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Right. Yeah, thanks. So welcome everybody. Um I've got plenty of slides. It's difficult to actually discuss pediatric trauma uh as well as trauma in general in 25 minutes, but I'll try my best just to be concise and uh I'm not going to detail. Um So yeah, let's kick off. Um Can I go ahead doctor? Uh Yeah, please go ahead, please. Ok, so um trauma is a prime cause of death um and serious death throughout childhood and 50% of all deaths in the first world countries and 50% of those are due to unintentional related deaths as a result of MBA S and approximately about two thirds of injury are related to deaths are, are, are are involving males. And uh neurotrauma is the leading cause of all mobo morbidity and mortality when it comes to trauma. And therefore it's very important for us to take a very careful history and an exam. Sorry. KT uh can it? Yeah. Mm Yeah. Uh a neurotrauma related um The reason being is that we've been receiving quite a lot of referrals with patients picked up in the street. Patients were unconscious and not necessarily pediatrics. Uh not so much pediatrics but adults that uh you know, you get referred to directly to neurosurgery as a result of um uh uh of uncertainty whether the patient is, has been assaulted or was involved in the MVA because there's no collateral injury. But I'm not gonna harbor on that information. Any child with a GCS less than 14 to 15. Um with clinical evidence of skull fracture or penetrating head injury requires an urgency to brain and um trauma, whether by ATL SA LS or A LS. Um it is very important to prevent secondary brain injury and also important to improve outcomes in, in, in, in, in pediatric patients with trauma, brain injury. And it's very important that the triage team work together. They coordinate the management and resuscitation and direct the treatment of, of, of, of, of patients with traumatic brain injury. Um The other important factor is to try and allay the fears of the family and, and, and the parents by speaking to them, counseling them and you know, keep them uh uh uh uh uh uh uh alert or, or way of things that are happening and what management we are implementing. So we're gonna look at the quick definition of acute brain trauma, brain injury, brain injury, resulting from mechanical injury to uh as a result of mechanical energy, energy to the head um due to external forces. And there are three diff uh uh different categories um or classifications which I'll look at later. Um mild traumatic brain injury where patient is confused or GS 14 to 15, mild traumatic brain injury, moderate traumatic brain injury. GC is 9 to 13 and these patients usually are unconscious or stuporous and severe traumatic brain injury where patients are comatose from GCS of less than eight. The epidemiology, about 75% of Children admitted with trauma have a tr traumatic brain injury and most of these in pediatric brain injuries are mild, approximately over 85% are mild um mortality of pediatric traumatic brain injury currently is recorded at between 10 to 13%. And these are international figures. I got this from my Australian Australian paper. Um and incident is up to 125 cases per 100,000 population, especially of ages, less than 15 years who are hospitalized and those that we don't know of actually are not recorded. The male to female ratio is 4 to 3. And uh most common causes of pediatric traumatic brain injuries are usually due to falls from in at our hospital followed by MBA and PVA S and obviously then followed by um uh uh non accidental trauma or what we call or child abuse. Uh Sorry, Kenneth, we are losing you traumatic brain injuries. Um plasticity of the skull makes it uh very accommodating for these patients to, to sustain certain degree of injury. And therefore we see these mild traumatic brain injuries and most of them are actually just present with ping pong ball injuries, especially those who are less than two years because the skull is so uh pliable or malleable. If that is the correct word, I'm using. Um the other rare conditions like posttraumatic leptomeningeal cyst also known as growing fractures can be problematic if, if, if one do encounter them and they do sometimes require surgery. And as I mentioned, patients, pediatric patients are quite resilient so they can tolerate a certain degree of injury compared to adults. Um classification of pediatric traumatic brain injuries, classification of pediatric traumatic brain injuries is is like adults. Um It's mostly clinical um irrespective of what the radiological findings are. And unfortunately, those are the guidelines that have been laid forward from, from years of research. And everybody has agreed to the Glasco Coma Scale, which has been long been used now. So the Glasco Coma Scale uh looks at three categories, I motor and verbal and the lowest points for each category is one. And in each of these category, we look at the best response but sometimes patients can present with confusing neurological findings. I mean, you can might find a patient who's cerebrating on the one side of his arm and and he's withdrawing or he's localizing on the right other side of his arm. Um And um the other confusing uh uh factor that comes in play with uh G CS is when it comes to patients are intubated or um who are wearing masks, 40% mask or um uh aphasic. Then we use denote uh denotations or descriptors uh to try and um give reason as to why there's a uh uh uh uh uh um A drop in G CS and is due to verbal response. So TM or A, I use a subscript uh uh descriptors um and where T will be main two M will um refer to mask and A will refer to aphasic. But however, these, these are not variables, they do not replace the value one, which is the lowest value of the. So hence G CS two T does not exist. And I think everybody has come to that agreement. Um The problem with G CS in Children, however, is when it comes to giving a total score, it's unable, we are unable to actually um um determine determine what the value of V is because of patients who are less than two are unable to speak, or there might be limitations due to development delay or so forth. And just is just one example of a pediatric Glasgow coma scale that is in use currently. And as I said, this is not a uh uh uh uh um a definitive Glasco commerce scale, but basically, it's, it's just a guideline for us to use as to try and give um some people just, some people just avoid the V and work out classical coma scale out of 10. So it, I think that it lies with the neurosurgery's pre preference as to how he wants to keep the G CS. There's no lay down law. Um When we look at mild traumatic brain injuries, we mentioned that 80% of Children fall fall in this category and they usually GCS 14 to 15. Previously, it used to be 15. Uh but now they've included 14 to 15. Um they may have loss of consciousness, amnesia or neurological deficit. Whereas the moderate traumatic brain injuries are, uh the incidence is quite uncertain. Um um it's found that 18% of all traumatic brain injuries fall in this category and the severe traumatic brain injuries are less. Uh they're approximately 2% of all traumatic brain injuries and they mostly comma and they um actually present with high mortality rate if they are uncounted um when it comes to management. So, as mentioned earlier, management is quite important. So every trauma case that we deal with, irrespective of whether it's brain injury or general pediatric trauma or general surgery, um, the courses that we do the advanced pediatric life support, advanced trauma, life support or a LS advanced life support and basic life support actually prepares us to manage these patients. Um uh uh uh um Expedia uh uh uh um uh to men, manage them promptly and also to direct uh uh uh appropriate treatment as a multidisciplinary uh uh uh team. So it's very important to then look at the ATL S PRI principles or ATL S principles and apply these when coming to trauma patients. And the reason being why we go through all this PT is to prevent secondary injury from occurring. Um And when we talk about secondary injury occurring, we're talking about hypoxia circulation problems that lead to hypertension that will decrease cerebral perfusion, hence causing further um cerebral injury on top of the primary brain injury. So it's important that we apply these principles, whether the patient is G CS 14 out of 15 or severe and which in most cases we use uh ATL S and and A PS in severe cases, it's important that we look at the principles. So I'm not gonna go into detail, I'm assuming everybody has done a LS or done some form of um advanced uh uh right. Um I'm sorry for the background call. It's important right behind me is the COVID ward. So there there's no more neurosurgical ward. Um S. So in a secondary survey, we look at history, um um a complete examination is important. Uh not where we apply the brief uh disability neuro neurological exam um and do the investigations. So what are the indications for CT scan? So um according to the trauma guidelines and uh pediatric trauma guidelines, GCS of less than 14 in children's uh that's an indication for CT scan. Um some do mention that some articles or some literature do mention that A G CS of 15 with a local uh uh uh uh focal neurological deficit uh may also require urgency to scan, but that is also contentious. Um um Some of these patients do well. There is no evidence to prove that such patients will have a better outcome whether they had seizure. But I'll discuss that later when it comes to um uh simple skull base fractures. Um focal neurological deficit, signs of skull fracture, penetrating skull fracture. It all depends. And um it's a strongly consider they are unequal pupils that we saw in primary uh uh survey. Uh an aoria with one blown pupil and a normal reactive people that may indicate there's a intrasurgical lesion in the brain. Um abnormal behavior, patients that are restless, always considered that such patients may be hypoxic or they might be expanding lesion on the brain or cerebral worsening, cerebral edema, penetrating injuries, open skull fractures, quite important and also depends on the mechanism. And the object used. Persistent vomiting may also indicate raised intercranial pressure or worsening. ICP. Um posttraumatic seizures depend on the on the lesion, uh especially if it's delayed when the patient never had seizures. Initially, one should actually do a urgent ct scan just to find out why this patient is having had a seizure. Um So, the PEC A algorithm which was actually implemented uh to um identify patients with uh mild traumatic brain injuries with uh low risk for clinically uh significant brain injury. Uh It's basically an algorithm to try and exclude whether the patient needs CT scan or whether we can do without a CT scan. Um In the first category where patient age gcs is 14 or other signs of mental status. If it is, yes, the patient requires CT scan, it's recommended. Um I'm not gonna go through this whole algorithm. You can have a look at it. Um The, if there's no one, she didn't look at uh occipital parietal or temporal scalp, hematoma or history of loss of cancer. Since greater than five, no CT not recommended. Patient can be observed for 24 hours and um yeah, can be discharged home into the care of mother if the child is improved, obviously following the prin basic um Atlas or APLS principles in the category BGC S 14 or other signs of altered mental status, no signs of vasal fracture. If yes, the CT is recommended a history of loss of consciousness with vomiting and severe reply raised in inter pressure. Then I want you to query and monitor and look at the patient and question with observation versus CT. Um This comes, this is where the neurosurgeon comes in. Unfortunately. So if you the the the the front line doctor, casualty doctor, you're obviously gonna have to refer to the neurosurgeon at this point and, and, and, and then request their opinion, their expert opinion as to what to do for the patient. Um And then obviously, if it's no, then the patient doesn't need a CT scan and then clinically, the patient can be observed for 24 hours and then be discharged. Um, management of traumatic brain injury. So, pa uh pediatric patients do present with different types of uh uh uh uh um injuries and cephalhematoma is one of the common ones that we find. Um, um, there may be subgaleal cephalhematoma. There are two types, subgaleal hematoma where it could be or could be without any or um fractures. Um This is bleeding into the loose areolar tissue between the galea and the, and the and the and the epineural and the periosteum. Um It may cross sutures. Um, transfusion may be acquired in these patients because they tend to expand the mass is fluctuant and doesn't calcify unlike subperiosteal um uh hematomas where it's common in newborns. They are firmer and less palatable or fluctuant and they are limited by the sutures uh of the, of the uh of the periosteum uh with the periosteum attached to the sutures and um 80% usually resorbs within reabsorbs within 2 to 3 weeks. Um This is a rare type of uh uh of skull fracture, uh posttraumatic leptomeningeal, I don't think you will ever see this. Uh It's very rare. Um uh these are growing fractures, um fractures tend to widen, they appear as Arachnoid cysts and they do tend to um breach the dura and most of them require surgery. So these are the patients that you will have to refer to neurosurgery. Unfortunately. Um, simple depressed skull fracture studies have shown no difference in outcome uh uh in surgical outcome or non, uh in outcome in sur versus surgical versus nonsurgical treatment in 100 and 11 patients. And um these patients usually, um the skulls usually remodel. Um So it depends on the institution, the resources you have. And obviously, the presentation, if such a patient presents with a neurological deficit, then you'll consider a surgery if it's seizure. Um Unfortunately, lifting that fracture is not gonna take the seizure. You might find if you lift that fracture, there might be a contusion, there might be a gliosis or some form of uh epileptogenic lesion on that brain and the patient will then continue to get uh um antiepileptic treatment despite the elevation of the fracture. So, like I said, it's, it's very contentious. It's, it's all up to the surgeon and, and I, and the guidelines that we principles that we're following. Um in this case, uh such patient would not uh require surgery, but I think we will observe and then treat for antiepileptic treatment load with 20 mg per kg of normal saline in 60 minutes and then observe uh pediatric skull fractures, non accidental trauma, also known as uh child abuse. Uh These usually occur in 10% of Children less than 10 years of age. Uh The factors that are uh for uh non accidental trauma are retinal hemorrhage, bilateral, chronic subdural in especially patients, less than two years of age, one should be cautious when seeing patients with V patients. Um It might be also that a chronic subdural maybe due to overworking uh vs uh skull fractures, uh they may be communed, they may be bilateral, they might, they may be multiple, they may be basal skull. Um There might be diastasis, diastasis, meaning the fractures through the suture line. Um So there's no specific pathognomonic um sign for nonaccidental um trauma. They have to go through a lot of series of, of, of, of investigations to try and um uh identify uh the pathognomonic uh uh pattern or child abuse pattern. Um And this needs urgent referral to neurosurgery as well as social worker. Um I'm gonna go through the brain trauma Foundation guidelines for severe traumatic brain injuries. So these guidelines are the latest guidelines that were formulated. Uh I think these are the third edition of, of the Brain Trauma Foundation guidelines for severe pediatric trauma, brain injury, unlike the uh adult ones, which are already on the fourth. And um we call the Living Experience guidelines of the um brain Trauma Foundation. Um So basically these guidelines are meant for severe traumatic brain injury. So the this is where the neurosurgeon has now taken over the patient. The patient is admitted into um IC, the GCS is less than eight patient has been intubated, stabilized. Um All the A PS principles have been applied and the neurosurgeon has now been called to take over management of the patient. Um obviously based on the radiological findings, um uh it will determine uh whether the patient needs a ICP monitor. And the gold standard for the ICP monitoring is an external ventricular drain. There are other uh ICP monitor catheter, but the gold standard is E VD that you can use both as a therapeutic and a monitoring agent. Um The Brain Trauma Foundation has actually improved on the previous findings. They have made several recommendations. Uh There are 22 evidence based recommendations. I've just listed them. I'm not gonna go through them. Um I don't think we have enough time and this is not the platform to discuss them, but it's just a guide for us to see what are the treatment uh modalities for patients with severe traumatic brain injuries and what, what are the latest evidence based uh uh uh uh um uh uh recommendations that are implemented and these guidelines obviously will help us then uh ins instate a protocol uh based on our institution and also based on, on, on, based on the resources that we have. Um So looking at the first uh guideline that looks at intracranial pressure monitoring, I hope you can see this uh this table. I'm sorry. II actually uh took it from the um directly from the Brain Trauma Foundation guidelines. Um It, it is, it is implemented at level three where you use of ICP monitoring is suggested um and, and to, to improve overall outcomes and where they looked at um brain uh uh uh uh uh the lipox sorry, oxygen tension monitoring as being uh uh uh uh uh relevant but not important or not really that important when it comes to improving outcome. But it does kind of like support um ICP monitoring and um uh it, it, it, it hasn't a di it hasn't got a direct uh uh uh uh uh what is, what I'm trying to say now, it hasn't got a direct link to the outcome of patient, but indirectly uh assists in the treatment uh of ICP monitoring and um raised intracranial pressure to improve overall outcome. Um neuroimaging uh it's also a level three. Um It's where they looked at CT examinations. In the past. We used to just kind of like a repeat two serial CT scans to see if the patient improved. But now it's recommended that it's not important anymore. The CT scan is only recommended where um patient's condition has changed by. And I think most protocols these days looked at two GCS units. If the baseline was eight gcs dropped to six, um then it will be indicated. Uh but sterile CT scans are not recommended anymore. Um The threshold of treatment obviously ICP target of less than 20 millimeters, mercury. I think it's just slightly lower than what the adult was. 22 or 23.6 I think it was. Um and obviously, it looks at uh uh uh CPP in the past CPP value of 60 millimeters mercury, I stand corrected was the cutoff point, the lowest cutoff point. But now it's recommended that 40 millimeter millimeters mercury is suggested um the treatment recommendations of ICP uh especially ICP greater than 20 millimeters mercury. Um I think the hypertonic Saline versus Mannitol argument still carries on. Um we do not have hypertonic Saline available. So we make use of, of Mannitol and unfortunately, um you know, we've just got into the habit of, of implementing ICP monitoring. So we haven't done it on kids yet, but we are gonna do that. Uh We've been doing a lot of EV DS and I think I've got one adult patient. Uh Well, I had one, a adult patient with uh EVD in situ that we did ICP monitoring directly to the ventilator monitor and uh vitals mo monitor. Um The EVD, as I mentioned is very useful. You can um use it for therapeutic uh uh purposes as well as monitoring if you monitor and see that the ICP is great to as the doctor or the IC doctor duty or you yourself who are on duty to open the tap let off CSF. Um I think the recommendation is to let us CSF for about five minutes. Um And then uh you can close the tap and continue transducing the ICP uh seizure prophylaxis. There's no difference between um uh liver piracetam or Capra versus phenytoin. So we do use phenytoin propofol is not recommended with for sedation or for um or, or for seizure prophylaxis or seizure uh therapy. Um because of a Propyl infusion syndrome, uh if, if used over prolonged time and at high doses, analgesia and sedation, that's also a level three. Um it is recommended, sorry, apologies. It is recommended that we um not use midazolam and fentaNYL. Um I think this is institution based. I think we use a lot of Midazolam as here but not fentaNYL. Uh Midazolam and morphine for sedation. Um uh I think we use propofol more in adults. Um although we haven't seen any problems in using Midazolam, but they do recommend that we don't use it where there is a uh uh ICP crisis because of that hyper hyperperfusion that it can cause um ventilation therapies. Uh hyperventilation is not recommended anymore. Uh Unless you are intermittently taking a patient to theater and you're begging the patient or you're gonna take a patient for a procedure or, or, or uh investigation like a CT scan. And then yeah, you can use uh hyperventilation for brief periods. However, it is not recommended anymore. Um Hyperthermia is a level two, prophylactic motor hyperemia is not recommended. Um Barbiturates level three for ICP control, high dose rates are recommended uh in hemodynamically stable patients. Uh However, this must be uh supplemented with continuous ABP monitoring. Um As well as cardiovascular support uh due to the cardiorespiratory uh instability that it can cause um decompress a craniotomy. Um if all else fails, all medical treatment fails, uh the patient requires a decompressive craniotomy. And then to after your decompressive craniotomy, which we haven't done for kids yet. Uh I II haven't done one for a child. I must tell you because I've never done one for a child. Um However, um it is recommended to retreat, refractory, intracranial hypertension with neurological decline or when patients is about to herniate. Um that should be continued with uh followed with continuous ICP monitoring, uh post surgery, um nutrition level, it's uh to improve all outcome. It is recommended that enteral nutrition should be implemented or uh commenced within 72 hours. Post uh severe injury, immune modulating diet is not recommended. And obviously the uh corticosteroid still remains a level three and it's not recommended in Henry injury based on the crash injury. The first study, um the key points to uh to take home, I think is a pediatric and adult traumatic brain injuries differ. Um, more than 80% of pediatric traumatic brain injuries are mild and most require an oct uh but observation and they can be discharged into the care of a patient of the family if they are um are stable. Uh, you discharge them with a head injury chart and obviously with counseling and um and uh to inform the mom if anything goes wrong, you visit the local base hospital or return back to the clinic. Um All injured patients require approach and management based on AP APL S and HL principles. Um remember, not all unconscious patients are neurosurgical related and the best prac practice principles uh based on PTF guidelines are the basis for protocol implementation. However, um there's still a lot of work that needs to be done to, to kind of like try and improve the traumatic brain injury outcomes because of the lack of evidence of all the um evi evidence based recommendations that have been implemented. I think uh that's my talk. Can I thank you very much. Um I know you, it's a last topic and, and you had limited time. Uh So, so thank you. That is, that is quite um quite comprehensive. And what I'm going to do is uh consultant. So I'm just going to um uh to uh invite one after the other consultants and obviously, then there should be plenty of time for uh our juniors to ask questions uh to Doctor Harrison. So I'll just invite Doctor Majola first. Doctor Majola. Any comments, any questions? Um Thanks car for a good talk. I think he's just covered all the sort of what I would wanted to know about management of acute uh neurosurgical cases. So I don't have any questions currently. Ok, thank you. Thank you, Doctor Moola. Uh Thank you. Yes, doctor, please. Any comment. Any questions? Yeah. Hi. Prof thank you. And thanks Kenneth. That was very helpful. I think our juniors uh will find it very helpful as well when they're managing these patients. I would like to ask out of interest if they, what are the indications for evacuation of an extradural or subdural hemorrhage or hematoma in a child? I know there was one case recently. So. Oh, ok. Yeah. So, so like I like, like we said in the classifications, you know, um most patients, most of your pediatric patients that present with intracranial hemorrhages, uh they usually fall in the severe traumatic brain injury category. So basically, these patients will be comatose and probably require, well, they will probably require um intubation and and obviously, neurological fallout, clinical uh uh def uh clinical deterioration are all important factors uh or indicators for surgery, uh surgical evacuation of these patients. It's rare, it's rare that you find a patient that you can sit with in a a pediatric patient. May I say that you can sit and observe with the extra, unlike the adults, the adults has got like a classification where you look at the size and look whether the how much midline shift is on the CT scan, but most of these patients are comatose. So, you know, from presentation onwards, uh you know, you can't, you can't, you can't just sit with that extra dal hematoma, you have to evacuate it. Obviously, you have to look at the clinic, the the overall clinical picture is the extradural the contributing factor or is there more cerebral edema or is there a diffuse picture to this whole uh uh uh uh uh uh presentation? You know? So yeah, I II hope that answers your, your, your question. But is, is it more there's no absolute indication but there, there's no absolute indication per se. But like I said, it, you're watching for deterioration, you watch for deterioration and they do present clinically as being comatosed. Most of them, some of them might have a very low moderate traumatic brain injury where the GCS is between nine and 13. Um Even then these patients, it, it depends on what you find on the CT scan as well. Ok. All right. Well, um and then just one other question, um if you see, um you know, in the Shaken Baby syndrome, you talked about the non accidental. Yes, we see, we suspect, you know, we should suspect, uh more often with Children with brain, you know, traumatic brain injuries or like a decreased G CS, you know, and do you see diffuse axonal injury on the CT scan? If you don't see subdurals, obviously of co and contra cool. Um definitely, I mean, uh if, if you look at at, at the pathogenesis of shaken baby syndrome, it's mostly um angulated acceleration, decelerated type of injury. The patient is CN the brain is moving up and down back and forth in the skull, the inner part of the skull is very uneven. It's got a lot of ridges, bony ridges and that's how the brain develops. This punctate hemorrhages, you know, and uh because of the deceleration acceleration come again. Uh it's within the paren, it's within the cerebral. Yes. Yes. Lesions. Ok. Yeah. Those punctate hemorrhages. And then you tend to see a diffuse picture from that as well. They'll have subarachnoid hemorrhages. They will have um uh uh uh contusions. Uh they might or may not have um subdural hematoma or extradural hematoma depending on how the, the the the the shaken baby syndrome. Was it against the heart platform or foundation or it was just in the air or something like that, you know? Yeah. So OK. Thank you. And one more question about is that something you see in Children? And um in our setting maybe from, from MVA S and the acceleration deceleration injuries uh uh as, as, as, as a definition states that these are spinal cord injuries without any um radiological abnormalities. Uh um You can, you, you do, you do sometimes find them, obviously you have to go as far as doing MRI and uh monitoring them and looking for other uh clues uh or, or, or spinal cord injury and most Children. Um I think most Children under the age of three are stated there. Um They tend to have high, I don't need, I don't need it for I. All right. And on the scan going far as the MRI will probably help and sometimes you might or may not find uh information in the MRI as well. So we don't see a lot of them to answer your question. But yeah, they do. Yeah. Ok. Well, thank you so much. Thanks for the answers to my question. Ok. And thanks for that. Yes, thank you. There. The there are two more consultants, but before that, I would just like to read the questions which uh Kirsty and Del have asked. So Kirstie wants to know which patients do we give Mannitol to? And at what dose and do we intubate at GCS eight at hospital? Yes. Um So, you know, I'd like to extend probably my answer to as far, not only as free hospital, but I think our management um extends as far as the peripheral hospital as well. Prof because I think our management should start with the primary physician who was seeing the patient. Um So, you know, patients with gcs of 10, I tend to want to intubate them, do a forced intubation. Uh The reason being is because, you know, you can't trust the doctor on the other side as to whether they've done the things they actually have mentioned to you. Uh That's one problem and the other problem is that these patients can um without having a CT scan and without any of us having seen what's going on in the brain, these patients can have a seizure and that can be the tipping point for them uh cause a seizure can raise your intracranial pressure. And um um according to the Ky Monro scale, that could be uh that could lead to decompensation and patients can deteriorate very, very quickly. So I tend to advise that we intubate these patients when their GCS around nine, let me not say 10, but a nine, that's a lower um point for moderate uh traumatic brain injuries. Um And when they're gonna be transported to free hospital from a periphery, most of our patients come live two hours or more uh uh uh uh uh away from free. Um If they come here and their GCS of eight, they need to, they must, it's not need, they must be intubated. And the reason for being is that we're following the principles of ATLS and APLS, we're trying to prevent secondary brain injury, which is up on the screen there and um preventing secondary brain injury improves outcome. And therefore, it's very important for these patients not to be hypoxic. If a patient is hypoxic, cerebral edema will progress significantly and the pressure in the brain will increase exponentially. So it's very important that they in they intubated, very important that they ventilate it as well. Not just intubated. Appropriate ventilation is important to make sure the cardia, the arterial uh carbo dioxide is between 4.5 and five. Um As per recommendation by the pro uh brain trauma foundation. Um And uh the other thing that I would like to extend uh is that we should have uh fluids available for these patients. Cause sometimes we don't even ask when the child has eaten, when the child has had a meal or how dehydrated these patients are, some of them come here without having bloods taken. So it's important that we speak to the primary uh physician that's uh initially seeing the patient and give them the appropriate management before sending the patient over to re and it, and it, it, and it improves hospital stay. Number one, patients don't have to stay here forever. Number two, some of these patients can be resuscitated, especially the mild traumatic brain injuries can be resuscitated in, in casualty. And then we can say, OK, we'll monitor for 24 hours and we send you home. But unfortunately, by the time they come here, things have gotten worse and now we have to look fight for icu beds and so forth and, and it makes things difficult and then best uh practice management becomes impossible to implement. Unfortunately. Yeah. Th thank you, Kenneth. I think it's, it's very important that you are repeatedly mentioning about prevention of secondary brain injury. So that's very important. Can you just answer question about Mannitol? So who to give and how much? OK. So if patients are moderate traumatic brain injury, so those are patients between um um OK, II, I'm gonna follow the brain trauma foundations, uh not what we're doing at the moment. So, brain trauma foundations, any patient she sees less than eight, we give Mannitol obviously, it should be guided by ICP monitoring. Like I said, we haven't been practicing ICP monitoring due to the lack of uh resources obviously and no ICU beds, we can't do ICP monitoring those ICP monitoring in the ward for uh uh sorry because ICP monitoring requires admission into ICU. Remember these patients must be flat. They shouldn't have much of a peep, they shouldn't be coughing, you know, they shouldn't be moving around because these are gonna all affect your ICP S and give you false um or pseudo raised uh ICP S. So it's important that we have the facilities available to, to treat them with ICP monitor. So we give ICP a Mannitol stat. Um naught 0.5 g to 1 g A kg is important. I think we use 20% Mannitol. So we use a conversion factor in, in a 500 M of Mannitol. There is um about 200 g per 1000 mil that comes to 1 g per five mil. You can use that conversion factor to work out how much moles you wanna give. All right, so you'll take the 1 g multiply by the KG and, and uh multiply by five to get you the total moles of. So she says between um uh of less than eight is uh Mannitol is important. OK? No, Thanks. And now Daniel has a question. When do we start prophylactic anti-seizure therapy if they never had a seizure? And if it in babies and infants, do we still do feto or obar? So when to start antiepileptics? And which is the drug of choice? So, um phenytoin is still recommended in, in, in all Children. Um It uh it Brain trauma Foundation hasn't um um excluded phenytoin from any of the Children, whether they're younger than two years of age or older than two years of age. I think um we still follow the whole school where phenobarb is used for, for Children less than uh I think one years of age if I'm not mistaken uh for infants. Um but uh there's, they've shown there's no difference between finito and and and uh Phenobar and obviously, leve levetiracetam was recommended previously because it's a good monotherapy drug. And uh it's quite expensive, less uh complications than phenytoin. But uh based on evidence, there has been no difference in outcomes whether you use levetiracetam or, or I mean the other name is Capra or Epanutin or Phenytoin is the other name. Uh Phenytoin can be used across ages. Ok. Um My Cory to that question, Kenneth is which Children need long term phenytoin following a to brain injury. So, so if, if there's evidence of cortical contusion, um temporal lobe contusion or any cortical injury that will act as an epileptogenic. Um uh uh uh focus those patients need therapy, irrespective whether they've had had seizures or not. So, prophylaxis is recommended to try and avoid the early um seizure from occurring within seven days. You treat it for seven days. Obviously, if there's no has, has been no seizure during that seven days, the um treatment can be stopped. That's according to the recommendations. Ok. If there's a seizure, we can carry on for a month. Ok? If there has been an early seizure, we can carry on for a month. But if the child has been seizure free for a month, obviously, then we can consider stopping the, the treatment. Ok. Ok. Thanks Kenneth. Um uh uh I see, I think, uh, pro Lazarus is uh still here. Uh So, so, uh, Colin, do you have any comment or any question for Kenneth? Uh Hi Kenneth. That was an excellent, an excellent talk. Thank you very much. Indeed. Thank you. I didn't know you were here. Oh, well, sometimes I don't know that either. Uh uh what I wanted to ask was you spoke about, about intracranial pressure monitoring and I just wondered if you could tell us how you place the ventriculostomy drain or monitor. Thank you. Yes, I'll briefly tell you quickly. Uh So, um whether it's adult or Children, uh I think Children above two years, uh where the skull is already formed and it's uh uh it's fused. We use what we call a caucus point. So basically how you work out the caucus point, you can work it in different ways. Um, if, if you've got a trained eye like a neurosurgeon who's been through a neuroanatomy, your caucus point will be your pu your pupillary midline. That plane where it connects with your coronal suture and then one centimeter anterior to your coronal suture on the pupillary midline uh plane. Um, that will be your coccus point. Or the other way. If you've got a ruler, you can use the, the um the s the sagittal suture, superior sagittal suture line, midline of your skull and measure from your glabella, glabella, sorry, which is just above your nasal bridge, your zero point will be there and going all the way back, uh measuring about 11 to 12 centimeters, um then marking your point from there and then directly from the midline, 3 to 4 centimeters of your midline would give you a direct coccus point. So coccus point is uh the point where we make a b obviously, you will make your incision over that marking over the coccus point and uh use a retractor, a self retraining, uh retaining retractor or what we call a mast retractor, um strip the periosteum from the skull and then use a perforator. We've got electronic uh perforator, make a hole in the bone, um clear the the edges of the bone. Uh and then do a cruciate incision. You can, you can use quarterly just to prevent unnecessary bleeding to just cauterize the dura and then use a in incise uh making cruciate incision on the dura. Um And then the coccus point is directly over your anterior horn of your right lateral ventricle. We always use the right side um because most patients are uh have a left dominant hemisphere and we do not want to affect language and speech. Um So you'll be directly, if you go perpendicular in your cus point, you'll be directly over the anterior horn of the right lateral ventricle and on your ventricular drain, this is not a shunt, this is just the, the ventricular part of the shunt. Um You will have markings and they're usually one centimeters apart. Um That's to guide you how far you to go. So we usually use a five centimeter length distance. You'll be in the anterior horn, you'll see if there's backflow close to the cork and then attached to a drainage system. Uh There is usually a drainage system that uh accompanies the ventriculostomy drain. Um And obviously, uh it doesn't end there, you'll close your wound. Um You will have to put the ventriculostomy with a little stylet uh tunneler, very sharp tunneler, put it sub subgaleally and that's transdermal and you will have to secure it onto the scalp. Um We used to make, we use, we usually make a coil of the, of the ventriculostomy drain and, and staple it to the or suture it to the scalp and once it's connected to the drain, make sure that you're zero point of the drain. There's also markings and different uh measurements. We use centimeter water mercury as our measurement. You can use millimeter mercury. It's got a rotator measuring um scale um zero the drain with the external acoustic meatus or the tragus, the small pin of the ear. Um And then there is a grading on the, on the, on the, on the actual uh measuring uh or the drainage system, you set the, the, the intracranial pressure, the level at which you want the CSF to drain. In other words, I like to say that that is your normal intracranial pressure. So if you set it at 10 centimeters water for a child which or 15 centimeters for water for the child, which will convert to about uh say 12 or 11 centime uh centimeters water. So one millimeter mer mercury is equal to 1.36 centimeters of water. So once you're zero, set uh intercranial pressure to 15 centimeters of water. Anything above 15 centimeters, water should drain out. In other words, you actually have now set a uh uh uh uh a point VD point at which um your normal pressure, anything above your normal pressure should be drained out. So when you couple it to your monitor, you're gonna have to use a arterial bag, um which will come separately and you can, there's usually a three stop cook that you can attach the, the, the arterial transducer line with the pressure cuff, the pressures increased to about 200 millimeter mercury on the 200 normal saline bag. Uh I think our IC USO only use a liter because their bags are big. The the pressure cuff is huge. So you can use a liter bag and with the giving set with the arterial giving set or transducer line connected to the stop cock and there you can actually change the tap to drainage or you can change it to transit to, to, to, to transduction. In other words, monitoring ICP on the monitor without drainage. And I think that's a set up for EBD ICP monitoring. Ok. Ok. Th thank you, Kenneth. Thank you. Uh call any any more comment, any question? Uh Thank you. No, Kenneth has given me the answer. Thanks very much. Appreciate the talk. Kenneth. Ok. Ok. Thanks. Uh Reth, we have a colleague from uh Harare Hospital, University of Zimbabwe, uh Doctor Taurai Zo. Um I'm just going to ask him Taurai, do you have any question or any comment, please? Do you still here? Maybe he's not able to hear me, Kenneth. What's his name? Doctor? No, no doctor. Uh don't worry. Yeah, Kenneth, I think it's, it's time for you to uh to sort of give a final message before we conclude the meeting. So your final word? Yeah, I think um we are faced with challenges at free hospital and it's been uh ongoing, I think for, as long as I've been here, I think we've had a lot of problems. Uh, neurosurgery couldn't be on its own. And, um, we've always tried to, uh, complement each other when it comes to dealing with head injuries. I think the take home message was the key points that I've mentioned. Uh, and I think, um, you know, because we got a shortage of staff, we are gonna be requiring, um, our colleagues from the other disciplines like pediatric surgery and general surgery just to try and be more accommodating when it comes to referring neurosurgery. So far, we've been receiving, receiving a lot of patients that require us to work the patient up and from scratch, I just come from casualty now where doctor has referred the patient, it's an adult patient, not a pediatric patient. And we basically went to go and see this patient and we basically have to start working this patient up from scratch and found out the patient has got renal. So these are the things that uh we're hoping that our colleagues who are gonna be referring to neurosurgery would help us with. And I think uh your assistance in pediatric surgery and, and, and general surgery is it's, it's greatly appreciated. Prof uh I don't think I've got much to say and uh the talk should talk to uh speak to itself. Um If we can just apply those principles. APL S principles, make sure that bloods are taken in patient, patients are stabilized, you know, and, and then, um I think we should have a good relationship, a working relationship in terms of trying to manage uh a traumatic brain injury or overall a multidiscipline or polytrauma patient. Let me put it that way. I don't think I've got any more to say doctor. Ok. OK. Can I thank you. Um We, we have already had a meeting about six weeks ago. Uh So we, we promise promise to work with you and we also promise not to trouble you. Uh especially and Dr Mack unnecessarily and uh I think this was like important step number two. II in, in uh working together and um uh I know you are studying but uh I will uh request uh Doctor Pedersen from our department. Um maybe not in December, but maybe in January under your guidance and Doctor Mao's guidance to try and formulate a standard operating procedure for emergency management of traumatic brain injury in Children. So I think if, if by in February or so we can get that out, then it will be there uh for everybody to see and, and, and implement um including the interns who are working in casualty. So, yeah, yeah. So like I said, II just got bad news from Doctor Thomas as well today. I'm sorry. Uh I know Doctor MC said I shouldn't uh talk about politics on this, but unfortunately, we can't avoid it. Um There is a moratorium on all appointments. So I'm not sure when we're going to develop our department. Yeah. So I just got that bad news today. Well, no, let's not, let's not discuss that. You have given us a nice talk and let's end on a good note. Let's leave that topic outside, uh, this meeting. Ok. Yeah. Yeah. Thank you very much. Thanks for, thank you everybody for attending and, and we wish you good luck for your studies and we want you to pass as soon as possible. Thank you very much. Thanks for your support. Thanks a lot. Goodbye, everybody. So our next meeting will be uh on the 19th of January 2021. And uh we will, you will obviously get uh email um uh notification once you register through the Google form, bye-bye.