CONTROLLING BLEEDING IN HEAD INJURIES

From without inwards, control a bleeding head injury like this:

BLEEDING FROM THE SCALP

Bleeding scalp vessels are difficult to pick up in haemostats, because they are held by the fibro–fatty tissue. Instead, use stitches, and control bleeding like this:

(1) Ask one, or even two assistants, to press on the patient’s scalp close to the edges of the wound.

(2) Pick up the cut edge of his galea with haemostats 1 cm apart along the incision. Then evert them so that they compress the bleeding vessels in the edge of his scalp. Keep them together in bundles with rubber bands round their handles, out the way of the operation.

(3) Add adrenaline to the local anaesthetic solution. If the patient is having a general anaesthetic, infiltrate his scalp and temporalis muscle with adrenaline and saline.

Try to control all bleeding before you stitch up his scalp. If you don’t, a large haematoma may form under it, become infected, and need opening later.

BLEEDING VEINS AND VENOUS SINUSES

When you operate, prevent venous bleeding by taking the following precautions before you start:

(1) Use methods of anaesthesia which minimize bleeding. It will be worse if the patient strains. Ideally, give him a general anaesthetic, intubate him under relaxants, and hyperventilate him. This will reduce his intracranial pressure and minimize bleeding. If general anaesthesia is unlikely to be perfect, local anaesthesia may be better.

(2) Make sure that nothing obstructs the veins of the patient’s neck. If necessary, raise his shoulders on sandbags.

(3) Reduce the venous pressure in his wound. Arrange the position of his head so that his wound lies uppermost. Give the table just enough head up tilt, about 10, to raise his head above his heart and minimize venous bleeding. Don’t raise it too much because air may be sucked in and cause an air embolus. The first sign of this will be sudden weakening of his pulse and an increase in its rate. Embolism will be less likely if there is fluid over the surface of his wound, so keep syringing it with saline.

Elevating the head of the table will also help to control bleeding from his dura or his brain, but is less useful on the more superficial tissues.

If a sinus bleeds during an intracranial operation, apply the above measures. But:

Don’t: (1) Apply haemostats to the patient’s bleeding sinus, because they will tear out and make bleeding worse. (2) Don’t try to sew up a torn sinus. This can increase bleeding, especially if you cannot get at it adequately.

Instead: (1) Tie any smaller sinuses on either side of the tear, or fix them with a silver clip. (2) Push muscle grafts or pieces of surgical gauze between his dura and his skull. Then keep them in place by passing a few interrupted sutures between his epicranium and his dura over the nibbled edge of the bone. These sutures will hitch up his dura, and help to keep the muscle grafts in place. (3) Plug his bleeding sinus with a piece of muscle. If necessary, hold it in place with a deep suture passed under the sinus with a big curved needle.

If blood pours out as a dark venous stream from his sagittal sinus, controlling it can be very difficult. This sinus runs in the midline on the inner surface of the skull from the forehead to the occiput. Several irregular venous spaces (lacunae) join it on the top of the head (63-6). Fortunately, it is rarely injured, because the skull is more often hit from the side than directly from on top. The transverse sinuses in the occipital region are still less vulnerable, but when they are injured, bleeding is even harder to control.

Plug the patient’s torn sagittal sinus with haemostatic gauze. Suture his scalp over it, apply a tight bandage, and refer him. If you don’t have any haemostatic gauze, or cannot refer him, use ordinary gauze and remove it cautiously in the theatre 48 hours later. If necessary, replace it with a muscle graft or a patch. Or, cover the gap with a thin piece of bone wax, and close his scalp over this. You can safely obstruct the superior saggital sinus in the first quarter of its length. Obstructing it further back will probably kill him.

Often, a sinus does not bleed until you begin raising a depressed fracture near it—don’t!—treat it conservatively! These fractures are for real experts.

BLEEDING FROM THE BRANCHES OF THE MIDDLE MENINGEAL ARTERY

These vessels lie between the dura and the inner table of the skull. Underrun them with silk or cotton on a fine curved needle. This is easier than trying to coagulate them with diathermy.

BLEEDING FROM THE DIPLOE

Push Horsley’s bone wax into the bleeding cut surface of the patient’s skull. Or, use Bismuth and iodoform paste BPC. Or, use autoclaved beeswax or paraffin (candle) wax. If an artery spurts from the bone, push the sharpened point of a sterile match stick into it.

BLEEDING FROM THE VESSELS OF THE DURA

These tear so easily that you cannot grasp them with haemostats and tie them in the usual way. Instead, control bleeding like this.

(1) Place the wound uppermost, as described above.

(2) Press gently on the patient’s injured sinus for about a minute. When you let go, the bleeding will probably have stopped. Pressing too hard may injure the smaller veins joining the sinus and make bleeding worse.

(3) Grasp the bleeding vessels with fine dissecting forceps and touch these with the diathermy electrode.

(4) Grasp the bleeding vessel with fine dissecting forceps, ask your assistant to hold them very still, while you underrun the vessel with 3/0 silk on a small curved atraumatic needle. When the suture is complete, apply a muscle patch, as described below.

(5) USING A MUSCLE PATCH If a piece of some suitable material is pressed over the bleeding area for a few minutes, blood will clot around it and seal it. Synthetic absorbable gauze is best, but if you don’t have that, use a piece of muscle, or muscle and fascia squeezed flat. The temporalis muscle is close at hand, so use it. Although these patches will not stop an obviously bleeding vessel, they will stop a steady ooze.

Take a piece of the patient’s temporalis muscle, and squeeze it flat between artery forceps until it is a thin sheet, the size of a postage stamp. The muscle will now be dead, but it will readily promote clotting. Press it onto the bleeding vessel, cover it with moist gauze, hold it in place with the sucker and drip saline onto it. The saline will keep the surrounding brain wet, and you will see through the gauze when bleeding has stopped. Leave it for five minutes.

If the flap you have reflected does not contain temporalis muscle, extend it so that you can take some. If you have already prepared the patient’s thigh, you can take some muscle from that.

Alternatively, scrape off a piece of the patient’s epicranium exposed by the wound, or take a piece from his mastoid process and hammer this flat to make the patch.

BLEEDING FROM THE BRAIN

Diathermy or silver clips will usually stop venous or arterial bleeding from any size of vessel. Use the lowest diathermy current that will cause coagulation, and the finest forceps. If don’t have diathermy, or silver clips, avoid using haemostats, because the bleeding vessel too easily pulls out of the brain. Instead, apply a muscle patch, as described above, or soak a pad of cotton wool in hydrogen peroxide and put this on the patient’s bleeding brain.

If his brain is bleeding, a warm pack will almost always control it. If necessary, put a piece of haemostatic gauze between his brain and his dura before closing it, and then place more gauze outside this. Don’t pack or plug head wounds with ordinary gauze.

ALWAYS OPERATE WITH THE PATIENT’S HEAD ABOVE HIS HEART