Traumatic brain injury (tbi) – online surgery course lecturio nanoxia ncore retro

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Welcome back.

00:02

Thanks for joining me

On this discussion of traumatic brain injury under

The section of trauma.

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Let’s start with a

Clinical scenario.

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Take a look at this picture.

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The driver, a 25-year-old man,

Sustained a high-speed roll-over motor vehicle accident who now arrives in

Your trauma bay, is not responsive.

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Do you know what to do next? I’ll give you a second

To think about it.

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Remember, back to our previous initial

Assessment and management discussion, always begin with the abcs.

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Now that you’ve ascertained

An intact airway, a breathing patient and a patient

Who has intact circulation, we move to the D of disability where


We ascertain a glasgow coma scale.

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The glasgow coma scale

Has three components.

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It’s a global assessment of the

Patient’s neurological status.

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Take a look at this table.

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You’ll notice that there are columns for

Eye, verbal, and motor examinations.

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The coordinated effort of the patient

Who is able to open their eyes, speak to you, and move their extremities

Is one that is an oriented patient.

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Glasgow coma scales are scored from a

Minimum of 1 to a maximum of 6 points.

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We assign the best exam finding.

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Remember, the best exam finding.

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When presented on an examination

Of what is the GCS score, always look for the

Best exam finding.

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The eye exam is

Listed from 1 to 4.

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The verbal examination

Is listed from 1 to 5.Nanoxia ncore retro

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And the motor exam is

Listed from 1 to 6.

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There is no precedence or importance

Of one exam over another, although it appears that

Motor is heavily weighted.

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Important to remember that

You just have to spend a few minutes looking at the

Slide and memorizing.

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Unfortunately, I don’t have any simple

Ways of memorizing the GCS EVM scoring.

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The patient does not open his

Eyes, respond verbally or move.

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My question to you is, “what is

This patient’s glasgow coma scale?” again, the patient

Doesn’t open eyes, has absolutely no verbal

And is not moving at all.

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This is a common trick question.

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The minimum GCS is 3 because the

Lowest score is 1 on a 1 to 6 scale.

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So, the minimum score GCS is 3 in

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This completely comatose patient.

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As a side note, if the

Patient is intubated, clearly you can assess the verbal but

Remember that gestalt is very important.

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The placement of the ET

Tube, if that’s the only limiting factor for

Patient’s ability to speak, we assign a T for endotracheal

Tube at the end of the GCS score.

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Let’s transition to a

Discussion of traumatic brain injury but first

Let’s discuss the anatomy.

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On this image, you see the first layer

As the skull and right underneath it is the superior sagittal sinus

Containing venous drainage blood.

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The yellow outline suggests a subarachnoid

Space between 2 arachnoid and pia maters.

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I’d like to start the discussion

Of specific traumatic brain injuries with a discussion

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Of subdural hematomas.

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Classically, subdural

Hematomas or any intracranial bleeding is associated with

High impact to the skull.

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They are traditionally associated

With tearing of bridging veins between the brain

Surface to the dura sinus.

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As you can see in this image, bleeding in the subdural

Space results in a semilunar or often called moon-shaped

Crescent hematoma.

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The reason is because the blood separates

The arachnoid away from the dura.

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It is not, however, bound

By the sagittal sinuses.

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There may or may not be medial deviation

Or elevation of the intracranial pressure.

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Remember, any space-occupying

Lesion in the brain may lead to elevations of

Intracranial pressure.

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We will come back

To this concept.

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How do we manage subdurals? Based on the clinical status and

The severity of the subdural, management is guided by midline

Shift, intracranial hypertension, clinical picture such as a

Comatose or worsening GCS patient or particularly large subdural

Hematomas as defined by bleeding hematomas greater than

One centimeter in thickness.

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If these findings are present,

Consider calling a neurosurgical colleague for surgical

Decompression of the hematoma.

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Of course if the patient doesn’t have

Any of these significant findings, then our job as trauma surgeons

Is to prevent secondary injury.

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What does it mean to

Prevent secondary injury? With any trauma, just like when you bang

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Your knee, some swelling is bound to happen.

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We want to decrease swelling and also prevent

Ischemia or low perfusion of your brain.

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Let’s move on and discuss

Epidural hematomas.

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Once again, epidural hematomas are

Associated with high impact to the skull.

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Unlike subdurals which are

Associated with bridging veins, the epidurals are associated

With middle meningeal artery.

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In a clinical scenario, this often

Describe classic lucid interval where the patient immediately following

The trauma may actually be lucid and after about 30 minutes to an

Hour has a second comatose episode.

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I caution the viewer though

That the classic lucid interval is much more disgusting

And seen in real life.Nanoxia ncore retro

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And seen on this CAT scan, you

Notice that the lenticular shape or biconvex shape which

Is limited by the suture line.

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How do we manage an

Epidural hematoma? Most epidural hematomas, unlike subdural

Hematomas, require a surgical decompression.

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If a clinical scenario is

Presented to you where a patient sustains high

Velocity or a high-impact brain trauma and they

Demonstrate a lucid interval, I encourage you to hold

Epidural hematomas high on your differential list and a list

Of surgical decompression.

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Once again, like any

Traumatic brain injury, we want to try to prevent

Secondary injury.

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Let’s discuss skull fractures.

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Once again, skull fractures

Are associated with high-impact mechanisms such

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As an assault with a weapon.

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It’s a classic scenario to

Have a patient undergo assault with a bat or a metal instrument

Direct blow to the head.

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Remember that skull fractures are often

Associated with cervical spine injuries.

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This likely has to be dissociation

Due to the high impact injury.

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Some very important

Classic signs include the raccoon’s eyes which is a

Bruising around the eyes.

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Remember, raccoon eyes and battle’s signs

Are signs of a basilar skull fracture.

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Battle’s sign is bruising

Around the mastoid process.

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Just to review, raccoon’s eyes is

Bleeding or bruising around the eyes and battle’s sign is bruising of the

Mastoid process just behind the ear.

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And depending on the severity, the patient

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Can have a CSF, cerebrospinal fluid leak.

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Most skull fractures

Are largely managed non-operatively unless

Couple of caveat exists.

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One, significant

Depression of the skull.

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This may require

Elevation of the skull.

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And most importantly,

An open skull fracture uniformly requires

Exploration and elevation.

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Earlier, I mentioned that one

Of the clinical signs to evaluate the patient for is

Intracranial pressure monitoring and to try to prevent intracranial

Hypertension for high icps.

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A very useful and practical equation to

Remember is the cerebral perfusion pressure.

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The cerebral perfusion pressure is a

Difference between the mean arterial pressure.

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That’s the systemic circulation

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Minus the intracranial pressure.

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Again, the cerebral

Perfusion pressure is a difference between your

MAPs and your icps.

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In severe TBI patients where their GCS

Is less than 9 were considered comatose.

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Intracranial pressure monitoring may help

With diagnosis of further deterioration.

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Remember, comatose

Patients will not likely participate in your

Neurological examination.

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Patients in whom we cannot

Follow the examination, for example, a comatose patient

Or one who is on severe sedation or anesthesia may also require

Intracranial monitoring.