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Can we send the recording, please? When it's high, everyone I'm sure you know me by now. I'm Megan Eso Today the topic now I'm going to be covering is traumatic brain injury. So we're going to start with a bit of the anatomy of the brain and some physiology, and then we'll go into some of the pathology. Such a stroke. A meningitis is well, So if you're a card of student of just for intimate, you're learning object is just for your reference, all that you review those in your own time. So let's begin that start off with be enough meat of the brain. It's circulation and a bit about the meninges. This is starting on the outside. So we have, um oscal, which is the bones of the skull are divided into two main groups. We have those bones that are making up the cranium, which are, um, this list here. So we have the frontal parietal, temporal, occipital steroid and f married on the first thought for in that list are named based on the lobes underneath. Remember going through that in a second Andi Other two have found on the base in the base of this cold as well as you can see in this diagram here. The others are those that make up the face. So that's this nice long list here, which I won't go through now. But you can read through in your own time and the bones of the cranium so that first group of six are joined together by suit just on the citrucel. Basically just fibrous really strong immovable joints because we don't want our school going anywhere. We don't want the joints moving. They're all joined by these suture lines, which you can see here. Can anyone tell me what the name of this structure is here that I've just highlighted in with a pink circle? Does anyone know what that's called? Battalion. Yes. You guys run. It's not ready. Get. Yeah. So the terror is a hate shape junction, I think just about committee that looks of it like hate off where the suitors of the temple, the parietal, the front or in this family bone come together on as well. See, a bit later, this could be quite a weak spot in the skull on. It's a risk of a fracture. If someone has a blunt trauma to the side of the head. Um, another thing that's really important that you need to know for exams, in terms of the bones and skull are the seven bones that form the orbit. And what I've done is I've just highlighted those in orange here on. Hopefully when you review the sides of your in time, you'll be able to see more clearly which ones make up the bony or bit so on to the brain itself now. So I'm sure you guys will know this cerebrum. The brain has to Maine hemispheres has left and right, each of which control the opposite side of the body. Um, now really quick in the chat. Can you guys type? The 4 may. Sorry. The five loaves of the cerebrum. Can you take them in the chart for me, frontal? Yep. Price. So yet, Temporo? Yeah. See more occipital. Yeah. Anyone know the last one? It's a bit of sneaky. Had him on insider. Yet You guys have got it well done yet. So we have our front aloe in blue parietal and yellow, and I don't know why, but this was on. I always struggled and mixed up with the temporal. So I like to remember that as prior to all sounds a bit like parent that parents always think that they're superior. So that's why it's the superior. The two jobs always helped me. Then we have the green temple. Oh, Pierre occipital in the back. And then we have the insulin, which you can't see on this diagram. But if you pulled back the brain between the front temporal lobe, you would see the insulin cortex just underneath. So coming quickly pop in the chat, just have a bit of a brainstorm. Some of the functions of each of those fried five loads. So, like the function of the frontal parietal etcetera, Can you guys just pop down the lobe and maybe a function of it? And we'll see what we generate. Frontal motor decision making. Yeah, frontal language. Interpersonal as he. Yet what about the price? So temple hair and get ready goods except vision perfect. Prior to attention, except your visual. Yeah, you guys have got some good ideas going on. Brilliant. So I'll let you guys review these in your in time, but you basically generated the majority of them. So for until we have our motor cortex off the in. Our precentral gyrus has speech and higher order functions. But you guys will said, obviously remember your prior to court exes Got your sensory samast sensory cortexes to do with the way of your sensation Temple. We've got our, um, hearing centers in the temporal lobes as well in the superior gyrus. So just remember that except tell you if I set that vision light color on the insulin cortex, I've written a few. There's the things that your vessels visceral sensation. So, for example, knowing when we feel full after we eat our balance, our emotions, etcetera, they're controlled by the answer Pretty good. So as you guys know the cortex, it's got loads of folds in it in order to increase the surface area of the gray matter off the cortex. So we have our so okay which are are depressions in the coal cortex on our gyro, which are the bridges or elevations in the cortex. On the way I like to remember that is so okay sounds, But like silk, which in a crude way and is convenient bed to being sad or depressed. So that's how you like to remember that one. And so those are the five main loads. Obviously, you guys, we know that we also have the cerebellum just underneath. So that's really important in motor learning as well as the refinement of certain movements. So making sure that if you reach for something, you definitely touch it and you don't just miss it, you get close. But don't quite touch on because I had the brain stem, which is composed of the midbrain pons and the medulla from top to bottom. And that's really important for connecting the brain and the spinal cord together. A zwelling lot of a lot of our auto autonomic functions. Such a czar breathing our cardiac center or vomiting center our circadian rhythm for a sleep on their really important in the mid brain limit dollar on the palms. So what I've done is well, is on this diagram of also labeled some of the others features that you should be able to identify the brain. So going on to our dramatic folds s. So it's really important that you know, these thought three main folds in the jury motto and I'll be going into the meninges. Ah, bit later on. So to start off with, we have our folks rebreathe So I hope you can see my star. It's this kind of crescent shaped because folks means sick or present shape. Um, it's this piece of the germ also phoned Here on basically, this is a verse Cool photo the germ artery in the sagittal plane. So kind of cutting the body and left and right on it's an unfolding basically between the left and right hemispheres that's separating the two off the cerebrum. Then we have the tentorium cerebelli Sorry, this tentorium cerebral, which is this kind of flat one here who, using my starts, this one, you imagine this bit wasn't cut out. It's this kind of horizontal type fold on that is basically separating the cerebrum from the cerebellum on that. Make sure that the two of them don't press against each other and putting much pressure on each other on D. I can't remember. That is 10 tentorium. It kind of sounds like tent s. So it's kind of a piece of like fabric in between the two. That's how I like to remember it on and finally have we have the folks are cerebelli on quite similar to the folks cerebral, which was separating the two loads of this cerebrum. The folks cerebrally separates the two halves of the cerebellum. So and that's it that you can just about see it on the diagram, and you should be able to see it best when you review the slides. So going on to the arterial supply of the brain so I like to do is from the aorta so that we fully know what's happening. So from the aorta, we know the aorta has three main branches that has the left subclavian, which goes off to the left upper limb. We have the left common karate, which goes off to the head and neck, and we'll follow that in a second. And we have the break in cephalic trunk, which we know then splits into the right Common courted once again, going up to the head and neck on the right subclavian, which goes off to the right upper limb. Now, if we follow those two common carotid, it's at the level off C fall or the superior margin of the thyroid cartilage they bifurcate into the external and internal carotid arteries. Now the external ones go off to supply areas of the brain and the neck external to the skull. So I'm gonna ignore those for now. But the internal carotid of the really important ones for today's session on they supply the brain, the eyes in the forehead. So at the same time, on the posterior aspect of the neck, another pair of arteries also travel up to the brain. On these are called the vertebral arteries on. So the vertebral arteries that I've shown you the left side here. So his, uh your I order again, this is the common carotid coming up the anterior surface of the neck. And this was our left subclavian as it was here, just coming off the aorta on the left vertebral artery on the right vertebral artery. A little slight comes off the subclavian on what it does is it travels through holes in the transversus processes off the C one to see six vertebrae. So I'll repeat that again. Thesis. Want to see six vertebrae on those little holes in the transverse processes A known as foramen transfer Seri. Um so see? Want to see six. It comes up and it pops in it. See, sex follows that up on. It comes out here on what this does. Is this forms a little estimated, if you like, where the anterior circulation coming up the neck and the posterior circulation come together On this form is the circle of Willis, and I'm sure you guys are seeing this doctor on many times, but I like to do it from the aorta, right, so you understand where it's come from, so we know that the circle witness it sits on the anterior surface of the brain stem on the inferior surface of the lobes of the cerebrum. A swell we know this gives gives rise to three cerebral arteries the interior, the middle in the post area and those cerebral arteries alone is end arteries on. That's because their terminal branches aren't connected together, so there's no collateral circulation between them. So if one of them gets blocked, say, for example, in a stroke that will cover a bit later on the tissue that those arteries that supply can't get any blood supply from anywhere else on back computer ensure lee cause damage, as was in stroke later. Um, now what's really important is at the base of these arteries is the circle of Willis. So you can see here this cycle hits. We have our antirougeurs. Sorry, brought three coming up the top on Middle cerebral artery here on our posterior cerebral to here so we can see there's a circle in the middle on. This is really important because it acts as a failsafe mechanism where, if, say, on the posterior communicating artery on this side was blocked, the blood could still come around and get to the middle cerebral artery, say, for example, So it provides that way of kind of making a new route around so that none of this Rebrov these are effectively blocked off. However, the circle with isn't always present in many individuals. It's quite a low percentage. So this isn't always the case, but in theory it should provide that fail safe mechanism to make sure that we always have profusion to our brain. Um, there are a few key points you need to know, but I'll let you guys read through the slides later. Just make sure that you can label this diagram really well because it it can come up on exams quite often. what I will say in terms of today's session and some really important key exam packs that commonly tested is that the most common site of clots it is in the middle cerebral artery on. The reason for this is this is the internal carotid artery on this this side of the circle of Willis. So on this side, it's the internal crowded. And, as you can see, the middle cerebral artery is a direct continuation of the internal carotid. So o'clock coming up, the internal carotid can just very, very easily go into the middle cerebral artery. It doesn't have to worry about going round any of the circle to go into the posterior or anterior through brought trees. And another common point is testing exams is the most common site of an aneurysm, and we'll be going through that later. But that is the anterior communicating artery, which is between the two left and right anterior cerebral arteries so very quickly on the venous drainage of the brain is off, See, important to know is well, eh, so we know that the venous blood is going to collect into these structures, which are no no's Sinuses on, but I go through the meninges later you'll see where they are on where they lay in the meninges. But they lay between the two layers of Germans that the periosteal on the meningioma. So we have our to such to a Sinuses are superior, going right over the top of the brain on the inferior, which is very close to the corpus Collosum and these to come together on They joined together at something called the confidence of Sinuses, which is a the back of the head just deep to the occipital bone on just outwards from the occipital cortex. So once the bloods met at the conference is Sinuses. It then travels kind of horizontally through the transvestite. This three of the sigmoid Sinus, which is, um, like a cuff. Shape down into the intelligent, give a vein into the break your cephalic veins into the superior vena cava and then into the right atrium. So we start with are sagittal sciences confidence of Sinuses, transversus sigmoid internal jugular vein breaker, cephalic superior vena cava, right atrium. So then on your CSF, another really important part of brain anatomy. Eso CSF Fort cerebrospinal fluid is an ultra filtrate of the blood problems, which basically just means it's made by putting pressure on the plasma, the blood in order to filter it on, make the CSF and it's done it very, very high pressures and CSF has to remain functions. Can anyone pop in the trap for me? What are the three main functions that CSF any A to Why do we have CSF removes waste? Yeah. Okay. Yep. Buoyancy. Yet brilliant protection. Yeah, reduces the way of the brain. Yet you guys got it. Bottom. So yet, protection. It acts as a cushion to the brain, which, if you have, say, a head injury is gonna prevent mule damage straight away. Because if you had new tissue right next to this goal, you're gonna cause damage really easily. Buoyancy? Yeah, It reduces the weight of the brain. If you felt the weight of your brain all the time, it would create a little pressure on the base of your skull, and that could lead to things like herniation and things like that on which aren't good. So it helps to keep the brain buoyant on the other. One thing other main function is with chemical on stability. So it make sure that there is a low extra cellular potassium concentration around the brain because we know that calcium is really important in our action potentials. So we want to make sure that there is not potassium lying around that could stimulate nerves when we don't want them to be so affecting kind of synaptic transmission from one nerve to another. So we don't want that. So the CSF provides the appropriate environment for the neurologist. You to work now, Can anyone type in the chart again? What structure generates CSF and where is it located? Think someone's already on still already chorioplexus? Yeah, and it's in the lateral ventricle. Yeah, really Well done, guys Yet So we have been normal cells, um, which line mainly the lateral vegetables, but also a little bit into the adventure call. And collectively, the F and I'm a sales form, a structure called the chorioplexus. And then I just want to go through the flow of CSF was Well, that's real important. So remember that there are four main ventricles. You have the right and left lateral ventricles of the third ventricle and your the four French full. So if we go through the flow is yes. If it starts in the lateral ventricles, then it goes into the intervention. Killer foramen are phenomena, which makes sense because it's the it's the from inner or the whole between those two lateral ventricles. Then, after that, it goes into this adventurer all. From there, it goes into the cerebral aqueduct. Um, and then it goes into the fourth ventricle into the foramen of Lucia on, um, muggy on into then the sub record space. No for exams. What's really important to know is the third ventricle is very narrow because it sits between the left and right thalamus in the brain. So it's really common site for CSF to build up. Um, another really important key 0.2 know is the Subbarao tried space is the final location of CSF before it's them re absorbed into the venous system into those Sinuses that I was showing you before. So let's quickly go through the meninges. So I've alluded to them already that the meninges aren't membranous coverings of the brain and the spinal cord on, and they have really important functions. So Azul see in a second. And as I've already said, their structure helps to support the veins and the Sinuses, but in the brain brain helps to support them and keep them in place. Um, and it also works together with the CSF as protection for the brain from any mechanical drum or anything like that. So starting kind of from outside in top to bottom. If you like, we have the scalp. That's the most external. Can anyone type in the trap for me, the five layers of the scalp? Anyone know the five days? I'll give you a clue. The weight. Remember, the five layers of the scalp is with the word scalp. So when we have our scalp here, what is the first thing you hit? Yet? Someone's put it pops in the trap. Really well done. That is how you remember it. So skin is the first thing you come across. Then it's connective tissue. So yep, it's a dense connective tissue, which is really highly vascularized, and the the blood you probably have experience. If you've hit your head or, you know someone that's had a head injury, you know that often. If you even if you have a small cut in your scout, it can often probability to really profusely on. That's because of the connective tissue layer, because it's really highly vascularized on do, um, because the blood vessels here already kind of tight to the connective tissue cells within this layer. If there's a laceration, if there's a cup, um, they kind of quickly bleed out really easily. Then we have the aponeurosis. So this is the epicranial, or neurosis, and this is basically a thing tendon like sheet. She that connects the occipitalis muscle on the frontal list muscle at the front of your heads. The Occipitalis bio acceptable and frontal is at the front. And then we have a loose areolar connective tissue, which is a really thin connective tissue layer on. Then finally, we have the periosteum, which is an outer layer off our skull bones. And so well done, everyone, that was really good. Can anyone type in the trap? For me, the three main layers of the meninges You're a rock. LaPierre. Yeah. Also model everyone. So we have the jury Malta, which, as I said, it's been 22, so we have the Periosteal, which lines the inner surface of the skull and is really adherent to that it's really important. Remembers where the parents stool. It isn't present in the spinal cord. It's only present in the in the skull in the cranium. Andre, have the mini in July aerosol. And then you guys all right, The ear actual day is below that. Then finally, we had the PML to below that, which is, um, equally very adherent to the brain itself. Then we have three main spaces between these layers, which is really important for intracranial bleeds, which will go into later, eh? So we have the extra dural or the epidural space extra or epee, meaning kind of above. So this is above the juror on between the skull on the periosteal day or the jurors. Then we have the subject of space so sub meaning below. It's the lower the meningioma, a martyr and above the Iraq Doing Walter on. Finally, we have the suburb Accurate space, which is between the Iraq thyroid and the PM Marta. Now, can anyone remember where I said the venous Sinuses have found? Which layers of a between between both a juror? Yeah, really Well done. The venous Sinuses are located in here between the two days of the juror. Does anyone know whether I said the CSF was found subarachnoid Smash it guys yet really well done since CSF. He's found here. So we does anyone know? I said before that when the CSF is finished with, it goes back into the venous supply. Does anyone know what the name of structure is? Sneaky. Sneaky him. It's on the slide that allows the CS after drain back into the venous Sinuses. Does anyone know what those are called arachnoid? Really? Yeah. Yeah. So I will refer to them as Iraq like regulations which basically structures that kind of pushed through these layers to get all CSF back into our venous senses. Brilliance you guys especially enough me. Well done. Let's go into some physiology, know about intracranial pressure. So what is intracranial pressure? What? It's basically the force exerted on the skull or the bony cranium by the contents within it. So we know that our school is a closed space. It's a fixed volume which is composed of four things. It's composed of Venus split a zero blood. The brain parenchyma Oh, the brain tissue itself on CSF. If there's an increase in the volume of contents within the skull, then this is going to increase the pressure in this girl because it's a fixed volume, and if you try and pack more things into it, it's just gonna create more pressure. So if the volume of one of these four components increases say you get all of a sudden you just get an increase in your venous return, then another one of those components is gonna have to decrease in order to keep our cranial pressure the same and raised intracranial pressure can be a real problem, and it can occur due to many different pathologies that can occur so it can occur due to a brain tumor or a brain mass developing within the skull. It can also occur due to a condition called 100. Careful is, which is. Basically where you get a build up of CSF within the skull is Well, um, so there's lots of different reasons why you might get raised intracranial pressure. So a normal intracranial pressure is between 7 to 15 millimeters of mercury on, but it gets over 20. That's when we really need to start doing something about it that is pathological. So I'm sure you guys have heard of the mom broke Ellie doctrine. Basically, this describes the relationship between the contents of the cranium and what's in there basically under the pressure that they're exactly on the scope. And there is one really important assumption that this doctrine requires on that is that the cranial volume or the volume of your skull is fixed. It's a solid bone, it can't move, and therefore the amount of stuff that you can pack in there is restricted. So in an average adult, the intracranial volume is about is about 1.7 liters worth 10% of that is roughly CSF, 10% of it is roughly blood, at about 80% of it is the brain itself. And so I'm going to talk through this doctrine. So looking at our first layer here, so in a normal state we have venous blood out here, a blood brain parenchyma on CSF, and they're all in equity room with each other. They're a constant volume. Or, as I said, if one increases, the other will decrease and it's all in a crib, really together on the CSF in the venous blood are produced and removed from the skull a continuous rates. So there are Winnetka Librium. Continue other. And therefore, we have a normal, um, intracranial pressure. ICP. Now, let's say all of a sudden a mass starts to develop inside the skull. Initially, what will happen is as that mask grows, the venous blood and the CSF will compensate on what happens is more CSF is pushed out off the skull through the frame and magnum to go into the spinal cord and also less CSF is made in terms of the Venus. But there is an increased venous return back to the right atrium in order to make sure that there's less of it in the skull to make room for this mass. So if I sorry, but with me, if I go back again and play the animation so you see that mass form and the the arterial blood in the brain volume status saying but the venous blood and CSF Williams decrease now, what happens is this mass continues to grow. Oh, at some point, as you can imagine, this venous blood in the CSF is being pushed out and out, and it gets to the point where you run out of it. Basically all of your venous blood has been pushed out. All of your CSF has been pushed out on you don't want to. Then stop pushing your arterial blood out because then you're gonna lose profusion to your brain on you don't want start pushing your brain out because then you're gonna get structure damage to your brain. So this point, this must can keep growing and growing and growing. But we can't change the volume in the skull anymore. We can't lose that arterial bottle that brain tissue and at this point is when the pressure in the brain starts, the pressure in the skull story in the cranium begins to rise. I hope that makes sense. I'm happy to go back and explain that later if it doesn't so just to explain it a bit more. Hopefully, that's look at this diagram. So on the y axis of intracranial pressure is the pressure within the skull on on the X axis? I have the volume off stuff in the skull. So initially, as I said, you have a nice equilibrium. We have venous blood out here about brain parenchyma and CSF on. Initially, if a mass starts to grow, people say can compensate because of the mechanisms off, making less CSF draining into the spinal cord cavity on having a greater venous return into the right atrium on as that Mastro's. There is a very slow rise in intracranial pressure on bats when you're able to compensate when you're losing us years after you're losing the venous blood. However, when you get close to this stage, which showed on the previous life where you run out or venous blood that you can drain the you've run out of CSF that you can drain your ICP or intracranial pressure rises very, very rapidly on. That's because, basically, you you can't compensate anymore. You run out of your compensation mechanisms, and this is really dangerous because it can cause compression to the brain on a say that can cause herniation or damage to the neurons themselves. Um, or it can reduce the perfusion to the brain as well. It must continues to grow, and it's not about with, so I hope that makes sense. So how are you going to know if a patient has a raised intracranial pressure? Well, one of the key things that you may notice is something called Cushing's. Try it on. This has three main components that has a widening pulse pressure. So your post pressure is the difference between your systolic and your diastolic blood pressure's eso. If that difference becomes bigger, it wouldn't That's one of the sons because she's tried equally. They're cysts. The reason why the post pressure widens is because the systolic value is going up so equally you could say that they have hypertension, and that's that's sometimes used in the trial. Then we have bradycardia and we have irregular breathing, and I will go go to explain those in just a second. If you do see anyone because she's tried or any signs of raised intracranial pressure such as these three or the one's ever it in here, it's an emergency because it suggests that your brain is starting to be compromised, potentially on disk, and be quite late signs. It's a real emergency if something needs to be done. So how did this cushions try? Come about? So as we said, something is causing a raised intracranial pressure. Your brain, whether that's a mass or excess CSF, etcetera, that, um, what happens to that is as your intracranial pressure rises. So if you look at the skull, here is your intra pressure. Cranial pressure goes up. Your next pressure between that and your mean are terrible pressure or your maybe pee decreases. So I'll explain that again. So your ICP is the pressure kind of pushing on your content kind of out of your school, if you like. And your arterial BP is the BP that's pushing blood into your school, too. Profuse it. The CPP is the cerebral profusion precious. This is basically a measure of pressure, but it gives an indication of how well is arterial blood getting to the brain? Basically, and you can imagine if your ICP is putting pressure on your score, it's trying to push the blood out. It can persist, masses growing. That's gonna increase. But you're mean, arterial BP is kind of working against that is trying to put on our terrible back into the store because it wants to profuse the brain. So as your ICP rises, the net difference between those true it's smaller and so less blood is being pushed into the skull. I hope that makes sense because your ICP your pressure downwards is rising and rising, rising, and you haven't got enough arterial BP to push blood into it anymore. So your cerebral profusion pressure or the pressure that you are exerting to get but into the brain too profuse, it goes down. So there's less blood enters into this. Go into the brain. You get cerebral esquina so your brain gets less salt in your blood. It becomes hypoxic, which isn't good on when that happens. The low perfusion on the hypoxia triggers a sympathetic nervous system response. And when that happens, um, what that does is it causes hypertension, and it causes a tachycardia because your brain is going hang on. My brain isn't being being profused. I need to increase my BP. And I need to beat my heart faster so that I can get blood there because oh, my God, my brain isn't getting oxygen. I'm going to die so it gets a fight or flight response going to in order to try and get some blood into your brain. However, as we know this ICP is rising, this masses growing so it doesn't really go that well that hypertension that's triggered then causes a parasympathetic stimulation on. That's because Baroreceptor is in the aortic arch. Detect that there's a high BP and go hang on. Mobile pressure's really, really high. I don't like this on it's stimulates muscarinic type two receptors to decrease the heart rate cause he's going. Hang on. My blood pressure's too high. I don't like this. Um, I need to reduce my BP. I need to reduce that. I'm one of the ways it does that is by slowing your heart right, because we know that one of the ways to reduce your BP is by lowering your heart rate. So that's where you get the branded car bradycardia from on. At the same time, your brain is being compressed because you've got this mass growing, so it starts to push on the respiratory centers in the medulla. Oblongata on back can cause irregular breathing. So that's how you get that triad. So you're getting less profusion to your brain, which causes a sympathetic response and just hang on only two perfused my brains are it gets that hypertension going in tachycardia, then the hypertension is kind of. It triggers the past sympathetic response toe. Try to reduce it a little bit, which causes the brother cart bradycardia on. The pressure on the respiratory center in the medulla causes the irregular anything. I hope that makes sense. So you've got some of a raised intracranial pressure. What do you do so before you need to? You need to do something about it, cause it's really, really important. As I said, it is an emergency on, but ultimately you're going to need surgery. But sometimes that surgery is it always available straight away. So it's really important to know the conservative and the medical management approach is when you see someone with questions tried or raised ICP sign so that you can start to reduce their I C p. A s a p so conservatively treat the underlying cause. Eso you might. If you do a CT or something like that, you might see the reason for the race Intracranial pressure. So, for example, meningitis s O. If you know the cause, start treating it. So if it's meningitis treatment, enjoy it, it's and that should hopefully help. Then we want to elevate the head to 30 degrees on the reason why we want to elevate the head is because head elevation helps to increase venous on CSF outflow from the skull. So we're making sure that all the compensation mechanisms that the brain usually uses are being used in enforcing so als the venous, but that it can't all the CSF that can is being drained. Because while we're waiting for this master be removed, we want to make sure that we're not getting to the stage where we compressing the baby because that could be really bad. And then we also want the patient undergoes and controlled hyperventilation. So if you think when you're hyperventilating, you're blowing off. So two on that produces a respect tree alkalosis because you're removing a lot of acidic gas. So two, it's very acidic. Um, the reason why you want to do is do this is because you 02 is a really potent basic constrictor, a vasal constrictor, all your blood vessels. So if you are blowing off oh, two, that's going to cause vasodilation. And we know if someone is raise a constricted that can raise the BP even more on that can cause a raised ICP, so you want them to blow off the CEO Tuesday vasodilator. So we reduce their BP in order to lower their ICP. So then, in terms of medical management, you want to give a drug called mannitol. A mannitol is known as something called an osmotic diuretic. So basically what Manitoba's is, it increases the plasma osmolarity or increases the concentration if you like a the plasma in the blood where there's more islands in it and less water Onda. So if I show you here, So this is the brain. This is the blood. So we just put some yellow man, it'll wind to it. And as you can see, the osmolality of the concentration of blood is not going up because you've got more iron. Is it in comparison to the water on a Z? No water likes to follow ions, and the is that the concentration is more balanced out between two compartments. So what happens is when you put the mannitol into the blood IV, it draws the water out of the brain. Um, and it flows into the blood on this. Come acutely, reduce ICP at us to say, until that definitive surgical management is available. So repeat that again. So having mannitol in the blood increases the bloods concentration increases its osmolality on that draws water from the brain into into the blood so that you have kind of a greater compensation mechanisms. We can also give dexamethasone, which is a steroid on what that does. It is acts on glucocorticoid receptors to reduce inflammation, reduce swelling in the cranium. On that, she was so hopefully make space for the mass again before we get to surgery. But as I've said surgeries, the definitive management we need to we need to have surgery. So we surgically you could remove the CSF if know all the CSF was being removed in order to make sure that we have, we're not compensating on the brain, so you need you could use the drains If you're monitoring someone's in intracranial pressure already, you can use that monitor, have a jury and attached to it and then drain it through that way with equally do repeated lumbar punctures. So, during a journal, um, puncture, you go into the subject, but it's basically you could draw out the CSF that way. Or you could also do something called a ventriculoperitoneal shunt. This is commonly used for condition called hydrocephalus on this is basically what you have. A thin plastic tube that's inserted into the ventricle system in the brain on drains the CSF into the peritoneum in the abdomen, where it can be absorbed, but it acutely takes out of the brain and out of the cranium itself. But as I said, the definitive management is a craniectomy, so removing a piece of the skull on, then taking out that vision. So that was all the physiology. Let's go into hemorrhagic and skin. It's trucks. And so what is the stroke? I'm sure you guys know a stroke or a cerebrovascular accident is a sudden interruption in blood supply. To the brain on that can cause potentially irreversible hypoxia damage for the brain tissue, which is very, very bad. Now they're too broadly two types of stroke. So we have hemorrhagic um, which is a bleed into the brain, which is caused by a vessel supply in the brain bleeding out that's less common. That's about 15% of cases on the other is a scheme it, which is when you have a blockage in the blood vessel, usually by a clot, and that's about 85% of the time, so that's the more common one. So what the signs and symptoms of a stroke? How we going to know someone having one where it depends on where the site of ischemia is and what bits of the brain are affected. But commonly it can cause motor weakness if the primary motor cortex in the frontal lobe is affected. Sensory loss of the somatosensory cortex in the prior to load was affected can cause visual field defects, commonly a homonymous hemianopia. If your symptoms lobe is affected, it may cause speech defects on deficits if they broke brokers or Vennochi's area is affected on that can also cause balance problems and swallowing problems as well. So how are you going to recognize it? Well, different systems used a penny on who's using them and, well, you well. So in the community, generally by the general public, you guys have probably heard of the fast you Monica your face arm speech in time. So if someone has facial drooping on one side, typically you asked him to smile and see if they can symmetrically smile on both sides. Arms. Are they able to raise their arms and keep them there. Do they have slurred speech on def? Um, if any of those features of present, then you need to call. No, no, no, because it's an emergency. Does anyone know off those three face arms and time as all right face on speech? Does anyone know how many of those do you need to have present as an abnormality before you call 999? Do you need one of them G two of them? Or do you need a three 11 radiant yet? So you just need one of those, I think, as a misconception that you need or three you don't. If you have one of them, it's time to cool down. I know so in general. Healthcare professionals On In hostels, we use something called the Rosy, a school, which helps to assess if a stroke is likely or no eso. This looks at a facial weakness, arm weakness, leg weakness, speech disturbance, a visual field defects similar to what we've already talked about. Those done you a point. Where is it? Someone has a loss of consciousness or any seizures that takes away a point that's less likely to happen with stroke on but this scoring system a stroke is likely if the score is greater than zero. So repeat that again. If you have a score of greater than zero, it suggests that stroke is the likely cause of your patients presentation on Do. Therefore, you should begin the investigation for that. On the investigation of choice is a long controversy T head scan, so we'll start off of hemorrhagic stroke or less common one. They're five million times you have extra dural sash, epidural subdural supper, Ackroyd into intraventricular on interest a rib or ensure interrupt parent, come on. So I'm going to be going over the top three Uninterested trick. You know, one is basically when that happens within the ventricular system that we talked through earlier, where the CSF lows on an interest of people is basically where the the stroke or the bleeders occurring within the brain tissue itself. So let's go through the three main types. They're gonna come up your exams. So in extra urine after toujeo hemorrhage, as the name suggests, it occurs an extra or epidural space, which is between the skull and the periosteal Germont. As you can see on this diagram here, How does it presents? So the typical presentation stone that you're getting exams is someone's had a low impact trauma, typically a blow to the side of their heads on. Then they'll have something called a lucid, it lucid interval on board. Release it into voice is where somebody loses consciousness on die. There you lose consciousness because of the shock of the initial blow to inside the head. Or they're low impact trauma there, then regain it. Assay kind of get over that shock on, but they're usually find for a while a few hours, and then they suddenly lose consciousness again. And that's because that bleed on the brain gradually glow, grows and grows and grows as they are as time goes on on. So then they lose continence consciousness again. When the the school has run out of volume, they can no longer compensate, and they've got a raised intracranial pressure. So you get that lucid interval where they are able to regain consciousness between two loss of consciousness on do the common SBA. Typical question as to what causes an extra. Your hemorrhage is a rupture of the middle middle men and your artery, which is due to trauma at the Italian. So you guys said earlier this hate shape suture on the side of your head. Just underneath that is the middle meningeal artery. If you hit the battery on as we said, it's a bit unstable. If you hit that, it can hit the middle men, men and your artery on. Then that's what causes an extra dural hemorrhage. It's one a CD head. What you're going to see is is really important to remember, cause this is classical. For exams, you see a bike, um, backs or sometimes called lentiform or Aleve been shaped lesion. So you can see here in this light of white color, it's It's limited by suture lines because, as we said before, the Periosteal juror, Marta is tightly adhere to the skull on. But it's it's kind of continuously this girl at the suture lines. So when you get a bleed there, you're you're almost peeling away the periosteal air from the school. It doesn't like to come apart from it very easily, but when you get to that suture lines where it's even more tightly, it here is, and the bleed can't can't continue. It's limited by those situations commonly, As I said, it's in the temporal region because of that plate to the battalion and because it's usually an acute presentation, it will be a white or sometimes go to hyperdense on view on the CT, so it looks whiter compared to the normal brain tissue on that shows you that it's an acute bleed, and it showed acute blood. So what do we do in terms of management? So if there's no neurological deficits and none of those symptoms that I spoke about before in terms of a strike, then you can radiologically and clinically observe them, so make make sure they don't deteriorate further. You can do, um, repeat CT's and things like that just to see how their condition is going on. But if you do want a definitive management, you do something called a craniotomy, an evacuation of the hemotomas and the humans. Homer, referring to the blood eso a craniotomy occurs where you basically you peel back scalp. You remove a part of the skull on that relieves the ICP a little bit, and you take away that bug basically using suction. But what's really important? Is it in a crazy ostomy you put the skull bone back afterwards. So you've taken off. You got rid of blood. You put it back on and you attach it on with some clips may have made of titanium, and you consume your back. The scalp is well in comparison. Here's a subdural hemorrhage, so once again name suggests where it is. It's in subdural space, which we said was between the men in general, on the arachnoid multi layers. So how does this present? Well, this can present differently depending on the situation. There's two main different types of presentation, so it can present acutely where someone will have a really high impact. Almost a a road traffic accident. They'll have a worsening headache that might have some nausea. But remember confusion. They might even be comatose. Eso that can present a subdural hemorrhage alternatively, and probably more commonly, for example, is you get a chronic presentation where a bleeder slowly been bleeding out into the brain, kind of without anybody noticing it. Because he's been that's low on. That's really common in both alcoholics and out the elderly population, and I'll explain why in a second, So what is subdural hemorrhage occurred uh which due to tearing of the bridging veins. So bridging veins are basically veins in the suburb Ackroyd space that drain into the job. Giovino Sinuses between the Julia's so they, um, they go between the subject road space, which is here on they drain into the jaw. Venous Sinuses between the periosteal, um, and in Georgia Amartya, it's kind of connecting these two spaces on. Do you can imagine when they rupture the liquids he needs to go into a space? It's going to go into the subdural space between them, So why does it affect our Colics on? But those are elderly. Well, that's because people that are elderly or have an alcohol and addiction their brain atrophies and it shrinks over time. And you can imagine the PMR. So, as I said before, is really adhering to the brain on the jury monitor is very adherent to the skull, so if you could imagine, your brain is getting smaller. But object, obviously your scholars staying the same size. What happens is is the brain shrinks and drinks. It makes those veins more taught. They become more stretched out if you like, and so eventually they the brain gets smaller and activities those veins get more talk, more talk, more talking than Sunday They go something they sat know they've they've been bled out on. Then they complete into the subject of space. Um, and typically these people can present with a say kind of weeks to months of confusion, maybe reduce consciousness and maybe some neurological deficits as well. So what do you see on a CT had well, this time, instead of a lemon shaped, you see kind of a crescent shaped picture as you can see here, which crosses suture lines on, that's real important, because, remember, we're not dealing with the jury maths. Now we're dealing between the germ out on the Iraq right. Butter on the jury monitor is still stuck for me to the skull, but the energy or amantadine in the rec of recommend multi layer aren't as family is here. Therefore, it can cross those suits lines sometimes because you can cross suture lines and therefore could potentially have quite a big believe it can cause something called mass effect of midline shift, which is basically we're getting such a big bleed on one side that your brain just slowly works. That's where one side, because it's getting compressed and this has said, because it can present acutely ill Chronically, it can be a white or hyperdense collection, which is what's been shown here. Or it can be dark hyperdense a darker than the brain tissue so more of more of like a dark gray black color on that suggests it's more of a chronic bleed. So how do we manage them? So once again, if it is, if it's an incidental finding, they're not having any symptoms. Excuse my type of neurological deficits. There's no mass effect. Then we once again can observe them conservatively. Manage them. And so, for example, he's on the hyperventilation of mannitol techniques. If someone's come in with an acute presentation, uh, the definitive management is a surgical decompressive craniectomy. Eight. I I see piedmont a ring. So when I explain the difference between craniotomy and craniectomy craniectomy, you peel about the skull. Same as before. You remove part of the skull, which relieves the ICP. You take the blood away, but you don't put the skull bone back afterwards. And the reason why we do a craniectomy so not putting the skull bone back for a subdural is because subdural are more likely to re occur. So what they do instead is they put the skull bone into the abdomen. Eso that it's free from infection because the peritoneum is very steroids, very infection free, and it has a really good blood supplies, but you're gonna keep that bone nice and safe. Um, it has a good blood supply it working crows. It allows you to put the bone back later if you want to, but often it's it's not done on. So the reason why we do this First of July is because because you have these small bridging veins between the Iraq Lloyd, a separate kind space on the Venus Sinuses. They're very small, and that's quite a lot of them, so you can't really quarterized them will stop them from bleeding because there's too many. It's not like the middle men in July, artery with a M with a extradural hemorrhage. Where is one artery? You can cauterize it. You can stop it bleeding. It's fine with these. There's so many little ones that would be hard to hard to get them all to make sure that the bleeding doesn't come back, and therefore we do a craniectomy because we don't want that. I see Peter Bryce again on We don't want to have the same problem occur against. They usually keep this called brain skull bone off. If someone has a chronic presentation, something similar is done. Such pretty compressions are taking the blood out. This time you do a burn a hole surgery, and that's usually because they say it can be an elderly patient. These patients are not 10. They don't tend to be as fit for surgery, so taking out a large part of the skull would not necessarily end very well, eh? So we do Bourjos surgery, which is basically kind of drill small holes in the side of the skull in order to drain it rather than taking out kind of a whole bone. Basically, So our last type is a separate troy hemorrhage. And so, as names just subarachnoid space between the Iraq right in the PM Marta, how does this present classically thunderclap headache, worst headache of the persons life? And they may also present with nausea, vomiting, seizures or a sudden death? It's quite it's very it's very severe and the reason why this occurs isn't untrue. Granule aneurysm has ruptured. So in an aneurysm is basically any weakness in an arterial wall, and that causes an outpouching or a ballooning in that region of the blood vessel if you like. So you can kind of see it on these images here. So you have your normal blood vessel and all of a sudden a little out pouching acres. The most common type is one called a berry aneurysm, which is basically a small Seroquel your eczema's. You can see here with a very small neck, so you can't really see where this is pinched. There isn't like, isn't like Podunk. Yeah, lated. Um, it's just kind of attached almost on the side of the artery on that's called a berry aneurysm on that typically occurs in this Rebrov res. So the the reason why this occurs is because there's either a spontaneous rupture of these aneurysms or you might have a traumatic injury, which then causes them to rupture and bleed. And you guys will remember that, I said. The most common site of an aneurysm is the anterior communicating artery connecting the two left and right anterior cerebral arteries. So what is it like on a CT has? Well, it has this spider shaped appearance A zoo can see here. You can see this light white, acute blood here on. But what the reason why it looks like it's because the blood is going into something called the basal systems, which are basically dilations in the summer. Accurate space between, as you say, the erectile it in the PM alta, where the CSF tends to pull because it's a bit wider. Other structures passed through here, such as the blood vessels themselves heads where they believed in these areas on the cranial nerves. But they're basically dilations in the subarachnoid space. If you do a CT head on, someone you need to spend got a subdirectory hemorrhage because they're telling you they've got the worst headache of their life. Um, and you can't see any bus. You should do a lumbar puncture at later than 12 hours. Because sometimes, as you can imagine, these small dilations not very big, you might be able to pick it off in a CT head, but we need to treat this patient so we want to find out if they got a subarachnoid. So you do a lumbar puncture it 12 hours on this presents with something called Xanthochromia, which you can see here, which is kind of a yellow discoloration to the CSF on Do This is basically do two red blood cell breakdown that's occurred in the CSF in the subarachnoid space, and it turns the CSF kind of a yellow yellow color. And if you see any blood and even though you think that blood cell breakdown should be read if you see any blood, it's more likely because when you inserted the needle you've had something called a traumatic tap, which is basically where you've caused trauma as you've inserted the needle on that's caused blood. To get into the sample another way, you might go to test. Um, so the subject know temperate is because the intracranial pressure will be higher because you've got a raised Sorry. The opening pressure when you do a lumbar puncture will be higher because of the raised intracranial pressure. So how do we manage them? Well, getting straight over to neurosurgery after you confirmed the diagnosis, That's really important. You want to do a CT intracranial angiogram that's really important to confirm, um, where the, uh, aneurysm is because it's so point. Trying to do surgery is something if you don't know where it is. Um, and it was confirms, but it is an aneurysm on what type it is. The definitive management is a coil, a zit here. So basically, they get lows a metal, and they put it inside the aneurysm so that it's not going to forward blood. It's not going to bust on. And they also can do something called clipping with dignity in this image, which is basically where they insert a metal clipped bottom off the aneurysm to cough its blood supply. Basically, it's already bleed on D. Also, give them, um, no more pain for three weeks on. Basically, this drug prevents basis presents prevents those arteries from contracting and causing further bleeding. So I'm going to go over a scheming stroke. So we have our 33 broad trees. Anterior middle posterior. I'm sure you guys notice I'm not going to go into too much detail, but just remember, the anterior cerebral treat supplies the prefrontal cortex on the motor areas, particularly the lower limb, because the anterior cerebral artery, if you look at the medial brain surface supplies most of the medial brain surface around the motor and sensory cortexes on, As you can see of the monkey list, that's the main supply in the lower limbs. And then we have the middle middle cerebral artery, which surprise a lot. The lateral brain brain surface that supplies are auditory cortex. Broca's area over like his area on the motor areas for the upper limit trunk, which arm or on the lateral surface of the brain. As you can see from the monkey list on, we had the PCA, which many supposing septal of which, as you know, is mainly responsible for vision. So it's giving strike. I'm not gonna do well on this in too much detail, but basically it's a reduction in blood supply to the brain because there's a physical obstruction to the blood flow. There's two main types from about it. It's getting extraordinary. Embolic in bolic Sorry, ischemic stroke. So Thrombus is when a clot of blood is forming within a blood vessel and it remains attached to its place of allergies. The clot is forming in place on that's reducing the blood flow downstream. Reason Embolus is the material could be a blood clot or it could be fat. It could be it could be lots of different things that's carried from one point in the blood and then got lodged. Another point. So thrombus in situ reducing blood flow further down the line and bolic come from another place. It's embolized from another place, and it's blocked off a blood vessel somewhere else in the base. I've written here the risk factors for your own review your own time in general. They're mainly cardiovascular risk factors on also atrial fibrilation. Because if you guys can do our case 12 12, you know the atrial fibrilation produces turbulence blood flow in the atria, which can cause clots to form on. Those clots can then be thrown off on belies to other parts of the body. Fatigue to the brain. Um, cause even asking strike. So how do we manage these patients about human to do an urgent CT head? Because once again, I want to see what it's a hemorrhagic stroke, producing the symptoms really skinny one and then, depending on the time that the patients have the symptoms for how quickly the present, you either want to give from Bill Isis to break down the clock or thrown back to me. So having surgery to remove the clock in order to reduce the ischemia generally thrombolysis is used. If it's less than 4.5 hours since the stroke symptoms began that there's a lot of other things in plain. That's a general rule. Um, then you also want to give them aspirin on antiplatelet in the statin in order to reduce the risk of another s, came it straight down the line. Another thing you guys may have heard of is a transient ischemic attack. So this is basically when you have, ah, transient episode of neurological dysfunction without you being able to see any area of infection on a CT head, it used to be defined as being under 24 hours. Now we just say it's typically under 24 hours, but it's basically when you go and you get neurological dysfunction, but you can't see any infection or brain tissue there, so there's different types. I'm gonna let you guys go through this in your own tanks and over running out of time, but it's basically a total anterior circulation stroke which is to do with your anterior circulations in your anterior middle cerebral arteries, and you need all three of the criteria below. Then you have a partial, which is basically when you have smaller branches of those being blocked, and you only need two of those criteria. See you, then have a lacune a strike, and you also have a posterior circulation syndrome or stroke, which has their own specific criteria. But I'll let you guys learn this in your own time, so I'm not going to go into meningitis. So what's his million doses? But it's basically an information off the meninges, which is, we said, other layers covering the brain typically presents with neck stiffness photophobias not liking bright lights, headache, fever, nausea, vomiting, drowsiness, seizures on Sometimes you can get a rash is well in terms of the cost of agents. You if you get a bacterial meningitis, that's very serious. If you get a viral one that's more common, but it's typically less serious, and you can also get some fun, fun guy cause it as well, his a little summary table of the causes. I recommend you learn this for exams, even though it's not when I assisting to learn it's really important. And as a little help for learning it, I will look at this table. I mainly focus on the two main causes for each age group on I kind of remember something local. The crossing overrule s O in a newborn main cause Strep B streptococcus. Then we have streptococcus pneumonia. The structure caucus Pneumonia crosses over to be the main cause in a baby or a child on. Then that second main causes my serum and ninja Titer's, which then crosses over to be the main cause in a teen or young adult. Their second main cause being strict course pneumonia, which they were sorry, which then crosses over Sorry, let me go back, which then crosses over streptococcus in radio to be the main cause in the older adult. On the Neisseria meningitis crosses back over to be the main cause, an 18 or younger adult. I hope that makes sense. That's just how I remember it, because it's not always fun to then I hope that's helpful. So number puncture. If you do meningitis, you want to do a lumbar puncture just to understand what the cause of the meningitis is. I've done a little summary table for you here as to what you'd expect. So in a normal on number punctured, expected to be clear. And you'd expect all of these, um, these features to be within the normal range the A polymorphism. Let your neutrophils your basic disease, your center bills. So your white blood cells from your innate immune system Any of your lymphocytes, which are more in your adaptive immune response protein in a glucose. So in bacteria, TB and fungi, the appearance of the lumbar puncture fluid is yellow. Um, it can be quite cloudy as well. The problem also raised only in bacteria bacteria is the only one not have raised lymphocytes. The protein is raised highly em bacteria and slightly raised in TV. In bacteria, the glucose is reduced a swell Azzan TV on. Sometimes it could be reduced in fungus. Well, now, the way I like to remember this is I try to think of bacteria as very messy and not very sneaky. So because bacteria messy, they didn't use up a lot of the protein to kind of reproduce and your bird processes baby to do on the use up a lot of glucose that you have a swell on but makes it quite obvious that they're They're they're not very sneaky. And the appearance of the blood of the lumbar puncture is yellow that they give away on the back here aren't very sneaky on, but they're very messy because they leave a lot of protein in glucose hanging around. Where is your virus? Says our bit more sneaky. There appearance is clear. Eso it almost looks normal. Your problem, officer Normal, your protein and your glucose is also normal. So you think the virus has got away with it. But it hasn't because your lymphocytes was the only thing foiling their plan. The lymphocytes erased in TB, you got a mix of both. It's a bit messy. You get a color change, you get a little bit of a change in protein and glucose, but it's not as bad. On glimpse. I will also pick them up, but your polymorph and then you found guys similar to debates basically the same. Except I have a normal protein and then the management for meningitis very broadly is you start off a little antibiotic called IV and cefotaxime me on but is very broad spectrum. So when you first suspect many judges him, it's important you treat it very quickly. So you want to give him a broad spectrum to basically try and capture lows of different bugs that could be causing it on. Then, later on, based on what you find from cultures from the lumbar puncture example, you may change the antibiotics, and I've written the ones that you would change to hear. So these are some extra electrolytes loads for you guys. So just for you to review on your own time a little bit here on hydrocodone is a little bit on brain herniation as well. A little bit on base base, Brazil. A skull fractures or fractures to the base of your skull and a little bit on comparing encapsulitis and sweeper obsess. I'll let you compare those in your in time, so that's me done. I'm going to give you guys a cup for SBA is just test your knowledge on S. Oh, if I could have the pole launch, that will be fun. So the electro explains to you the mom broke any doctrine on how intracranial pressure is affected by a mass growing within the skull within the intracranial cavity. He explains that this doctor is not used in the urinates. Why is this doctor not used in the early years of life is quite a long pressure. Give you guys time to read all the answers as well. Okay, I'm going to give you five more seconds. Okay. I'm going to end the pole there. Just going to take. That's beautiful. So Yeah, well, don't, guys. You completely smashed it Well done on. So, yes, the correct answer is he wasn't all of those of you that put that. That's great. Sorry. I'm just trying to go into my next slide. There we go. So, yeah, as you guys remember, one of the key principles of the mom locally, doctor in is that the skull is a fixed volume. And in the neonatal, that's just not the case. So they have fontanel's, which are basically these spaces between the suture lines where the school has school been Temperley joined together in their development on, but they're two main front nails are antirougeurs posterior on the anterior is between the frontal and parietal bones on do the You have the Corona will suit you hear on the subject with teacher here on, then posterity. It's between the parietal on the exception bones at the lamb lamb Boyds future and the presence of the open suture lines. And the fontinalis basically means that there's a potential for a change in the size of the skull and the intracranial volume on, because it's not a fixed volume, this doctor and can apply so well done. So next question, a 54 year old man presents any I'm feeling very, um, well, a CT head scan is performed, which shows a subdural hemorrhage causing midline shift. You recognize that the patient's symptoms due to a raised intracranial pressure onda um, which of these is not a sign of raised intracranial pressure? If we could not on a tight on the tape on the slides, that would be fun. Brilliant. So I'm going to end the pole there. Well done. Everyone up really good. Once again, majority of you got the correct answer. It's a good job. So, yeah, the correct answer here was Be so as you remember, we have in Cushing's tried It's a washing pokes pressure, um, or hypertension, irregular respirations and Braddy cardio and know tachycardia. Because remember, we're getting that parasympathetic response him. And when the hypertension occurs, well done. So our next question I'll let you guys read this and then if we could launch the pole, okay? Crime. You know, in the poll that so well done. The majority of you did get this one right. But it is definitely more of a split on this one. So I will I will explain this one. So the correct answer here is See the reason being this patient has a severe headache attention to the west of their life. On day A have a smoking history of hypertension which in this case, our risk factors to subdirectory hemorrhage. And so, you know, ct. There's no intracranial pathology. But as we said, that can happen with supper, right? Correct. Heparin on the lumbar puncture is performed 12 hours later showing that some of the criteria but yellow discoloration to the CSF. Now I see a lot of you put a and I've been 100%. See where you put that. But just be aware of the SP way. Don't let it catch you out. Definitive management Not next step know anything like that was the definitive management. So doing in angiogram? Yes, it's important that you need to know where the aneurysm is, but that's not managing the condition that's just getting you ready to manage the condition. That's not the definitive management. So the definition tip management for some erectile hemorrhage is a coil or clipping. It's well done to those really put See so four from Final Question. I'll let you guys read this some more lunch. Suppose kills, and I'm gonna in the poll there. So we've got a big split, I believe, which, mainly between am be, so I'll explain the answer. The correct answer here is a so well done. Everyone but a that is correct. So let's break this question down. So the patient is drowsy, the funny it hard and painful to lift their necks that suggest maybe next. If nous on he keeps his eyes closed, was talking to use that could suggest photophobia. These are all signs of meningitis on, so if we look at the results, we've got a yellow appearance. No, no change in polymorphism polymorphism. Normals are neutrophils and everything normal raised lymphocytes, rays, protein and less lower glucose. So the correct answer is TB Because you remember, this is a mix of bacteria vial presentation. The appearance is yellow. We have a race protein. We have, ah, lower glucose on which suggests or bacterial. But the lymphocytes are raised by the pollen off signal. So that is where it's pointing towards TB being a sermon injured city is this is the most common bacteria causing young adults with teens. A D is the second most. If you look at the age of this, it was a 16 year old male. So you guys were all on the right lines in terms of the bacteria. However, just remember the pollen most will be raised in bacterial residents sites won't be as much. Um, c CMP is virus. If it was a virus number, that really sneaky is there will be a normal protein and normal glucose. And he is a type of fun guy on. This is very similar to this, but the protein won't be raised, so I hope that makes sense. Remember of TV shows a mixed bacterial viral picture on a number puncture. So that's me done. Sorry. That was quite long. Session. You guys were really well, that was probably the heavy apart are passing straight over to Toby. Thank you so much. I, um thank you, mag, for doing such a great presentation there. Thank you. Come tomorrow. The important points on has a great memory. Age is well, say thank you. Um, just, um, ex green. Okay, so I'm aware that we've run every little bit, so I'll try and just pick out main points from mine on, so I'm going to be covering upper airway anatomy, cranial nerves, imaging, and then the A B c, the approach and every management. So here's the upper airways on she breathing through your nose. Your yeah, passes over these structures. Um, in the middle of your nasal cavity. Did anyone tell me what they are? Okay. The Rafidah on someone said, um, me a test. So would be Guess if the lines pointed Teo below you. The area indicated So, um, you noticed, like, below on the Conquer, which is, uh, what the structure is. There's someone else to sign. This is so I've written here, um, upper airways condition in spider. So a lot of that is to do with humidifying the air on, um, the conquer meters and Sinuses play a role in that. So I guess three or nice, but needs to conquer intermediate cysts. And then from there, they can go into the Sinuses about here, actually pointing out there, um superior, middle and inferior conquer. Okay. Yeah. Um, why do we have Sinuses? They they've got three main reasons. Is anyone know some reasons why we have a nurse. Is Yeah. Have residents? Yeah. That's really good. No, no wonder I order, uh, to make the skull lighter. Yeah, someone's put that on more. This is a bit niece. Um, protect the bet brain from from to draw map. So I guess that's just an added bonus by happening the cushioning the Sinuses on the front of your head. Then it would stop damage or infection. Getting into your brain and static. Go into your sciences. Um, Onda. Speaking of infection, you can get sinusitis. So, as I said, on the air goes through your under your content in two mediators. And then from there, they have the option of going into a Sinus. Is Andre the pathway endured? Maxillary Sinus has a, um, especially narrow channel. That's good. The osteo meatal complex on D. And if that compacts gets inflamed, then you end up getting no way, um, term IV mucus or fluid from your Sinuses on. As a result, you get the pressure build up Onda. That's why when you have a cold, you might feel we're back. Uh, clock clogged up on on. Did you also got that feeling of pressure And your hat? Okay. Okay. Say under the tongue. So those So obviously you've got the time to do. Is your back your threat? These codes, your Palatine tonsils. But then you also have your lingual on. But I didn't know it. Tons of us on. If you have seven episodes of tonsillitis in a year, then you'd be considered to get your tonsils removed on specifically in charted. If your tonsils become inflamed to the point where it's obstructing your breathing, you might get your palatine tonsils removed on. Do you also get, um, your adenoid tonsil was removed as well. Good. Um, someone put, Did you move on or your tonsils in the chat or just some of them? So often? You basically always get your palate time tonsils removed. That if you are adenoids causing an obstruction. You often get those removed as well. But that's more common in charge. It that, uh, lingual. I think you can get your lingual removed, but they obstruct the air flow less on just simply because the liquor, the anatomy of the image it shows, um, they're more tucked away at the back of the tongue. Your finger ones. Okay, so your eustation cheap. Um also known as your for enjoyed tympanic tube connects your inner ear to your, um, upper airways on. I'm sure you've all felt the sensation when you're is pop on a flight, Onda. If you swallow, then that can cause your is the pop So imagine you're on a plane plane goes up in the air on the air Pressure decreases now cause your tympanic membrane Teo, suck out as, um, the pressure is lower, Um, outside of the year. Been inside the uterus them when you swallow, then your soft palate, which of labored here actually rises. And then that would cause a slight increase in pressure in your, uh, nasal cavity, which will then cause the station trip open, which can then relieve that pressure. And that's what is actually causing, causing your ears to pop on your lines. So, um, your larynx, otherwise known as your voice box. It's here on glaber, some different areas. Cartilage. So does anyone know what these cartilage is? It could yes, say your crippled cartilage and your thyroid cartilage, just fixing it in on that. Your thyroid cartilage is where a lot of your vocal cords of a quick phone attach from that on at the back. You get your arrested Castellet, which is on the other area cast lived. Read the very good masses or four words attach on. So in this image, the thyroid cartilage is anterior. So that's what's on the front of your great and then, um, more like within your neck is your on our asteroid cartilage. And I said, All of these muscles are innovated. Bye on. Don't know the answer. It's enough. Yeah, So someone said Recurrent laryngeal Enough on is the brown to the vagus nerve on all of your vocal cord. Muscle is innervated by it, apart from your quicker thyroid muscle, which is innervated by the superior laryngeal love on. But I think it's important to know it's that the posterior quicker or arrested muscle is the only up doctor of the vehicle cords. So is the only muscle that actually opens the cords and opens the airway. So without that, then your airway wouldn't be able to open on. If your airway isn't able to open on, do you consider performing intubation? So maybe if the patients got reduced level of consciousness or you're worried that the patient, my aspirated Cem stomach acid been, uh, you could contribute it, and then that will maintain an open airway on said patient. Complete it. You'd be unconscious, crazy, crazy enough's. So yeah, I'm sure you know how you the cranial nerves by now, so I wouldn't spend time going over them in great detail. Factory have, obviously, if the smell, I think it's good to remember the Freeman. So it's the cribriform plate. Then you can see the cribriform plate on the image. They're just going through into the nasal cavity. Okay, the optic nerves society, and then the frame is there. Uptick canal on the other. One of the other, um, ocular master's is the ocular motor nerve on this innovates most of the ocular muscles, and it controls people constriction is well, is movement off the ibu on the eyelid and that's the city area. Or go to bed truck clear, um, depression and abduction of the eye. So that's down and out. Um, mation of the eye. And I'll come on to which muscle is innovative. My wine amendment. Any of Jesus' Syria We've skipped here, remember, From four now, we've gone straight to six on the adjacent muscle. So did Jesus. Nerve is the movement the I boom. And it's also in the superior to pressure. There isn't any more that on We're not need my neck bone memory aids on so a Lhasa extensile lateral rectus six. So the sixth, uh, cranial nerve is the lateral is of juices and that innovates the lateral rectus muscle. So it did Jason's on dc'ing trolls natural movement of the eye there and s 04. So four is but, um troubling enough on D s 04. So soup area oblique on the superior bleak can makes the I go down and out and then all just and so Oh, the rest Which is the ocular mate Now I think all the muscles of the I quite straightforward apart from the superior and inferior bleak, which I think is quite country and your it'd so the superior bleak, although it says Superior actually makes the I move downwards. So you could say imperially, Um, and if you look carefully on the image, um, you can see it and that the superior bleak muscle attach is brother lower down on the eye. So when that's pooed approval from the back of the eye and then it rotates the eye to leave downwards on. That does mean that when you have nerve palsy, then all of your muscles in the eye, apart from lateral Actis on diphtheria ble and don't work, say as a result, your I can only move laterally from your natural practice on down and out from your superior bleak. And that's why, in that nerve palsy you get down on out front of the eye, um, dilated people onda Tosis on. I guess they know that comment that no, that's similar, but you might get confused with Third now Posey and Wholeness syndrome. But one of the main difference is is then Horner's syndrome. You get a constricted I that that nerve palsy you got dilated eye on, then voted have toast this or they third know Posey. You get complete tasteless that in hornets and drain and taste it. It's only partial, and taste is adjustment reaping of the island. Okay, I'm going to try. Try this in your eyes. So after one image here, Onda, I've tried to link it to the function of the nerve. So it does anyone know how this image might relate to the trigeminal nerve if this doesn't work? Um, egg sense. I just get paid. Any guesses? Anyone know the function of the trigeminal nerve? Any function? Yep. Say someone's put, um, modification in the grip. So this image in particular, was the drawer movements. But the trigeminal nerve is also responsible for sensation. So it's got the three branches opthalmic maxillary um mandibular brant on to the sensation that it will also control with your movements. Okay, Aunt, give another guy so patient. As on why my I attach this image to the function of the facial love. Yeah, so someone's not sleep, but they're crying on the grape. That's really good on. Get the child's crying on the facial nurse responsible for salivation on black remission But I guess it's main function would be, um, the and mister say movement at the base on, um, or say on anterior taste of the tongue. And he can just see the branches of the face. You know, I've said it. The temporal zygomatic, bugle, mandibular and cervical onda is a nice memory Aids. So two separate is bit my coccyx on forties of the branches of patient. Um, and he had just made a night to close to zero. So, um, so here I say, Well, the the the facial nerve responsible for, um celebration. It's not. It doesn't innovate the prostate gland. However, it does pass through the carotid gland. So if you would have surgery on your prostate gland, then you could end up damaging your facial nerve. Rich would result in both posey. So you don't have controlled the muscles of your face, which causes this treating. Okay, this is an easy one. Sure, you get it. Say the big is responsible for hearing. That's binoculars. Onda. That's the intern. Okay, stick meatus. So there's another one. Um, this one's quite tough, but I will give a guy. Does anyone know why this image might link to the glass. A phone, June. And yeah, So on the glossy phone, Jonah does, um, innovate the carotid gland on. That's why a pit a picture of the dog celebrating on, um, Also important function is it controls the bar receptors for sensation. Sorry that Aricept sensation and chemo receptors sensation in the carotid Sinus. And then the vagus nerve of the heart. Um, I won't make a guess just in the interest of time. So baroreceptor is And chemo receptors there in the aortic arch. Some of that symptom parasympathetic innovation. So, yeah, to slow down your heart rate, you might have read, or so send signals down the biggest. The accessory enough. So the accessory now that I like this photo a lot so you can get us for this photo. Why? I have drawn a draft to the accessory now. Yeah. So innovate Systemic lot of mass storage, hand trapezius muscles for head and shoulder movements on. I think that's all of my silly images. Oh, night. Because another one, um, high, because I have is the tongue movement. Okay, I say if you're having trouble remembering the order for the nerves and what number they correspond Teo on this is what I eat so o touch and feel very good. Belvin it Heaven optic want to the maitre um sorry off. Um, you know, you know, with them, um on d on. Hey, So although the last one waas for the names of the nerves here is, um, to stay at a function of the nerves So whether than a century meter or both So it's some It's a very money, but my big brother says big brains matter more. Say, um so with the s is sensory over the arms motor. Know that these both Okay, Andre, it's going down towards the end now. Um, so it's made a list of reflexes. The the corner of reflex when you touch your eye, Um, you were blank on. So the sensation comes from the I'm sorry. You feel the Afrin now with the opthalmic nerve. But does anyone know this effort now? So what would cause the response from the cornea? Oh, reflex. Yeah, it's a facial nerve. And then maybe on there crowded Sinus reflex. So, for example, if you massage of corrected Sinus, then cause your BP to decrease any gas is on the Afrin mouth. So lots of saying Vegas so vagus nerve. Um, that would cause your BP is decrease. However, the sensation from the carotid signer. So what sends the signal? Actual brain is actually the glass of orange juice and out okay, on the A B C D e. Approach. I'm sure your drill this on Mexico. So as I could primary survey, but so obviously, yeah, always, um, can do a basic head coach and lift the airways on. Do use a really adjuncts to maintain the airways. So if you're in a hospital setting seen she, um, excessive patient that, um, controversial. Want to maintain the airways by using one of these breathing, um, rising for the chest flare chest are coming on to what blow test means in a bit. Um and, yeah, you would want to check the patient's oxygen SATs and then give him oxygen if needed circulation. So BP post a pip blood on the floor or four more. So if you have made to blood loss than obviously, you can have blood in your floor on the floor, um, on about, be a cause for hybrid hypotension, but form. Or you can get internal bleeding so you can get bleeding into a door actual abdomen and your pelvis or into your long bones as well. So that's storax abdomen, pelvis and long bones disability so I can check Patient's GCS on. You should never forget the ends, Major, cause for a unconscious patient would be having low blood sugar, then everything else experience the patient into a secondary Saturday, right? Okay. At an FC, this is something I've actually learned the other day on it refers Teo the major causes. Um oh, so it's the things you would die off quickly. So a stance airways. So I, um if your airway is an open bend, you're gonna die very quickly If I box here tension, Um, with all access tea, so have a pneumothorax can't breathe, and you're gonna die very quickly unless that's treated just on gets trained. So you have to relieve the pressure through, like needle decompressions it concert needle on your armpit on that will relieve the pressure causing on the tension. Pneumothorax Say, I think I skipped Well, now I should have said, oh, stands for open you mouth or ACS. So, um that's when they're pass freely into the lung Onda tension hemothorax He got passing in, causing increasing pressure 80 pneumothorax on back and passed both based on then massive hemothorax on obviously blood in the lung flow chest This what I mentioned before? So if your lung if your ribs break in multiple places, then they can break away from, um, the rib cage itself. And as a result, when you decrease the pressure in your lung to draw a in done that every of rib comes in with you, Onda. As a result, you don't get that inspiration of hair eso you can't do oxygen into your bloods and you would die very quickly. And then the last one is just cardiac tamponade. So blood around the lung preventing your heart for be able to pump efficiently. Okay, then looking at D so disability, I said to look for the GCS and the patient, Onda causes a reduced GCS. Um I guess is this lengthened confusion as well would be the EMS. So low clear case eight days alcohol, sodium or calcium. Say, um, if you have abnormalities in your side, um, a counselor and then you can end up becoming confused on Day zero to toxicity head injury in Catholic, The strike on seizure So and generally it's in that order, a swell. So PM's most common cause for a juice GCS and then overdose second actually go down. Then baseball's is for GCS become a less common. So imaging, that's the last section Now, thank you guys for staying on so long, say, Emery's first CT, these two massive area imaging in the medicine Uh huh. Okay. And our eyes generally take high resolution images, but they are more expensive and they take longer. Whereas CT Scan's a lot faster, um, cheaper and quicker. But they do use a nice thing. Radiation. Is this some more anatomy for you? Um, does any of the 65 95 people left know what the structure is? Yeah. So the corpse close and say helps communicate between the two different sides of the brain on in your cortex. Anyone know the annular cortex is responsible for night? Okay, um, the cortex is responsible for linking sensory experience with emotion here, the bench cruise on, but they can take contain CSF, which Megan did a really good job explaining earlier on the thalamus awareness on sleep processing. Relaying information on then here's some white matter tracks on D. I've got some SPS say we're going to those that 53 year old man tends your clinic. Um, united is He has since chin tucked into his neck on Terra. She he's had problems with double vision. He has a history of head trauma. You believe he's a crayon of cozy. Which nerve is most likely to be affected. Okay, give you three more seconds. Three Teo one. Okay, So most of you at bay, um, which is the actually most nerve? However, the patient is unable to look down and out. So if he's unable to, then it's going to be his CP areas leak. Um, isn't lacking on your superior. Bleak is innovated by your fourth. Now you're truculent. Have on if it was the third know if that was, um, out of Posey, then you would actually end up only looking banning out. Okay? And I'll just quickly take photos of the results. Okay, Uh, the next question, um, you arrive that scene of a color crash. There's blood on the floor on the passenger has managed to escape the car. Uh, it's safe to help a passenger booked step. We take fast. Okay, Give you a few more seconds. Right? So theanti waas head touch in, left most of, um, for that, but they I completely understand why he said check the spinal cord injury on this is important to day. However, the airway is the thing that's going to kill the patient most quickly on down with her head token left. You shouldn't be causing any injury to the spine. So, um, yeah, you wouldn't be worrying about the spinal cord injury in the first instance. Okay. Next long. Uh, you see a patient here is a flexed arm and extended leg on the left side. Um, and it was I have facial drooping. Um, the only confuse to tell you what happened, but the door to set that she was fine. 4.5 hours ago. What would you do next? Okay. Chemo seconds. Okay, let's talk about that. Yeah, basically, if you got this right, um, you'd want to do a surgeon CT head on. That's because, um, you have to rule out there being a hemorrhage before you give any anticoagulants. So you don't have to remember. You don't want to thin the blood with any aspirin. If you're not 100% sure that this strike has next scheme it cause, um, yeah, you always do a CT before treating. Yeah, and it's the last one before my cranial nerve. Examine the patient. When you look into their eyes, you see that people's both responsive to light other when you do a swinging test, so that's a swinging light test. Um, both people was dilated slightly, Um, in the night is shown on the left eye. So I meant to put the swimming light test. There is cool. It's a test for a relevant Afrin people. The effect people very defect. It's quite a tough question, and I only brush donut during the presentation. I'm not sure you can. I do know what would know what the swimming light test is on. I don't really have time to explain it now. Could be run over by say much there is about having a look at, and the answer is the left optic nerve. It's a normally here. You're like the, uh, sorry. Normally your eyes this dilated slightly. Then when you shine the light into the right eye, but people is construct. And that's because on that information from, um, you're right. I going down the optic nerve and then coming back down your, um, ocular mates nerve both sides of your eyes, causing on construction both eyes. However, um, if the optic nerve isn't working, then when you shine the light on to the left eye, then that left eye gets no information about how great lighters. So even if your ocular mates nerve is intact, then you still won't be able to produce a response because your brain doesn't know that there's like, there in the first place. Sorry. I can explain that better. Um, yeah. Spring light test is a good thing to have. Like, uh, Onda, that is Oh, thank you, guys. On. Thanks. So funny. State on. I hate to enjoy that on Be able to neck. Yeah. Thank you so much of one for saying once again apologies it run over. Hopefully, it was still helpful to your and you found it helpful in the use of session. I know. So I certainly did. Toby, you did a great job running through a B. C. D. It's so important for years of medical school, so really important to them. Um, if you guys, Do you have any questions? Do problem in the chapter on, We're happy to answer them. We've got the Google forms. If you guys do want to put your thoughts on where we pop, RSV is in our presentations. We would be super super grateful if you could fill that out. But if you guys are having trouble getting the Medrol ng in order to get the recording on the sides, which is on the end of the Google form, I've popped the Meddling Med or link in separately as well for you to access. We just a few other upcoming things coming up with our ski Z. So we've got our ski easy, Siris, our title Siris, where we're doing a skin teaching on order. The main specialties. It's really, really good for you guys to get relief. You'll excuse this year as well. We're sorting out the one to for those of you that signed up, thank you so much. We got amazing response to that will be less and you'll know soon how how that's going helps get a random. We will be in contact soon as the harness didn't start. Look out for the surgical Siris. If any of you guys are interested in surgery or learning more about it kind of more finals level, that would be really interesting thing to attend on. We'll see for our next frequency in. I believe we've got a respiratory coming out. Cardiology case. You have questions on down in terms of year to college, since we've also got, um, the spine is our next case. So thank you so much for attending things for them. The feedback for me. If you have any questions, pop in the chapped Toby and I will be happy to wants the memory stuff. Guys was a