305. Opening the valve, cleaning, and coagulation

In the eyes of Peang and Cediyo, the so-called exploration is like looking for Xiaoqiang's nest in the ward. It is possible to look anywhere, but you may not be able to find it even if you drill the entire wall. But as Kawei said

For investigation, you must at least know where the hematoma is most likely to appear, otherwise you will not be able to start.

The drilling exploration itself is not blind, it also involves location determination. Even if there is some lottery element, it mostly relies on the accumulation of experience.

In the era when Kawei first became a doctor, only large hospitals in the country had CT machines. If you wanted to locate intracranial hematoma without a CT machine, you relied on drilling and exploration. As for the back of the head when it hits the ground or falls,

There is a relatively complete detection sequence for deceleration injuries caused by impacting objects.

"When the focus is on the back of the brain, that is, the occipital region, our exploration sequence is ① the bottom of the contralateral frontal lobe - ② the bottom of the ipsilateral frontal lobe - ③ the pole of the contralateral temporal lobe - ④ the pole of the ipsilateral temporal lobe.

"【1】

Kawei found a chair and sat on top of Shebasto's head, gently tapped his forehead with a drill, and asked Payne to draw numerical circles with a black pen on the four preset positions: "If these places are not found

For hematoma, the last thing to look for is the occiput or posterior fossa on the same side." [2]

The reason why the frontal lobe is targeted first for posterior occipital injuries is because Sebasto suffered a deceleration injury to the left occipital area. This type of injury causes limited damage to the force-bearing position, and is often blocked by the skull, but accordingly

The force will be transmitted forward, causing a reverse impact.

So the most likely cause is damage to the frontal lobe on the opposite side, that is, on the right side.

The frontal lobe damage also responded to Shebastow's urinary incontinence, vomiting, and slightly dilated right eye pupil.

"The location of the occipital injury is relatively high, so we choose the bottom of the forehead, at the intersection of 3cm above the eyebrow arch and 3cm beside the midline, to incise the scalp first." Kawei used a scalpel to gently incise the skin to separate it, "Remember

, be sure to determine the drilling position first, and then make the incision. The incision needs to pass through the drilling position.”

"gauze."

After cutting the blue-purple dura mater, Kawei quickly moved the rubber hose used for suction.

Cediyo didn't find it too scary, but it was far different from the treatment picture in his mind: "Doctor Kawei, can this barbaric method really work?"

Kawei put his fingers in front of Shebasto's nose, measured his respiratory rate, and then began to direct the work outside of the operation: "Put the blower next to the operating table, connect the rubber tube and mask, and pour some air into his mouth."

Be careful not to leak air from the interface, and use gentle force so as not to blow out his lungs."

"Okay, I'll try."

"Here, I just got it from the kitchen of Charles Restaurant!" The nurse was too lazy to complain about how she got pig blood, "How do I get it?"

"Why do you want leech saliva?"

“Is this a money issue???”

"saliva?"

"It's really tight, so epidural bleeding is often caused by a ruptured artery."

"It's connected." Another nurse brought the suction device over.

Soon the first drilling was completed with a refreshing feeling of failure. The bone debris was washed away, and the dura mater inside could be clearly seen through the hole.

At this time, the door of the operating theater was knocked open, and the nurse in the ward ran in with several patients and family members. Together they carried a small blower, as well as a large jar of leeches, pig blood and snails.

: "Dr. Kawei, what you asked for has arrived."

Speaking of which, the little nurse was just a nurse from a hundred years ago. She had no status and all she could do was complain.

No one understood the meaning of this sentence, but when it came to brain tissue bulging, Cediyo did have some experience.

"Tissue forceps"

The nurse was very angry. She endured foot odor, urine smell, vomit, and had to run back and forth for nearly an hour for this operation. Thanks to her good brain, familiarity with the surroundings, and good luck,

Otherwise, these things will not be prepared at all.

"Fortunately, when I went to the pharmacy, a new batch of goods was just unloaded at the door."

"Can their saliva prevent blood coagulation?" As soon as Cediyo asked, the scene when he was undergoing bloodletting flashed through his mind. "After you said it, it seems that it is indeed the case."

"This layer is the dura mater under the skull, and below it is the brain tissue. It is also the location where the hematoma appears." Kawe pointed at the newly opened hole with the smallest forceps, "It is the same as the peritoneum during the ectopic pregnancy in the morning.

, Mr. Sebasto’s dura mater appears blue.”

Firstly, the effect of hirudin is too strong and long-lasting. Excessive dosage can easily cause coagulation disorders; secondly, the extracted liquid is only a crude liquid and cannot be purified, which further affects the dose control. Adding this substance to the patient's blood

, will make autologous blood transfusion, which already has side effects, more unpredictable, just like gambling.

Intracranial hemorrhage will gradually form a blood clot, and complete removal requires incision of the skull. Large bone flap removal is also the most common surgical method.

Intracranial hematoma is sometimes accompanied by the rupture of small blood vessels. These blood vessels are located in the cerebral cortex. After the rupture, the brain is covered with clotted blood. It is difficult to even see where it is. There is no way to ligate it with sutures. It is very difficult to stop the bleeding.

.

The nurse was sweating, her hair was spread out, and there were many yellow and green stains on her clothes. She thought she would get some praise for her hard work, but she didn't expect that the young man in front of her didn't understand this at all.

"Oh, money is no object."

"Yes, I have run out of anticoagulants, so I hope to postpone the afternoon surgery. After all, I have rectal cancer." Kawei saw that when he mentioned rectal cancer, the other party's face became ugly, and he immediately changed his words, "Actually, I had

It was found that leech saliva also has this effect."

The nurse was very tired from her busy work, but she still did as Kawei asked: "Then what?"

Back then, he had been on the battlefield and worked as a military doctor. He had seen the appearance of brain tissue swelling outward after a broken head. Now listening to Kavi's description, it seemed that Shebasto's brain was also undergoing this kind of torture.

Kawei first used a drill to make a shallow pit mark, then held the hand drill vertically against the skull, gradually changing his hand speed from slow to fast.【5】

It was indeed against the gentlemanly etiquette for a young girl from the 19th century to do such a thing at night. But Carvey didn't know how to express it, so he could only reply awkwardly: "Thank you."

"Yes, epidural hematoma will definitely cause skull fracture."

"Well, that's right." Kawei said, "It's the same as my judgment, the bleeding is under the subdural mater."

"So this is..." Kawei was a little confused by what she said.

Kawei became anxious when he heard that leeches were very important. If they did not meet the requirements, it might be too late: "Are these all full of blood?"

Once the respiratory center is suppressed, the respiratory rhythm will disappear. The blower is a respiratory airbag that forces the lungs to work. The only disadvantage is probably that it is a bit more powerful.

At this time, autologous blood transfusion is the final guarantee. Without this guarantee, Shebasto would probably die here.

"It means there is bleeding in the brain!" Peang answered quickly.

"Give me the tube, you shake it." Kawei took the rubber tube and used scissors to make an arc shape for the mouth of the tube to prevent excessive contact with the brain tissue and cause unnecessary trouble. "Pay attention! Don't shake it too fast.

, you have to take your time."

(Epidural and epidural development are both called epidurale, and the prefix epi means "above" in medical terminology)

"Of course."

But Shebasto's situation was too critical, and it was indeed a last-ditch effort.

"The anticoagulant you're talking about?"

Kawei's scalpel drew an arc on Shebasto's right forehead, passed through the top of the forehead and turned all the way to the outside. It was about 5cm long, and the cutting direction was aimed at the right temporal pole [3]. Because it was just a drill hole.

Exploration is required, so the incision length is limited. After the location of the hematoma is found, the incision can be expanded to make an arc-shaped or horseshoe-shaped skin flap.

"Where's the pig's blood?"

In fact, Kawei would not be willing to get hirudin if the sodium citrate had not been used up.

When she saw Cediyo in the audience, she calmed down and did not have another attack.

She endured it for a full two hours and finally couldn't help but burst out: "Dear Dr. Carvey, I don't know how you practice medicine in Austria. At least French doctors don't have as much ostentation as you. Paris, you let me

Where can I find a blacksmith? I have to knock on doors and ask them if they have the 'blower' you want!"

"There is a blood clot." He tried to be gentle and quick with his movements, and got rid of any distracting thoughts. "When encountering blue-purple dura mater, no matter what happens next, we should make a cut to let the patient decompress as soon as possible."

"OK."

"Use pig blood and snails to stimulate those leeches." Kawei watched Shebasto put on the mask, and his chest gradually rose and fell, and said, "Tread lightly. No matter how gentle, just this intensity, slow down

Slow down and hold on!"

Kawei gave the answer and supported this with bloody "facts": "In frontline military hospitals, we often receive wounded soldiers who were hit on the head by heavy objects. It is a high-speed injury. Usually the skull is fractured.

, a large hematoma appeared in the epidural. Because it was arterial bleeding, it could easily cause shock."

The nurse put the leeches on the table in the preparation area: "I heard that they were just shipped from Turkey and they were hungry for several days. I don't know the exact number, and I don't want to know. Anyway, that's it. If you think it's not up to standard, there's nothing you can do about it.

One leech alone costs 20 francs!! Including the jar, this time it cost 500 francs!”

"Pour out the pig blood clots in the bottle, then put only one snail in it, and then put in all the leeches." Kawei explained, "Let them stay in there for half an hour, and neither the blood nor the snails will be enough to feed them.

, but it can make them salivate."

"Suture the needle and thread." Kawei handed two small retractors and gauze to Payon, "Protect the incision."

The drilling that Kawei is doing now is only preliminary preparation work and helps with positioning. Therefore, when incising the skin, you should consider the location and size of the skin flap and bone flap, and try to avoid unnecessary incisions that may cause postoperative healing difficulties.

"After half an hour, induce vomiting in them," Kawei said. "Put on gloves and wipe their mouths with a small amount of salt."

The role of the blower is self-evident, it is to make an air infusion device in Paris where there is no rubber inflatable bag. This is also a last resort for Carvey, fearing that brain herniation may occur during the operation and inhibit the respiratory center.

Kawei looked at the audience: "Mr. Cediyo should have heard me talk about sodium citrate this afternoon."
To be continued...