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I If you conceive the first slide, you see the first large. Yeah. I can't now see metal, so I can't see any of you. But that's all right. So my case is, uh, keep that came to any here with a typical seizure. So he's a 15 year old man. He was brought to any is a party school, came with his dad. History was that he had been less Rosabal since 5. 30 am had not been doing his normal activities. He wasn't using his right arm, and Dad felt this was a seizure. That so they called an ambulance. He's got quite a significant background. So, um, it's got a c a c n a one. A mutation which can cause 23 couldn't cause cereal infections with edema. He's got recurrent episodes of epilepsy is because status of flipped because, um, hippocampal sclerosis on his MRI brain. So that free previous reflects not succeed is global developmental delay. So he definitely has reasons to have seizures on That's his drugs list. The Flonase urin was a new drug. It hurt only been started two years ago, and he did have, uh, Coumadin as well. Um, but notably that wasn't given because parents didn't feel that had an effect. So he came in his initial assessment. His airway was patent. His 02 SATs with 98%. His chest was clear. He had a rental. Galateri No crackles. Always normal heart rate was your size aren't moving for us. If you've moved off the title one I have. Okay, But we're only seeing it in night. Be 70 this for money. If I do that, can you see the different fronts? Yeah, yeah, yeah. Have you got particle seizure? Yeah. Perfect. Um, okay, so that's his background on his meds. Eso It's initial assessment. His SATs 1 98. Stress was clear. He had a global entry by Electromed. No crackles. Um, heart rate was slightly elevated, but your polls, he looked tragic, A tid, but noted the initial person said his Jesus was eight. They didn't document the breakdown of that. His glucose was 6.6. It was noted he wasn't using it right arm and he wasn't communicating with that. His abdomen was soft and arrested. Examination was normal. So But the discussion How does he know me? Communicate with that and he normally is. Um it was significant from his baseline and dads. This is how he presents with seizures. So we charge but face Moscow, Do what she did not tolerate. As I said, she wasn't giving the best of them because of the the feeling that it didn't do anything on D. Despite this being four hours since Dad's first had a concern, nothing had been given. So he had IV access on IV. Lorazepam was given at 9. 50. Um, so post lorazepam. He did start moving his arm, but he's still not communicating with that. And he wasn't back to baseline. He had a temperature. So he got smart. We kept track saying, and then on further history had a very similar episode in 2016 where he'd had status for a few days in his local hospital. And then I had had a cerebral infarction and he had had if then, um, teen, But nothing since stopped doing, um, new medication. Um, but it was very difficult to elicit it, whether he was still seizing or no. So he was now moving his arm after the rest palm that that feel felt that he was still seizing because of the previous trouble in function. We got a CT head. This is an old copy off the presentation, because was nice pictures in the new copy. Uh, we'll come back to the pictures. They're not that great. Um, but it received he had showed old infarction, but I was still concerned about this being a seizure that was painted hey, had equal air entry. GCS was 52 13 now, up from eight. Um, and there was this mention of the left arm initially being discolored, but it it resolved. So we have multiple were in a tertiary hospital. So we've got a urology team on site, um, pickle in sight. But the initial call to the urology team said treat is a pill s pick. You also said tree is a Prilosec, and they would review. So we had, um, That's still saying he's seizing. He's not using the enemas much and felt sleepy, and he thought there was a change from after the raspberry. So we gave inflammatory in as per a Bulus. So this is that 2021. A pill s go alone. I am. So the new point on this is kept for all finito and or phenobarb. We did give Benitor in because in our unit we're still not completely on keppra a Zafon first line after Benzo. So either capable finito is given to most of our patients. And then for me, the discussion was, Where do we go next? Because this I didn't necessarily think he needed intubation, but he was still seizing. And obviously, the next step in the guideline is to do Teo do you are? So if that doesn't work So he had a review by Pick your consultant, which felt there was no significant improvement. And then we finally got through to the consultant urologist who said that actually, this child's got seizures refractory to a policeman. It and they need to start with as, um, infusion in pick you, which you then got admitted to make you to start on and was distressed the following day. It's just issues discussion points that I thought from this case. I don't know what other people think. It wasn't a typical status, um, but that in this case, was very convinced that it was status. He did have some improvement after lorazepam, but he was never back to his baseline. Um, despite being known to our new origin, the person that we spoke to a neurology didn't inform us about the treatment plan. So it was six hours since it started seizing before, Actually, we found out what works for him. Um, and that goes into the next point. And also how far down the AP less algorithm do you go? Do you need to intubate these Children if you think they're in status if they have not got any respiratory compromised? And would it have been different management in the DJ, you don't have to go inside. You don't have a neurologist in sight. You can obviously call them. That was my thoughts around this. What we could potentially discuss much with, uh, unshared, that untreated it. Yeah. So I don't know if anyone has any thoughts about how if they could have managed it differently. What else they would have Dumb. It's quite interesting. Case on. I would have been a bit stomach's a swell, I guess, as he has. He had EKGs while she's had these episodes to kind of say that these are seizure episodes because it's interesting if he's not really having like obvious 20 chronic movements. Everyone's labeling of the seizures. Um, I guess my other kind of thought was, you know, you know, my my back to basics. My understanding was we kind of mainly treat seizures because of the fact that if you have a prolonged seizure, you're going to become hypoxic, and that's the reason we want to terminate them. Um, and actually, if he's not hypoxic, he's gotten a respiratory issues, actually. What? What's the kind of mm man like, what's the aim low? What's the aim? And it would be the same in his case. Um, but yeah, I mean, it sounds like a very tricky situation, and no, easiest do that parents free, convinced that it's something that needs. But we don't just integrate them because of hypoxia, do we? We integrate them because the agents that we used to terminate this seizure, uh, often causes depression. Oh, or or, you know, And so I guess you couldn't allow. So if you're gonna try and terminate it, is it something that could end up with, um, it's the most effective. I mean, certainly even the benzos and things can make you sleepy enough that some Children get intubated because of that, whether it's lots of airway tone or hyperventilation, the last step on the guideline is an anesthetic drug, isn't it? So you know that does require information when you're giving those types of drugs. Um, your question about the box is really good. We definitely have Children that we've scanned after they've had periods of other prolong seizures or status. And actually you can get a demonstrates bits of the brain where we we think that's kind of focal point of the seizures is coming from. So as a general point of state, except it just not breathing a bit. I pox IQ, your brain, the hugely metabolics you're you're right, That's what you want to avoid. But I think even at a at a lot of localized level, you can, you know, if we've seen bits of brain. A demon that presumably means the brain is not happy, that it's fitting and consuming a lot of these or this energy locally, eso in an ideal world today, people leave anyone in status and it can be sub clinical status could be really challenge to pick up, actually can't. But nonetheless, you know, we know there are some Children that you are. They can't stop them having pretty regular fits or something. I just a few. It's very difficult to get them out of subclinical status. But if we can, we like to. I think your point that any GI to know, to be sure, is a good one. I think this chart mean he's pretty well known isn't a something we probably worked through that in the past? The other question would be about mid as a damn infusion in a non invasive child. How would you guys all feel about that if you were running a high dependency unit? Pretty, pretty anxious. Don't feel like a good idea, right? Know it's funny. I mean, if you if it comes in and they've had it before, that can reassure. It's I mean, if I wasn't too confidence about the child, I probably wouldn't start at 1 18 go out. You might start a 30 or 60 in and go up step wise, but actually, if you do it slowly and gently a Conner's you think that we've done it and have to intubate someone. They usually tolerate fairly substantial doses. If you If you go up gently, but yeah, I sort of share that concern as well. But actually, when if we do it, it seems to work quite well. And if you are doing it in something status and that should bring them out of it rather than depressing, they're CNS actually. Get them out of state. It's first wake up in the middle of them, which is almost a bit counterintuitive. Is that you? Certainly, I think, have to be kind of ready and prepped to manage them. If they do, you know, starts getting, say, side effects. Can I ask the other? Okay, can I saw the other consideration of the winters went to wean it and how to wean it. And what your limitation, where your cut off would be like, How long would you keep them on and what what? What do you try treating up to say? Start on 30 and 1 80 what's your threshold for saying, Oh, now, now we're better than not seizing. How long do you want to be not seizing, for we start dropping it down. That kind of thing. You're really good questions again. I think in reality, it's a discussion of neurology, and it's weighing up. You know, the patients that you do this for, they're usually very unique. So beginning lot, he talked about that mutation. So the SCN one a was it. So that's a sodium channel. Apathy. Um, you know of this sort of midazolam fusion is usually for the very challenging Children on. Essentially, you'll go up and up and up until you've achieved what you want, which hopefully is to either stop them visibly fitting or two. Break the sub clinical status. Knee actually appeared to get better. And then probably the neurologist to guide you in intensive side. Probably a patient start weaning quite soon after, but actually, we usually get told to just sit on a level for sometimes up to 24 hours, just almost to, like, reset the brain a little bit on. But we you can choose how you wean. But you might just reduce it again by 60. Might speak, you know, per hour every four hours or something. So no hard and fast rule. There's no hard and fast limit either. Um, different centers use different units. Read it might spike, you know, per hour and you know 600 eyes getting out to a pretty hefty dose. So that would be 10 Mike's pick, you know, per minute if you work in those units. But there's no hard and fast rule, but the more the higher you go, you may run into BP problems or side effects in terms of breeding, breathing of insulation. A good question. But in reality, we're using making up in discussion with a neurologist. Something does that match your memory? Lottie. I think he's a bit of a special case in that he starts quite high and then has it for a short period of time. And then it stops and he's his dad described. It is a reset, so it just stops. And then he's back to his normal self the next day and then, actually, he's self discharged. Quite a few times you're finally play, but I think that's because the parents have seen it a number of times and know it works. But I think the problem in this case was that nobody that was working knew him because he had been so well for two years, whereas previously had been in every couple of months and it would start on that pretty much straight away this time because nobody knew him. It was just a bit delayed because you ended up going through all the process of do A B. L s and things. I think that's where you really need them to have a letter that they come with. You know that that says this is their seizure management land. I think that's like often the problem with patients. They don't have your letters on the system or letters that they come with the hospital saying, This is this and this, um and that that's what makes it really tricky when they have different types of seizures. Yeah, Big bro, Any other thoughts about that for We leap over. Ellen, do you think you've successfully mastered the technology? I think I haven't verified my accounts. It wasn't letting me do it. Eso I'll see if it works now, that's what do you do? You just click on a link in your email something So, yes, I had to bury my friend, verify my camp, but the number hadn't come through the ages. But now I'm verified and allowed person. So let's see if this works verified so bad that in mind for everyone else that's helpful today, although that still doesn't seem to work. Ah, why is it not working anti screen? Well, so you're waiting to my also a quick question about, like, managing seizures in a pick environment. Yeah, in terms of, um, like, how do we you know, once they've had there are side and the rest ically we terminated the CT. I guess the question is, you know, what's the one of the best ways of looking out for subclinical seizures under anesthetic on, But, you know, managing them when they're intubated, because I like, I mean, working every day. We don't tend to use midazolam. Yeah. No, that's true. Although they shifted a little bit. Um, I mean, if somewhere doesn't use it as a lamb admitted state eplectic, it's That's probably one of the cases where, actually, they may choose to use but, uh, and rather than morphine. But if you think you've broken the seizures with the anesthetic and they're fine, me number one, what you do big picture. If it's a fairly straightforward case, we would usually give them a period of rest just because usually you're in the middle of the night shift. Wean off their sedation in the morning. If you're If you've got a reason to do a lumbar puncture number one you have you're headed in imaging. Looked at number two. You just a safety check that the pressures are kind of things work You'd want to see the child waking up a little bit. And then usually we use a short acting drugs like Procrit fall back to sleep. Lumbar puncture done, broke for wears up, off they wake up when we extubate them. Um, what was the other parts of your question? I forgot. Now, um, I think I slightly lost you guys as well. I think it seems to be about, um yeah. No, I think that kind of honest it really say dosage. 80. Wasn't it out. So if so, your muscle insidated, but you have a seizure. It's all those physiological things. So tactic pupillary dilation, if they're not, must relaxed and it's a motor seizure. You you'll still see that That your BP, heart rate and people's on the you. And so yeah, nothing. Ellen Ellen's having technology stress, isn't she, um, unlisted help? We'd still go on to it. It's like I press on window and I pressed the share, but and then I just go the way nothing happens only having mild You know what? Separate. And yes, you need to save it as a power cord. Okay? Yeah. As I explored to power point and then you Well, I got find a swell, but, uh okay. And then you go, Yeah, I can't. Let's, um, so that we got okay, Jason, do a reaction. Uh, document. What topic? You doing it And I forgot. Is your head injury injury? Perfect way the F in a minute. That would be fine, too. Okay. I think we sent to do What's up? I play. It's 48 Magallon. That's probably the pope. I don't know how big things are, but the file button, it lets you reduce the file size. She's got a lovely video. That's the problem. Uh, reduce file size. Okay. Don't need a movie quality off. Little safe. Okay. Sorry, guys. Yeah, but it not actually the white white white work. Lots of yours works very quickly, didn't it, you know? No, no, no. It says there's 49 seconds left and in the presentation. Doing what? Okay, Okay. I think it's going to try and say smaller one now. Okay, that is sent. Okay. I love you. I can't see anything. It did you send it to me? Are they coming? Says it's three megabytes a month. Yeah, right. Here we go. Yeah, he reduced his ice theophylline taking too long, right? Yes, I will. Look at this. All share my screen and then can you see that? Yeah. I can't. Yeah. Uh, yes. Yeah. Let me just try slide show on on. We'll see. Can you see that? And then if I move on, Is that moving? Yeah. Okay. Is yeah. Yeah. You just tell me when you want me to. Yeah. Yeah. Okay. Yeah, right. So Hi, everyone. I'm sorry about the technical difficulties. Eso I'm Ellen. I'm ST seven. It varies. I see at the moment on this is a presentation about a 16 year old boy who came into our unit few weeks ago. The next light might be a lag about done it. So, uh, hey. Yeah. So he was brought in by ambulance to his local district general, and he was unresponsive on the history from mom was that he had been fitting well the day before. But on the day he had been brought in, he was have complained of a bit of a headache. He had one large woman and he seemed to be sleeping a lot. And at 10 o'clock in the evening, she's noted him to be acting strangely. So he was naked in his room and seemed confused. But then he went back to sleep, so she went in to check on him at midnight on, she found unresponsive and he'd be on incontinent, so she called in ambulance. At that point, he was still breathing, though on down sort of brother questioning is that being any injuries she was aware off. She recalled a fall in the shower a week prior to admission, but, um, nothing else. Ondas past medical history. He had no previous significant illnesses, and he was high functioning autistic in the mainstream school and had a t H. D. And um had been quite challenging, and Mom was actually concerned he might be sneaking out at night without her knowledge. Hey was on methylphenidate, so doxycycline melatonin wasn't allergic to anything. It was known about and next light on turn to the family and social history. Lived a home with mom and three siblings, and Dad was in prison for drug offenses. Mom didn't think that he drank alcohol, but thought he possibly smoke kind of this ended inhaled match Got side on the had beans. Um, concerns about his involvement with a certain group of boys at school felt to be reaming him on down. And some travelers nearby. He did have a social worker on there had bean a story of him stealing mom's car keys and going for a joyride. So she kept her keys on money locked away. And he had previously in verbally aggressive. You've never been violent on Dad said he was in the mainstream school in year 11. So at the district hospital, I don't have much information from them because this is just what I got from our admission. He was had reduced. GCS was wanting to pain. He wasn't moving his left side at all and he had right fixed people, but fixed and dilated right people. So obviously that bought him a CT head, which hopefully will play video. Um, my days. Oh, yeah, that very kids on the next page says Just some stills of the images. I don't know if anyone wants to shout out the answer. It's pretty clear. Cut one. The abnormalities that could be seen that make you wait for it. Okay. Anyone think you got that's really rolling in the shower? Yeah, exactly. Yeah, There's, like, a yes. So he's got a lot of troubles, Cordner. But, um yeah, like this large extradural hemorrhage will. Yeah. Yet with midline shift, there's, like, so called a basement. You either the ventricle. What? You can't see the right ventricle. It'll it's squished on space in the brain. You can't see the silk I and yep, Kerry on. So it was. This is obviously a time critical transfer There was. Mantle was given it the local, and he was transferred by the statistics directly to the attorney, where he had a right craniotomy and evacuation of the extra little hemorrhage. Hey, had ICP bolt placed on a CT had postop on the advice from the neurosurgeons. Was that a foreign ICP of less than 25 on? If the CT head and I see people were okay, then he could be woken up next line. So when he got to pick you hey was obviously trouped hey was on minimal ventilation settings and actually, that point was maintaining a good map about any idea tropes. He still had, obviously, the right fixed people with the breast left people. They had the ICP Bolton sick, too. He was sedated with propofol and we added fentanyl. Um, the surgeons hadn't said to start any prophylactic antiepleptics on DWI targeted a CPP of a cerebral perfusion pressure of more than 60 an ICP of less than 20 um, on full exposure he had raised in scouts breezes his right upper thigh. Um, large rays of the back on the right side, this back and right hip. And it was Doctor. He had a liter of fluid in theater, and sure, he had some blood products as well on. Then we started on 40% of total fluid intake. Um, tummy was fine. His HPV was 1 to 7. He was febrile. So he started on a cooling blanket, but not started on IV antibiotics. At that point on, he had central line outline and cannulas next light. Eso based on day wanted to he had increasingly a raising rays, ICP, which was persistently more than 20. So the strategy is used to make Teo modify that work ventilation changes to maintain a strict PCO to between 4.55 point three. He had quite a few sedation Bolus is on then eventually started the midazolam infusion on. But once he was on the data that, um, he then required your adrenaline to keep his map above 80 and keep a CD. People of 60 he had one hypertonic saline bolus. He continued on the cooling blanket to maintain know Mathon normochromia, and it was discussed with the new resurgence. She said they were happy if it spikes were intermittent, but to call them, um, if it was persistently more than 25 for 15 minutes. And meanwhile, Mom was told by a friend of hers that there were pictures off her son on Snapchat on a motorbike the day before he was admitted to hospital. So the mystery was solved. Today, three he being you're protected for over 24 hours. His right people started responding and so sedation was weaned and he started moving all his limbs on. I see people was taken out, but he still was spiking. Temps, despite being actively cooled on, actually had a CRP of 376 and he was noted to have quite a bit mark tracking cellulitis in his right hand at the site of her cannula C. We started on cataracts in and back of my sin. You also had a CT head, with contrast to look. If there was any source of infection in the brain, there was a really large subgaleal collection. But they said there was no evidence of abscess or empyema on. There was still some persistent right uncle herniation, but that was better than previously. And then he actually then got X rated on Day three, and he was awake obeying commands, moving all his limbs, just with a bit of slowed speech. And then Day four by Day four, he was self ventilating in remember and with GCS of 15, he was orientated. He was answering questions appropriately bit of a horse voice and slightly serves beach. But then he was distracted. Award on. I just looked at him yesterday on the ward. He's been having rehab and he actually went outside, walk for a walk to the shops outside the hospital. His main concern is his GCSE because he wants to be an engineer. So in summary, this is a 16 year old boy with extradural hemorrhage and raised ICP require an urgent neurosurgical transfer. A newer protection on the I see you, we happen the ward. And obviously there's always the safeguarding issues with teenagers. That's it. Super. Really nice case, actually. Thank you for sharing. Um What what questions or topics do you guys want to put out for discussion from that? My question was, why didn't they start into projects at the beginning? Yeah, I don't know this either. It was discussed with the neurosurgeon. They said doesn't need antibiotics, doesn't you? Damp heat. Anti epileptics wake him up If the CT heads okay in his eye. CPS Okay, basically, um, that office e once dopey on he was still spiking temperatures. Then then? Yeah, we, of course, started antibiotics. I know lighter. So Well, this is what I don't know is well, and it didn't seem to really fit because he then went to the ward and he continued on two weeks of antibiotics and and it seems like a very sporting. See, I was very marked cellulitis and there was sort of, you know, some point the plastics were involved that concerned. Maybe it could be necrotizing fasciitis. And but I didn't, I guess, given it that he obviously fell off the motor bike on the good night before and had lots of, you know, entry points expose the infection. I would have thought starting antibiotics prophylactically, probably. I probably would have them. I mean, in terms of the head, there was no sort penetrating entry that might it was presumably it was a close wound and all that. Yeah, they're all say, than the surgeon's not not necessary. What about is, if you don't know what the CRP is? It would just be pre op against from the local. But I don't know what that was. A few things I thought be worth asking you guys as a group. So number one Herget, you're a surgical transfer and then also dealing with raised it training or pressure. What experience or questions they have about these things? Pull out the transfer, for example, is anyone experience problems getting Children move quickly or if you got examples of it working very Well, yeah, case, it's a red goodness it for a awful. So I got in case of tweets and maybe your expression it came in with history of apnea is possible. Sepsis, but essentially had a CT head, actually. Depressive hemorrhage as girlfriend, the needed surgical transfer. Teo. Gosh, that the least it's refused to take. I'm being honest. Consulted? He was there. You don't want to actually on and actually ended. Refused on. Demanded to speak to cats who actually, really, fortunately were busy in the beginning of the shift and body sets out to come and pick them up. It was a Was it normal at the time, so it was relatively close it and get it. But yeah, it was a really challenging conversation to have a blast. Also obviously worried about the child. And they've got stuff at the place and everything else you got to do to them. The trying to convince any cyst that they need to take. Um um but I just find that it's it's in the world. College guys want to do it Well, has been highlighted since to make him sick. Really good points. And it can be difficult. I mean the reason pediatric treatment services has been set up. Um, moving Trojans days. I might just need a good looking just said, um, somewhere I think so. This is the document you're referring to, It going step on British nipper surgeons. And this says very clearly that the anesthetic about the setting hospital should move. That's the doctor referring to you know you can Ultimately, you may just need to get that. So whoever talking to each other yeah, really good point can be very difficult, but actually, I mean, if it's cold, does bad leg from it? You know, the repercussions would be. Actually, it should be the local anesthetic team who moved That's made very clearly in this document as a result off, presumably people having difficulties getting Children moved. So what was the mini situs reason for not taking? He wasn't able to give a clear reason on. He just he did. She just said, I'm not doing it. I don't want to do it, but it's not actually got to do it. You need to get cats to do it on. But that's unfortunately, cats. Mr decided they were happy to come out and take and yeah, I had already left by the time we then contacted them back to say, Please, can you speak any cyst and confirmed that they did to do it? Um, we consultant was already there involved. I was going to go with them. So we have had a little complicated, so he wasn't really able to give a definite reason on, I think. But I think it was a little lack of confidence on he's feeling uncomfortable about it. And having worked with times following that, he was quite nervous about pediatrics, and it was a really poor balance. Take a baby. So I think back of confidence that he wasn't able to take plastics and fly the retrieve it is. We'll set off and go. It is not far the difference much on, but you're right. It usually is that confidence and worry, and that that that's not wrong is if you're worried, then essentially your perhaps not directly. But you're recognizing that maybe you have some limitations or whatever. Uh, if you're if you're in that situation again where you weren't somewhere retrieval service could get there quickly. Is the possibility of like a pediatric person going with the anesthetist. I mean, definitely, isn't it? I mean, somebody doesn't want to do something. What isn't going to convince Mr Setting and they have to do it. That's the trouble with that role. College statement, isn't it? Yeah, I think it is just a question of working out. Who's best it? There's a risk that that under confident consultant just tells the registrar today. It isn't there who who may be actually more able to be equally might not be that might not be able to say no. So it's definitely, you know, it's a really world tricky situation. I think it just needs a conversation between everyone. See who the best person is. What about. So Ellen talked a little bit about controlling intracranial pressure. Did that make sense to people? Don't experience of that. Or, um, did you follow the things she said she did and why she would have done that? Oh, yeah. I've got, like, drinking from being a girl day controlling cranial plastic. He didn't put you explain that and for the sentence, I couldn't quite hear the question. Could you tell me it's just been fuzzy? Uh, yeah, I've got no, I've got no experience off controlling intracranial pressure. Um, the number, please. The abstract were they Were they the numbers you would normally track the our aim for? You know what? Like your normal ICP would be Yes. So, yes. I mean, I like less than 20 is what I've always seen used on, then, Obviously, the cerebral perfusion pressure is, um, is going to be your meat on your pressure minus your insulin. You're rushing. So I think you used your increased intracranial pressure that maintain that. Well, we have to increase your, um, me. Not a real pressure. So that's why we Because we were aiming for less than, um, less than 20 with a cerebral perfusion pressure or 60. That meant we had to aim from up the weight workout. So obviously I want to do is to say pressure. The other strategy is to do short of CP. I'm still the measures that are, um so see how you do because of the See if you have lots of two that Betadine attention and redeem It increases your pee that same time. You don't want to make too low, because then you get vasoconstriction on. But, um um, then you get ah, that that's not, you know, you don't get good blood supply to the brain. Um, then maintaining and then obviously then 3% saline could be given in a kind of a a cute situation on Go with this, you know, to a swell if you have, like, a if they're going up and using, they're basically koning. You can just hype. We don't usually hyperventilate them, but you can hyperventilate them in an acute situation to kind of reduce that quickly. Um, what else was that there was maintaining with, er me? A hypotonic saline bolus is, um, and and there's I mean, there's a whole there's there's really good, like guidelines that marries a swell because other things just sort of trying to reduce the metabolic work, I suppose, of your brains or maintaining normal glycemia maintaining oxygen p two above 12. Um, I remember the others Now, um, that's thank you. So one way to think, Yeah. Carry all gone night. Go ahead. Get it here. We're just going to say one way to think about is actually what? Put your pressure up in your head and therefore that kind of leaves you to thinking, um, how do you get it down? So number one obviously, is just if your brain is swollen, so the two things Ellen talked about is one oh to control so high, so to your body dilates your blood vessels to try and flush out the 02. It's actually if you lower your seizure to the blood vessels in your brain, and that's inside the fix compartment of the skull so they don't reduce in the blood vessels, reduces the volume and therefore the pressure so low to control in a sort of low normal range. Put 4.5 to 5.5 kids. Pascal's so that's neuro protector of See You to control swelling if the brain's bruised or battered. So that's where I have your 33 or 5% saline. We're minutes whole comes in, and then what else could put your pressure shot things out, not giving it away on the screen. But so if the agitated yes, being under sedated, perhaps even being muscle relaxant under sedated so they actually the patient tensing up or being in pain so therefore giving antsy a little six analgesia. So fentanyl Bolasie's midazolam making sure they're well sedated or runny. Sit ties? Yep. If they're not muscle relax and you've got a problem. Then you probably should muscle relaxing in case that's contributing. What else? What else could make your in training precious spike up? You've obviously got also that, like, the basic things, like keeping the head in the midline and 30 degrees Teo trying to get around and stuff. Things are mostly around trying a a blood flow for your head. So if you know, head up a venous drainage head in the midline aids venous strain itch. If your veins are draining out well, it allows your arteries to push to push blood in good BP. Good oxygenation. They probably that your ICP too much. What else could put your ICP up? Seizures s You're gonna look really carefully to seizures on day either. You know, a bad brain injury treat prophylactically. But just think, actually, could this I see peace fight the seizures. So are you giving an anti seizure drug are your mid as lamb? Should you Bayliss midazolam that sort of thing so I can just go quickly show you our You know, my night. She said, Because I'm in the light DEA eyes. They always seem to give prophylaxis prophylactic anti after that fixed. But in this, I didn't over is different for, like, extradural hemorrhage. Um, because it's not like a diffuse injury. Exactly penetrate injury. I think we definitely would. And after that it's just it's just a bit of ah, you know, deciding where the risk lies. If you've had an acute bleed and you drain it, you would hope that actually probably won't be too bad. If it's very big like yours was or it's been there for a while and you don't really know, then you you may have significant kind of a demon postop of things as well. So probably a balance and see if if you've got and I see people problem, then you know you probably just want to get it all out and treat everything don't you as best as you can. So this here gives you just a little, um, a little like being so grazed ICP in the orange there. So it talks about the CEO to sedation analgesia 5% muscle relaxing. That's all those things we talked about. And then, of course, if actually are not giving intro. Do you need to get back for another scan to see, to see if something's changed? If you have individual ready, do you need to go to this? Or if you've been theater, actually, is something played again? Do you need to go back? If you were managing a patient in your E. D. A post head injury and you also work out what to do? What would you say of the two most important things that will affect outcome at that stage when they're just in your E. D bed and you're working out a plan if you pick two things two numbers that you can control, what you get for not pressure? Yeah, definitely. That's That's one of them. Oxygen. Yeah, exactly. That's all about getting oxygen to your brain. Is it? The BP drives it there. And then if the blood hasn't got one and it's a bit points so head injured child, right dose. You cannot accept the SATs being a little bit iffy. So, really, it should be SATs above 95% so any doubt they get oxygen. That's easy. Um, and you must accept a borderline BP. So again, if it's a proper brain injury, you should follow a guideline with BP targets. But a head injury is a one time. We don't walk past the bed and say all the BP is just about okay. It's a bit low. So that would be a patient that actually getting ideally seen nor adrenaline going just to give you a good BP. And they're good. Diffusion pressure would be important. We should probably wrap up fairly soon. Some keep that. We do keep these sessions short. This is my kind of one slide about all the things you should do for someone with a head injury. You know, they come in so see Spy on ABC Assessment. Really, it's all about imaging on decision making and time critical transfer and then the to learning points. I think our number one you have three choices. Okay, So brain injured patient if they've been in east ties for whatever reason off for a scan, you either should go to theater if they need it, or you should wake them up and extubate them and see what their neurology is like. Now, once you've seen the scan or if you're not taking them up and you're not going to be a two, you must have intracranial pressure monitoring device. And as you heard felons case, if you go to theater for whatever reason, often they'll come back with it. What is not on that option is staying asleep with an anesthetic, but no pressure monitoring. Because then, actually, you can target your therapy. You don't know what I CPA is. Therefore, you don't know what your cerebral fusion pressure is on. And actually, you could be challenged if the patient has a bad outcome, you've had them asleep, you can assess their neurology. And also you didn't have a pressure monitoring device him. So they are three options, and then the key bits delivery of oxygen, isn't it d 02. And that is your BP and how much oxygen is in your blood. And then als neuroprotective measures. You talked about two there, so 30 degrees up, which is a lot safer than you might mention. Avoiding necklines head in the midline. And then it's about see you to control chest videos. Your lungs are clean. Issue can control the c a. T a little bit restrictive on the fluids. We make sure stadiums above 145. So if it's not, we'll give some hypotonic saline just to bring the number up. Not being hot, but not too cool Idea Onda Ultimate Nutritional axioms antibiotics, if appropriate on Dante Collective Drug and then back to this guideline. So this just gives you a kind of ticked box of things to achieve. When you admit your patients, you just have a look at those things down the side. We've talked about most of them, and then these are the green in the orange box is just guide you so your blood pressure's low, what you gonna do about it? And if the ICP is high, what's he going to do about it? Because ultimately, these are the two things affect your cerebral perfusion pressure. Your CPP will be bad if your blood pressure's low or your ICP is high or both, so you need to deal with it rapidly and quickly on. But I think that's that. So this will be on the George is picky website and you know you use whatever BP sent aisles that your local trust uses is not actually great evidence for these, so trust often have to just choose BP targets that they think are appropriate. That's that's our guideline. Ellen. Anything else in that case that you think the worth exploring before we break up? Not that we could get everything, any questions or any other discussion points from anybody. These platforms knew I hadn't actually realized I could only see a few names on the kind of video bit. Actually, I clicked on the people, but there's actually 14 people here on there. I thought there were only six of us for a while, But even even this platforms need to me a swell so good. So just a quick question about the platform. I know we had a little bit problem presenting. I'm actually not sure what that is seem to work for me and Charlotte. I think video quality is reasonable. Um, I know my and Lattis Internet's not great, which may contribute a little bit, but let's say after this you should get a link for feedback. If you feel it in your then automatically get a certificate of attendance. Ellen and not you should get speakers certificates. We'll see if that comes through. It means we'll get feedback about the what? We're running. You're getting attendant certificate on deal. See how it goes. I will put the feedback link in the What's that group is? Well, just in case it doesn't come through automatically, but I think it should do. Um we got quite a big group. We haven't heard much from some people, but any any last questions before we or go separate ways. Deathly silence. All right, I think What? We're probably going to keep the date next month as it is on the calendar. Out way as far as we planned anyway. Yeah, all right. She left one. Go. Wonderful. Good. See you next month. For you. Very much. Thank you. Thank you. All right. Thank you. Naked better islands. Poor room was you and I were still It's latent. Ellen wasn't started on that. Um, Might be I put her in a speaker, but actually, the system seems to be saying everybody's a speaker, so Yeah, you might be right, Actually. Well, you would administrator on the whole thing. Yeah, but you and her relisted a speakers which I would have thought should give you the power anyway. I don't know. We'll explore it anyway. Looking at this now some people of you is And for example, Charlie's down. It's a speaker and I didn't put a speaker. Not sure I'll explore and you will see body, but thank you.