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Hi, good evening, everyone and welcome to this evening's webinar on Neurotrauma. Um This is hosted by Edinburgh Student Surgical Society and as part of a series we have um covering surgical aspect of the undergraduate teaching curriculum. And this evening, we're delighted to have MS Sarah Venturini. Um joining us to teach on the topic of neurotrauma. Sarah is a neurosurgical registrar and academic clinical fellow, Addenbrooke's Hospital. She graduated from the University of Leicester and completed a neurosurgery themed academic foundation program in Aberdeen before starting neurosurgery training. Sarah's primary academic interest is acquired brain injury epidemiology and her research focuses on neuromonitoring brain injury prevention and global neurosurgical capacity. She has done extensive work in the field of global surgery, working with national and international organizations. She is passionate about students' education and engagement with the field of academic medicine and neurosurgery and she is neurosurgery section lead for teaching me surgery and is a research mental students internationally. So without further a do I'll hand over to you, Sarah. Um ok, good. Um Can you hear me? Okay? I think I hope. All right. Um Perfect. So thank you very much, which is for introducing me and for inviting me to talk today. Um So hopefully today's session will be useful for everyone attending. Um and um be covering the topic of neurotrauma, which is a very big topic. So, um this will be kind of an introduction and we'll be going through some of the key principles of how neurotrauma patient's are managed. Um So this is just the holder slide. Um So what we'll cover in the next half an hour or so into in the talk will be um the, the concept of neuro to remind what, what, what it is. Um specifically, we'll focus on the head injury and so traumatic brain injury rather than uh sort of broader aspects of neuro to remind general, um we'll discuss some of the approaches to patient's that present with traumatic brain injury and how these are managed. Um And they will cover a little bit about the pathophysiology of TBI. Um And why patient's presenting the way they do and what that means in terms of how we treat them uh will cover a little bit about common investigations and immediate management for these pay when they present to, to our emergency departments or hospital wards. Um And at the end, there will be a, a chance to ask questions and also a chance to go through a number of clinical cases just to apply some of the concepts um that will um talk through in the first half of the session. Um So hopefully you'll find it useful. Um And I think there's a chat function for, for questions and comments. Um So after the talk section is over, we can address those. Um So um let's get started, I think. Um So um neurotrauma, some of you may be familiar with this concept already or not. Um for those of you that our students in probably final years of medical school, um you may have covered um uh concept of regarding this but for, for those of you in preclinical years or kind of earlier on in medical school, this may be all quite new. Um So I try to describe things in, in in kind of general terms first. Um So when we think about neurotrauma, um this really is a broad term that is used to define any injury that happens to the head or spine um that is secondary to trauma and often this results from an external force. Uh be it an injury being a full, be it a um insole from it, from an external object. And so neurotrauma is a term really is an umbrella term and it covers a number of conditions on a on a spectrum of severity um from milder end of the spectrum where patient's may have a more minor head injury that's usually known as concussion, um to patient's that suffer injuries that result in injury and trauma to the brain itself, um which is what will cover today, uh which is defined as traumatic brain injury. So, um it defined as, you know, for any reason or another, uh the brain itself is injured because of, because of an external um external force been applied to the head. Um And there are also um parts of the ureter um uh that focus where um particularly on spinal injuries both to do with fractures of the spine. Um So the bones in the spine but also interested a spinal cord. Um I won't cover these things today specifically because of time. Um But some of the same principles that will be discussing in the context of traumatic brain injury or TBI for short, that's what I refer as today will apply to also patient's that have spinal cord injury or spinal fractures, etcetera. So, um so some of the same concept will apply to these patient's too. Um And here, just somewhat of photos are highlighted just to show you the kind of breadth of conditions that patient may have. And we go from, you know, minor injuries that result in a bump on the head to very severe injuries of the brain and spine um in both kids, adults, elderly patient. Um So the principles apply to everyone, but if we focus a bit more in depth um into TBI, which is the, what we'll focus on today, um We can think about a definition. So what does it mean to have a TB I, um what does it mean when we take, we say that a patient has a traumatic brain injury. Well, a TBI is an injury, meaning that it's some form of insult of the brain, which is usually not the generic of condition and not a congenital condition. It's something that's happened because of a traumatic event. Um usually to um something that's hit the brain or hit the head um in one way or another and this can lead to either temporary or permanent impairment of any function that's related with the brain. So, for example, cognitive function, um physical disabilities, um and psychosocial functions as well. Um TBI by definition usually is associated with it some degree of altered state of consciousness. Um that can be um from a more minor end and we'll discuss how we assess minor, moderate and severe injury to a very severe um kind of level of brain injury where a patient maybe in a coma or maybe completely unconscious. Um And the important thing to mention about TBI, the reason that I chose this is a focus for today is that T B I S are very common. Um the one of the leading cause of death and disability worldwide and, and about 70 million people um across the world every year suffer a TBI. Um and meaning that this is a really big problem on a global scale um and it affects all kind of countries in different ways, for example, in a country like the UK um, the leading causes of T P I S at the moment, our brain injuries and elderly patient's because of falls in particular, but in other parts of the world, um some of the most problem cause of T B I s are more um, road traffic accidents or um sort of other types of injuries and they often happen in younger patient. So there is variation but overall it's a common condition. Um and no matter what field in medicine you will go into in your future, um you will probably come across at some point, a patient that has either had a traumatic brain injury acutely or they've had it in the past. And so I think understanding a bit more about it is quite relevant to ever and not, not just neurosurgeons. Um and TBI in itself um is one of the substance of a guess of neurotrauma, but TBI in itself is also quite a broad term and also an umbrella term. Um because TBI is a traumatic brain injury can present itself in various forms. Um So on the screen here, I've just highlighted some of the types of T B I S that patient's may present with. Um And again, for those of you that have done clinical placements and uh kind of further on in your training, you may recognize some of these pictures are some kind of classical examples of of sort of brain injuries. Uh but TBI means really any injury that's happened to the brain. Um and injuries often resulting bleeding and different components. Um And from the left hand side, going on to the right. Um TBI can, can be, can involve patient that present with hemotomas on the top left of the, of the slides where you see a patient over here that has had what's called an extradural hematoma to bleeding um outside the jurors outside or the lining of the protective lining of the, of the brain and that's causing pressure on the remaining brain underneath. So over here, um we can also have bleeding that's in the subdural space. So just underneath the dural, the outer layer of the meninges. Um and again, with that also can cause pressure on the rest of the brain. And we do see that here. Um we can also bleeding inside the brain, parenchyma, the brain tissue itself. Um and that leads to brain contusion. So, basically bruises across the brain like everywhere else in the body. And the issue with this is that they can swell um and put a lot of pressure on the surrounding brain tissues um going forward. Um And so the patient here has bifrontal confusions um that can be seen here as this hyper dense area in the frontal lobes. Um They can also be subarachnoid hemorrhage. So, bleeding in the subarachnoid space um due to trauma, um of course, you might have heard of subarachnoid hemorrhage do two aneurysms or kind of non traumatic forms. Um, but trauma can, is also one of the causes of this. And finally, on the right hand side of the screen here, we see a scan that you might think doesn't look that normal. But, um, it's a scan that looks a bit fuzzy. Um, and some of the traumatic brain injury can lead to kind of shaking of the brain and basically some small microhemorrhages and ruptures or small axons and vessels. Um And this is a type of TB I called uh diffuse external injury, which is actually quite a severe um injury um in itself. Um So just this is just a highlight to you that TBI is not just one condition. Uh There is a variety of ways in which patients may present. Um and these can, can co exist as well. So patient may have um affect, here's scans upward characteristic for, for an individual pathology, but patient may have more of these in combination. Um and as well as different types of TBI. It's happening in combination. Um patient's with traumatic brain injury can also and often do have um other systemic injuries as well because of the fact that they've had a trauma, an important thing to note about TBI and why we talk about it, why I think it's important for you to, to learn about it and recognize it early is that um we often cannot reverse the primary injuries. So the injury that's happened, the bleeding that's already happened when we see a patient, that's not something that can be undone. Um But what we need to do is to try and prevent any further injury down the line that may happen because of ongoing mechanisms and going ongoing pressure to the remaining brain tissue, for example. And so, recognizing a TBI early um is really important so that we can start treatment early, uh whatever that may be both medical and surgical as, as we'll discuss um and prevent the brain getting more injured. Um Down the line. Um How does to be a happen? So why does that get the brain get injured? Um If there's bleeding, if there's pressure, um well, um the most common type of brain injuries, often head trauma. So maybe a blunt injury. So somebody gets hit on the head or somebody falls um and hit the head on the ground or even penetrating injuries that in the UK are not, not very common, but in other parts of the world are uh such as gunshot wounds, for example. Um And when, when something hard hits the brain, um then this leads to a um brain dysfunction. So basically the brain moves within, within the skull itself, sometimes it breaks in the bone as well, but breaks in the skull that lead to vessels rupturing and bleeding, taking, taking place. Um And the overall functioning of the brain gets deranged, often TB associated with a lot of consciousness at the time, which basically is a representation of dysfunction and um of the normal brain functioning. Some patients may recover and kind of uh they just have a transient episode of um of unconsciousness and then they wake up, but in more severe forms, um they remain in a state of not being conscious in terms of pathophysiology and mechanisms um down the line. So what happens after the initial injury? So what happens after the initial hit to stick in place um on a more molecular and kind of cellular level um is that the brain has been injured, um injured. Um And the areas of the brain that have been uh damaged, put under pressure because of bleeding, because of swelling, because of edema. Um see some changes in the molecular constitutions of those tissues. Um And there's a number of secondary cascades that lead to um leakage of fluid and leakage of um um uh leakage of substances around the brain tissue leading to swelling disruption of the blood brain barrier, which as you may remember from your early physiology studies in medical school means that the brain is kind of a privileged and kind of protective space compared to the rest of the body. Um And these are, these leads to lots of changes in the kind of normal homeostasis of the brain tissue itself. Um uh And this leads to more damage at the molecular and cellular level uh that then can go onto potentiates and and cause secondary brain injury. And secondary brain injury is really what we try to prevent. Um as I said in our treatment, because secondary brain injury can result in further ischemia, further death of neurons and glial cells, um swelling, further swelling, inflammation in the brain. The important concept that you probably may have also heard in the past before. Um that it also relates to why secondary brain injury happens and why bleeding and swelling inside the inside the brain is very dangerous. Is that the concept of what's called the Monroe Kelly Doctrine, um which is a basically doctrine and and way of explaining how um anything that we increases pressure inside the skull um can have really deleterious effect on to the brain tissue itself as you know that the skull is what protects the brain and what keeps the brain kind of in its own, its own space and normally in a normal tissue in normal, in normal circumstances inside the skull, we have space for the brain who have space for blood, both venous and uh materials. And we also have space for the CSF. But what happens in injuries and trauma is that we have if we have anything that is a new mass or a new something that takes up new space and that could be a hematoma forming, that could be a contusion that could be just swelling because of the brain being um injured and swollen. It means that actually, the skull itself can't expand and therefore, um, more space gets taken up and something has to go. And usually the first things that go first are spaces for the CSF. So CSF gets pushed out, um And blood can also be pushed out. But if that's still not enough, uh then um eventually even the brain tissue will be displaced. And that's usually uh in a very severe sense what we determine as Koning. So when a patient um um is basically um will eventually end up being um uh having a diagnosis kind of brain death because because of increased swelling and there's no more space for, for, for um blood flow and also the brain important structure of the brain gets compressed. Um And so the monarch, any doctrine explains its relationship between what happens when the volume uh tissues inside the skull. Um change, for example, um there's more blood because of a hematoma um and how this relates to pressure. So we know that whenever um something extra is um inside the skull, this study is very rapidly result in increasing intracranial pressure, which is something that we can monitor in our patient's. And we also use to guide our management. Uh This is different to other parts of the body where there isn't a rigid box that's kind of containing those. Um And therefore there is more room to accommodate swelling and injured tissues. So, thinking about all of that, well, what does it mean for a patient. So what does it mean if we see a patient that set A T B I or a brain injury and presents the hospital? Um Well, we have ways of assessing patients' because often because of the injuries that they've had, our patient's cannot tell us what's going on. They may not be able to speak or they may have amnesia regarding the events or they may be so severely injured that they are not conscious and therefore we are unable to ask them any questions. Um So if we think about a patient that may have a scan that looks like this here at the top showing a subdural hematoma that's pressing on the brain and causing mass effect midline shift. Um We would assess that patient expecting that there won't be able to really answer our questions. And therefore, we use a way of assessing patient that is standardized, that means we can assess every patient in a reliable way. And that's called the Glasgow coma scale. Um And the Glasgow coma scale, you as I'm sure you may be familiar with already is an assessment scale that should be reliable. Um And therefore me and you examining the patient should get the same answer. Um And this um Glasgow coma scale involves assessing three key things. Um So a patient I response, voice or verbal response and motor response. Um and we start off from a G C S of 15 which is the kind of normal G C s of somebody who's well um who is somebody who is opening the rice spontaneously, they're looking around. Um They're alert, they can speak. Um So they can have a conversation with you. They are orientated, they can answer your questions. And if you ask the patient to do something, for example, raise their hand or squeeze your hand, they are able to do that and obey that command and instruction without issues. Um But if in somebody who's getting more and more unwell from a brain injury point of view, they will be starting to lose points. And so we have um in the, in the middle of the screen here below, um I've highlighted what the scores of G C S means. So a patient that's particularly well, we'll score top points for eyes, which is a score of four. They're opening the rise in the royal. Um They're orientated when they speak to you. That's a score of five for the verbal response. And there will be obeying commands with a score of six uh for a motor response. Uh But if a patient is not able to do that, then we have to try and understand how well they are. So where do they score on this scale of conditions that I've developed it and outlined here? And so the next best thing we do is we use a pain response. So we cause the patient pain usually by pinching the trapezes or um putting some uh superficial pressure and we see what they're doing in response to that. Um So do the patient's um open the rise when they have a painful stimulus, do they have a motor response that's purposeful? For example, do they try to get to a hand and move it away from them that would mean localized into pain or do they do something that's completely abnormal? Um And so that gives us a scale that tells us how they respond to each of these three components and the maximum messages 15, the minimum score is three, which is somebody who's not doing anything at all. And the other thing that's really important for our assessment is pupil response. So what do the pupils of the patient look like when we shine a bright light with a pen torch um into them? And normally in somebody who's well, the pupils should be symmetrical and they should be reacting to light, meaning that they should constrict. Um if we shine a light, a bright light into them. Um and that's really helpful for us because a patient that may have a unilateral brain injury such as the patient here with the scan, uh may well have asymmetrical pupils because of pressure um has been placed on this side of the brain uh by the hematoma. And so what we might see when we assess the patient like this may be that the pupils on the opposite side of the injury may be reacting absolutely fine. But the people on the side of the injury maybe dilated and fixed and non reactive. And that tells us is that there is acuity going on that there is pressure on the brain that needs to be relieved. And that's a very good indicator for us in terms of how urgent we need to need to act and how unwell somebody is. So that's the kind of most neurosurgeon neurological kind of part of the assessment in terms of G C S and pupils are the key foundations of how we assess a patient with the TBI. Um But we have to remember that a patient that has a traumatic brain injury or TBI is an unwell patient and usually they're a patient that assad significant trauma. Um and therefore, in terms of managing those patient's, uh this is not just done by one individual, but often it's done as a team effort with people with different expertise. Um And this usually is done by what's called a trauma team. So a team of individuals that have different roles in a team um and some will be looking after the patient's airways, um for example, and any cities or an emergency medicine doctor, um and other members of the team will also be looking out for other injuries that the patient may have in the rest of their body. Um and um trauma patient's are usually managed according to trauma principles or 88 E LS principles. Um and usually their assessment for follows a native the approach which I'm sure you're very familiar with. Um in terms of your medical school studies. Uh And in addition to that, we normally focus on what's called a primary survey, which is basically the initial 80 assessments, identifying, you know, any life threatening injuries. Um and once things are stabilized, then there's been more time to complete what's called the secondary service to gather more information around the patient around the injury itself and do a more detailed kind of top to toe assessment about what other things may be going on. The other thing to remember about the 80 assessment that may be different to other a two assessments that you've done on other patient's in in a context of trauma. Is that something that's very important is not only the head but also the cervical spine because the vital spine is the place where the spinal cord will be traveling down to the rest of the body. And um it's a place that is quite prone to injuries in the context of trauma as well. Um and therefore, as well as the standard data, we approach that we may adopt for an and well patient, something that's really important to do in in patient that have suffered trauma uh is to make sure that cervical spine um is immobilized until we know that it's safe to move it. Um and this have highlighted here in ways in which we do that. So the patient here on the right hand side um is placing what's called the cervical collar, uh which is a kind of an external structure that we can use to make sure the patient doesn't move the neck um side to side or too much until we're happy there's no injury going on. Um And we can clear the cervical spine, meaning we can determine its okay, doesn't need any more intervention clinically if a patient is fairly well and they can tell us if they have pain on movement, if they can answer a question and we can test that they're moving their limbs um in a normal fashion. But in patients that are not well enough to do that, we often have to rely on imaging and the patient and, and the scan here on the, on the left hand side of the screen that I've put out for you is a scan of a, a CT scan of someone's cervical spine that shows a fracture. Um um in the middle of the cervical spine, meaning that the spinal cord may also be at risk. And so they may also have a spinal cord injury um as well as a brain injury. Um and then therefore, in that patient is really important that we remember this because um this is another key component that we don't want to forget as well as these more specific things that I've just highlighted about trauma, patient management. Um It's important to remember that really doing the basic things well, is what matters to patient and what changes outcomes. Um, a patient that's very unwell uh and may have suffered trauma, um may well be bleeding from other parts of the body. They may have abdominal injuries, um limb injuries as well. And therefore all these patient's need to be treated in the NATO the approach um focusing on being resuscitated. So if their BP is low, if they are hemodynamically unstable, then we need to make sure that they obviously are stabilized from a point of view of just systemically, not just the brain injury itself. And that is because what we want to achieve in terms of managing brain injuries overall is that we want to try and achieve normal physiology. Um And that, what does that mean? That means that we need to make sure the patient's airways are protected and secured. And we know that in patient's that have a low gcs or are unconscious, they may not be able to maintain their own airways. And therefore, this often means that they may need an intubation. Um We need to make sure the well oxygenated um for general reasons, of course, because they need blood throughout the an oxygen throughout the body, but in particular, the brain itself needs to be well perfused because the brain is very sensitive to changes in oxygenation. And therefore, if the oxygenation overall is poor, then the brain will also suffer. And that can also lead to increased swelling of the brain tissue itself. We also need to make sure that the BP is controlled. Um And it's not too low. So we don't want hypertension. And again, that is because the brain needs a continuous perfusion of blood and oxygen. And therefore, BP is really important in making sure that the brain has uh inadequate profusion pressure. And for similar reasons, we want to make sure that the um uh there's no, the patient is not too anemic. They may well require blood transfusions if they've lost blood. Uh they need to have an algesia to make sure that they are not in pain. And those are all the standard things that you would do for any and world patient's, but they're really important principles to apply um here as well. And in addition to these are some specific measures that we call neuro protective measures um that we use to treat patients with brain injury in particular. And these are measures that in addition to the basics that I've just mentioned, help to ensure the brain stays um in a good physiological state and as protected as possible. And this means doing things simple things such as making sure the patient's head is slightly elevated. So venous return is not impaired, making sure that if there's any colors on the neck, they're not too tight to make sure again, that they venous return from the head is, is controlled to make sure that that oxygenation is good. But also that the patient is not hypercapnic or that CO2 is not too high because again, that can impair um uh that, that can cause more swelling inside the brain tissue itself. Um And all of these things together um are the best things we can do initially to stabilize the patient and give them the best chance of a good outcome. And throughout all of this, the key thing we need to do is to make sure that we monitor a patient's neurology. Uh what does that mean? That means that if the patient is alert enough and awake, then we have to have a regular assessment of the neurological status with the G C S assessments asking them questions, uh ensuring that pupils response remain the same. But if the patient is unconscious, uh and they've had to be intubated to protect their airways, for example, then we may need additional monitoring um to allow us to monitor how their brain is doing. Um And so in the, as I said, in the kind of alert patient that's awake uh neuromonitoring. So are kind of neurological observation involves the same thing as before. So the G C S and the pupil response which will be performed by um the nursing team by the doctors are looking after the patient on a regular interval and any change um in any change in these would prompt a rapid reassessment and potentially new imaging uh for this patient. Um in terms of what we do, um in terms of investigating the patient itself when they arrive, um as any unwell patient, we start simple and we started the bedside. So as I've already mentioned, in terms of the, the kind of treatment that we use in terms of investigations, we want patient's to um have good overall physiology. So we need to make sure that their blood gases are good that they're bloods are taken and they're sent to the lab urgently. We particularly need to make sure that the coagulation is normal. Uh And we know that trauma can deranged somebody's coagulation just from the stress response of it. And so we need to really be careful in terms of correcting that if that's needed, we need to make sure that we have blood available for our patient and therefore take group and say yes and check the blood typing to make sure that we have available resources to give them, should they need to. And then other tests in the uh important thing for, for overall overall care of the patient would be imaging studies. So in particular, in the context of trauma, um and, and TBI, we would look at scanning someone's head. So with a CT scan in the first instance, or a CT of the of the head and cervical spine would be the kind of minimum standard. But often because these patient's may well have had systemic trauma, they will have a kind of head to pelvis scan, which is called a city kind of trauma serious. Uh the invo scan in their head all the way down to the pelvis to identify any other life threatening injuries. And finally, because in terms of the investigation, which I've put here as an investigation rather than as history taking, because it's something that you would do after the initial assessment will be to try and get collateral histories if the patient can't answer any questions. Um for example, from family members that may have information about the pregnancy condition, from anyone that was present at the time of injury that may have seen what happened. Um and that can help us to determine how high risk the mechanism of injury was and also to investigate for a medical record. So if there's any previous record for this patient, that can also be a really useful place to find any relevant information that we may need to know um for treatment in terms of practical consideration. So if you're thinking yourself in the emergency department, seeing a patient that's just arrive with, with uh with the TBI, um the key questions that we should ask ourselves that when we're assessing the patient's are too. So one is in terms of safety. So, you know, where does this patient need to go following our assessment. Are they well enough to just be able to be discharged and go home? Should they stay in hospital and be monitored? Do they just need to go to award or are they unwell enough that they need more critical care settings? They need um to go to surgery, for example? And who do we need to enact our plans? So he need who needs to be involved in the management of our patient's. Um Do we need any other teams? Do we need any other expertise? Do we need anyone more senior helping us? And I think especially at your level as medical students, these like these questions are good questions to think about in any unwell patient that you assess. Um but in particular in the context of a patient with a T B I or a trauma who can be really quickly and well. And so if we think for example, the first example um that I've lined here, so a patient that maybe 23 who's G C S 14, um they've been hit in the head at the pub and we've done a scan of the head showing that have some contusion in the brain. Um What does this tell us? This tells have a TBI, they have some confusions. Um They have been hit at the pub, they may well be intoxicated at the same time. We don't know the GCS is 14. So that's pretty good. They probably are a bit confused and not fully coherent, but they can obey commands and follow our instructions. And so I think that a patient like this clearly can't go home. We need to make sure that we monitor them and make sure that they are observed, make sure that they don't get worse, which they could do in the following hours. So a patient like this to me should come to the hospital, should be admitted to a ward. Um But just in level one standard ward where they can be having observations regularly and we can pick up if anything changes and then uh deal with that as needed. In contrast, the patient below um is a patient who is 32 they've been involved in the road traffic collision. Um They're currently drowsy uh that gcs is 12. Um And on the city head, we also see that they have contusions. Now, this patient, I'm a bit more worried about that gcs is 12. So that's getting lower. Maybe they're not fully able to obey commands, but if we cause them pain, they can move a hand away. Well, maybe are happy with the airways at the moment because that gcs is 12, they're not snoring. Um And we don't think they need immediate intubation, but they're more at risk of getting worse rapidly. And so I think a patient like this to me probably needs a more monitored setting. So maybe they need to go to somewhere such as the at least high dependency unit where they can be observed more closely. Um And if they are to get worse, they're more likely to need further support, for example, with intubation. And so that in this kind of process, um it's important to have in your mind in terms of where does this patient need to be and who do I need to look after them? Um And just two in the last few, last few slides, um I thought I'd just go through a couple of principles in terms of um uh when we talk about TBI and different severity scales. So if we think on the more mild end of the spectrum of TBI, um so patient who, for example, like the first uh example that I gave you a patient who's Jesus 14 confused, they have some injury that we see on the scan, but otherwise there, okay. Um Normally these patient's need to be admitted for monitoring. We need to make sure that they don't get worse because we know they can deteriorate any bleeding is that the brain can get worse. And um a lot of these patient's, although they might be quite well and over time, they may well become fully alert and orientated again, back to the sense of 15, um they may well have ongoing amnesia around the time of the event in particular, um or around the events following the, the injury itself and that's called post traumatic amnesia. Um and these patient's that may have blackouts um or they may well have ongoing issues with their cognitive function, even if more subtle. So there's things that we may not pick up just in a quick assessment. Um And so the important thing to remember for these patient's that they may well need input from other healthcare professionals such as our occupational therapy colleagues and our neuropsychology colleagues that can do further more in depth assessments about the cognition. And it's a movie to remember that even a mile to be high because of these reasons can have a longer term impact if we think about moderate to severe TBI. So these are the patient's like the ones that in the second example I gave you. So somebody who is more drowsy, more unwell, they probably are not really able to follow our commands and sometimes they are so unwell that they require intubation or they require um surgery because of um life threatening um injuries. Um These patient's often need to be admitted to a critical care setting. They often require airway protection because they're too drowsy to maintain their own airways. And in these patient's when we can't assess the G C S and then urology, um by asking them questions and asking them to do things often require intracranial pressure monitoring. Um And our intracranial pressure monitoring is um something that we do as neurosurgeons where um we can insert some monitoring, um catheters inside the brain itself making through making small holes in the bone. Uh And there's some examples of them. So we can insert um parent chemo monitoring. So basically uh small catheters inside the brain tissue that monitors pressure. We can add um there's different versions of those. And we can also add um intracranial pressure monitors that go into the ventricle system. And these is really the way we monitor brain function and brain pressure and how healthy or unhealthy. The brain is uh in somebody who is asleep, uh intubated and ventilated it on sedation. Uh And it's something we do in our patient as a standard method because it helps us to guide how our treatment and it helps uh to guide how much uh intervention, how many interventions we need for our patient's. Um and some of our patient's but not all require surgical intervention, um and surgery. Um maybe in the form of evacuation of a mass lesion lesion such as a extradural or subdural hematoma. Um It may be in the form of what's called a decompressive craniectomy. So making a big hole in the bone to allow for the brain tissue that may be injured, swell and then the bone doesn't get replaced. Um um but it gets left out to allow more room for expansion. Um All we may insert um catheters into the ventricles to relieve some of that CSF pressure um and try to reduce the overall pressure down. So there's various things we can do and not palpate, not all the patient's require these things, but we have to remember that some of them may we'll do um depending on what injury they they suffered. And as I've mentioned to begin with, the key thing to remember is that we need to think about the rest of the body as well. Um So TBI often doesn't happen in isolation, especially when we talk about more severe brain injuries. For example, if the patient's falling from the roof of building, uh they may have suffered a severe TBI, but they may well also have injuries of the abdomen, for example, spleen liver, um they may have bleeding in the abdomen, they may have long bone fractures. And so these are all things that have to be dealt with at the same time and require a team effort. Um And this is what I mean by the context of polytrauma. So, so lots of the patient's that have severe brain injury may well be polytrauma patient. So they may have 123, multiple injuries that all require different levels of intervention. And so when we think about all these patient's, we need to keep, think about what other clinical priorities. Um So the brain often does come towards the kind of forefront of these priorities because we need to ensure that that's um that's dealt with acutely. But some other times um there may well be other injuries are more life threatening for example, a patient with an open um uh an open fracture that's bleeding out clearly, that needs to be addressed initially, you know, acute hemorrhage will be something that kills a patient very early. If that's not treated similarly, bleeding into the abdomen, way will be need, need to be treated as a as a first priority. Um If somebody has uh you know, hemodynamic instability because of abdominal bleeding. Um and really, this is just to highlight to you that although we've talked about neurotrauma today and traumatic brain injury, um any trauma patient should be managed as part of a trauma team with various members of the team uh taking on the, they're part of the um they're part of the body, that kind of they're experts with. So in summary, um what I've covered over the last half an hour or so is I think that um TBI as traumatic brain injury is really a spectrum of disease. Um As I've showed you the beginning, there's there's different types or subtypes of TBI that somebody could suffer. Um both in terms of what kind of part of the brain, maybe injured, but also in terms of severity. Um and patient can be because of this fairly well. So they might look not too unwell. Um and they might able to talk to us tell us things um or they could be really acutely sick. Um and it could be some of the sickest patient in the hospital. And so again, that spectrum has to be um considered when we see a patient in terms of um where do they live on the spectrum and how quickly do we need to act um to treat them? Um And the last thing that I think is one of the key messages is really that all good treatment in terms of TBI starts with the basics and doing the basics well. And those basics are things that you know, from all kind of talks and experience in treating any patient that's acutely unwell. And those are the things that we should always do first um that are really important in the, in the overall uh patient treatment. So that's the end of the talk part of the session. Um I have a few cases um that we can discuss um to apply some of the concepts that we um mentioned in the talk. Now, um theater. Should I carry on or should we take any questions? Now, I'm not sure, very happy for you to carry on, Sarah. I'm sure the questions will come in as part of their cases. Ok, great. Um Perfect. So um I hope that that was useful as, as a overview of neurotrauma in TBI in particular. Um And I now have just three cases that we can run through um to hopefully apply some of the things that we've seen and some of the principal that I've discussed it in the talk. Uh it's not a test. Um So um I think you can all kind of right things in the chat. So please do try and participate. Um And these are just really a way to try and consolidate some of those principles in a more applied fashion. Um So if we start from a first case, um uh I'll tell you a bit of a kind of background of this patient. So um if we think about this patient who is somebody who's 42 there were a cyclist and they were hit by a van on the bike. Um When the ambulance arrived at the scene, uh the patient had a G C S of eight. And when we talk about G C S, we like a breakdown of that. So we don't like just eight, but we like to know each individual score. So the patient had an eye score of two, meaning that they were opening ice to pain, they had a voice score of two as well, meaning that they were just making some incomprehensible sound to pain and had a motor score of four. Uh meaning that they were withdrawing to pain. Um So overall, there's a number of eight um and that tells us that eight is really the cut off for us when we were concerned for, for, for the patient in particular, we think that they are quite unwell because of the fact that the paramedics had concerns about the airways because of the low gcs that were intubated at the scene and they were brought to the emergency department recess um to be assessed when they arrived, the pupils on the assessment, we're both small. Uh There were three millimeters on both sides and we're reacting to light. And we also on the observations noticed that the patient was hypertensive. Um So my questions, I guess, you know, if I think about this case would be, what is there anything, you know, are you concerned about this patient? Um If you are, are you concerned about anything in particular? Um And you know, how might you go about assessing this patient? Um I don't know if I can uh wait a second for people to add some suggestions. Um And then I'll talk through sort of the um what I think I'm worried about and what I think we should do for this patient. But I'd like to hear um what you think normally takes a little bit for their messages to come through. Okay. Oh, great. Some messages that started to come through. So fantastic. So Katia says um uh cervical spine uh stabilization is needed. Yeah, absolutely. And they need fluids, increase the BP. Yes, you've, you've highlighted two key things. So it's a trauma patient that GCS is low. Um We talked about um 80 assessment in trauma and you remembered correctly that we need to think about cervical spine. So, absolutely. So I would hope that when they arrive with the ambulance crew, that they would already be um immobilized in term of the cervical spine. But if they're not, then we should do that. And I agree with the hypertensive, then we need uh fluids to increase the BP. Uh And we might also be thinking about taking bloods um to make sure that we can cross match their blood in case they need transfusions. Um Somebody is also mentioned, worried about the cognitive functions. Yet I agree. Um At the moment, I think they're too unwell for us to be able to say what the cognitive fashion will be later on because they currently are unconscious. The G C S of eight or less for us is what we classes, they're in a coma. But I agree. I I uh long term, I'd be worried about them having cognitive issues um if they survive the injury. Um and then somebody also said glucose needs to be checked. I agree. Um So, um as well as trauma, we obviously need to make sure there's nothing else we're missing. Um And so informal in terms of our A two assessments, we, we obviously have to do all the parts of the HOA assessment, including checking the glucose and all the electrolytes and everything else um that we should correct. Um And in terms of how you assess the patient. So some, so Catty mentioned, maybe they need S A P monitoring. I think that's a really good thought because at the moment this patient is in our emergency department, they are intubated. Um, and clearly they are too unwell for us to probably wake them up now. And so we have to be thinking a step ahead. So where are they going to go and what do they need? And I agree that I think they're likely to need intracranial pressure monitoring because we can't really assess their neurological status. Now, they're asleep, they're intubated, they're sedated before that I think um what we need to do is get some more information. Um and we should stabilize the patient's first, like you guys have said, in terms of doing NHP assessment, checking all the things that we should correct um and make them hemodynamically stable enough to then take them to a scan. Er um so that we can scan their head and also the rest of the body and identify what kind of brain injury they might have because based on the history of being a cyclist hit by a van, the fact that the G C S was low, we are very concerned that they may have a severe brain injury. Um And I agree it may well be that they may need monitoring um going forward. Um So um when they arrive in our emergency department, we do a bit more of the assessment. Um So I've broken it down for you in the um in the 80 kind of fashion. Um So if we do the assessment and check the things that we've mentioned, including the glucose, um We know that they're intubated and ventilated, they have bruises on the left side of the chest. Um The shots are okay, but they're quite on quite a bit of oxygen on 60% oxygen, the BP, his head is a bit low. We're giving them some fluids. Uh There's no obvious external bleeding that we can see. Um So no blood on the outside. Uh and they currently are intubated and sedated and therefore at the moment, the G C S is three, uh which um is completely normal in somebody who is intubated, sedated and ventilated because we are giving them medication to keep them asleep. But we have to remember what their initial GCS was. The pupils are still small, we check the glucose, we check the temperature, their temperature is a little bit low. Um And in terms of other assessment, of course, we have to check for any other life threatening injuries and what we noticed that the abdomen is distended but soft and the left lower limb is deformed, doesn't look in a completely normal shape. So, in based on this assessment, um, do you have any other particular worries? Um I know we're worried about brain injury because that's the concept of the, well, the topic of the talk today. But does this assessment worry you about anything else that may need attention? Um Yeah, somebody said cool peripheries that that's a concern, especially in the context of somebody who has a low BP there, a trauma patient. Um uh we may be worried about bleeding. Um And we may be worried about internal bleeding. Uh I told you that we can't see any blood on the outside. Uh But um I would be concerned that on the assessment, um I can, we can see that the patient has bruises on the left side of the chest. Um And they have a distended abdomen and they have a left leg deformity. Um So my concerns maybe, are they bleeding into their chest? Do they maybe have a hemothorax? Um They may have well have had reaped fractures uh that are causing bruising and bleeding on the, on the left side of the chest and they may have bleeding inside their lung. Um that in the left lower willing limb that's deformed, we could have bleeding inside their limb compartment as well. Um So that's one of the concerns that I would have. Um somebody's mentioned also hypothermia, that's a really big concern as well. We know that um low temperature is not good in terms of acute, being acutely unwell. Um It can affect clotting negatively in particular and certain, therefore, we don't want patient's to be cold. Um because uh that can lead to more issues in terms of coagulation status and our patient's may become coagulopathic, um which is obviously a bad thing to, to happen in the context of bleeding in trauma. Um So I agree with you, I think these are all, um, worries that I have. Um, and in terms of the neurology and my concern that the G C S is now three compared to eight. Um, no, and that's because this is just the effect of ask, giving them sedation. Um And we're doing that on purpose. Uh But in terms of what we do next, I think based on all these things, we have to stabilize them. Um, as we've discussed and then we need more information in the form of um imaging to determine where, what, what particular injuries are they having. We have our own concerns from our assessment. We need um peripheral, we need more objective evidence. And so if we scan the patient, um these are some of the things that we see on the scan. Um Does anyone want to try and suggest some of the things that you think are wrong? What do you see? Um Yep, there's a nasty femoral fracture that we see on the, on the X ray. Absolutely. So that's a concern because some that could have vascular compromise, the patient could be having bleeding from that. Yeah, there's also pelvic fracture. Absolutely. Completely agree with that as well. So that's another concern because somebody can lose a lot of blood in their pelvis. Um What about the brain scan? Are you happy with this? Um, are you worried? But maybe you're not sure exactly what's wrong. So I'll give you a hand. Um, so, um, on this CT scan, I've given you a couple of, um, uh, slides of that. Um, I, I agree. So somebody's just mentioned some edema. Um, so I think there's probably a bit of swelling. Um, I agree and there's also some small areas that are scattered, uh, that I'm just pointing, uh, to now in terms of with my arrow here, here and here, uh there is more areas of hypodensities which probably suggest acute bleeding. Um And because he's a scattered, the things that we see are that there isn't a big hematoma that needs surgery compression. We can't see a big, a big extradural or a big subdural, but we see a number of small hemorrhages. Um And maybe a scan that shows a bit of a dumb a and some kind of fuzzy appearances. And these are concerning for uh more diffused kind of injury in the brain. Um Meaning that the patient may well have ongoing brain swelling um and requires, as we mentioned before and somebody mentioned already before, um some intracranial pressure monitoring to keep assessing the pressure inside their head and make sure that it doesn't rise to greatly. So the patient gets admitted to the intensive care unit. Um because of this number of ridges that they had and we insert an ICP monitor uh to measure their intercranial pressure and the measurements that we get after we insert the monitoring um is a management of 28 millimeters of mercury. Um Now, we've not talked a lot about ICP and intracranial pressure um in the talk in detail just because I think it's likely beyond the scope of, of the kind of talk on the kind of principles of, of neurotrauma, but a number of 28 is high. So we would expect normally an intracranial pressure to be less than 20 in somebody who's asleep and kind of lying down and, and you know, in a kind of normal state of just like being calm, I would expect probably a number between kind of 5 to 10, but anything that's above 20 we think it's kind of abnormal and, and, and too high. Um and here on the right hand side, just for your own reference because I'm not sure if you've ever seen any intracranial pressure monitoring. This is the curve that we see on the monitor and the monitors get connected up to a kind of monitoring screen. And so they, they run like an E C G or, you know, an EKG monitor or like a blood continues BP monitor. And this is what a normal curve of ICP looks like there are three peaks and the first one is usually the highest one and that's a normal shape. Um What happens when the ICP usually rises and becomes higher and often that's due to kind of increase swelling and um and changes in the dynamics which the curve often shift to a system that's less compliant to changes in pressure. Um And so we see this curve shift slightly to um this opposite shape. This is not something you need to know for your medical school exam. So don't worry. Um but I just thought that it's something that in case you're interested. Um I just highlight it there in terms of C P, I think this number is high and I think this means that we need to treat it further. Um and to treat it further, there are things we can do medically. So based on the scan of the patient, um we saw there's no big mass effect from any hematoma. So we can't just go and remove hematoma to make the pressure lower. And so we normally treat sp medically with more medications, more medication to keep the patient well, sedated, make sure that the oxygenation is good. Um Make sure that we do all the neuro protective measures that we mentioned earlier in the talk. And there are other things that we can do um increase in increasing levels of um in in invasiveness to try and reduce the pressure. The concern if, if we don't leave, if we leave the I C P too high and untreated is that that will eventually uh lead to further brain injury and will lead to uh poor perfusion of the brain with blood and that will eventually lead to ischemia, which often leads to more swelling and then perpetuates the cycle of uh of rising ICP. So let's move to case number two. Um maybe a little bit more, um, uh straight forward in terms of pictures. Um And in terms of maybe assessment now that we've done a case already. So now we, we've got a second patient. Uh and this patient now is a woman who's in, this is who's 70 and she fell under stairs. Uh An ambulance was called um and she, when the ambulance arrived, assessor, she had a large bruise on her scalp. How G C S initially was 13 was the three. So she was opening eyes to voice. Um She was V force meaning that she could speak but she was confused and she was M six. So she was obeying commands. Um two instructions and she was complaining of a headache. She arrived in the emergency department. Um And after a while when she was in the emergency department, she became more drowsy and high gcs dropped and it dropped to 10. Uh She now was not obeying commands anymore. She was localizing to pain. Uh She started to be able to only say a couple of words but no complete sentences and she now was only opening her eyes to pain. And when we assessed her pupils, we saw that her left pupil was dilated uh compared to the right side and was less responsive to light. Um So we rushed into the scan, er to the CT scan and this is what we see on the scan. Um Does anyone want to suggest what, what you think diagnosis is here on the CT scan? Um and maybe see if you have an idea of these kind of type of the questions that I've highlighted in red here. Um Do you have any idea about, you know, what do you see? Why do we think she was a? Well, initially, um how do you think she sustained this injury? Good. Somebody said there's a left sided um epidural or extradural, whichever time you want to use um hematoma. That's exactly correct. Um So yet somebody else said the same thing well done, that's the correct answer. Um It's a cute because it's very bright on this, on the CT it's hyperdense blood. Um And uh that's what's causing the patient to be unwell. Um And why do we, do we, do we have any idea about why she was? Well, initially, what, what kind of why do you think that she wasn't immediately unconscious like she's now. Um And do you know how a hematoma like this may happen? Uh What do you think has happened to this lady to cause it to bleed? Um Yeah, that's good. Some good suggestions coming through. So, yeah, so the bleeding doesn't all happen all of a sudden. So um usually the extradural hemotomas are caused by uh bleeding in extradural vessels. Um for example, the middle meningeal artery is one of the common um uh blood vessels that causes extradural hematoma is, but it's not the only one and they may well be associated with the skull fracture and offer us more uh more fracture of the skull may tear a vessel leading that to bleed. Now, the term extradural means that the bleeding happens outside of the juror. Um And normally normal circumstances, the reason really space between the juror and the inner table of the skull. Uh There's a kind of a potential space that only gets formed in, in cases of pathology. Um And therefore, initially, uh the bleeding is very small and it's contained because the Dulera is pressed against the bone. Um and therefore, the bleeding will be small and small and small, but because his bleeding are often material in origin, um they are quite high pressure. Um And as within time as the vessels continue to bleed, um the hematoma will start to expand and share the jury away from the bone itself. Uh And that's why the patient deteriorates later. Um So, um there was a good suggestion and I'm glad that it was picked up and that's why I think this patient presented in this way. Um We also noticed that the patient has a unilateral pupil that's dilated and not response ing not responsive. And we have to think about what does it mean what's, what's the, you know, what's the significance of this? And um the significance of this is kind of partly explained by this diagram that I've highlighted here. That's very kind of a schematic representation of what happens when there is a hematoma that's putting pressure on the remaining brain tissue. Um So, because of, as we said before, the monarchy doctrine and the fact that the bone of the skull contains the brain um as as a box, if there is something that's expanding, such as a hematoma and it's getting bigger and bigger with time, this means that it's putting pressure on all the structures underneath it. Um And for a hematoma, it's unilaterally, it starts to push the brain tissue to the contralateral side and a blown pupil or a pupil that's dilated and unresponsive to light um is often assigned that that pressure and that shift um caused by something that's a mass effect, mass and mass lesion is getting worse and it needs urgent intervention and that's usually caused by um the uncle. So the middle component of the temporal lobe been pushed underneath the um over here um to to the middle um to the contralateral side. Um and that causes um pressure on um cranial nerves and therefore, that leads to um a blown pupil. And so that's really relevant for us to know that this patient has this clinical sign because it means that the, the hematoma in the pressure, it's li is getting to a critical point where if we don't do anything rapidly, then the next steps after this, everything gets moved to this side is that this will keep getting bigger and then the patient can eventually um have herniation that happens downwards through the Foramen magnum, which is the only opening um in the skull um in itself. Um And if that happens, that's what we, what we call koning. So the brain stem and we push through the frame and mark and that will lead to ischemia and that unfortunately leads to, to death. And therefore, we need to treat this um a toma rapidly drain it, reduce the pressure to prevent the patient from deteriorating further, which can ultimately lead to, to them dying. So, with this in mind, um do, do you have any suggestions about what you think this patient needs um in terms of treatment as well as all the general things we talked about before yet. So somebody suggested a bubble to drain the, the hematoma. Um So that's a good suggestion. Um I would go a step further. I think this patient needs a craniotomy. Um So bare hole is just a one hole in the bone, which is a very kind of immediate life saving procedure. But if we think this blood is all acute, um and it will be a big clot, it'll be very um uh it won't be liquid, it will be, you know, blood that's clotted is quite uh solid. Um And so it will be really difficult to evacuate all of this through just one small hole. So I think what this patient needs is a craniotomy. That's basically an operation where we make a bigger opening in the bone, uh probably relieve sort of make an opening the size of the hematoma in the bone, uh to then allow us to wash away and drain the hematoma, which is um you know, it's, it's often solid at this stage. Um make sure we've taken away all of it or as much as possible and relieve the pressure um and then possibly put the bone back into place. Um if the brain underneath is not too swollen, but sometimes we have to leave the bone flap that we make out in cases any more severe swelling underneath. But I agree in principle, I think this patient needs urgent surgical intervention um to relieve the hematoma, wash it away and relieve the pressure from the, from the brain underneath. But um as everything, uh there's a little bit of extra information that we need to address. So we have a next of kin as we are assessing the patient and we get a bit of medical history as we are assessing them and getting them ready for surgery. And we notice that in the medical history, the patient is on Warfarin for atrial fibrillation and they have some gold in the medical history. To, um, what does it mean for us? Does it mean that we shouldn't do the surgery? Um No, we should still go ahead and do the surgery, but we need to be careful about how we do the surgery safely. If the patient is on Warfarin, we expect the clotting to be abnormal and the iron are to be high and for them to be obviously more prone to bleeding, maybe that's why the bleeding was severe in the first place. But if we were to take them to theater to theater for surgery without correcting the abnormal bleeding, uh we would be in a big trouble because we probably wouldn't be able to stop bleeding from even the skin. Um the patient may lose a significant amount of blood and we wouldn't be able to get good hemostasis at the end, which is really important to make sure that bleeding doesn't um happen again or recut. So I think this matters and that's why history and finding out information is really key because in this case, we notice the patient's on Warfarin. So we need to act on it and we need to act on it quickly. Um And in terms of acting, acting on it quickly, this means involving the hematology team. Um And sometimes if the patient is losing blood from elsewhere, also alerting uh the kind of blood bank to instigate hemorrhoid protocols and make sure we have blood available uh to give the patient specifically, we need to reverse the effect of the Warfarin. Um And that's done through administering um specialist medication to, to, to reverse the effect of that. And we need to have proversity of it, quick, fast to make sure that we can take the patient to theater safely without delays. And that's not something that a surgeons we do ourselves. And therefore, this is really one of the other examples where we need to involve other team members. We need the hematologist to tell us exactly what they think we should give the patient. How much of what we, we know the patient will need more than just red blood cells. They may well need um uh for the blood components to address the um all the components of the of the clotting that maybe well deranged. Um And so that's just a fact to highlight that this is very normal, this happens in day to day life and we have to be alert to the fact that we have to think of the whole patient and not just the injury itself. So the patient comes to surgery, we correct their clotting. Uh They um we evacuated the extradural hematoma and after the operation, they improved, they extubated and the G C S improved to 14. So they're just a little bit confused after the operation. Um But that's a really good outcome. Um What if instead of the scan that I showed you earlier with the extradural hematoma the patient's can initially showed this that I'm showing you down here at the bottom. Um What do you see on this time? Do you see a different diagnosis? Um Do you think there's anything different? Good? Somebody's suggesting this is now a right side, it's subdural hematoma and that's correct. Um So instead of extradural hematoma, we now can tell this is subdural hematoma because the shape of the blood bleeding is now different. Um It's not confined by suture lines and it's spreading across the whole complexity of the um of the brain tissue itself. Um It's still causing a lot of mass effect on the rest of the brain. We can see the midline here that should be nice, symmetrical um uh symmetrical space in the brain. Uh But now we can see that the brain has all been pushed to the opposite side. Um These are the ventricles and we can see the ventricle on the side, the lateral ventricle on the side of the bleed has been completely squished because this bleeding is putting a lot of pressure on the on the brain underneath. So this is a different kind of pathology. It's a different type of TBI and the mechanism of these usually um involves venous bleeding rather than arterial bleeding. Um And because in the subdural space, there are some bridging veins which can often be uh torn um in the case of trauma. And this kind of bleeding is more common in patient in sometimes elderly patient that have more, um, a little bit of brain atrophy, but also in the younger patient that have quite high impact, um, quite severe injuries. And in terms of what you know, is this any different in the acute setting? Uh, not really, we still need to take the patient to surgery. We still need to evacuate the bleed and relieve the pressure that the bullied is causing on, on the rest of the brain. But in terms of longer term outcomes, we know that patient with this kind of some hematoma may well have more underlying damage to the brain tissue itself. And so we have to remember that they may have more severe and due to the brain tissue over here because of higher impact of trauma that we may not see just now. And so we have to bear that in mind in terms of the outcomes going forward. And finally, um let's conclude with the last case for today, um which is now a case of a patient who is 27. Um It's a 27 year old man um admitted to E D after a fight. Uh They are currently intoxicated and they have bruises around their face. Um They currently are G C S 14. So they are alert opening arise. Um They are confused um and they were being command and they had one episode of vomiting. Um So if you saw a patient like this, um would you have any concerns? Um And is there anything that you would like to do for this patient? It's a little bit different to the other two, I guess in terms of how unwell they are, but still, um, yes. So somebody's suggesting facial bone fractures. That's a really good thought. So I told you they have bruises on their face. So we need to think about injuries to the, to the face and bone and facial bones as well, um which may well be severe and may well need treatment. Absolutely, completely agree. Anything else? Yes, somebody mentioned toxicology screen. Yes. So, so I told you they're intoxicated. Um and that complicates the picture a little bit because we don't know um if the confusion is due to the fact that they had a brain injury or to the fact that they are intoxicated and we also don't know if there's any kind of other substances they may have taken as well as for example, alcohol for their intoxication. So I agree that's a really good thought. Um And we also talked about so there's more suggestions coming through in terms of imaging, um which are all good suggestions. Would they may well have facial fractures? We obviously, I don't, I haven't told you anything about the rest of the body, so they may have other um other injuries too. So I think scans are definitely a good idea. So if we scanned them, we see some fractures around their nose. Um and particularly looking at the scan of the head because we're in a neurotrauma talk. Uh This is what we see. Um Do you have any suggestions of what you see on these, on these um CT scans? Um What can you see? Um So somebody is suggesting concussion. Um I agree the patient is definitely concussed, but I think the scan shows a little bit more as well than concussion. So concussion usually is the kind of more milder end of the spectrum where a patient has uh potentially loss of consciousness. But on a CT scan, we often I don't see um acute intracranial um uh bleeds um as well as that. So I agree that patient probably has been concussed when they, when they were punched and hit their head. But I think the other thing that we see on this can hear um is some eras of contusions. Um So these areas that are hyperdense uh in the frontal lobes on both sides um that represent bleeding. So bruising inside the brain tissue and the area surrounding that are probably some earlier Dema that's developing around the concussion, around the contusions um that we see on both frontal lobes. So based on this, um I think the patient needs to be admitted, um they obviously are awake at the moment, which is good. Um But we need to keep observing them because based on this scan, showing contusions, we know that this can become bigger or blossom over time so they could get bigger in size. The patient could start to get more pressure on the rest of the brain based on this contusions. And there's also a risk of other events happening such as seizures, um such as, um, you know, getting worse overall. So in the second day when they're being observed, they get more confused there a bit more aggressive. Um and they start to get a bit more drowsy, um, suggesting to us that he's getting worse. Um And if we think about where the contusions are, so they're in the frontal lobes bilaterally, that actually can explain the fact that they were seeing now some kind of personality change with some aggressiveness, um and more confusions, um which, um fits with the picture of what we see on our scan. But now the patient is on day two, uh, they're getting worse clinically and they're on a ward. And I think in a painting situation like this where somebody's admitted and it's getting worse clinically, then I think we need to repeat some more imaging, I think to see, um, if we now are faced with another kind of evolution of the injury, um to begin with. Um And if we see that there's any big increase in the, in the contusion, the patient may well need surgery. Otherwise we'll keep monitoring them. The other thing that can happen in this kind of patient's is that they get more prone to events such as seizures. Um and in this case, the case of this patient on the and that they're following this, they start, they have a seizure which they are not going to have it in the, in, in the medical history. Um they have a tonic clonic seizure that tell minutes on its own. Um Does this matter, do you think this matters? Um and if it does, um would you do anything with this patient that s now had a seizure? Um Do you have any thoughts about it? Mhm So I'll give you a bit of hand in with these questions. Um So um seizures are not uncommon after brain injury. Um We don't fully know exactly who gets them and who doesn't, but we know that a number of patient's do have seizures and the reason that they happen is often to do with the brain being injured. And so that can alter the electrical activity. Um making patient's prone to seizures, the cortex, in particular, when there's contusions, especially in the cortex, these areas can be quite epileptogenic and therefore injury um can be um and trauma and the injury itself can lead to abnormal activity uh that can lead to seizures. And in terms of what we do for those, if we see somebody have a seizure in this case, it's terminated on its own. So it doesn't need any immediate treatment to make it terminate. Um such as Benzodiazepines but once somebody has a seizure, then we need to give preventative medications to make sure that the seizure doesn't happen again. And so in this case, we will start a patient on an anti epileptic medication. For example, Levetiracetam is one of the common ones that we use nowadays, but it depends a little bit on which hospital, etcetera. Um And so we would have to initiate the patient on treatment for that to prevent them having seizures again. And the implications of seizures is that if somebody has a seizure, they obviously they may be more prone to having more in the future and thinking longer term in terms of when the patient recovers. Um Anyone, once they're well enough to leave hospital and go home, we'll have to think about longer term implications such as them not being able to drive for a longer period of time. Um and give them advice about seizures, medications and when we need to um re address those. So that was the last case. I've got one final slide that I'll leave you with tonight because it's something that when I was in some similar teaching with other medical students, they thought it was really helpful. Uh So we talked a lot about brain scans and especially CT scans and how to interpret those. Um And I'm not sure how much um teaching you've had in terms of interpreting CT scans of someone's head. You may know plenty some of you especially earlier in medical school may not have seen many. Um And so I think that it's good to have a system, like it's good to have a system for most things. You probably all have systems to interpret chest x rays. Um But there's a simple system that can help you interpret a city scan that you may not be familiar with. Um And it has a helpful acronym um which is blood can be very bad. Um And each letter, each word has a kind of the first letter stance. One thing that you should look at in a city scan um that you can describe when you're interpreting it to make you sound um organized and you know what you're looking for and uh to make sure you don't miss anything major. Um So the first be uh stays with blood. So we want to look for any, any scan for somebody who's acutely and well, we look for acute blood on a, on a CT scan. And as you said before, acute blood looks bright. Um So if we take this scan here for it as an example, um we can see acute blood um around the basal systems and in the subarachnoid space. Um And this suggests that this patient has had a subarachnoid hemorrhage. Um So that's one thing. So we've looked for blood. The second thing that we can look for in a CT scan um is uh system's so the systems are CFS space is usually around the mid brain and brainstem. Um And this is a normal CT scan that I've put just an example. Um So these areas here around the brainstem uh that should be black, they should have CSF in them and we should be able to see some CSF in that space. If we can't see any CSF anymore, then usually that's a sign of compression, meaning that something is putting too much pressure on the systems in the brain. And some of the CSF have been um squished a way to make to, to kind of reduce the overall volume. Um And so, not seeing basil systems um is a sign that something is not, not quite right. The second B stands for brain. So we want to look at the brain tissue itself, it's the brain parenchyma. Um And in particular, we look at a few things we should look at symmetry. So the brain should be symmetrical, the right and the left side should be the same. We can look at sulka and gyrate. Um And although CT scans are not as good as MRI scans, we should be able to see a slight difference in the cortex and the subcortical tissue. Uh and if we see something in one area of the brain that looks asymmetrical, that is causing soccer injury to be to be different, and then it's something that we can comment on uh V stands for ventricle. So the ventricles So the fluid spaces in the brain uh here, we can just see the temporal horns uh of the lateral ventricles and the fourth ventricle here at the bottom. And again, in terms of ventricles, we want to look at size and symmetry. So some of the scans that I showed you earlier when there were bleeds and causing mass effect, some of the ventricles were faced or squished. Um And now they looked asymmetrical Um and the last B is to look for bone. So CT scans, normally we look at them like this in the kind of brain window. So in the in the era that we look at brain tissue itself, but we can also change that to look at bones. Um And as we talked about before, sometimes fractures in the bone can lead to bleeds inside the brain. And we want to know if there's any fractures. And so whenever we look at CT head, we should also comment on the bone. Um And that's it from me. Um Everything I have for you today. Um I hope it was useful and I'm happy to take any final questions. If anyone has any or otherwise, I'll leave you to your evening. Thank you very much Sara. That was a really interesting and helpful talk and particularly the acronym at the end, the very helpful for future interpretation of CT head. Um If anyone does have any questions, please pop them in the chat. Um And I've also put in a feedback form which is really helpful for us to learn what's gone. Well, what we can improve for future tutorials to make this even more helpful for you. And if you feel that in, you'll also get your attendance certificate. Um But if there aren't any other questions, thank you again, Sara very much. Um And that concludes this tutorial. Um No worries. Thank you very much. Should I stop sharing my slide? Yes, if you're happy to. Yeah. Thank you, Sarah. No worries. Is that the end?