to the area of the infratemporal fossa to a depth of 4 cm is sufficient to exclude complications in the form of trauma to the neurovascular formations.

 The amount of injected novocaine solution of 40-60 ml on each side ensures its distribution from the infratemporal fossae through the interfascial-cellular spaces to adjacent areas, as well as along the neurovascular bundles in the neck, reaching the upper border of the mediastinum. Thus, a solution of novocaine simultaneously infuses the branches of the trigeminal and vagus nerves, arterial trunks with sympathetic fiber, the sinocarotid zone and the thyroid gland, which is confirmed in the clinic by the presence of vasomotor reactions and Horner's syndrome. A similar effect does not provide any of the analogues.

 The scheme of administration and the zone of distribution of novocaine solution is shown in the attached drawing (Fig. 1), where on the left are analogues, on the right is the proposed method. In FIG. Figure 2 shows a photograph from an X-ray of a corpse, which produced contrasting liquor according to Vishnevsky, according to Zhakov, and according to our method.

 In FIG. 1 shows: trigeminal angles - 1, internal jugular vein - 2, external carotid artery - 3, internal carotid artery - 4, vagus nerve - 5, sympathetic trunk - 6, carotid glomus - 7, thyroid gland - 8, novocaine solution distribution zone with trigeminosympathetic blockade according to Zhakov - 9, the distribution zone of novocaine solution along the vagosympathetic blockade according to Vishnevsky - 10, the distribution zone of novocaine solution according to our method - 11.

 The method is as follows. When the patient is in a position with a raised head end, the needles are injected 2 cm anterior to the ear tragus under the lower edge of the zygomatic arch in the notch region, directing it perpendicular to the skin surface to a depth of 4 cm. In this case, the end of the needle is located at the border of the temporal fossa into the pterygopalatine, without injuring anatomical formations. A 0.5% solution of novocaine is slowly injected through the needle in an amount of 40-60 ml (at the rate of 0.75 ml per 1 kg of patient weight). Thus, in interfascial-cellular spaces to the neurovascular bundles lying here, the solution spreads not only in the infratemporal and pterygopalatine fossa, but penetrates into the pterygo-maxillary, submandibular, maxillary, posterior and pharyngeal spaces; upper, middle and lower parts of the neck to the upper border of the mediastinum.

 At the time of administration of the novocaine solution, the patients in the creation need to perform swallowing movements that promote the advancement of the anesthetic from top to bottom, from the base of the skull through the cervical region to the mediastinum.

 The frequency of blockades depends on the severity of the traumatic brain injury and is carried out before the initial surgical treatment of the wound and the immobilization of bone fragments. In some patients with severe brain injuries, a single block did not give the desired result, which we judged by the dynamics of changes in cerebral and focal symptoms, according to angiotensometry of system pressure and pressure in the facial arteries, as well as the state of the microvasculature of the bulbar conjunctiva and two ocular. Therefore, blockades were repeated until these indicators returned to normal and they were most effective on days 3 and 5.

 The extent of the distribution of novocaine is proved by the results of morphoexperimental studies. According to the claimed method, a contrast agent was introduced, which was located in the interfascial-stomatal spaces of the maxillofacial region and neck (Fig. 2). The relationship of novocaine with the neurovascular bundle of the base of the skull and neck (II and III branches of the trigeminal nerve, facial and maxillary arteries) was determined by angiography of the external artery with subsequent contrasting of the interfascial-cellular space according to the proposed method.

 The pathogenetic basis of the method, in addition to the effect of chemical neurotomy, is the improvement of microcirculation in injured tissues with the resolution of the exudation phase and stimulation of reparative-proliferative regeneration.

 The therapeutic effect was primarily in the anesthetic effect of the blockade, which allows performing surgical procedures in the maxillofacial region. Vasomotor reactions to the action of the novocaine solution, which we judged by the angiotensometry readings and changes in the microvasculature of the bulbar conjunctiva and fundus, prevented the development of soft tissue edema of the maxillofacial region of the brain in the first hours. Clinically, this manifested itself in a quick regression of focal and cerebral symptoms and the normalization of impaired vital functions, if they were compensated. Statistical processing of clinical material showed that the therapeutic effect when applying the proposed method is 2.6 times higher than the results of conventional methods of treatment.

 Example. Patient S.N., 27 years old, was admitted to the Scientific and Technical Center "WTO" after a traffic accident. The condition is serious, the patient is in stupor. Clinical and radiological diagnosis: brain contusion of moderate severity, open 2-sided comminuted fracture of the lower jaw. Before reposition and immobilization of bone fragments, the patient underwent novocaine blockade according to the described method. On the second day after the injury, the patient makes contact, in the environment is fully oriented.

 Angiotensometric studies showed: upon admission, systemic pressure was 145/95 mm Hg. Art. (control - 110/70); in the facial artery - 170/100 (115/65); in the lower labial artery - 110/75% in the lower labial vein - 43 mm in. Art. (thirty). 60 minutes after the blockade, systemic blood pressure was 117/80, in the facial artery - 125/80, in the lower labial artery - 95/60, in the lower labial vein - 33 mm cent. In the following days, the pressure decreased and by 2-3 days was equal to control.

 Studies of the microvasculature of the bulbar conjunctiva and retinal vessels have also shown a significant positive effect of the action of novocaine blockade. If, upon admission, the general conjunctival (OCI) and total vascular (OSI) indices were 22 and 14 points, respectively. 60 minutes after the blockade, the OCI was 15, the AIS was 11 points, on the next day their values were 8 and 6 points, by 5 days their values were equal to control.

 He was discharged home after 30 days without neurological impairment for outpatient follow-up care under the supervision of a maxillofacial surgeon and a neurologist, the fractures were healed, the tires were removed.

Claims (1)

 A method of treating a combined maxillofacial trauma, including the introduction of a solution of novocaine into the infratemporal fossae, characterized in that the needle is carried out to a depth of 4 cm from the skin surface and a 0.5% solution of novocaine is administered through it at a rate of 0.75 ml per 1 kg patient weight on each side.

Images