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Right. So it's only a few of us today. Own a lot of you online. So if we just try and get as inactive as possible in here, your benefit online. So I won't rough as much as last week. So this week is on neurosurgical emergencies. Neuro is a topic that filled me with dread. It is something that comes up a lot in more trauma cases because you've got to think you've always got to clear these head injuries, but it's also something as a general physician that you'll be picking up more in your fools history. So this is where neuro is really important one to cover. So as always case today, this is your history. So you've been given this, you've got Sylvia, a 75 year old patient who's admitted to me following a fall. She's accompanied by her granddaughter Sue who wins the fall. Sue says her grand are getting more unsteady on her feet. Please take a full history. Now, how many 75 year olds do you know who have had a fall and are getting a bit more on your feet? All of them. So this history is going to be your bread and butter when you start an em, your job. So what are the kind of things you want to clear from a full point of view? Stroke? Mhm. So what kind of questions would you wanna ask? Uh weakness? Um Like like hands, face sounds good. Yes, sensory sensory changes, speaking, understanding, so to speak, so fast as your stroke signs. So face, arm speech and then time is the one to say. but the main way of breaking down your histories is to work out what happened before the fall during the fall and after the fall. And these are the main things you've got to kind of narrow down to. And these are the questions you should be asking if this was your sys station. So what are the predisposing events before fall? So in this case, the patient Sylvia felt very lightheaded and dizzy. If you were thinking of other things, was it just a mechanical fall? Was she just walking and she tripped? Um And then you got to think of head trauma again, other factors that are involved in the mechanism of injury? Was it high velocity? What are likely injuries she could sustain? Then you're looking at more physiological causes. Did she have chest pain before it? Does she have shortness of breath? All these other things that you can think about before having a fall. So these are the main things to look for. Then you move on to during the fall. So did she lose consciousness is a key thing? You've got to think of your guidelines here. What are the things that are gonna scare you? Did she start having a seizure? Were there any other pains or any other traumas that she sustained during the injury? And then after the fall, can she remember it? You're looking for amnesic episodes and make sure she can fully recall it. And if anyone was there when they've got video images always useful for falls and for seizure seizure histories. So this is the case. So she was standing up from a chair, she felt lightheaded and dizzy. Her granddaughter who had noticed that she didn't pick up her feet properly and stumbled forward. So you've got the patient here saying, oh she's got a bit dizzy, which is one of those things and the patient end right next to k were going, no, there was more going on here. So you've got a mixed picture of a mechanical and then a physiological cause. Now things that can cause less blood flow to the head. It could be a cardiac cause, respiratory cause or a neurological cause. So you'd want to look into these other histories. So you can look about palpitations whether she's had episodes like this before. Um and then any other systemic factors. So you're saying in this one, she's got pains in her knees and she's got some shaking in her hand and then you wanna check her over cos she's a 75 year old. She may not have gone to the GP or the doctors in a long time. Just make sure you do the once over check if there's anything more. So she's constipated. Could that lead to a fall? Yeah. Why um um is like her absorption? They could be dehydrated. That's why they're constipated. Definitely. What I saw literally two days ago is the patient was straining so hard on the toilet, they did a vagal maneuver and had a face of vagal syncope and that's how we had a fall. You never know what factors could be doing. But as I say, dehydration is definitely when you're looking at this nutritional status and then you want to look at confusion cos what is your common subtype for people who have a full people with dementia? So you then any elderly patient, you're noticing some trust in their clerking, they want you to do a chronic er so the frailty score and you have to do an ATS while you're there or a mock score if you're doing really thorough dementia screening. But most patients when they come in, their initial clerking and the elderly geriatric C class want a frailty score. So it predicts their mortality and an ATS to early recognize whether they have a are at risk of dementia. So as a 75 year old lady, she has a lot of past medical conditions. So in this one type two diabetes. She's on Metformin for it. But what if she was on insulin? What could have caused her for? Exactly. And how do they usually present a hyperglycemic fall problems? Speaking, confused, comatose, dizzy, lightheaded. Is she, we said she's constipated, is she she not looking after herself got ischemic heart in a previous? And have we got another acute cardiac event or is she having some signs of heart failure? And that's why she's dizzy on standing with a postural drop and irritable bowel syndrome. Again, she's not nutritionally maybe lacking. If she's having to take Busan, we can see in her drug history over the counter to help with this. We've also on a beta blocker. Um And when you, what beta blockers, if you take too many of them or it's not monitored by your GP it could slow down your heart rate. There are so all I'm trying to hammer home with this case is there's so many things you can pick apart. There are so many causes and you're never gonna ask them all when you're an A&E clerking, but it's always have a differential of mine. There's constantly gonna be things going around your head and never will rule them out. Social history. Not too much. The main thing that social history with a geriatric patient is looking at what they're like at home. Do they have support? Do they have carers coming in? So that's why I've really put in here cos you should know what is the problem with hospitals? We have no beds. Why do we have no beds cos it's not safe. People have a heart attack say that we can't send them home cos there's no beds cos they've gone physiologically more frail since the admission. And so knowing what their status is when they come in, so you can recognize early, I'm gonna have to get ot involved is a really important thing practically when you become F one. Yeah, that's the case. Any questions about that so far? No, happy. So with an examination, what exam would you like to do on this patient? Um I would do a general exam and uh you would, how do we feel about upper limb neuro exams? Happy. What is this trying to demonstrate? I don't know if it, it might be too far to go. So this is how I remembered it. So indeed tall people can reach shelves. So that is the flow I would go through in my examination, starting with inspection, tone power reflexes, sensory and coordination. I forgot can. But there that is how you I remembered it back in the day. I haven't done one in a long time, but these are the kind of things you're obviously looking for at the end of the bed swift. So in this case, Sylvia has got this resting tremor in both of her hands. That's all you can pick up. She's quite physiologically frail she's sitting in the bed, she looks a bit tired, mildly dehydrated. But from the end of the bed there's no obvious scars or wasting. How do we assess tone? So, tone is one that they'll teach you to do it in each muscle group. The way I got taught by, um, a general physician is to just take their hand and do everything at once. You're distracting them so you hold their arm and twist like this and doing all the words and you can feel that increase in the upper limb. What specific tones are we looking for in a patient? Average cost? My cog wheel. Yeah. So you look at that ratchety movement is that increase in tone, you know how to separate your upper and lower motor neuron. So increase in tone, upper, less tone lower. There's a table to break down for your exams. So we then move on to, as I say, I've got a little demonstration here, the things you're looking for the core phenomenon indeed taught people. We move on to power. Obviously, I'm not gonna go through it all today. You seem all very comfortable with it, but grading it with your MRC S. The main thing I want you to practice when you're at home for your AKS is talk you through. So I had the simple movements arms up like a chip chicken, resist me, resist me, arms like spot, resist me, resist me, flick your arms up fingers spread out. Stop me pushing them together and thumb to the ceiling. That is what I did. You will have your own ways to test all of your nerves going down. The main thing is getting it done in time. You will never finish a neuro exam. I only ever got to vibration sense. Don't worry, I did all. All right. My ask is, so it's just about make sure you've got the flow. And I was taught traditionally to use like for like in your muscle groups, um just whatever's comfortable, sometimes the actors can be a bit funny with this one and will be slow coordination. Obviously, we're going to look for pass, pointing and intention terms and essential. But also at this thing you want to do with your pronator. So you have your hands out and you ask them to close their eyes and see if they do that. And then finally, in reflexes levels have, I don't know, some people have rhymes, but I just remember for ankles, 12 knees, 34 biceps, 5678 triceps and then yours as well, right? Your 67 practicing those at home again is the any way I can do it. You also get a point in your mark schemes for doing the exacerbating maneuvers. Usually when you're struggling with the super. So don't feel like you've failed in your exam if you say cut your t from three, it actually demonstrates that you are looking for the right reflex. So, don't be put off in your exams if that's what happens to you. So, get to differentials. What are the differentials going on in your head? So, just to recap the history, we've got a 75 year old lady who's multiply comorbid, she's had a fall when standing from the chair, she's been stumbling over her feet and she's got a resting tremor. Parkinson's. Mhm. Um, she is a little high. Mhm. He still had a stroke. Mhm. And arrhythmia. Mhm. Well, so still could be a seizure. I've mentioned she could have been having a hypoglycemic episode as well with tremors. It could be an essential tremor. She says she doesn't drink, but alcoholics are very secretive. So you never know it could be that. So it never exclude things. And then if you've got a Parkinson's, so you won't say Parkinson's disease or is it just a Parkinsonism? And then you've got all your Parkins plus syndromes. You just need to know them for your exams. I've never, I've only ever seen lower body dementia. I've never seen another one, but they're easy differentials to have. So, your main thread to say in this patient would be Parkinson's disease. Parkinson's plus syndromes, essential tremors and then stroke would be my main ones. So, these are the things you're obviously looking for in Parkinson's disease. These are the classic things you look for the shuffling stooped gait. So you can as well. In your upper mo and your own, using your lower, always get them to walk and you'll see these classical signs. Um When it comes to the pathophysiology of Parkinson's again for your exams, does anyone know where it starts? Soft? Niagra? Yeah. So you end up, you do a long standing or do a long standing N ne falls in a geriatric geriatric patient because they wanna know what scan, this is exactly that. So it's spect. So it's the proton electro scan showing the uptake or the less uptake in that area. So we know this is a bond or Parkinson's disease. So with management, any easy answer, when you're looking at management of a full, you want to have an MDT approach, it's an easy answer but you forget it. You think, oh, I just want to admit them cos I've had a full treat them for their posture will drop, review the medications. But if you're reviewing the medications, you're gonna need a pharmacist, she's had a full, you wanna get physio and ot involved speech and language if you're worrying about that, uh GP depression screening long time course. And then these are the medications they have these special utensils and other medications may be required. But this is neurosurgical. It's a bit that always interests me when I saw it. Was this, anyone's seen this. So this is deep brain stimulation. I've seen one in my time to treat uh, parkinsonisms. Usually in younger patients who've got Parkinson's disease. And you actually, I have seen a reduction in the essential tremor. But that is the one case I've seen, the main thing to take away is this table here. So these are the causes of your parkinsonisms. So primary is your disease. Always think what medications? So, any elderly patient every time you come in that they want to review the drug chart because nine times out of 10 patients have been on these medications for years and they've changed and they don't need them anymore. They may have been diagnosed with hypertension, but if they don't look after themselves, they're dehydrated, frail, their BP is gonna drop. And then these, as I say, your Parkinson's Plus syndromes, the main one is to think of low body dementia. So if the confusion comes first and then the Parkinson's, is that and vice versa in your primary Parkinson's disease? So enough talking from me, I have a look, we're onto the questions. Um, this week we're actually going for SBA S so single best answers. Er, because I was running out of questions in my question bank. So they're all the same options, but there's five different cases. So this is your first case. So you've got a 35 year old woman who suddenly developed facial palsy six months before that, she had an episode of blurred vision and unsteadiness. She is attacking in an afferent pupillary defect. Anyone got any clothes in the room. Yeah, MS. So you're looking for obviously in this one, she's got an ataxia and a pary defect. So the way to remember it or I did in my notes is team so tingling eyes, optic neuritis. So decreases central vision and painful eye movements, ataxia and motor usually uh spastic paraparesis. So you give them antispasmodics. That is the way I remembered it. Yeah. Question two, 70 year old has developed sudden facial weakness, which is proceed by two days of severe left ear pain, vertigo and deafness. She has vesicles around his ear and soft palate. Straightforward. Yeah, everyone happy. Which one is it? Yeah. Ramsay Hunt syndrome bar or if you're thinking about those vehicles in one strip, you know what it is. Next case. Yeah. Anyone happy. Yeah. G so you're thinking in this one, we've got a paralysis. So we know it's motor on the side of one side of the face. It is not forehead sparing. So we know it's not stroke. So it ends up being Bell's palsy. So happy. Which one? A? Yeah. So this one again, she's now this one is forehead sparing. So we know it's upper motor neuron. She's got a history of af so a history of clots bound or stroke. Kind of question. And finally, yeah. Yeah. Um I'm I'm guessing. Yeah. So it's slowly progressive. So we're thinking of a tumor. Well, you've got the thing of deafness and tinnitus. Um So this is where you're thinking of your vestibular system and ad duction is where you've got the involvement of your cranial nerves do with your eyes. There is rumor to be a genetic component. I've never seen it. But usually this is the kind of case when you've got deafness, tinnitus, it slowly progressing, you're thinking tumor and as well with avulsion of the other cranial nerves. That's what you're looking at. So that are the questions today quite straightforward this week. So this is the case this time. And as I said, this is one where I kind of, this is what I'm used to is a trauma case. So as is less of you today, I don't mind just leading this one if that works. Would you rather interject in you? Like being mom? Let's go then, right? So this is your case. You are all, you're the trauma team. Ok. So you all got a role so you can delegate as you go along. You are in a major trauma center in Saint Georges. A you've got Barry who is a tree surgeon who has fallen from the top of a big oak tree onto his head. He has been brought in by hems because they're very concerned about his head injury. Please. Can you assess Barry as per a trauma protocol? Um Blueberry, can you hear me? Yeah, do what on earth is going on there? We're doing a to eight. Is there anything different about a trauma A to E as per ATL C spine. So have you heard of C A CBCD? So you start off with catastrophic hemorrhage. So you may get a call when you're as part of a trauma team that you've got somebody who's been stabbed and you can start that major hemorrhage protocol early. You may be needing to put chest strains in early. If you need to deal with a catastrophic hemorrhage, you deal with that early as well with ATL S. They teach you about walking in the room like this and it's ready to stabilize that c spice. So what has Barry got on his head blocks? Yeah. So he's actually got sorry if online doesn't project as well, but he's got a collar blocks and tape. So you talk about triple immobilization. Also, this yellow board here is a spinal board. This is what the hems use to get them across. It's um you do have to get them off the spinal board and again about preserving the C spine. Once you've done your primary survey or sometimes when I was at Saint Mary's, we took them off straight away. You have the anesthetist stabilizing the c spine from the head end, the airway is there and you log roll and you have to have at least 45 clinicians, nurses, healthcare practitioners on the body to make sure you're keeping that spine perfect in line. So before you even got to saying, hey to Barry, he's got all these people around him. He's got the Anestis over his head. He's being held in blocks in a collar that's very tight around here and he won't be moving from this bed at the moment. That is a slight difference. This is more, if you are surgically orientated and you're interested in trauma, this is just about slightly adapting. But for your exams, 8 to 8 is exactly how you'd start, um, with someone who's falling on their head. Is there anything to do with airway? If Barry's airway was compromised that you would change? Mhm. Jaw thrust. Yeah. And if you're still worried about his airway, you want an adjunct, what would you not use MP tube? Yeah, exactly. That as well with this patient, he is someone who's fallen from the top of a tree nine times out of 10, the oxygen is still on um, while we're just doing the initial assessment. So don't be surprised. And in your airway you can always take it off if they fine. But actually in this case, what do you always want to do as soon as you start your airway? So with each intervention, yeah, you're thinking about it. No, before that simple. So oxygen remember is a drug. So you want to make sure you're getting your monitoring on early. So in your A to e when you start presenting it in your exams, you're gonna say, ok, so I'd introduce myself to the patient. If the patients speaking back to me, I would see an airways patent. I would then move on to breathing where I'd want to attach a non rebreather mask, 15 L of oxygen and I'd want to make saturations are taken cos you don't just say, II think you're taught. But in real life, it's not realistic. I want a full set of obs but demonstrate to the examiner what observations you want just makes you sound more sophisticated and like you've been down there. So his sats actually were 85% from there. So we're definitely doing that. And what did you say you wanted? Right. You all right. A VG. So remember whenever you give oxygen as a, as a drug, do the ABG and what else do I say whenever you give oxygen before that, what investigation should you order as the F one, you're on a computer chest, X ray, portable chest X ray. If you get into the floor? These I say this every single time it will be helpful. So you're assessing breathing. So what else would you like in breathing? Um Listen to check for, um, remember what can kill them as well just for ease. Start up the arm. It's just the way I use it. It's just make sure I've ticked everything off because there's one observation we haven't asked for yet that we should ask for. We, we're still in bay. So we've done a set. It's coming up with oxygen on 15 L. We've done an ABG, we've gone to the chest. We've checked the, at central, we've done expansion. We've across the chest. We've listed both lung bases. They're clear we have not done respirate and that is the one we want to do. So it's 12, is 12. Ok. It's a bit slow. So we're starting to get worried about Barry. We've got the chest X ray coming, we then move on to um circulation. So circulation once again, what we're looking for should be reading the softener. Yeah. So his pulse is 35 cap refill. Four seconds. Uh 210/100 and 10, 202 110. I'm sorry. Uh 35. He's got. Oh yeah, we getting there. But is he, is he alive? Is Barry's like he's getting more confused in front of you. Do we just stop at six? We wanna listen to the heart whilst we want, we want a formal ECG. So uh the nurse is just going to get the E CG cos as you say, his heart rate's a bit. So we're getting a bit worried about Barry here. We also want to do something else cos we're worried about Barry and we're surgeons. We're a trauma team. What do we want to prep him for? We want a group and say, what do we want? How, where do we want the bloods from? Two large Bo Cannula in each antecubital fossa I we draw how these things. So by session 10, I'm just not gonna say anything and you're all gonna say. Yeah, I've done circulation, done peripheral cap, refill P two large bo Cannulas bloods. You want to go up and say electrolytes and full blood count pretty much what you want. This is your ABG that you asked for. He is, he's on 15 L. Yeah. None of you. And I don't know how everyone feels online are happy about this ABG because it says AP O2 of 80. Now, the reason it's 80 is if you think if your inspired oxygen at minus 10 is roughly what you'd expect the PO two to be on a blood gas. So this isn't too far normal for. We're not too worried about Barry, but we do know he's got a respiratory rate of 12. Is he properly perfusing? Probably not. And that's why he's a bit lower than expected. But anyway, the nurse rushed over to you with ECG cos it said it's abnormal. Can you interpret this for me, please? So confirm name, date of birth rate and rhythm. So the rate is um how many big squirts? Probably three. So it's about 100 about 100 then we move on. Is it regular? Yeah, it's regular. OK. Is there ap wave before? So we know we're in sinus. Is there a normal pr interval? Yeah. Yeah, we've got no access deviation and then move if you remember the way I go through it again, you'll develop your own ways to V one and V six. We haven't got any William Marri not thinking of bundle branch books. So then we move on to our course. Well, we've got some ST elevation. I think we can all see and multiple leads. So 12, V four, V five, V six V three. Why is he having a stemmy? Why is he having an acute coronary event? If he's just come in with a head injury? It was a trauma. He fell out of a tree, he could have fallen on his heart and he could have a cardiac contusion. Hm. He could have fallen off you because he's having a heart attack. I'll explain why, but just think of your head and the differential of why this ECG has been presented to you. They can, you can get a right. It's just something that happens. So with raised intracranial pressure, obviously, your body is trying to preserve the main organ in brain. And so you're, you're getting some myocardial ischemia because your BP is so high just to get all the blood to the brain. So you raised intracranial, you, you've got this cushing's reflex, your heart is going down, so your blood, uh your heart isn't being perfused. So that's why you're getting this ECG. So, but we're happy with circulation. We're sending off the bloods, we've got two cannulas in his BP. We're managing it. Is there anything we wanna do about his BP? It's really high. What can we do to help a GT? Um oh they're big drugs, simpler, really simple. Uh You can move the head so you can tilt the bed to help decrease that pressure. So you can do maneuvers. You can also give Mannitol or hypertonic saline which can help draw down the BP. I think it is a because it's an osmotic diuretic. So you're just drawing whatever you can to help decrease it um day of circulation. Also, this is a trauma. So again, slightly differently to your normal A to e in circulation. You're looking for causes of bleeds. We've already cleared up catastrophic and we've checked the chest. So in the chest and we'd feel along that chest wall cos we were worried about cardiac contusion. Feeling for rib fracture is a really simple thing. Then we look out and see, I want to look at all the places. So where can you get bleeding from in a trauma, abdomen, abdomen? So you're feeling the abdomen in your circulation just to see if it's often and tender. You do a fast scan if you're worried about any bleeding a fast is a uh F I can't remember. But ultrasound, um acute sonography and trauma. But basically, it's an ultrasound where you're looking for blood in the abdomen if you can't wait for a CT because they're so unstable. But the main thing you're looking for is bleeding. So you've done the abdomen, where else can you bleed from? Mhm. So you're checking all the limbs, any bleeding anywhere. So the key thing you'll say in your e is everything else is that you fully expose the patient while maintaining dignity and preventing hypothermia. But in this, you wanna check for any open fractures, acute bleeding. So you've got one other place, you've got the abdomen, chest, long bones, you've got two other places done chest anywhere else. You're thinking in the right area. Yeah. Pelvis, pelvis. So any form of pelvis. So if you see any pelvic fracture, you can bleed a lot in the pelvis. So anyone's seen a pelvic binder. Yeah, go down to A&E see a trauma or you'll see all the stuff on here all the time. But basically you want to stabilize your bleeds. So there used to be an old way. You check stability of the pelvis. My old pelvic fellow mark would shoot you if you ever did that. But the main thing about that you saying about bleeding in the rectum. If you have a pelvic fracture, you can have an open fracture of the pelvis through the rectum. You wanna do APR and then a woman APV because you never know bleeding can go anywhere and a catheter because if you get blood on that catheter, you know, you've PF the bladder and you could have, it's a huge cavity of the pelvis. It could be filling with blood before you speak. And there's loads of veins all on the back of the sacrum. So that's where you have your belt. Uh your binder on, not to tamper another bleed, but more to not dislodge a clot because it's the bleeding from the veins that really share in the pelvis. So that's your circulation. That's a lot more in a trauma scenario than your normal A to e obviously don't start integrating this. This is more for interest and for learning, but we've done circulation. We now move on to D Yeah, if you notice there's like what bruising around the pelvis. Anything that usually Yeah. Um Yeah, he's got one on that is a pelvic binder. It's not projecting very well, usually hams that put it on nine times out of 10. They've also put it in the wrong place and you have to weigh out whether it's better, it's usually always better to move it. So it should be listed at the levels of your GT, your greatest cramps and you want it not too tight, but, but you want it at a good level to help maintain and stabilize that pelvis. Um So when they come in, you should see them on a spinal cord pelvic binder in situ and they should have triple immobilization. That's before they've even come in. And if they haven't, that's the first thing you're doing. So if you ever, if you ever do apply for surgery or any of you. You'll notice that in your spiel, never assume the trauma team is coming because the bleep goes on all the time. So if you present with a trauma scenario, say the first thing I would do, if I'm 80 less trained, I would make to make sure that the nurse put out a double two, double two and then get the trauma team coming to any Reuss where the patient should be assessed. Simple things, but it is important cos like it saves lives. So we're on disability. What do we wanna do in disability? GG CS? So, um Barry, um, he is not opening his eyes anymore. Um He's a bit confused when he's speaking. That's kind of like mumbled jargon and he um, isn't really moving right? He's kind of when you like do a sternal rub. He's kind of making a funny movement like he's not really localizing to it anymore or he's kind of flinching away from it. What's his G CS? Is he still aching when you speak to him? Neck? His eyes are not aching anymore. Neck. Ok. Not to pain. You not to pain. Ok. So that's the one. And then, um, but he is talking, hm. The odd word. It's kind of jargon. Is it comprehensible? No. Ok. Pt um what it's not and he's not localizing but is he still flex? Is he still flexing the pain? He's not extending? No. So he's recognizing the pain but he's, can't go. Mm. Mm. Wait, is it a normal or extension? Mm. Mm. He's not, he's just kind of flinching away from it. He can still move. He's not going like this and he's not going like this. He's just kind of going. Uh, so he's recognizing the pain but he's not able to push you away with his hand. Is that what? Ok, to extension? So, one is no movement at all. Two is extensive pushing away like this where you go like this abnormal flexion, you're going like this. He's just kind of withdrawing from the pain. It's kind of going like, oh, but he's not able to go doctor. So which one is that for? So 43 and one? Hey, what do we wanna do? We wanna tube in here? So as well. But what else do we do in disability? Hello. Two for next. Oh, yeah, we, we've got an ophthalmologist. She was bored and walking past. Yeah. And we'll know what that sign is. That's papilledema. Ok. So what do we think Barry's got, we've already said it due to oh, make your life easier. Just an intracranial bleed. You don't know until you get the CT head. So we go, what do we need? Everything else is clear. We need a CT head. Does anyone know the guidelines for that? Yeah. So reduce c it's a lot more. Yeah, more than once. Um Then um like any basal skull fracture. Signs or skull, skull fracture. I know. Well, we just cancel it. Yeah. So, GCS, less than 13 automatically gets you a CT head. So we're gonna take you Barry down, um, to CT, he starts seizing. What do we do? He's seizing. Yeah, he would. But what else are you going to do first? He's seizing in front of you. You can't get access. His cames are blown. They're all bleeding everywhere. He's seizing is this? He sees him. Come on, doctor pull the buzzer, he's seizing. When you pull the buzzer, the nurses are, the radiographer is like, what is going on? What are we gonna do about Barry? He's frothing at the mouth. His SATS are plummeting on the monitors. We've got the whole trauma team in here like what are we doing for him? We're not just stabbing him with LORazepam. We can give Benzos what are we going to do first before we just start whacking barrier with drugs? We're giving him 15 L again, aren't we? Oh, we eventually be. It's true. He's fine. But what else are we gonna do? We have achieved him finally because his G CS was eight but I shouldn't have made him GS eight. I should have made him G nine anyway, but he's still shaking. What are you gonna do? He's had a significant fall, protect his neck. You can put him on his side if he wasn't a, it's about protecting that. Give him the 15 L and then we move on to the trucks, which is depending on your trust. He, if he still does IV access, we can give LORazepam if it's just, we've got nothing in a clench door. You can rub in the Midazolam and rectal diazePAM up. The poop is always a very easy one. But you wanna give the drugs. But the main thing is your F one, you're attending a seizure as a tr called time because why do we need to time a seizure status? You're gonna need to let the anesthetic team know early. So we can move on to this more of that. Why? Why is it brain damage, hypoxic brain damage. How long has he been out? How long has he been seizing? So you want to, how quickly do you keep giving your boluses as well? Two obesity was fine and then you can move on to or pin and all these other things. It's, I've seen it quicker if we're not seeing a response, the only thing that's going to stop them and protect their brain is to give him the medications. But obviously we can't give certain things so we can start infusions of drugs. Some people start off aone, we can't embury his, his heart rates but we stop the seizure. Then we get a CT head up. Oh yeah. These are your head injury guidelines, but this is his CT head. What is this demonstrating? Which is, it's large extra inflammation and you can also do some bleeding outside the skull or what do they like to call for? I didn't know when I was in one. What do we call this soft tissue here? No. Um sub gi read it in reports as an F one and I didn't know until I was quite far on. So I googled it what it actually meant, but this is just a previous. So this is where you probably got an open wound. It's all collecting here. And then you can see the lens of form is the classical thing of an extradural subdural. Remember is a little old lady. It's Beryl, not Barry who's fallen and stripped all her bri and veins or an alcoholic. And it's more trick around the edge and then you ser outwards more and then you've got your what is moved here, midline shift. Can you see the ventricles here? You can't on this side. So we know nothing's draining. So we know why he's got raise each cranial pressure. So what's the only thing that's gonna save Barry's life, decompression, decompression? They're gonna crack his head. We get a neurosurgery involved. Luckily we have neurosurgery on our site, we evacuate the hematoma, we ligate the vessels that are bleeding. Um And we put him, we put in a monitoring probe to monitor his intracranial pressure. We've got him on itu because we want to have him on the right bed. He's tubed as well. Barry is very sick. Um And we're calling up his family. This is what I was saying earlier about defining where you've got your bleeds and what it looks like on the CT scan. What's your difference is your extradural, subdural, inter intraparenchymal and subarachnoid. But the main thing to flick back to is this. So this is the nice guidelines of CT heads. These are and MC Qs, whether you do it within the hour or within eight hours. Again, if you've got very little old lady falling over, she could have had a sub Gerald could have a chronic anyone over 65 history of bleeding dangerous mechanism. So Barry would have got a CT an eight hours anyway, because we know he's had a significant height. But the main was to look at here less than 13 or initial or less than 15, 2 hours after the initial assessment, open base seizures, any neurology or as you said, more than one episode of vomiting. This is your usual guideline for justify radio neurology. Why you need a CT overnight? Just learn it. It'll probably change by the time you graduate and I'll put more things in. But at the moment, this is the nice guidelines and that is head injury and a little intro trauma. Any questions, no, any questions online. Um Nothing about this. We did have a question a little while ago about, could you repeat the team? Oh, the MS. So M is about the paresis. A ataxia, E is eyes optic neuritis and the t I've forgotten. I think it's oh God, it's been a while. No, as I said the first it was more revision for me as well. Tingling, tingling. You've got the neuropathy. Sorry, my grand bless her. She had MS before she died. So I should know this all very well. Um Yeah, tingling. That's why I know she was always on Busan, right? Sorry to be a pain, but just to prove you were all here. Quick scan of this, please. And thank you very much. Um was movements pais spastic paraparesis? OK. OK. Yeah, I mean, yeah, definitely while you're at George's, I know you obviously you have to go to DG HS but like go to any and see how trauma is done is just interesting and fun.