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Uh by it. No, not being on our usual day. Um A quick reminder to fill out the post session feedback form where we'll put a link in the chat and a QR code on the screen at the end of the talk. Uh We use these as a marker for attendance. Uh So make sure that you keep the same name as you've always had before. Um And I'd like to, we uh welcome Mister Tsang, a neurosurgical consultant based at Saint Mary's Hospital and Sharon Cross Hospital. Thank you very much Laura and uh apologies from me as well for rearranging the the session to a different day. I do apologize for that. Um Hopefully you can also see my slides, do let me know if my slides are not moving as I talk. Um But today we're gonna talk about head injuries. I think we have a different session on spinal injuries. Um So we focus on the head today and um uh I don't know how many of you have been to my previous talks and listened to me talk about head injuries before I try not to be too repetitive just in case any of you have heard my talk before? So I've changed the format of my talk a little bit. And what we're going to do is um I'm going to show you a case and then we're going to work through the case uh together um you know, using the standard ABC DE approach. Um And within that, we'll talk around, you know, intracranial pressure and surgical decision making and things like that. Ok. So um the first patient is a um patient um that was brought in by Hams. So you're on call. Um And what happens is the ambulance crew or the Hams doctors call through um to the red wing in A&E and they say there's a pre alert, it's a 32 year old male hit by a train gcs three at the scene. So they intubated and ventilated the patient and they put two annular into the patient and they're about 10 minutes away from your hospital. And this is typically the amount of detail that you get from a pre alert call. And to be honest, sometimes you get less than that recently, I had a pre alert that literally just said head injury et five minutes. And you're thinking, well, what kind of head injury, what's the GCS, you know, what are the pupils doing? Um Yeah, they, they don't often give you much details. Um but you know, you now have 10 minutes to assemble a team and think about what am I going to do with this patient. And obviously they don't send you the photo of the patient either. Uh So, yeah, so based on this pre alert, you know, you've got a patient with a severe brain injury, both in terms of the mechanism of injury and also in terms of the G CS that's been provided, you know, that airway is protected, that's always a good start. And usually if hes is involved, you know, you know, it's usually a pretty good start, which is good. But otherwise, you know, nothing else. You don't know if this is polytrauma. You don't know if the patients tachycardic or hypotensive and they're bleeding out from somewhere or the other way around bradycardic and hypertensive because they're already showing cushing's from coning, you have no idea what's going on. So it does get quite difficult when you're the on call doctor. So what you want to think about when you're heading down to A&E for this particular patient is obviously what am I going to do for the head? They've been hit by a train, their GSS is three. So most likely they're going to have terrible skull fractures. Most likely they'll have contusions to the brain. Most likely they will have some form of hematoma. They may need to go to theater straight away. Um But obviously, you need a CT scan first, but you want want to also give some consideration as to whether this may be a polytrauma situation, which means they've got more than one injury, you know, the spine might be injured, the arms, the legs, the pelvis, the chest, the abdomen. Yeah, anything else could be potentially um injured. So the kind of consideration you need to give is that um I need to think outside the box, I need to think outside the box. I need to work out what's going on. Um, so um sorry, just hold on a second. Thank you. Sorry, trying to sort out my Children at the same time multitasking just like when you're in A&E um hopefully not with your Children. Uh But anyway, um so yeah, so think about what else would I do if the patient indeed had other priorities, you know, if they were hypotensive and they were in hemorrhagic shock, um then, you know, the general surgeons might come to you and say actually there is no time to go to CT I need to go straight to theater and then you're going to have to think, well, what I'm going to do with the head. Ok. So, so all of these things need to go through your head before the patient even arrives, you know, where should we be dealing with these patients? Should we just stay in recess and do as much as possible? Should we move the patient up to theaters where potentially you've got more equipment, the anesthetic machine, it's obviously a lot better. Um And you know, you've got the drills and things that you need and the general surgeons have whatever they need as well. Um So potentially you may not even want to stay in A&E you may want to literally arrive in A&E book the patient in get a wristband on, so you can identify the patient. Um and then swiftly go up to um theaters where you've performed the rest of your A TLS protocol. And ultimately, if the general surgeon say to you, there is no time for CT scan and they have to go straight up to theater because they have to open up the chest and the abdomen. You have to think well, in the GCS, three patient, am I thinking about? We'll just wait until the general surgeons finish and it could be as quick as 45 minutes. It could be as long as six hours. You have no idea what they're going to find or should I open up the head? At the same time, you could potentially put a couple of bur holes on the head and see if you find a hematoma that you can evacuate. Knowing that the tear, which is obviously where the union is between your frontal parietal, temporal and sphenoid bones, the hick shape that you all learned about in the temporal area that is clearly the thinnest part of your skull and that's where your middle meningeal artery is. So if someone has got low gcs and it's something that is easily salvageable, it's going to be an extra dual hematoma in the temporal region. So one of the things you can do is do an exploratory temporal burr hole where you just make an incision in front of the ear, make a burr hole and see if any blood comes out. Um and potentially they will buy you time um before you go down for the CT scan. Anyway, just to keep things simple for this particular case, we will say there are no other injuries. It's all around the head area, the isolated traumatic brain injury, that's what TBI stands for. This is what the patient looks like. You've got bits of brain coming through the forehead in between the eyes, a bit of brain coming actually just around the medial inferior junction of the eye as well. So clearly looks horrendous, but don't cut any corners. You might look at it and think, oh my God, I have no idea what I'm doing with this. But actually, if you stick to your ABC BB, which is why it was derived in the first place, then you miss anything and it will remind you what kind of things you need to do. So it's actually a really useful tool to have. Obviously, in a real life situation, you've got a whole team of doctors and nurses. You're not the only one there. You don't really have to go through ABCDE in order because the anesthetist is taking care of A and B and hopefully someone in A&E will be sort of the blood transfusion of the fluids and taking care of sea. And you're mainly dealing with DNE, for example, but just to make sure that you hear what's going on with all the other um parameters and you're not just focused on the one neurological exam and forgetting everything else. It's really important during these kind of difficult trauma course to keep your ears open and listen to everything that's happening. Anyway, so let's go through our ABC DE. Now, those of you who have heard my talk before will know that I've got slight variation to the ABC DE that you may learn from A TLS or any other courses. Um Partly because I think the brain needs to fit in somewhere. Um I think it's too late to think about the brain at the end. Um And also you're unlikely to look after someone's airway without looking after their breathing. You then get an anesthetist who intubate a patient and then forgets to plug it into the ventilator, right? Um So a it's for airway and breathing. Um So the question here really is when and why do we intubate? Now, this particular patient is already intubated because they're GCS three and most textbooks will tell you that if their gcs is less than eight, you should be intubating them because they might lose their airway. So, one of the reasons for intubating a patient is to maintain the airway. But the other thing is not to forget that ventilatory failure is a good reason to protect the airway as well. So if their GCS is low, not only may they lose their airway because their muscles are relaxed and obviously, it presses down into the closes of the air and the tongue falls backwards, et cetera. But actually, they're not breathing adequately. So they're not taking in enough oxygen and they're not breathing out enough carbon dioxide. And as we'll come to in a minute, carbon dioxide is really, really important for control of intracranial pressure. So in a normal situation, think about airway maintenance and ventilatory failure in a head injury, patient also think about the GCS and am I needing to protect the brain or what we call neuroprotection. In which case, you may want to intubate and ventilate the patient even if the GCS is more than eight, just so that you can control the carbon dioxide levels and just a quick connect about carbon dioxide, carbon dioxide. As you can see in this schematic diagram, basically controls the contraction of your endothelium of the blood vessels. So if you have a very high carbon dioxide level, you get dilation of your cerebral blood vessels. And therefore everything opens up in the brain. And what happens is all the arterial blood flow that goes to the brain doesn't come back down through the veins because it's trying to fill the dilated arteries. So you get more and more blood going up to the brain. It doesn't come down through the venous return system and it pushes up your intracranial pressure. So if you've got someone whose gcs is kind of slightly low on the lower side, so like 10, 11, something like that. And you know, they've got terrible brain injury either because you've seen a CT scan or just other clinical signs suggest they've got terrible brain injury and you then the blood gas and the CO2 is high. Then actually, that's a very good reason to intubate and ventilate this patient to get the CO2 down, bring the ICP down and that actually will prevent secondary injury to the brain. Talk about the brain B is for brain. And when we think about the brain, we have to think about the Mon Monroe Kelly doctrine. Monro Kelly Doctrine obviously come from Monroe and Kelly. But I've also added in the picture of Harvey Cushing there because when Monroe Kelly came up with the idea CSF wasn't discovered. So they only, they talked about the brain and blood flow, they didn't talk about CS and it was Cushing who then put the CS into the Monkey Doctrine that we know nowadays. And essentially what was said is that a change in blood brain or CSF volume resulted in reciprocal changes in one or both of the other two were not possible attempts to increase the volume further increase IC P. So that essentially is saying that because your skull is not expandable, it is a closed box and it's rigid. When you increase the volume of one of the three components, you have to reduce the volume of the other two components. Otherwise, the pressure goes up altogether. And the main player in this really um is your blood flow. Um because the blood flow is the thing that can alter the most in terms of arterial flow going in and then venous flow coming out. And it's really important to maintain this venous outflow back to the heart. Now, obviously, CSF can be squished out. And you can see in this um diagram, you know, you've got the happy state uh on the left hand side with um brain CS and blood. And if you increase, you know, um the volume of the brain because of brain swelling or there is a big hematoma or it could be a tumor or anything else. Um Then the the body will automatically squeeze out some CS by pushing it down the spinal column down to lumbar feca. And it can also squish out some of the blood by increasing venous return. Um but if your mass continues to grow, so you've got an expanding hematoma, for example, or your brain injury is so bad that the brain continues to swell and you've pushed out as much CSF and blood as it is possible, then either your ICD will just shoot through the roof or actually, there is no blood left in the brain, there is no blood flow. Um and the whole brain will become hypoxic because there is no oxygen delivery and the brain will just become ischemic and die of. Um And you definitely don't want that to happen. So remember Morro Kelly Doctrine really, really important and talking about, you know, pressures and things, of course, I'm going to have to show you what normal is. So normal ICP, intracranial pressure in an adult should be less than 15. I mean, in reality, it depends on what you're doing at the time and depends on your posture. When you're lying down, your ICP is slightly higher than when you're sitting up of gravity and your CSF going down your spinal column. So someone standing up, potentially have an ICP of around zero or even in the negatives. Um someone lying down shouldn't have an ICP more than 15 at the very most. Um Now in a head injury patient, often the ICP goes to 20 or even higher. So one of the problems with raised IC P obviously is coning. If the pressure is too high and the brain has nowhere to go, then there's only one route to escape, which is down the, from the magnum. And that's what we call coning. And obviously, patients die if they cone. The other problem as we've kind of alluded to with raise pressure is that your brain is not perfused properly partly because your blood flow may not be maintained if your pressure is that high or just the fact that the pressure gradient between the blood vessel and the brain becomes too narrow, so that the glucose and the oxygen cannot be extracted because you need a good enough pressure gradient. And that is called your perfusion pressure or cerebral perfusion pressure. In this case, CPP. So to calculate CPP is very easy, straightforward mean arterial pressure minus your intracranial pressure. Ok. So I've listed what the kind of optimal CPP range is um for the different age groups. So in this particular adult, um let's assume the IC P is 25 to 30 given that GCS was three and then you want an optimal CP of somewhere between 60 70 you're now looking at needing a mean arterial pressure if you add the two together of around 90 to 100. So that's the kind of mean arterial pressure you should be aiming for in this kind of patient. Um And often um you have to remind the anesthetist about this because they may not be thinking about that, especially in a polytrauma patient. And we'll come on to that in a minute, just a quick graph on auto regulation C. The do line of C is the one you want to be looking at this is what we call autoregulation, which basically means that between the mean arterial pressure of about 6100 and 60 millimeters of mercury, the cerebral blood flow which is on the y axis remains static at 50 mils per minute, per per 100 g of tissue per minute. So there is a very static blood flow because what you don't want is every time your BP changes the blood flow to the brain change. Because then every morning when you get up from, from bed, you will stroke out. So this auto regulation is really important in a brain injured patient, especially in a severe brain injury. Like in this case, you will lose this auto in in your line will look a lot more like b where a small change in the BP results in quite a large change in the cerebral blood flow, which is why these patients can stroke out very easily. Um So BP control is really, really important and that's why I've spent so long talking about uh the brain. And then finally looking at the ICP, I've been talked about keeping that number down so that they don't change so that you maintain good perfusion pressure. It's also quite important not to just look at the number, but look at the wave form just like when you read an ECG, you can't just look at the heart rate, you have to look at the P RT waves. So similarly, you can't just look at the ICP number. You should look at the wave form. There are three cuff notches within a single ICP spike. Um P one P two P three. Don't worry so much about the names of them. All you need to know is that P one should be the highest followed by two, followed by three. Very, very simple in a head injured patient where they've lost their auto regulation. P two becomes the highest. So rather than looking like a skewed distribution, it looks more like a normal distribution if you're into statistics. So if you ever see that on a head injury patient say in the intensive care unit, even if the number looks like it's well controlled. So it's around 12, 13, 14, they've lost the auto regulation. And what that means is that anything you do to this patient, whether it's suctioning for secretions, whether it's rolling the patient for pressure areas or that you are thinking, oh, the number looks a bit low. So let's try weaning them off the sedation and see what happens. You can almost be um certain that the ICP will shoot up because that auto regulation at the moment is abnormal. Um So don't um don't, don't uh what's the word? Don't um alter anything in the head injury patients until um you know that the auto regulation is returned. So it's quite useful to look at this right last slide about B and then we can move on to C. Uh Most of the talk is about B as you can imagine. So, don't worry. Um So now they've heard about Mon Kelly Doctrine. You've got this patient who's intubated and ventilated already and you think about the brain. So what can you do well from a blood point of view to reduce blood pooling in the brain? We've already talked about this, sit the patient up. So you improve venous return down the Julius, ok? Make sure there's nothing strangling neck, nothing pressing on the jugular veins. Um because obviously that reduces your uh venous return. Um And by that, I mean, collars, um most trauma patients come in in the collar um because you're unsure whether they've a head injury or not take the collar off. If you're really uncertain of they are neck injury or not, you can put blocks and tapes on either side, but the neck carrier can be freed. You don't have to put a hard collar around the neck. Um And as soon as they've had the CT scan, try and clear the cic spine radiologically so that you can remove the collar safely. Um But you don't really want to keep the collar on and we've talked about carbon dioxide, keeping it down so that you don't get vasodilation, you don't want it too low because you don't get vasoconstriction. And obviously that causes a stroke. So you want it quite tightly controlled between 4.5 and five kg pus and you can only do this by ventilating the patient CS, how do we get rid of CS, to be honest, in a head injury patient, the CS usually is already pushed out of the system by the body. There is very little CS F left in the head. Um But if there are still ventricles present, you can stick a drain in there, an extra ventricular drain. Um or you can do a lumbar puncture if it's safe to do so often. In essence, because there are contusions and hematomas and obviously, there is a contraindication to doing a lumbar puncture if you've got very high pressure at the top. Um So, so that may not be possible. And then we down to the brain, you've got a swollen brain because it's been injured. How do you reduce the brain swelling? You are not reducing brain volume by chopping brain out. You can but not recommended or at least not as the first step. Anyway, you want to shrink the brain down a bit and you do this by taking over the function of the brain. So the brain doesn't have to do anything. It's resting, the metabolic demands go down and automatically the edema goes down. So good sedation and I don't just mean a little bit of midazolam. I mean, keeping them like really deeply asleep much deeper than you would do during a normal operation. And you'll hear Aie and intensivist talk about ras score and you're looking for a ras of five. This is how deep asleep you want them to be So sedation with propofol midazolam, um, you can add in a muscle relaxant if you want. So, Atracurium Rocuronium, whatever you want to, um, get your hands on analgesia, don't forget the fentaNYL or morphine. Um, and then obviously avoiding uh, hypoxia and making sure the temperature is normal. Um, we used to cool patients down, um, uh, when the, um IC P high and it does bring the ICP down, but the Euro, the trial from a couple of years ago showed that although the ICP S are better controlled, there's a much higher mortality in that group because of multi organ failure from the low temperature. So we no longer cool patients, we cool them to normal temperature if they've got fever, but we don't go below 36 °C if the ICP S are still high. So let's say you're still in A&E you don't actually have an ICP monitor, but they've got fixed pupil and think, could they be seizing? Should I be giving them anticonvulsants or should I be using some form of osmo therapy? And I'll come on to both of these things in a minute. So I won't dwell on the, about it too much. And ultimately, if none of these things work, you can either induce a barbiturate coma by giving them some thiopentone um or you can do a decompressive craniectomy which is opening this closed box that Monro and Ky talks about. Um and obviously the benefits of surgery or lack of benefit depending on how you read the papers come from the Australian Paper D er, and also the uh UK paper A Rescue IC P. Rescue A SD is not published yet, hopefully in the next couple of weeks. Um but essentially what you're seeing is that you are saving a lot of lives by decompressing them, but you're also producing a lot of patients with quite significant disability. Um So decompressing them is not the ultimate answer. And it may not be the right thing for every patient. Once again, that's a separate talk together. But these are the options you've got to use, right? So that deals with airway breathing and then B for brain. So C for circulation. So we talk about perfusion. We've already looked at this, so we won't dwell on about it anymore. And we've talked about the CPP being somewhere between 60 70. Now, if you've got polytrauma patient, so someone hit by a train, like in this case, actually, it's quite likely to have polytrauma pelvic fractures, you know, ruptured spleen, et cetera. They may well be bleeding out somewhere. So firstly, it may not actually be possible to get the BP high enough to perfuse the brain because they are using blood actively. Also, if you push the BP up, you will just increase the amount of hemorrhage, you're basically turning the tap on even further. So sometimes what you might have to tolerate is a short period of low BP so that the bleeding slows down, gives the surgeons a chance to get in there and turn off the tap as it were. And then you bump the BP back up to perfuse the brain. And that's called permissive hypotension. And that really should not be lasting very long. So as possible stop the bleeding, get the BP back up, very important. But this actually the most important point to highlight here is actually the importance of working as a team. And, and you know, if you come and work with me at ST Mary's Hospital, I'm always saying that the sh and the registrar should be at a trauma call. I know it's not standard practice for neurosurgeons to be part of the trauma team. Usually you're one of those specialists who gets called if they need you, which fair enough to a certain extent. But certainly I do not agree with someone sitting in the office waiting for the CT scan to be done and then say, oh yeah, it looks like a clot. Let's go to theater because actually if it's a polytrauma patient and the general surgeons there saying I need to open up the abdomen and I need a really low BP. And unless you in the office saying no, no, no, don't listen to them. I need the BP up. That really is not helpful. You need to be fair, see what's going on in front of you when you see that there are 16 units of blood going in and they're not getting a BP. You suddenly realize saying I want, you know, AC PP of 60 is completely unreasonable. So it's really important to go and see a patient and talk to the other teams and work out what is important. Yeah. So, so probably that's the take a message if there is one from this talk, DNE, I have not changed anything here. D is for disability. So think about the trends in the gcs pu post and neurology. I always talk about trend giving me a single number for GCS is useless. I need to know what's been happening. So you know, if someone who was GCS 15 at the scene and it's now GCS three, you have no time to lose. There is clearly an expanding hematoma and they need to go straight to theater if there were GSS three in the scene. And then now GSS 15, then actually, they've improved significantly and they probably just had a seizure and they were post I or something like that. In which case, you're much less worried and you can just proceed as usual and you don't need to be rushing as much. So it's quite important to work out what's going on with the gcs at every stage. And another quick N about the GCS is the motor score really is the most important score. Eye opening can be affected if they've had direct injury to the eye. So in this particular patient, for example, where you can see brain coming through the forehead, I mean, obviously his GS three, but there clearly is a lot of fracture around this area. Otherwise the brain won't be able to come through. And if you fractured around the orbit, it could be so swollen that they just can't open the eyes. So it may not be an indication of their conscious level. It may just be that they physically cannot do it. And similarly, for your verbal score, if they don't speak your language, they may not be able to understand what you're asking. Um And also, um if the injury is to the uh the the motor speech area or B area, so they've got a contusion to the inferior frontal gyrus, for example, they may not be able to talk, they may be aphasic. Um But that once again, is not an indication of low G CS, that's an indication of them losing a function. Um So sometimes a low G CS is not indicative of someone who's lost consciousness, but rather loss of function. So motor function is the most important thing to think about. And then e for exposure, I always think nurses are very good at doing these things. Doctors are terrible, we always forget to check BM, we always forget to check temperature. But luckily the nurses always do them without us asking them. And then obviously in a trauma situation, think about alcohol level, think about sending a top screen. Are they under the influence of any drugs? And obviously, at this point, are we needing to go for a CT scan? Now, before you go for a CT scan, just a couple of things which ties in with what we've talked about before, which is f for fluids. So we've talked about giving fluids already. Um Now, if you've got hemorrhaging patient, then you should always replace like for like which means giving blood and not giving crystalloids. I hate crystalloids in the trauma situation and I should never see anyone giving saline, it should always be blood. Today. You're giving red cells platelets. S um there's also an ongoing trial from Royal London um Prehospital team looking at giving whole blood versus the blood products to see what works better but replace like for like and if you think that ICP is high, like we said before, think about osmo therapy, which is your Mannitol and your 3% sodium. The Mannitol is an osmotic diuretic. So it draws fluid from your third space back into the blood vessels and then it makes your kidneys pee it out. Mannitol also has an effect of improving the rheology of blood, which basically means it changes the shape of your red cells and improves the blood flow. So the blood flow is more smoothly and less turbulent and so blood flow is improved. So Manni has many called positive effects. I guess the only problem with man is it makes you pee. And if you've got polytrauma and you've got the hypotension because you're bleeding and then man is making you pee because it's diuretic, it's not going to be very helpful. 3% sodium chloride, um which is hypertonic saline because it's hypertonic. It also draws fluid back into the um uh vasculature. Uh It's not a diuretic, so it will stay in your vasculature for a bit longer. Um So it's got that advantage, but obviously your sodium level will start climbing. Um So you can't give too many doses of this. Um So there are good and bad points of both. We don't really know if one actually works better than the other. We don't actually know if either of them improves mortality or long term outcome at all. So, there is an actual ongoing trial called the SOTO Sugar Study um OS, which is currently run across the UK in various intensive care units. And hopefully we'll find out if one's better than the other very soon when you've done all of that, get some help. If you haven't already got help, hopefully you're there with the whole trauma team and you're not by yourself. Um But if you're not working in a major trauma center, you're working in a, you know, district general hospital and you're in the middle of the night, you could well be the only doctor in A&E. Um there are some small hospitals where you only get one doctor in A&E. Um and you have to call the anesthetist to go down, come down, you have to call the mere to come down because they're not going to know that this is happening. So make sure you get help. And one of the things that people can help you with is inotropic support, let's say in this case, isolated head injury, no bleeding from anywhere you've given some blood or fluids. Um and the BP just isn't coming up. In which case, you're going to need some inotropic support to help improve the BP, improve the blood flow, improve the um perfusion pressure. So we talked about the normal blood flow being around 50 mils per 100 per minute, which is about 15 to 20% of the cardiac output. So it's significant and that's what the brain is used to. So if it drops down, the brain will become ischemic very, very quickly, which is why it's important to start fluids and start inotropic support early. If you don't think you can get the BP to come up really important. And as you know, this is important because the brain cannot store glucose and oxygen, it's completely reliant on the delivery of these substrates from the bloodstream. Um And obviously, that's important. Um and the the the things to think about is do I have enough of these substrates in the blood stream in the first place. So it's the patient hypoxic, it's the patient hypoglycemic. So those are very important things to check. Do we have a good enough blood flow? So this is where the BP and the tropic support comes in. Um And obviously, the substrates have to cross the blood brain barrier, something you don't have to worry about in head injury because it's broken down. Um Anyway, so we've gone from a to I back to our patient um with the brain coming through the forehead. Um This is the CT scan where it's a 3d reconstruction of the bony window. You can see the horrendous comminuted fracture around the um skull around the orbit onto the midface. Uh I mean, if I I hope you can see my arrow, it is, you know, fractured across the maxilla um across into the medial and um uh medial wall and lateral wall of the orbit, superior um orbital rim. Um the zygoma is fractured around the side. And then as I said, you know, the whole frontal bone is um fractured into multiple pieces. And this is what the actual brain scan looks like. Multiple contusions you can see by temporal contusions, frontal contusions, bilaterally, some subarachnoid blood, a few dots of blood back here as well. So this is quite diffuse injury but mostly really bad hemorrhagic contusions. Now, one of the things that you should think about when you look at the scan. Firstly, the ICP is clearly going to be very high. Now, you may not see much midline shift. People talk about mass effects by measuring midline shift. If you've got injury on both sides of the brain and they're squeezing the brain in between them, you will not get a shift. I mean, you may get a little bit of shift if one side is clearly worse than the other, but overall you may not see a shift. But what you see is effacement of the ventricle. So the ventricle gets squashed and becomes smaller and clearly on one side in this particular case. And also the brainstem itself may look a bit thinner than it should, which is a sign that you've got bilateral ankle herniation pressing into the brainstem. So just because there is no midline shift doesn't mean there is no mass effect from the injury. So just be slightly careful when you're interpreting CT scans. The other thing about this particular patient, apart from the fact that there's brain hanging out as well as temporal and frontal contusions is that they may well have a seizure because you temporal lobe obviously is where a lot of seizure activities are generated. And if this patient is not already coning a seizure will make this patient cone. You know, a seizure is essentially these called ectopic aberrant activity within the brain. And right now, we've been talking about resting the brain if this brain starts throwing off random signals and electric activities, it will swell massively and your ICV will shoot up. So carrying on with the alphabet J is for jerking. So think about could this patient be fitting if this patient is intubated and ventilated? Like in this case and under sedation, you and especially if they've got muscle relaxant on board, you will not see muscle jerking because the muscles are relaxed. But that doesn't mean they don't have seizure activity because seizure ultimately is just the electrical signals coming from the brain. It's just that the effect is it makes the muscles, you know, contract in the chronic seizure. But when you relax the muscles, they won't contract, but the electrical signals can still be coming through which you cannot see. So just because they are not physically swinging the arms and legs around, it doesn't mean they can't be seizing. Um So always have a thing. Could this patient be seizing or postictal? Um, in cases like this where they've got terrible frontotemporal contusions, you may want to start an antiepileptic medication anyway, as a prophylaxis. Um and if they don't cease out, you can always stop them again. You can use either Phenytoin, which is a slightly more old fashioned drug or you can use Keppra or the other name for it is obviously, uh Levetiracetam. Um If it's for prophylaxis, currently, we give it for seven days. Um It's kind of a traditional thing that we've been doing since the pa byte back in the 19 nineties, we don't actually know if it stops people from having seizures. Uh And if one drug is better than another, hence the ongoing mass trial. Um and you can randomize anyone that you think might be at risk of having a seizure after head injury into having phenytoin Keppra or placebo. Um So that's an ongoing trial. And if they really are seizing, then obviously follow the trust status epilepticus protocol in terms of your LORazepam phenytoin, uh uh Keppra, you know, um intubation, propofol, et cetera, uh the protocol, it's really important to think about that. And whilst we're on the topic of giving medications m is for medications. So think about what are the medications the patient might already be taking. Um, now, in this particular case where a patient has been hit by a train and brought in, you may not have any idea who this patient is and there will be no way of working out what medications they're on. Um, unless they got it in the bag. Um, but if it's someone, the ambulance crew has managed to identify, they may be able to provide you with some details from the family at home or you might be able to get hold of the GP. Um, but it's really important to work out what they take partly because it gives you an idea of what their pre morbid condition is like. Partly because, um, the drugs they take might actually affect the GCS affect the pupil or the way they react to light or the lack of reaction to light. You know, some eye drops make your pupils dilate and stop them from reacting. So it's quite useful to know this information. And if it's an elderly person who's got Parkinsonism and they're on some form of dopamine agonist, then the timing of the Parkinson's medication is really important because if you miss a dose or even if you delay a dose by an hour, they start to get really bad rigidity and stiffness to the extent that they may not actually wake up from the sedation. Um So just think about that. And finally, from a surgeon's point of view, you want to know, are they at risk of bleeding? Are they on an anticoagulant? A doac an antiplatelet medication or actually sodium valproate, which is an antiepileptic medication that blocks your platelets. Um, and you can get quite a lot of bleeding from people being on valproate. Um, there was a study from about four or five years ago called a patch study which looked at intracerebral hematoma in patients who were on aspirin and, and or clopidogrel, um, and randomizing them to receiving platelet transfusion versus no platelet transfusion. And they found that um, the group who received the platelet transfusion actually did worse. Um So, unless you're planning to operate on the patient, in which case, you do need to give platelet to reverse the effect of antiplatelets. Otherwise, um you don't need to reverse the um the, the antiplatelets moving on with the alphabet N is for sodium levels or N A. Um And I'm sure you don't need me to remind you, but sodium obviously is how you propagate an action potential. Um So it's really important for cell membrane stability. One of the most important electrolytes when it comes to the uh central nervous system. And so a very high or very low sodium level will massively affect your threshold of creating an election potential. And it will affect whether your patients will wake up from the sedation or not and it will affect how likely they'll get a seizure. So it's really important, sodium is maintained within a set limit. So when you're doing your ABCDE of a patient and you're taking blood, make sure one of those bottles is your urines. So you can see what the sodium level is like. Um And the sodium could be low in a trauma patient either because they drink a lot of alcohol. In which case, they may well be used to a very low sodium level. Um Some drugs obviously drop your sodium such as um I mean the obvious ones are the diuretics, but PPIs can also drop your um sodium levels. Some antidepressants can drop your sodium level as well as antiepileptics as well. Um And ultimately, if they've had a severe brain injury, like in this case, you may have affected their pituitary function. In which case, they may well have si ADH syndrome of inappropriate ADH. So you're creating too much ADH you are retaining a lot of water and therefore you're diluting out your blood or you've got cerebral salt wasting where your brain is actually secreting BNP and CMP, which is telling your kidneys to we out a lot of sodium. Um so you're losing sodium. So the two is quite different as you can tell. One is dilutional and one is losing sodium. And so treatment has to be tailored according to which one it is. But it's very important to know what the sodium level is because that may well be the reason why your patient is drowsy and Sez Zing on P which is your cough opioids and pain medication. Uh We talked about using fentaNYL and morphine earlier on already as part of your cough sedation protocol for the patient. Um and not because you use opioids to sedate them, but you need the opioids to make sure they're not feeling any pain and that's very important. Um Pain officer can push up your um BP and push up your ICP. Um The only thing to think about I is in an awake patient. So in an a sleep patient, opioids is great in an awake head injury, patient opioids is terrible because if I give you traMADol or morphine right now, it will make you feel sick and it will make you feel dizzy if you have a head injury, that will make you feel sick and that will make you feel dizzy. So, if you never take opioid after having a head injury, you will be really sick and really dizzy. Um So actually opioids a terrible drug to give a head injury patient to treat the headaches. Um In fact, I'm sure you've all heard of codeine induced headaches. Codeine can give patients headaches. Um So we don't tend to use opioids in an awake patient. They have the paracetamol, they can have nonsteroidal anti-inflammatories if they're below the age of 65. Personally, I don't worry about this antiplatelet effect. Um I've never seen anyone have a hemorrhage in the brain as a result of an NSAID. So I'll just give them um naproxen and they can have prochlorperazine. Prochlorperazine is really, really useful. It is good for headaches. It treats dizziness and it treats nausea. So it's fantastic combination of this. Um So that's what you give along with some cyclizine or Ondansetron, that's necessary and you can write up some oxyCODONE uh as a Prn opioid if they really need it. Uh But you don't want to be relying on it. Now, you've gone from a, all the way to p on this patient with brain hanging out of the forehead. The next thing is you have to stop and you have to question yourself. Have I done everything necessary? Am I missing anything else has this patient stabilized? Um Or are we still in a terrible situation where we've got no option but to take them to theater. Um So question yourself and repeat the assessment. That's Q and R and S is obviously for surgery. So, on the left hand side, it's a patient with an extradural hematoma. On the right hand side is our current patient with terrible skull fractures. You know, is there a reason to take this patient to theater? If they've got large extradural hematoma, of course, there is, if they've just got skull fractures, then probably not in this particular patient with the contusions. It's a bit 50 50 we'll come on to that in a minute. But think about, is it time for surgery or if it's not time for surgery and you're not winning with conservative medical management? The option is either you continue doing everything we've talked about, they go to ICU, they have an IC P monitor and you continue doing all the A two R things that I've mentioned so far or you can think about TLC tender love and care. So you're going to palliate the patient because you said too much is too much. Any further escalation is inappropriate for this particular patient. And the way to make this decision is really based on the patient's premorbid status, underlying conditions. So you for underlying conditions, think about the underlying conditions. Um If you've got trauma geriatrician, then that's great news. I'm very lucky. We've got a couple of um, um, surgical liaison, geriatricians at Saint Mary's Hospital, um who will come and see patients with us, um, and give um their view on things, uh which is really, really helpful. Remember we talk about how frail the patient is. We're not talking about how old the patient is. We've done a craniotomy on an 80 year old recently. We've done buros on the 101 year old recently. It is about their frailty. You know, we've caught it a day on someone in their fifties because they were so unwell from all the medical problems. So it's not about age, it's about comorbidities. It's not about their current condition. If you look at a patient in A&E and in a hospital gown, they're lying there on a hospital trolley, they waited six hours to see you. They will look frail. I would look frail. I mean, you might say I look frail anyway, but I would look frail if I was in a hospital gown lying on a A&E trolley. You know, so you have to think what was this patient like two weeks ago? You know, that's what you're trying to judge. If two weeks they already had congestive cardiac failure, they couldn't walk up a flight of stairs. They've got home CPAP home oxygen, they're three times a week, dialysis, then of course, they're really, really frail. But if they just ran a marathon last weekend. And actually they've come in because they fell over and someone trat on them during the marathon, then actually, they're usually quite fit and well. So think about that and you know, this is a chart just to show you what happens when you apply any kind of stress. And this, we're talking about just a minor illness or injury to different kind of frailty patient cohorts. And you know, those who are managing well will return to the standard baseline relatively quickly. Those who are a bit frail. So they've got a couple of comorbidities will recover to a certain extent, but they're probably not going to be as good as they were at baseline and they'll take a bit longer to get to this new baseline. And if they were really frail to start with, they may not make any recovery and they will become dependent or even die as a result. So it's really important to think about frailty and we judge them based on there are lots of frailty scales, but this is the one we use. It's called a Rockwood clinical frailty score. And I like it because it's got pictures and this is how you can judge how frail someone potentially is. Um And you know, if their frailty score is six or higher, then the chances are they're not going to do very well. And you may want to think twice about, you know, doing a big operation. The other thing that's useful if you've not seen it is if you go into Google and Google crash calculator, you'll find this, this is a, a head injury outcome calculator based on the 20,000 cases that were recruited into original crash trial, looking at head injuries and when you fill out this form, so you fill in which country you're in because obviously resource is important. Patient's age, GCS, pupil reaction to light and the non head injury, um trauma. Um And then if you've got a CT scan, what does the CT scan show? It will then tell you the chance this, this patient will die in the next 14 days and the chance of an unfavorable neurological outcome in six months. So it's actually quite useful, especially if you're about to go and speak to the family, not suggesting you go in there and say, oh your, your, your son's got a 76% chance of dying in the next 14 days. No one wants to hear that, but it gives you a bit of confidence when you go into a family discussion, that's what you're about to tell them. It's relatively accurate and backed by data, right? That's A to U. Moving on to VV is for voiding. You're thinking, what does passing urine and opening bowel? Got anything to do with the head? Well, go back to your Kly Doctrine. If you are very constipated or you've got very large bladder, you have raised abdominal pressures that presses down on your inferior vena cava, increasing your venous pressures, causing venous congestion, venous congestion, reduces venous return and therefore increases the blood volume in your head. And that in turn increases ICP. That sounds all very far fetched. Go to ICU, find someone who's been constipated for five days, give them an enema and watch what happens to the ICP. It comes down by about 10 centimeters of water. It's quite impressive. It's really important. Um Obviously not in A&E whilst you're doing a trauma cor but in terms of looking after head injury, patients on the intensive care unit, um and just to throw in there, but you'll hear more of this next week. Um If they've got spinal cord injury, you'll have to think about something called autonomic dysreflexia. In which case, voiding is extremely, extremely important. Um, a little bit of homework for you, read up about autonomic dysreflexia. We'll talk about that next week, right? Almost there w is for withdrawal. So this is withdrawal of alcohol, withdrawal of drugs if someone withdrawing, um they may well have a low G CS, um they may well, um start seizing um and it could give them a lot of delirium and affect their cognition. Um And so, you know, think about withdrawal, it's very common. Um I'm not going to tell you how to score someone's withdrawal symptoms. Um You can read up on that. Um And obviously check the alcohol levels, check the tox screen. Um And think about providing your um uh uh you know, uh chlordiazePOXIDE. Um and your um two pairs of PEX and X is for any other xrays and imaging that you have not yet obtained. Very unlikely you'll get to this point because everything should have been done along with the head CT scan that we saw earlier on. Uh but think about getting a chest x-ray or even a chest CT. Hopefully you will never see a tension pneumothorax like this and a CT scan. But we do um and obviously think about CT in the rest of the spine, the chest abdomen and the pelvis. Um Don't worry about the details of the CT scan. And ultimately, you might need an MRI scan for prognostication. But once again, not whilst you're in uh A&E this is something a few days down the line obviously. So that's the saying ABC A to, well, I like to call it A to Z but it's A to X. Um I uh I still can't think of Y and Z. I've been talking about my version of ABC D for about two years now and I still have not managed to find a Ynaz to add in. Uh So uh anyone think of anything uh send me a message tweet me or whatever and I'll add it in and I'll acknowledge you for that. So that's this particular patient um up to this point. Now, let's go back to the scans. We've talked about these terrible contusions. Um ideally, you don't want to operate on contusions because contusion, although it looks like blood on the CT scans. So remember, white is acute blood if you go in there surgically to remove these contusions. So you're sticking a sucker into these hemorrhagic foca, you're actually sucking out bruised brain and once the brain is gone, it's not going to grow back. So that function will be lost permanently. And in this case, you've lost your dominant temporal lobe and also your nondominant, temporal and frontal lobes, if you're taking everything out, and that's quite significant if you manage to go through this period and the patient doesn't die. Um and they recover, then actually, there is a chance that bruising goes away and the brain which is still there will have an area that hasn't died and will recover some function. And the younger the patient is, the more plasticity there is the more likely they'll recover function. Um So ideally, you never operate on a contusion. You allow it to mature and all contusions swell just like a bruise on the arm. They always swell over the next 24 48 even 72 hours before it starts to settle down. So you just have to brace yourself, go to icu maximal amount of sedation, you know, uh ventilation, potentially even uh repeated doses of osmo therapy if necessary to try and pull through this period. Um So that you don't have to operate if you do have to operate. Ideally, you do a decompressive craniectomy rather than actually suckle bits of brain. Um Once again by pre pres um preserving the brain, hopefully you get through this period, the brain settles down, we can put the brain back in as a cranioplasty operation at some point and everything is much nicer. So in this particular patient, um actually a week down the line, the I CPS were absolutely fine. A big reason why this patient's ICP was fine is probably because of all the skull fractures and the brain coming out. So they've actually done their own decompressive craniectomy if you like. So a week down the line, we took the patient to theater for anatomical reconstruction of the craniofacial fractures and that's the other point to talk about. So the first point I talked about that you really must remember is to be at the trauma and talk to the teams and make decisions together. The second point is damage control principles. So all trauma patients, we use something called damage control principles, which come from the Navy, which is basically if you have a hole in your ship, then you want to do damage control. You don't want to spend hours and days and weeks repairing the ship, you just want to patch it up so that it gets you back to land. Ok. That's what you want to do. So, same thing here, you don't want to be spending 6 to 8 hours in the operating theater, fixing facial fractures, making this patient look pretty when you don't even know if they're going to survive. And also that period is actually quite significant insight to the patient and potentially the physiology and the metabolism and everything would go downhill intraoperatively. They're cold because the head is opened up and they become coagulopathic. You lose more blood, massive transfusion causes problems, et cetera, et cetera. You want to do the minimum necessary to save the life, prevent infection and get them to the intensive care unit. So in this case, all we did was mopped up the bit of brain that was coming out, give a really good wash to brighten some of the wind. I just closed it for now, straight to IC U with the intensive with the IC P monitor a week down the line back to um theater to reconstruct everything else. So this is the craniofacial team. If you haven't seen any craniofacial work, it's made up of a whole load of us from every walk of surgery almost from the head up anyway. And we all work together to depending on where the fractures are to fix a bit of everything. Um And the principle is you want to do an early one stage repair, you don't want to have to come back to theater repeatedly. You want one big operation that does it all. Hence, you don't want to do it on day one. You want a day, do it a week or two down the line, expose all the factor fragments, put in rigid fixation and then bone graft it and then soft tissue management to close the wound nicely. So you want to do all of that in one go. Ok. So here's the surgery we did by coronal incision across the top of the head to expose everything. This is after everything's exposed. So from the top and from the side, you can see quite terrible fractures everywhere, you can see the orbits completely flipped forward. Um So it's quite nasty fractures of the worst I've ever seen actually. But like I said, you need to expose all the fractures. So you know what you're doing. And the important thing here is once you've exposed everything, the ideal is to fix around the orbit and the orbital rim first before you fix the rest of the skull. The reason for that is however good you think you are at fixing fractures, there will be gaps. You know, when, when this was fractured, there were bone that was lost, it wasn't just crack, there was some bone loss as well. And so if you try and fit all these bone fragments really tightly together, which is what we all do, then you actually end up creating a gap at the front. And which means that you have a gap between the skull and the orbit. If you then try and fix the orbital bone onto the skull and you're lifting it up, then actually you're lifting up the orbit and you're lifting up the eyebrow and you may end up with one eye higher than the other and the patient is not going to look good. So what you want to do is fix the orbital rim at the very least so that you know where that's supposed to go and what is symmetrical and then the rest of the scalp and fixes onto this rim. Now, if you end up with a gap at the top or it done at the back of the head, that doesn't matter, no one will see that and you'll be covered up by the scalp. Yeah. So fix the rim and the orbit, fix the rest of the scalp and then you can do the mid phase, the jaw and everything else as necessary. So, as you can see here, all the bone fragments are fixed. Um And uh we've plated everything together very nicely and then obviously, you stitch it all up and just so just to close this particular case, this patient did extremely well. Um amazingly uh left us with a gcs of 14, a little bit confused uh with some cognitive problems. As you can imagine having had this injury went to neuro um for six weeks and actually, they are now back in community having an independent life, which is quite impressive for someone who's had such a bad injury now for the last five minutes just really gonna quickly show you. Um, a few things that I haven't shown from this particular case, the same principles I won't go through them in a lot of detail. But essentially, you've got extradural hematoma on one side, subdural hematoma, on the other side. These are extra axial injuries, they're not brain injuries. If you take the clot out, you should get very good recovery, especially with the extra dural hematoma, subdural different because the bleeding is coming from the cortical veins and arteries. So the brain itself is a little bit bruised, but extradural definitely is not a brain injury. And this is what it looks like intraoperatively. You've already seen that picture. If you open the dura for subdural, then that's what Sule hematoma look like. And that's what the brain looks like after you take the clot out and then very quickly, this is a diffused brain injury. You don't see big hematomas. You see tiny little dots of blood here and there, here and here. And this is a diffuse injury where the whole brain has shaken. You have torn some of the white matter tracts and that's the result you have tiny little pe particular hemorrhages. So the scan looks good. You look at the scan and you think what's the problem? And actually, you know, that's nothing to operate on, but actually the whole brain is now shared all the white Methotrex are shared. So their functional outcome is terrible and potentially mortality is extremely high, especially in the elderly age group. So if you see diffuse axonal injury in elderly patients, most of them actually don't survive in young patients, a lot of them do survive but with some form of disability. Um, so this is probably much worse than any of the other head injuries that I've shown you so far. And then the last thing to mention are penetrating head injuries. So gunshots, stabbings and NP airways that's going in the wrong direction. Um Now, once again, it looks scary when you see these things, especially for the first time if someone comes in the A&E with a knife coming off the head with a bullet in the head. Um You're thinking, oh my God, I've never dealt with this doesn't matter, same principles. ABC DE and you won't miss anything, ok? And here it is a patient who stepped himself with a screwdriver. We used to turn a big craniotomy open the dura around a screwdriver, put in brain retractors and you know, and follow the screwdriver all the way down, taking it out very carefully so that it doesn't shear the brain on the way out and looks at any bleeding point, et cetera, et cetera. So that's what we used to do. We don't do that anymore. This is what we do. Now, you literally just turn it and you pull not the most uh elegant operation I've ever done. Uh but works really, really well and you do that for knives, you do that for any kind of um penetrating injury. Um uh and what you do once you pull the material out is they then have an angio. Um And if you see any contrast extravasation, you can embolize the vessel on table um and stop the bleeding anyway. So that's how you manage an acute head injury. Uh very important and I always feel bad that I only have one slice on this. Uh, but actually nutritional support is extremely important. Uh If you remember, um, you know, we all need somewhere between two and 3000 calories a day, um to keep up with our metabolism. If you've got uh any kind of injury or illness, you probably need 2 to 3 times that amount of calories, um for good recovery. And so nutritional support is really important from day one in order to um ensure they have a good recovery. So get your nutritionist on board, think about pressure areas, especially if they're intubated on ICU. They're not gonna turn themselves, you're gonna have to turn them similarly. VT prophylaxis, they're not gonna move if you don't wanna give them Clexane because they've got lead in the brain and make sure they've got head stockings, they've got flow Trump boots on and early physical therapy, early speech and language therapy, occupational therapy, and ultimately psychological counseling, not just for the patient, but also for the family because potentially they've now got life changing injuries that's going to affect the whole family. And I think we always forget about people who potentially end up having to look after them in the long term. So counseling for the whole family is really, really important and that should be the end of my talk. Any questions I'll stop sharing. So I can see. Thank you. That was really interesting case. I have a quick question, what happened to the patient? And what was the actual cause of injury? Uh The one I talked about. Um, so he was, he was at Paddington Station and got hit by a train. Um uh we saw on CCTV that actually he lean forward, we don't know if he was taking a look or whether he was trying to commit suicide. Uh but he len forward and the train just went wax straight into his head, er, and amazingly only on his head. So actually he did come in with an isolated head injury. There were