[Music]
welcome back thanks for joining me on
this discussion of traumatic brain
injury under the section of trauma let's
start with the clinical scenario take a
look at this picture the driver a 25
year old man sustained a high-speed
rollover motor vehicle accident who now
lives in your trauma Bay is not
responsive do you know what to do next
I'll give you a second to think about it
remember back to our previous initial
assessment and management discussion
always begin with the ABCs now that
you've ascertained an intact airway
breathing patient and a patient who has
intact circulation we move to the D of
disability where we ascertain a Glasgow
Coma Scale the Glasgow Coma Scale has
three components it's a global
assessment of the patient's neurological
status take a look at this table they
notice that their columns for eye verbal
and motor examinations the coordinated
effort of a patient was able to open
their eyes speak to you and move their
extremities is one that is an oriented
patient Glasgow Coma Scale are scored
from a minimum of 1 to a maximum of 6
points we assign the best exam finding
remember the best exam day when
presented on an examination of what is
the GCS score always look for the best
exam finding the eye exam is listed from
1 to 4 the verbal examination is listed
from 1 to 5 and the motor exam is listed
from 1 to 6
there is no precedence or importance of
one exam over another because although
it appears that motor is heavily
weighted important to remember that you
just have to spend a few minutes looking
at the slide and memorizing
unfortunately I don't have any simple
ways of memorizing the GCS evm scoring
the patient does not open his eyes
respond verbally or move my question to
you is what is this patience
Glasgow Coma Scale again the patient
doesn't open eyes has absolutely no
verbal and is not moving at all this is
a common trick question the minimum GCS
is 3 because the lowest score is 1 on a
1 to 6 scale so the minimum score GCS is
3 in this completely comatose patient
and as a side note if the patient is
intubated clearly you can assess the
verbal but remember the Gestalt is very
important in the placement of the ET
tube is that as the only limiting factor
for a patient's ability to speak we
assign a t4 come for endotracheal tube
at the end of the GCS score let's
transition to a discussion of traumatic
brain injury but first let's discuss the
anatomy on this image you see the first
layer as the skull and right underneath
it is the superior sagittal sinus
containing being a strange blood the
yellow outline suggests a subarachnoid
space between two arachnoid and Pia
matters I like to start the discussion
of specific traumatic brain injuries
with a discussion of subdural hematomas
classically subdural hematomas or any
intracranial bleeding is associated with
high impact to the skull they are
traditionally associated tearing the
bridging veins between the brain surface
to the Douro sinus as you can see in
this image bleeding the subdural space
results in a semilunar or often called
moon-shaped Crescent hematoma the reason
is because the blood separates the
arachnoid away from the dura it is not
however found by the sagittal sinus --is
there may or may not be medial deviation
or elevation of the intracranial
pressure remember any space occupying
lesion in the brain may lead to
elevations of intracranial pressure we
will come back to this concept how do we
manage sub girls
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
if these findings are present consider
calling a narrow surgical colleagues for
a surgical decompression of the hematoma
of course if the patient doesn't have
any of these significant findings then
our job is trauma surgeons is to prevent
secondary injury what does it mean to
prevent secondary injury with any trauma
just like when you bang your knee some
swelling is bound to happen we want to
decrease swelling and also prevent
ischemia or low perfusion of your brain
let's move on discuss epidural hematomas
once again epidural hematomas are
associated with high impact to the skull
unlike subdural which are associated
with bridging veins the epidurals are
associated with middle meningeal artery
in a clinical scenario this often
described classy elusive interval with a
patient immediately following the trauma
may actually be lucid and after about
thirty minutes to an hour has a second
comatose episode I caution the viewer
though that the classic lucid interval
is much more discussing and seen in real
life and seen on this cat scan you
notice the lenticular shape or by convex
shape which is limited by the suture
line how do we manage the epidural
hematoma most epidural hematomas unlike
subdural hematomas require a surgical
decompression if the clinical scenario
is presented to you where a patient's
sustained 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 elicit surgical
decompression once again like any
traumatic brain injury we want to try to
prevent secondary injury
let's just discuss skull fractures
once again skull fractures associated
with high impact mechanisms such as an
assault with the weapon it's a classic
scenario to have a patient undergo
assault with a bat or a metal instrument
direct blow to the head
remember that skull fractures are often
associated with cervical spine injuries
this likely has to be the Association
due to the high impact injury some very
important classic signs include the
raccoons eyes which is the bruising
around the eyes
remember raccoon eyes and battle signs
are signs of a basal skull fracture
battle sign is bruising around the
mastoid process just to review raccoons
eyes is bleeding or bruising around the
eyes and battle sign is bruising of the
mastoid process just behind the ear and
depending on the severity the patient
can have a CSF cerebral spinal fluid
leak most skull fractures are largely
managed non-operatively unless couple of
caveats exist one significant depression
of the skull this may require elevation
of the skull and most importantly an
open skull fracture uniformly requires
exploration and elevation earlier I
mentioned that one of the clinical signs
that evaluate the patient for is
intracranial pressure monitoring and to
try to prevent intracranial hypertension
or high ICPs a very useful and practical
equation to remember is a cerebral
perfusion pressure the cerebral
perfusion pressure is the difference
between the main arterial pressure
that's the systemic circulation
minus the intracranial pressure again
the cerebral perfusion pressure is a
difference between your Maps and your
ICPs in severe TBI patients where their
GCS is less than 9 or considered
comatose intracranial pressure
monitoring may help with diagnosis of
further deterioration remember comatose
patients will not likely participate in
your neurological exam
patients in whom we cannot follow the
examination for example a comatose
patient or one who's on severe sedation
or anesthesia may also require
intracranial monitoring
[Music]