Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

This platform doesn't let you change your background, is it? No, unfortunately not. Yeah, I have to find somewhere to sit that doesn't show anything awful in the back. Yeah. II once did a talk on here and then I think my kids ran, ran past and then realized they were on camera. So they then decided to stand here and start waving. Oh, yeah. How old are your kids? How much better block them out? Um, seven and nine. Oh, they're quite young. Yeah. Very young. Yeah. So, so they just think it's really funny and then they just stand in the back and not pulling faces and I'm trying to give it to you. Ok. Uh, so, so are they budding budding neurosurgeons? Uh, no, apparently fighting gamers. I've been told they're gonna be a gamer. Oh, really? Yeah, they're gonna be like, world's best. That's, I don't know, whatever games they wanna play and they're gonna be a vlogger and, and like millions apparently on youtube. I was like, sure. Oh, wow. So, sounds like my younger brother. Oh, is that right? Yeah. Yeah. Yeah. He's, uh, fortunately grown out of that phase in the last few years. I feel like I've got a long way to go with those two. Uh, they can do whatever they like. I, I'm not gonna make them do anything they don't want. So, if they're not interested in medicine then actually, well, go and do something else, there's plenty of other things. Yeah. Try not to be the very old fashioned traditional, you know, Chinese parents that's always doctors and lawyers. Yeah. I feel like you can't really force them to do something that they don't want to do. No, you can't really do that too. The kids nowadays, they're too smart to just follow all this. In fact, they never obey the months. I always say that their G CS 14, I think they've learned, they don't obey months. So the G CS 14. Oh yeah. Mhm So good. All right. So let's make a start. I'm gonna quickly introduce you, Mister T and we will hand it over to you. So, Mister Kevin Zung is a highly experienced consultant, neurosurgeon at Emer College Healthcare NHS Trust where he has been serving since 22,014. And he completed his medical training at Gaza in ST thomas' Medical School in the UK alongside an Intercalated BSE in Neurosciences. His extensive surgical training took him across London, Cambridge Oxford, Plymouth and Bristol. Culminating in his specialist registration in neurosurgery in 2014. Mister Son specializes in a wide range of neurosurgical conditions including craniofacial deformities such as craniosynostosis, hydrocephalus, uh cherry malformations, traumatic brain and spinal injuries, spinal tumors, degenerative spinal disorders, and minimally invasive endoscopic brain surgery. With a commitment to excellence and innervation. He continues to advance neurosurgical care for patients with complex neurological conditions. So Z over to you. Thank you very much. It's a very, very comprehensive introduction. Thank you. Um So, yeah, so, um that's quite a lot going on in neurosurgery just like there are in all the other surgical disciplines. So I've chosen trauma to focus more on to tonight. Um uh Just because it demonstrates quite a lot of the principles that you can then apply to other conditions where there's a brain tumor, hydrocephalus, Arna, hemorrhage, everything comes back to very similar principles. So I'm gonna show some trauma cases um kind of the workup decision making processes. Um And hopefully gives you a bit of an insight as to what neurosurgery is like. Uh And maybe hopefully one day you'll choose to want to become a neurosurgeon, which would be lovely. Um Right. Hopefully you will see my screen. Um Right. So um I don't want to turn this into too much of like an actual lecture like you get in medical school just because um uh in medical school and also, you know, um in, you know, f one F two teachings and teachings just because you get enough of that already. So I promise you there's only a couple of slides on physiology and then we're moving on to proper clinical practical things. Um This slide is important because it's probably does underpin all of neurosurgical decision making, which is the Monro Kelly Doctrine. Um And if there is only one thing, they're gonna ask you in an MRC S exam about neurosurgery, it probably will relate to this. Um, so Monro and Kelly are two class region physicians. Um And what they've said is that the skull is a closed box and that you've got brain in this box, which is not very expansive. So it can't really change much in volume. And the main thing that changes is the blood flow. We've got blood coming in through the arteries and blood coming out through the veins. And so the original hypothesis is that your arterial inflow and your venous outflow from the cranium has to balance. Otherwise, the brain is going to swell and the overall pressure within this closed box of the skull is going to go up. And then after that time, um someone else came along and said, well, there is also a CSF in the brain. Uh So ultimately, uh we have Harvey Cushing, which is the gentleman in the middle there. Um Harvey Cushing being the godfather for neurosurgery, he put everything together. And nowadays, when we say Monro Kelly Doctrine, what we talk about is the scalp in a closed box. There are three things, brain blood and CSF if you increase the volume of one of these things, you have to reduce the volume of the other two. Otherwise, the overall pressure will shoot up in this closed box, which is what you're seeing in this graph here. And that's an important principle because with neurosurgical things, patients basically present with a problem that's causing raised pressure in the brain, right. So we're not talking about neurology where people have multiple sclerosis or Alzheimer's disease and Parkinson's disease, which is a path biological change to the neurotransmitters or the neurons. And the actual function here in neurosurgery, we're talking about a physical problem that is displacing the brain or causing swelling of the brain and essentially increasing the intracranial pressure. And therefore, based on the moor um doctrine, the way to treat intracranial pressure is to reduce the volume of those freaky things inside this box. So the first we said is blood arterial inflow, venous outflow, how to reduce blood in the brain. Well, you don't really want to reduce blood flow to the brain because otherwise you end up with a stroke. So what you're trying to do is to encourage venous outflow, right? So you want the arterial blood coming in, but you also want the blood getting out again. So the venous return is really important and the easiest thing that anyone can do is to sit the patient up. Uh it makes a huge difference. And if you've never seen that before and I don't know where you guys work. If you have a neurointensive care unit where you're working, go to the intensive care unit, find a patient with an ICP monitor in the head and lie the patient flat and just see what happens to the ICP. It usually goes up by about 10 to 15 centimeters of um water, which is quite remarkable considering normal should be less than 10. Um Just make sure if you do do that, sit the patient up very quickly so that the ICP comes back down. Otherwise you're gonna get hold of or I'm gonna get hold off for saying this. Um, but sit the patient up really, really important. The other thing is um losing anything around the neck. So in the old days when I was, you know, at your stage, it used to be, make sure you take the tie off the gentleman and undo the top button nowadays. No one wears a tie. So that's no longer really an issue. Um But everybody comes in with a collar. If you've got trauma patients, you've got collar on for c spine immobilization, the collar should come off if you've got a patient whose ICP is so high that you need to do things to actively reduce it. Well, then they are going to be intubated, they're going to be sedated and they're going to be paralyzed with Rocuronium atracurium, you know, whichever muscle relaxant you want to use. And if the patient is not moving and what's the point of the collar. So take the collar off the collar, pressing on the internal jugular veins will reduce your venous outflow. It's a very important. Uh Ultimately, the thing that makes a massive difference is the carbon dioxide, carbon dioxide is a very potent basal dilator. So if you've got high levels of PC two, what happens is all the cerebral vessels will dilate and so the blood flow going to the brain will just keep going up to feel the dilated system and it will come back down and that is going to cause a raise in of pressure. So it's really important to control your PC to in the normal range which is 4.5 to 5 kg particles in an adult, we kind of allow it to drift down to about 4 kg particles in a child. But anything less than that, you will cause vasoconstriction and the patient will have will have a stroke. So the control is very tight and you can really only achieve this by intubating and ventilating the patient. You can't have this kind of tight control through a CPAP or bipap machine. So the patient have to be um intubated. So this is how you control someone's blood flow to the brain, sit them up, loosen things around the neck, intubate and ventilate them and control them