1 00:00:07,200 --> 00:00:09,279 Hi, everyone, and welcome back to another episode 2 00:00:09,279 --> 00:00:11,759 of Amplify. I'm your host, Sam Michu. Thank 3 00:00:11,759 --> 00:00:14,080 you for joining us. Today's episode is an 4 00:00:14,080 --> 00:00:16,824 interview with the author of the February 2025 5 00:00:16,824 --> 00:00:20,265 emergency medicine practice article on traumatic intracranial hemorrhage, 6 00:00:20,265 --> 00:00:21,704 and I think you're going to find this 7 00:00:21,704 --> 00:00:24,184 to be an outstanding interview. I can't wait 8 00:00:24,184 --> 00:00:25,864 for you to hear it. Before we dive 9 00:00:25,864 --> 00:00:28,649 into that, just a quick reminder, ebmedicine.net 10 00:00:28,809 --> 00:00:30,570 is your one stop shop for all of 11 00:00:30,570 --> 00:00:34,090 your emergency medicine and urgent care needs. There 12 00:00:34,090 --> 00:00:36,969 are three journals, emergency medicine practice, pediatric emergency 13 00:00:36,969 --> 00:00:39,770 medicine practice, and evidence based urgent care, plus 14 00:00:39,770 --> 00:00:42,254 all of the courses. There is so much 15 00:00:42,254 --> 00:00:43,934 available to you at the website. I can't 16 00:00:43,934 --> 00:00:45,454 wait for you to go see it and 17 00:00:45,454 --> 00:00:47,614 subscribe today. And don't forget, if you are 18 00:00:47,614 --> 00:00:50,574 an emergency medicine resident, your subscription is free. 19 00:00:50,574 --> 00:00:52,015 Just write us at the email in the 20 00:00:52,015 --> 00:00:53,534 show notes, and we'll make sure that you 21 00:00:53,534 --> 00:00:55,695 and everyone in your entire program gets free 22 00:00:55,695 --> 00:00:57,689 access. Access. And now let's jump into this 23 00:00:57,689 --> 00:00:58,189 interview. 24 00:00:59,850 --> 00:01:02,409 My name is Erin D'Agostino. I'm currently a 25 00:01:02,409 --> 00:01:03,549 neurology resident 26 00:01:04,170 --> 00:01:05,709 at the University of Vermont. 27 00:01:06,569 --> 00:01:08,649 My background is maybe a a little bit 28 00:01:08,649 --> 00:01:09,790 unusual because, 29 00:01:10,295 --> 00:01:13,094 before my career started in neurology, I'm now 30 00:01:13,094 --> 00:01:14,474 two years into that residency. 31 00:01:15,094 --> 00:01:17,494 I did a brief four year stint in 32 00:01:17,494 --> 00:01:19,034 the neurosurgery world. 33 00:01:19,334 --> 00:01:20,694 It took me just a little bit of 34 00:01:20,694 --> 00:01:22,614 time to realize that that wasn't exactly the 35 00:01:22,614 --> 00:01:24,634 direction that I wanted to go in, but 36 00:01:24,989 --> 00:01:27,069 I still I love the content. I'm interested 37 00:01:27,069 --> 00:01:29,230 in neurocritical care, so there's a ton of 38 00:01:29,230 --> 00:01:30,209 overlap. And 39 00:01:30,510 --> 00:01:33,390 this kind of content, especially traumatic intracranial hemorrhage 40 00:01:33,390 --> 00:01:35,310 and the managements are pretty near and dear 41 00:01:35,310 --> 00:01:37,069 to my heart. So I'm pretty excited about 42 00:01:37,069 --> 00:01:38,609 this article. I hope that it's helpful. 43 00:01:39,055 --> 00:01:41,454 Yeah. Now you're one of three authors for 44 00:01:41,454 --> 00:01:42,584 this February 45 00:01:42,584 --> 00:01:43,394 2025 46 00:01:43,614 --> 00:01:46,494 issue of Emergency Medicine Practice. The other two, 47 00:01:46,494 --> 00:01:47,795 doctor Reyes Zargosa 48 00:01:48,254 --> 00:01:49,394 and doctor Siket. 49 00:01:49,775 --> 00:01:50,275 And 50 00:01:50,655 --> 00:01:53,659 this article is focused on traumatic intracranial hemorrhage, 51 00:01:53,659 --> 00:01:55,439 but, really, this thing is like an encyclopedia 52 00:01:55,979 --> 00:01:58,780 of all things bleeding in the brain. You 53 00:01:58,780 --> 00:02:01,599 covered a lot of information, and it's quite 54 00:02:01,899 --> 00:02:04,539 heavy, like, meaty. There is no fluff in 55 00:02:04,539 --> 00:02:06,465 this article at all. It's, like, all things 56 00:02:06,465 --> 00:02:08,465 you need to know regardless of your practice 57 00:02:08,465 --> 00:02:10,224 setting. Is that right? I'm hoping that it 58 00:02:10,224 --> 00:02:13,125 doesn't come across as too nitty gritty heavy. 59 00:02:13,185 --> 00:02:15,425 I love this stuff. I feel like it's 60 00:02:15,425 --> 00:02:18,564 a great example of understanding pathophysiology. 61 00:02:19,185 --> 00:02:19,764 It translates 62 00:02:20,145 --> 00:02:20,965 really nicely 63 00:02:21,610 --> 00:02:23,930 into the clinical management of these conditions. I 64 00:02:23,930 --> 00:02:25,370 think what I did try to dive into 65 00:02:25,370 --> 00:02:28,169 a little bit is how not every brain 66 00:02:28,169 --> 00:02:28,989 bleed is, 67 00:02:29,449 --> 00:02:30,110 the same. 68 00:02:30,409 --> 00:02:31,469 And if you understand 69 00:02:32,009 --> 00:02:33,949 where they come from and why they happen, 70 00:02:34,090 --> 00:02:35,229 you can appreciate 71 00:02:35,530 --> 00:02:37,310 what to expect from them 72 00:02:37,745 --> 00:02:39,444 and how to treat them differently. 73 00:02:39,745 --> 00:02:41,985 The treatments for different types of leads are 74 00:02:41,985 --> 00:02:43,745 totally different, and the expectations for them are 75 00:02:43,745 --> 00:02:44,245 different. 76 00:02:44,625 --> 00:02:46,705 So I'm I'm hoping that some of that 77 00:02:46,705 --> 00:02:49,824 comes across and isn't too heavy. Or Oh, 78 00:02:49,824 --> 00:02:51,360 yeah. Oh, yeah. For sure. I I wasn't 79 00:02:51,360 --> 00:02:53,460 saying that it's a criticism. I'm just impressed 80 00:02:53,520 --> 00:02:55,919 that you were able to synthesize all of 81 00:02:55,919 --> 00:02:58,319 that information into one article. I really think 82 00:02:58,319 --> 00:03:00,719 it's helpful to see them side by side, 83 00:03:00,719 --> 00:03:03,074 different injury patterns, different pathophysiology 84 00:03:03,614 --> 00:03:06,334 for different injuries altogether in one article really 85 00:03:06,334 --> 00:03:08,334 gives me an appreciation for more of a 86 00:03:08,334 --> 00:03:10,655 spectrum instead of just, oh, this is how 87 00:03:10,655 --> 00:03:12,254 we treat this, and then I've gotta go 88 00:03:12,254 --> 00:03:13,854 find some other resource for how we treat 89 00:03:13,854 --> 00:03:16,174 some other injury because it's completely different and 90 00:03:16,174 --> 00:03:16,674 unrelated. 91 00:03:17,080 --> 00:03:18,919 It's nice to see them all in one 92 00:03:18,919 --> 00:03:19,900 article together 93 00:03:20,199 --> 00:03:22,520 and related, but it's rare. I think very 94 00:03:22,520 --> 00:03:24,280 few authors take that approach, and I really 95 00:03:24,280 --> 00:03:25,560 like it. I enjoyed it. I thought it 96 00:03:25,560 --> 00:03:27,879 was very well written. I I appreciate that. 97 00:03:27,879 --> 00:03:30,280 I think it's part of the big thing 98 00:03:30,280 --> 00:03:32,324 that I was trying to tackle is that, 99 00:03:33,364 --> 00:03:34,985 I think there is 100 00:03:35,444 --> 00:03:38,264 somewhat of a misconception on the medical community 101 00:03:38,485 --> 00:03:38,985 that 102 00:03:39,764 --> 00:03:40,745 medical management 103 00:03:41,284 --> 00:03:44,185 of these kinds of injuries is a temporizing 104 00:03:44,405 --> 00:03:44,905 measure 105 00:03:45,629 --> 00:03:47,969 to get to the definitive treatment of surgery. 106 00:03:48,590 --> 00:03:50,830 And far in a way, that's actually not 107 00:03:50,830 --> 00:03:52,830 really the case. The medical management is the 108 00:03:52,830 --> 00:03:53,810 definitive treatment. 109 00:03:54,189 --> 00:03:56,830 Surgery is if all else fails, and there 110 00:03:56,830 --> 00:03:59,625 are actually plenty of caveats to when surgery 111 00:03:59,625 --> 00:04:01,865 does not work depending on what the injury 112 00:04:01,865 --> 00:04:04,205 is and how the pathophysiology is evolving. 113 00:04:04,745 --> 00:04:07,224 So I think that was maybe why I 114 00:04:07,224 --> 00:04:09,084 tried to dive a little bit deeper into 115 00:04:09,625 --> 00:04:11,405 how some of this transpires 116 00:04:11,705 --> 00:04:15,159 because the medical management is in many, many 117 00:04:15,159 --> 00:04:17,160 cases, the management. So it's not just a 118 00:04:17,160 --> 00:04:19,720 temporizing intervention in the ED. That's what gets 119 00:04:19,720 --> 00:04:21,800 continued in the neuro ICU as well, and 120 00:04:21,800 --> 00:04:24,839 surgery is only in the situations that, the 121 00:04:24,839 --> 00:04:27,480 medical management fails and in the right clinical 122 00:04:27,480 --> 00:04:27,980 context. 123 00:04:28,535 --> 00:04:29,814 And I did have fun with I mean, 124 00:04:29,814 --> 00:04:31,014 it's jumping a little bit ahead in the 125 00:04:31,014 --> 00:04:31,915 article, but 126 00:04:32,375 --> 00:04:34,774 I I also do some illustration stuff, and 127 00:04:34,774 --> 00:04:37,415 I had fun trying to simplify what some 128 00:04:37,415 --> 00:04:38,555 of the surgical procedures 129 00:04:39,175 --> 00:04:41,654 are and what they actually do address because 130 00:04:41,654 --> 00:04:42,394 it's actually 131 00:04:42,949 --> 00:04:43,449 fairly 132 00:04:44,069 --> 00:04:46,069 I don't wanna say limited. There are specific 133 00:04:46,069 --> 00:04:48,069 indications for what actually is going to be 134 00:04:48,069 --> 00:04:49,209 helpful for a patient. 135 00:04:49,509 --> 00:04:51,110 Alright. Well, before we get into all that, 136 00:04:51,110 --> 00:04:53,290 tell me about some of the epidemiology 137 00:04:53,670 --> 00:04:55,910 of traumatic intracranial hemorrhage. Is it common? I 138 00:04:55,910 --> 00:04:57,990 mean, working in the ED, obviously, we see 139 00:04:57,990 --> 00:05:00,335 it, but do we have any numbers about 140 00:05:00,335 --> 00:05:02,495 how common it is every year in The 141 00:05:02,495 --> 00:05:02,995 US? 142 00:05:03,535 --> 00:05:06,574 It's exceptionally common, especially if you're considering the 143 00:05:06,574 --> 00:05:08,975 mild range of traumatic brain injury. It's about 144 00:05:08,975 --> 00:05:10,595 two point five million Americans, 145 00:05:11,370 --> 00:05:13,290 that are seen in the emergency department every 146 00:05:13,290 --> 00:05:15,770 year. I mean, it's an exceptionally common thing 147 00:05:15,770 --> 00:05:17,709 that practitioners are gonna see in the ED. 148 00:05:17,930 --> 00:05:20,649 The number that actually are going to evolve 149 00:05:20,649 --> 00:05:24,705 into critical intracranial pressure patients that need surgery 150 00:05:24,705 --> 00:05:27,925 is obviously far, far fewer than that. But 151 00:05:28,305 --> 00:05:30,464 the ability to be able to assess those 152 00:05:30,464 --> 00:05:33,024 patients where every ED practitioner is going to 153 00:05:33,024 --> 00:05:34,944 see and be able to decide who is 154 00:05:34,944 --> 00:05:36,305 at high risk and who is at low 155 00:05:36,305 --> 00:05:36,805 risk 156 00:05:37,110 --> 00:05:39,290 is a skill that every ED practitioner 157 00:05:39,750 --> 00:05:40,729 obviously needs. 158 00:05:41,189 --> 00:05:43,669 So when you were doing research for this 159 00:05:43,669 --> 00:05:44,169 article, 160 00:05:44,470 --> 00:05:46,490 where are we in terms of 161 00:05:46,870 --> 00:05:49,350 literature or body of evidence for these kinds 162 00:05:49,350 --> 00:05:51,589 of injuries? Is it pretty voluminous, or is 163 00:05:51,589 --> 00:05:54,324 it pretty, like, guideline driven? How is that? 164 00:05:54,865 --> 00:05:56,964 The the research on this topic is 165 00:05:57,264 --> 00:05:59,365 tricky. I would describe it as 166 00:05:59,824 --> 00:06:01,745 messy. There's a lot of it. Is it 167 00:06:01,745 --> 00:06:02,485 is voluminous. 168 00:06:03,425 --> 00:06:04,805 The problem is that 169 00:06:05,210 --> 00:06:07,610 the ability to do a randomized controlled trial 170 00:06:07,610 --> 00:06:09,550 in this kind of population is really limited. 171 00:06:10,250 --> 00:06:12,170 The size and scope of different studies, the 172 00:06:12,170 --> 00:06:14,730 demographics are different, what you're qualifying as the 173 00:06:14,730 --> 00:06:16,490 level of injury, what you're qualifying as level 174 00:06:16,490 --> 00:06:17,230 of outcome, 175 00:06:17,884 --> 00:06:19,644 All of those things vary and make it 176 00:06:19,644 --> 00:06:21,185 pretty challenging to draw 177 00:06:21,805 --> 00:06:24,064 real guideline driven conclusions. 178 00:06:24,524 --> 00:06:26,285 So a lot of it is based on 179 00:06:26,285 --> 00:06:27,185 expert consensus. 180 00:06:27,485 --> 00:06:29,904 It's in combination with evidence based research. 181 00:06:30,365 --> 00:06:32,305 Some of the data is controversial. 182 00:06:32,685 --> 00:06:34,629 I mean, it's a challenging thing to be 183 00:06:34,629 --> 00:06:35,829 able to do a deep dive and come 184 00:06:35,829 --> 00:06:36,810 out with really 185 00:06:37,430 --> 00:06:38,490 confident conclusions. 186 00:06:39,509 --> 00:06:41,669 But there are certainly some things that come 187 00:06:41,669 --> 00:06:42,649 through as 188 00:06:43,110 --> 00:06:45,990 clear, and I'm hoping that in this article, 189 00:06:45,990 --> 00:06:48,550 we were able to define what those elements 190 00:06:48,550 --> 00:06:52,004 are. And are there organizations that stand out 191 00:06:52,004 --> 00:06:53,605 as kind of the big players when it 192 00:06:53,605 --> 00:06:55,464 comes to guidelines for these kinds of injuries? 193 00:06:56,004 --> 00:06:59,944 Yes. The Brain Trauma Foundation guidelines are probably 194 00:07:00,004 --> 00:07:02,964 among the most helpful. The CIVIC guidelines, s 195 00:07:02,964 --> 00:07:04,185 I b I c c, 196 00:07:04,660 --> 00:07:08,339 are also fairly clear cut. The major trauma 197 00:07:08,339 --> 00:07:10,980 organization, I'm blanking on what acronym they go 198 00:07:10,980 --> 00:07:13,319 by, also has some pretty clear guidelines 199 00:07:13,779 --> 00:07:15,620 on their page. I would say those are 200 00:07:15,620 --> 00:07:17,779 probably the most concise ones to be able 201 00:07:17,779 --> 00:07:19,745 to go to. Alright. So let's dive in 202 00:07:19,745 --> 00:07:21,125 a little bit of the pathophysiology 203 00:07:21,745 --> 00:07:24,404 of these injuries. What do we know generally 204 00:07:24,544 --> 00:07:25,764 about the morbidity 205 00:07:26,064 --> 00:07:28,004 from traumatic intracranial hemorrhage? 206 00:07:28,625 --> 00:07:30,884 So a lot of this comes back to 207 00:07:30,944 --> 00:07:32,865 the basics of what's referred to as the 208 00:07:32,865 --> 00:07:34,004 Monroe Kelly hypothesis, 209 00:07:34,620 --> 00:07:36,620 which is simple. It's just that there are 210 00:07:36,620 --> 00:07:39,660 three elements within the skull. There's blood, brain, 211 00:07:39,660 --> 00:07:41,120 and cerebrospinal fluid, 212 00:07:41,420 --> 00:07:43,819 and, it's a pressure volume curve depending on 213 00:07:43,819 --> 00:07:45,759 how much you have of those three things. 214 00:07:45,980 --> 00:07:48,074 So if you have too much blood, that's 215 00:07:48,074 --> 00:07:49,754 going to cause you to escalate on the 216 00:07:49,754 --> 00:07:50,975 pressure volume curve, 217 00:07:51,435 --> 00:07:53,935 and it is notable that that's an exponential 218 00:07:54,475 --> 00:07:54,975 curve. 219 00:07:55,354 --> 00:07:55,854 So 220 00:07:56,314 --> 00:07:59,055 adding a little bit more volume 221 00:07:59,435 --> 00:08:01,294 is going to, at some point, escalate 222 00:08:01,675 --> 00:08:02,654 pressure generated 223 00:08:03,035 --> 00:08:05,639 by a huge amount. And that's where we 224 00:08:05,639 --> 00:08:08,199 run into the situation of just a little 225 00:08:08,199 --> 00:08:11,400 bit of extra, for instance, blood prompting something 226 00:08:11,400 --> 00:08:13,100 like herniation clinically 227 00:08:13,480 --> 00:08:16,779 because the intracranial pressure escalates to a critical 228 00:08:16,839 --> 00:08:17,900 point really quickly. 229 00:08:19,004 --> 00:08:21,245 So in some ways, it's simple. And then 230 00:08:21,245 --> 00:08:23,725 if you dive into the weeds, it gets 231 00:08:23,725 --> 00:08:24,545 more complicated, 232 00:08:25,085 --> 00:08:27,165 but it does come back to that basic 233 00:08:27,165 --> 00:08:27,665 element 234 00:08:28,125 --> 00:08:31,085 of intracranial pressure. I don't wanna neglect here 235 00:08:31,085 --> 00:08:32,970 that it's there are three elements of this 236 00:08:32,970 --> 00:08:34,909 equation. It's the medial arterial pressure 237 00:08:35,450 --> 00:08:38,830 minus the intracranial pressure gives you the cerebral 238 00:08:38,889 --> 00:08:41,370 perfusion pressure. And I think sometimes when we 239 00:08:41,370 --> 00:08:43,470 think about intracranial pressure, we forget 240 00:08:43,784 --> 00:08:46,284 about cerebral perfusion pressure as being 241 00:08:46,745 --> 00:08:47,565 a really 242 00:08:48,024 --> 00:08:51,544 fundamental element here. Because, for instance, if you 243 00:08:51,544 --> 00:08:54,825 drop the blood pressure in a patient, sure, 244 00:08:54,825 --> 00:08:57,964 you can reduce the intracranial pressure as well. 245 00:08:58,209 --> 00:08:59,029 But at some 246 00:08:59,570 --> 00:09:01,330 point, if the blood pressure is too low, 247 00:09:01,330 --> 00:09:03,250 you're just not going to send any blood 248 00:09:03,250 --> 00:09:05,830 to the brain, and then the cerebral perfusion 249 00:09:05,889 --> 00:09:07,809 pressure is also going to drop to a 250 00:09:07,809 --> 00:09:08,950 critical low. 251 00:09:09,330 --> 00:09:10,769 And that's going to mean that not enough 252 00:09:10,769 --> 00:09:13,110 blood is getting to the brain. That's critical 253 00:09:13,725 --> 00:09:14,945 hypoxic injury, 254 00:09:15,325 --> 00:09:16,924 and you're going to globally stroke the whole 255 00:09:16,924 --> 00:09:18,704 brain. So in our 256 00:09:19,245 --> 00:09:20,225 battle against 257 00:09:20,605 --> 00:09:22,845 the evils of intracranial pressure, I think it 258 00:09:22,845 --> 00:09:24,625 is really important to remember 259 00:09:25,004 --> 00:09:27,004 that our ultimate goal is sure to keep 260 00:09:27,004 --> 00:09:29,370 the intracranial pressure below a critical limit, but 261 00:09:29,370 --> 00:09:30,970 also to make sure that the brain is 262 00:09:30,970 --> 00:09:32,910 getting enough perfusion. 263 00:09:33,690 --> 00:09:36,649 The classic mistake that happens here is, for 264 00:09:36,649 --> 00:09:37,789 instance, hyperventilation 265 00:09:38,809 --> 00:09:42,029 because that will allow for vasoconstriction, 266 00:09:43,134 --> 00:09:46,514 and that will reduce intracranial pressure because less 267 00:09:46,735 --> 00:09:48,975 blood flow and less blood are getting to 268 00:09:48,975 --> 00:09:51,375 the brain. So by Monroe Kelly doctrine, that 269 00:09:51,375 --> 00:09:52,754 will reduce the pressure. 270 00:09:53,454 --> 00:09:53,954 However, 271 00:09:54,254 --> 00:09:56,174 if you're reducing the amount of blood getting 272 00:09:56,174 --> 00:09:57,794 to the brain, you're also risking 273 00:09:58,179 --> 00:10:01,220 ischemic injury by not getting enough perfusion. And 274 00:10:01,220 --> 00:10:03,399 that is why one of the clearest guidelines 275 00:10:03,860 --> 00:10:06,440 that exists now is that hyperventilation 276 00:10:06,820 --> 00:10:09,320 should really only be used in a very 277 00:10:09,460 --> 00:10:10,759 transitory setting. 278 00:10:11,115 --> 00:10:13,615 Namely, I think that as an intervention to 279 00:10:13,674 --> 00:10:14,414 get someone 280 00:10:14,875 --> 00:10:17,375 to the OR, like a half an hour 281 00:10:17,754 --> 00:10:20,475 intervention just to keep someone from her needing 282 00:10:20,475 --> 00:10:22,335 for a very short period of time. 283 00:10:22,875 --> 00:10:25,115 Yeah. Yeah. That's a critical concept, and I 284 00:10:25,115 --> 00:10:26,014 I really appreciate 285 00:10:27,090 --> 00:10:28,929 the figure. This is figure one on page 286 00:10:28,929 --> 00:10:31,669 four, basic principles of mean arterial pressure, intracranial 287 00:10:31,889 --> 00:10:35,250 pressure, cerebral perfusion pressure has got three images 288 00:10:35,250 --> 00:10:37,110 there. One showing the logarithmic 289 00:10:37,410 --> 00:10:40,529 increase as the decompensation occurs and intracranial pressure 290 00:10:40,529 --> 00:10:43,245 goes up, One showing the relative volumes. You've 291 00:10:43,245 --> 00:10:46,605 got brain volume, 80%, blood volume, about 10%, 292 00:10:46,605 --> 00:10:48,764 and CSF, about 10%. So it doesn't it's 293 00:10:48,764 --> 00:10:50,285 not a whole lot of blood in there 294 00:10:50,285 --> 00:10:52,045 to start with, and it doesn't take much 295 00:10:52,045 --> 00:10:53,804 to push you to that right end of 296 00:10:53,804 --> 00:10:55,990 the curve to increase the pressure. It's a 297 00:10:55,990 --> 00:10:57,910 it's a good illustration. And if you're listening 298 00:10:57,910 --> 00:10:59,750 and have access to the article, that's figure 299 00:10:59,750 --> 00:11:02,790 one. I think that solidly explains the concept 300 00:11:02,790 --> 00:11:04,570 in three images, which I love. 301 00:11:05,110 --> 00:11:06,550 Well, and a fun thing that you that 302 00:11:06,550 --> 00:11:08,710 you can even look at, for example, the 303 00:11:08,710 --> 00:11:12,335 the venous volume is signif it's not nothing. 304 00:11:12,715 --> 00:11:15,195 And for instance, if a cervical collar is 305 00:11:15,195 --> 00:11:17,835 too tight, the venous outflow is gonna be 306 00:11:17,835 --> 00:11:19,595 limited. You're going to increase the amount of 307 00:11:19,595 --> 00:11:21,355 venous back pressure in the brain, and you're 308 00:11:21,355 --> 00:11:22,875 gonna spike ICP that way, and you can 309 00:11:22,875 --> 00:11:26,174 resolve it by loosening the cervical collar. Wow. 310 00:11:26,730 --> 00:11:28,750 Now does this make intracranial 311 00:11:29,210 --> 00:11:30,509 pressure monitoring 312 00:11:30,970 --> 00:11:34,509 a critical part of treatment for intracranial hemorrhage? 313 00:11:34,970 --> 00:11:37,529 Oh, that's an excellent question. The guidelines in 314 00:11:37,529 --> 00:11:40,429 this have actually gotten less specific over time. 315 00:11:40,884 --> 00:11:42,504 I think that the data has shown 316 00:11:42,884 --> 00:11:46,084 that it is helpful in the population of 317 00:11:46,084 --> 00:11:48,504 patients that are less than 65 318 00:11:48,565 --> 00:11:49,464 and with, 319 00:11:50,164 --> 00:11:52,264 GCS of less than eight 320 00:11:52,644 --> 00:11:54,745 in the setting of traumatic intracranial hemorrhage. 321 00:11:55,920 --> 00:11:58,480 It's really a little bit more challenging than 322 00:11:58,480 --> 00:12:00,639 that. It depends on what kind of lead 323 00:12:00,639 --> 00:12:03,279 we're talking about and what kind of exam 324 00:12:03,279 --> 00:12:05,059 the patient has. The reality is 325 00:12:05,519 --> 00:12:06,960 it's helpful to have a number if you 326 00:12:06,960 --> 00:12:08,800 don't have an exam to follow. If a 327 00:12:08,800 --> 00:12:11,575 patient has a followable neurologic exam, 328 00:12:11,955 --> 00:12:14,434 then that's actually potentially even more helpful than 329 00:12:14,434 --> 00:12:16,274 having a strict number to be able to 330 00:12:16,274 --> 00:12:18,595 make decisions based on. But if your patient 331 00:12:18,595 --> 00:12:19,654 has such a low 332 00:12:20,034 --> 00:12:21,735 GCS, such an unfollowable 333 00:12:22,115 --> 00:12:22,615 exam, 334 00:12:23,070 --> 00:12:24,990 Or, for instance, if they're going to the 335 00:12:24,990 --> 00:12:26,910 Operating Room and they're gonna be under general 336 00:12:26,910 --> 00:12:27,410 anesthesia, 337 00:12:27,950 --> 00:12:30,590 there are indications separately to have a number 338 00:12:30,590 --> 00:12:32,509 to follow just to make sure that the 339 00:12:32,509 --> 00:12:34,690 patient isn't having a critical decline 340 00:12:35,230 --> 00:12:37,574 while you can't follow an exam. So I 341 00:12:37,574 --> 00:12:39,674 think that it certainly has its role, 342 00:12:40,294 --> 00:12:42,235 but it's in specific context. 343 00:12:43,254 --> 00:12:45,654 Alright. Let's talk about types of injuries. So 344 00:12:45,654 --> 00:12:48,875 when we're talking about traumatic intracranial hemorrhage, what 345 00:12:49,379 --> 00:12:50,840 types of injuries specifically, 346 00:12:51,620 --> 00:12:53,879 and categories would these injuries fall into? 347 00:12:54,259 --> 00:12:56,019 Sure. I I end up dividing it into 348 00:12:56,019 --> 00:12:58,660 a few different basically based on location of 349 00:12:58,660 --> 00:12:59,160 bleed. 350 00:12:59,620 --> 00:13:02,420 The category of traumatic subarachnoid hemorrhage, I think 351 00:13:02,420 --> 00:13:05,644 of as sort of the most benign phenotype. 352 00:13:06,264 --> 00:13:09,004 I should note that I'm qualifying traumatic subarachnoid 353 00:13:09,065 --> 00:13:11,164 hemorrhage primarily as peripheral 354 00:13:11,465 --> 00:13:14,024 subarachnoid hemorrhage. And when you're looking at a 355 00:13:14,024 --> 00:13:15,544 scan, the easiest way to be able to 356 00:13:15,544 --> 00:13:17,129 look at that is, are we looking at 357 00:13:17,129 --> 00:13:18,269 just on the superficial 358 00:13:18,649 --> 00:13:20,809 surface of the brain along the sulci and 359 00:13:20,809 --> 00:13:22,889 gyri, or are we looking at blood that 360 00:13:22,889 --> 00:13:25,289 goes deeper into the Sylvian fissure, into the 361 00:13:25,289 --> 00:13:26,190 basal cisterns? 362 00:13:26,649 --> 00:13:28,490 If you're seeing blood going deep down into 363 00:13:28,490 --> 00:13:31,285 the brain, it can happen with traumatic injury, 364 00:13:31,285 --> 00:13:33,045 but it would make me suspicious that it's 365 00:13:33,045 --> 00:13:36,085 not truly a traumatic subarachnoid hemorrhage. And I 366 00:13:36,085 --> 00:13:38,424 think that's probably the biggest takeaway from subarachnoid 367 00:13:38,565 --> 00:13:41,465 hemorrhage. Peripheral traumatic subarachnoid hemorrhage 368 00:13:41,870 --> 00:13:44,929 largely is not a terribly concerning finding. 369 00:13:45,389 --> 00:13:46,370 But subarachnoid 370 00:13:46,830 --> 00:13:49,149 that goes deeper than that should prompt suspicion 371 00:13:49,149 --> 00:13:51,730 for there being an underlying aneurysm or vascular 372 00:13:51,789 --> 00:13:52,289 malformation. 373 00:13:53,149 --> 00:13:55,804 And that begs the question, was this spontaneous 374 00:13:56,105 --> 00:13:58,825 with some peripheral trauma? Like, did they have 375 00:13:58,825 --> 00:14:00,904 hemorrhage first and then fall over and hit 376 00:14:00,904 --> 00:14:02,664 their head as opposed to they hit their 377 00:14:02,664 --> 00:14:03,725 head and then blood? 378 00:14:04,024 --> 00:14:07,085 Exactly. The first question that any 379 00:14:07,465 --> 00:14:10,924 ED provider can be asking themselves with 380 00:14:11,519 --> 00:14:13,679 a brain trauma that comes in is, was 381 00:14:13,679 --> 00:14:14,879 it a fall then bleed or a bleed 382 00:14:14,879 --> 00:14:17,919 then fall? And, largely, it's that they fell 383 00:14:17,919 --> 00:14:19,279 and hit their head, and they have blood 384 00:14:19,279 --> 00:14:21,279 related to it. But it's a it's a 385 00:14:21,279 --> 00:14:23,519 critical thing to be able to pick up 386 00:14:23,519 --> 00:14:26,339 that there's something funny about the story. And 387 00:14:26,465 --> 00:14:29,745 I've seen subarachnoid hemorrhages from an aneurysm cause 388 00:14:29,745 --> 00:14:30,565 a car crash. 389 00:14:30,945 --> 00:14:33,504 I've seen people have seizures as a result 390 00:14:33,504 --> 00:14:35,044 of, an aneurysm rupture. 391 00:14:35,504 --> 00:14:37,424 Certainly, you can get those presentations in the 392 00:14:37,424 --> 00:14:39,920 mix as well. And that distinction is important 393 00:14:39,920 --> 00:14:42,480 because that treatment algorithm is very different than 394 00:14:42,480 --> 00:14:45,279 the traumatic type. Yes. Totally different. And that 395 00:14:45,279 --> 00:14:46,800 is not what we're talking about today. So 396 00:14:46,800 --> 00:14:49,040 if you're listening and you've got a patient 397 00:14:49,040 --> 00:14:52,580 with a spontaneous subarachnoid hemorrhage or intracranial hemorrhage, 398 00:14:52,720 --> 00:14:55,555 this is not the correct podcast. Go listen 399 00:14:55,555 --> 00:14:57,634 to one of our other ones. Definitely not 400 00:14:57,634 --> 00:15:00,055 a traumatic injury. That's a very important distinction. 401 00:15:00,195 --> 00:15:02,514 So good to know. Alright. So that's the 402 00:15:02,514 --> 00:15:06,754 traumatic subarachnoid hemorrhage. What's next? Subdural hematoma, I 403 00:15:06,754 --> 00:15:10,089 would broadly categorize into, is it acute or 404 00:15:10,089 --> 00:15:10,909 is it chronic? 405 00:15:11,370 --> 00:15:13,689 And then where is it? Those are also 406 00:15:13,689 --> 00:15:14,189 different 407 00:15:14,490 --> 00:15:14,990 entities. 408 00:15:15,529 --> 00:15:18,409 So an acute subdural is a much more 409 00:15:18,409 --> 00:15:20,509 concerning entity than a chronic subdural. 410 00:15:20,889 --> 00:15:23,049 I mean, it's a venous bleed. It's bridging 411 00:15:23,049 --> 00:15:26,065 veins that are spanning from the parenchyma into 412 00:15:26,065 --> 00:15:26,725 the dura. 413 00:15:27,184 --> 00:15:31,044 And so generally speaking, it's a slower bleed. 414 00:15:31,264 --> 00:15:33,904 An acute one can absolutely be a life 415 00:15:33,904 --> 00:15:35,125 threatening injury. 416 00:15:35,504 --> 00:15:38,404 But chronic bleeds, especially in the elderly population 417 00:15:38,465 --> 00:15:41,750 where you've got brain atrophy, that's gradually putting 418 00:15:41,750 --> 00:15:43,269 more and more tension on those poor little 419 00:15:43,269 --> 00:15:46,149 bridging veins. I've seen people with a coughing 420 00:15:46,149 --> 00:15:48,629 fit rupture, a bridging vein, and they get 421 00:15:48,629 --> 00:15:52,070 little oozing that gradually accumulates into a chronic 422 00:15:52,070 --> 00:15:52,570 subdural. 423 00:15:52,894 --> 00:15:55,634 They can even eventually have mass effect associated 424 00:15:55,774 --> 00:15:58,335 with it. But because there's so much time, 425 00:15:58,335 --> 00:16:00,174 and that's kind of a big concept in, 426 00:16:00,174 --> 00:16:02,654 you know, the pathophysiology of brain dynamics that 427 00:16:02,654 --> 00:16:04,335 if your brain has time to adapt to 428 00:16:04,335 --> 00:16:06,034 something, generally speaking, 429 00:16:06,414 --> 00:16:07,715 it can adapt better 430 00:16:08,389 --> 00:16:10,549 as opposed to an acute change is going 431 00:16:10,549 --> 00:16:12,549 to cause an acute problem. So a chronic 432 00:16:12,549 --> 00:16:14,870 subdural, I worry about far less. It doesn't 433 00:16:14,870 --> 00:16:16,470 mean it doesn't need an intervention, but I 434 00:16:16,470 --> 00:16:19,110 worry about it less. An acute subdural can 435 00:16:19,110 --> 00:16:21,705 evolve much more quickly. And then where it 436 00:16:21,705 --> 00:16:23,865 is also matters hugely. If it's at the 437 00:16:23,865 --> 00:16:24,365 convexity, 438 00:16:25,144 --> 00:16:27,865 anywhere along the periphery, that worries me a 439 00:16:27,865 --> 00:16:30,365 lot more. It's much easier to build pressure 440 00:16:30,585 --> 00:16:32,285 and to cause a big problem. 441 00:16:33,440 --> 00:16:35,379 Falcine and tentorial subdurals 442 00:16:35,919 --> 00:16:38,100 tend to be much more benign entities. 443 00:16:38,639 --> 00:16:41,200 It doesn't mean that they can't ever cause 444 00:16:41,200 --> 00:16:42,820 a problem, but it's less likely. 445 00:16:43,279 --> 00:16:45,299 So I worry about those ones less. 446 00:16:45,695 --> 00:16:47,774 Now the subdural population can also have a 447 00:16:47,774 --> 00:16:50,335 mixed density, so acute on chronic. Do you 448 00:16:50,335 --> 00:16:52,254 just treat those and worry about those like 449 00:16:52,254 --> 00:16:53,934 they're acute, or is that a whole separate 450 00:16:53,934 --> 00:16:54,434 category? 451 00:16:55,054 --> 00:16:56,654 I kind of put them somewhere in between 452 00:16:56,654 --> 00:16:58,495 because they do have an acute component. You 453 00:16:58,495 --> 00:17:00,575 don't know exactly how much blood is going 454 00:17:00,575 --> 00:17:02,220 to accumulate there. So I guess for the 455 00:17:02,220 --> 00:17:03,740 most part, you treat them like an acute 456 00:17:03,740 --> 00:17:06,299 subdural, but you know that this is someone 457 00:17:06,299 --> 00:17:08,299 based on the imaging that you're seeing that 458 00:17:08,299 --> 00:17:11,420 repeatedly has leads like this. And if they're 459 00:17:11,420 --> 00:17:14,299 presenting only now, then the previous ones weren't 460 00:17:14,299 --> 00:17:14,960 too symptomatic. 461 00:17:15,605 --> 00:17:16,884 So I I would say I put it 462 00:17:16,884 --> 00:17:18,805 kind of somewhere in between, but because there's 463 00:17:18,805 --> 00:17:20,805 the acute element and you don't know exactly 464 00:17:20,805 --> 00:17:23,365 that that bleed has stopped, you do have 465 00:17:23,365 --> 00:17:25,384 to treat it more along the acute end. 466 00:17:25,605 --> 00:17:27,765 Alright. Epidural hematomas, this is the one we 467 00:17:27,765 --> 00:17:29,445 seem to be most concerned about, the the 468 00:17:29,445 --> 00:17:32,170 football shape, the double convexity. What about these? 469 00:17:32,230 --> 00:17:33,509 Yeah. I feel like this is the board's 470 00:17:33,509 --> 00:17:35,269 question. And and I I do think that 471 00:17:35,269 --> 00:17:36,710 when people think brain bleed, this is the 472 00:17:36,710 --> 00:17:38,809 one that people think of, which isn't necessarily 473 00:17:38,869 --> 00:17:40,630 a bad thing. It is probably better for 474 00:17:40,630 --> 00:17:43,029 us to on the side of caution and 475 00:17:43,029 --> 00:17:46,835 want to treat patients as conservatively as possible. 476 00:17:46,835 --> 00:17:48,755 But the reality is epidural lymphomas are actually 477 00:17:48,755 --> 00:17:49,255 fairly 478 00:17:49,714 --> 00:17:50,214 rare. 479 00:17:50,914 --> 00:17:53,634 It it takes a fairly big trauma typically 480 00:17:53,634 --> 00:17:55,714 to the temporal bone at surface referred to 481 00:17:55,714 --> 00:17:56,775 as the terrier on. 482 00:17:57,150 --> 00:17:59,309 And the classic is that it causes a 483 00:17:59,309 --> 00:18:01,950 rupture of the middle meningeal artery as it 484 00:18:01,950 --> 00:18:03,490 exits the foramen spinosum. 485 00:18:03,950 --> 00:18:05,710 It's a part of the temporal bone that's 486 00:18:05,710 --> 00:18:08,190 fairly thin, and the vessel is right there. 487 00:18:08,190 --> 00:18:10,190 So it is sort of classically in that 488 00:18:10,190 --> 00:18:10,690 area. 489 00:18:11,085 --> 00:18:14,464 And it's a different animal because it's arterial 490 00:18:15,085 --> 00:18:17,404 and because that blood is going into an 491 00:18:17,404 --> 00:18:19,744 area that's bounded by the cranial sutures, 492 00:18:20,204 --> 00:18:22,444 and so it actually can't expand the same 493 00:18:22,444 --> 00:18:25,005 way that a convexity subdural hematoma can go 494 00:18:25,005 --> 00:18:27,320 all the way around. It has room to 495 00:18:27,320 --> 00:18:28,140 be able to 496 00:18:28,519 --> 00:18:31,259 expand before it compresses down on the brain. 497 00:18:31,400 --> 00:18:34,140 An epidural hematoma doesn't have that luxury. 498 00:18:34,440 --> 00:18:36,599 It's confined into this one space, so it's 499 00:18:36,599 --> 00:18:39,080 a much more focal pressure that it's going 500 00:18:39,080 --> 00:18:40,299 to insert on the brain. 501 00:18:40,694 --> 00:18:42,694 So the reason that people worry so much 502 00:18:42,694 --> 00:18:44,694 about it is because someone who's young and 503 00:18:44,694 --> 00:18:47,335 otherwise healthy can look there's referred to as 504 00:18:47,335 --> 00:18:48,394 lucid interval. 505 00:18:48,694 --> 00:18:52,694 They can look fine while that arterial bleed 506 00:18:52,694 --> 00:18:54,554 is still in its early stages. 507 00:18:54,880 --> 00:18:56,179 And then classically, 508 00:18:56,559 --> 00:18:58,319 they, you know, drop half an hour, forty 509 00:18:58,319 --> 00:18:59,539 five an hour later 510 00:19:00,240 --> 00:19:02,159 as that blood reaches a critical level and 511 00:19:02,159 --> 00:19:03,700 the compression gets severe. 512 00:19:04,480 --> 00:19:07,714 From the, you know, neurosurgical perspective, it's, I 513 00:19:07,714 --> 00:19:09,255 don't know, one of the most addictive 514 00:19:09,555 --> 00:19:12,755 cases in the surgical world because often it's 515 00:19:12,755 --> 00:19:14,835 a young, otherwise intact person who just had 516 00:19:14,835 --> 00:19:16,674 the trauma like this. They can come in 517 00:19:16,674 --> 00:19:18,295 very, very sick. They rapidly 518 00:19:18,674 --> 00:19:21,015 decline. Maybe even have a blown pupil. 519 00:19:21,599 --> 00:19:22,960 And if you get them to the Operating 520 00:19:22,960 --> 00:19:25,119 Room fast enough, this is the situation where 521 00:19:25,119 --> 00:19:27,039 you can actually have and I think as 522 00:19:27,039 --> 00:19:28,720 a medical student, I had a young guy 523 00:19:28,720 --> 00:19:30,720 who came in nearly dead and the following 524 00:19:30,720 --> 00:19:32,740 warnings asking why he was in the ICU. 525 00:19:33,119 --> 00:19:35,565 Wow. And the thought is that that can 526 00:19:35,565 --> 00:19:38,224 occur in part because there is 527 00:19:38,684 --> 00:19:41,904 the dura separating this bleed from parenchyma. 528 00:19:42,445 --> 00:19:43,825 And so the amount of 529 00:19:44,125 --> 00:19:47,005 irritation and injury that happens from contact of 530 00:19:47,005 --> 00:19:48,625 the brain with blood directly 531 00:19:49,259 --> 00:19:50,000 is minimized. 532 00:19:50,539 --> 00:19:52,539 So there is some thought that if you 533 00:19:52,539 --> 00:19:54,460 can resolve the pressure fast enough, you can 534 00:19:54,460 --> 00:19:56,859 actually prevent there being really much of any 535 00:19:56,859 --> 00:19:58,640 substantial neurologic sequela. 536 00:19:59,180 --> 00:20:01,599 So the epidurals are their own 537 00:20:01,900 --> 00:20:04,080 animals to be excited about. 538 00:20:04,454 --> 00:20:06,214 That said, you actually can get them from 539 00:20:06,214 --> 00:20:06,954 other sources. 540 00:20:07,575 --> 00:20:09,434 You actually can get them from 541 00:20:09,894 --> 00:20:12,394 Venus bleeds. I love this little pathophysiologic 542 00:20:13,095 --> 00:20:16,660 example. There was historically a time where we 543 00:20:16,660 --> 00:20:18,500 didn't have areas for kids to sit in 544 00:20:18,500 --> 00:20:20,180 shopping carts, and so kids would be in 545 00:20:20,180 --> 00:20:22,339 the cart. And it was referred to as 546 00:20:22,339 --> 00:20:24,180 a shopping cart injury if a kid flipped 547 00:20:24,180 --> 00:20:26,359 backwards out of a shopping cart and 548 00:20:26,740 --> 00:20:28,440 landed on the back of their head. 549 00:20:28,755 --> 00:20:30,755 And the first thing that a kid does 550 00:20:30,755 --> 00:20:33,154 when they hit their head is cry, and 551 00:20:33,154 --> 00:20:34,595 that might be a little bit different than 552 00:20:34,595 --> 00:20:35,894 the adult's pathophysiology. 553 00:20:36,434 --> 00:20:37,494 The reason it's relevant 554 00:20:37,795 --> 00:20:39,555 is because if you land on the back 555 00:20:39,555 --> 00:20:41,494 of your head, you have a posterior 556 00:20:42,035 --> 00:20:42,535 fracture. 557 00:20:43,220 --> 00:20:45,220 It can injure the sinus as it travels 558 00:20:45,220 --> 00:20:45,720 around. 559 00:20:46,180 --> 00:20:47,779 And then if the next thing that you 560 00:20:47,779 --> 00:20:49,700 do is cry and have a whole bunch 561 00:20:49,700 --> 00:20:50,359 of intrathoracic 562 00:20:50,660 --> 00:20:52,980 pressure, that's going to decrease the amount of 563 00:20:52,980 --> 00:20:54,200 xenus outflow, 564 00:20:54,580 --> 00:20:56,500 back it up into that same sinus that 565 00:20:56,500 --> 00:20:57,640 just got injured. 566 00:20:57,994 --> 00:21:00,975 And, actually, that does bleed into the epidural 567 00:21:01,035 --> 00:21:01,535 space. 568 00:21:01,914 --> 00:21:03,295 So you do sometimes 569 00:21:03,595 --> 00:21:06,875 see posterior fossa, small epidural hematomas that are 570 00:21:06,875 --> 00:21:07,375 actually 571 00:21:07,835 --> 00:21:09,134 venous, not arterial, 572 00:21:09,595 --> 00:21:11,674 tend not to cause as much of an 573 00:21:11,674 --> 00:21:12,174 issue. 574 00:21:12,640 --> 00:21:14,079 And it it's just a different way that 575 00:21:14,079 --> 00:21:16,079 you can get an epidural hematoma that doesn't 576 00:21:16,079 --> 00:21:18,559 follow the classic logic. You can also get 577 00:21:18,559 --> 00:21:20,240 them directly from bony bleeding if you have 578 00:21:20,240 --> 00:21:22,640 a significant enough fracture, and that would also 579 00:21:22,640 --> 00:21:24,960 be in the epidural space and wouldn't cause 580 00:21:24,960 --> 00:21:26,400 as much of a problem. So there are 581 00:21:26,400 --> 00:21:29,164 also epidural hematomas that don't need intervention. 582 00:21:29,784 --> 00:21:31,964 It's probably not good to memorize that as 583 00:21:32,024 --> 00:21:33,404 the direct correlation. 584 00:21:33,865 --> 00:21:36,444 Far and away, epidurals are highly concerning, 585 00:21:37,065 --> 00:21:37,964 just not always. 586 00:21:38,505 --> 00:21:40,984 Okay. And there are some great images, CT 587 00:21:40,984 --> 00:21:43,420 scans of each of these injury patterns in 588 00:21:43,420 --> 00:21:45,259 the article. So, again, if you've got access, 589 00:21:45,259 --> 00:21:47,519 go take a look. The last one, 590 00:21:47,900 --> 00:21:48,400 intraparenchymal 591 00:21:49,180 --> 00:21:51,740 hemorrhage. So this is kind of deep hemorrhage 592 00:21:51,740 --> 00:21:53,279 within the meat of the brain. 593 00:21:53,740 --> 00:21:56,025 Yeah. Intraparenchymal hemorrhage is I also think of 594 00:21:56,265 --> 00:21:58,984 differently because when you have bleeding actually, within 595 00:21:58,984 --> 00:22:01,065 the parenchyma, blood is actually pretty irritating to 596 00:22:01,065 --> 00:22:01,644 the brain. 597 00:22:02,105 --> 00:22:05,065 And so classically, when you have a contusion 598 00:22:05,065 --> 00:22:07,085 and intraprancyal hemorrhage that's traumatic, 599 00:22:07,625 --> 00:22:10,019 the first image that you see of it, 600 00:22:10,339 --> 00:22:12,900 you know that it's actually not completed. There's 601 00:22:12,900 --> 00:22:15,140 still an active process going on. So you 602 00:22:15,140 --> 00:22:16,119 actually expect 603 00:22:16,900 --> 00:22:19,559 contusions or interprincal hemorrhages to blossom, 604 00:22:20,019 --> 00:22:22,580 meaning that the first image that you see 605 00:22:22,580 --> 00:22:24,980 within six hours, I'd actually expect it to 606 00:22:24,980 --> 00:22:27,125 be worse. I expect there to be edema 607 00:22:27,184 --> 00:22:28,005 around it. 608 00:22:28,305 --> 00:22:31,125 I expect there to be more cortical irritability. 609 00:22:31,664 --> 00:22:32,865 And a lot of that has to do 610 00:22:32,865 --> 00:22:36,484 with there's some complicated cytokine release and pathophysiology 611 00:22:37,424 --> 00:22:38,805 that I don't know is necessarily 612 00:22:39,184 --> 00:22:42,200 relevant, but they are going to behave differently. 613 00:22:42,200 --> 00:22:45,240 They generate more pressure than just a simple 614 00:22:45,240 --> 00:22:47,500 volume of blood that's there is going to. 615 00:22:47,880 --> 00:22:50,380 Good. And then there's a discussion about 616 00:22:51,000 --> 00:22:54,200 skull fractures and penetrating trauma. Tell me a 617 00:22:54,200 --> 00:22:55,980 little bit more about these injury patterns. 618 00:22:56,335 --> 00:22:58,735 So skull fractures, I kind of divide them 619 00:22:58,735 --> 00:23:01,134 into, are they closed and non depressed, and 620 00:23:01,134 --> 00:23:03,134 are they anything else? Most of the time, 621 00:23:03,134 --> 00:23:04,894 they're closed and non depressed, and they don't 622 00:23:04,894 --> 00:23:06,975 need much of anything, especially if they don't 623 00:23:06,975 --> 00:23:10,089 have underlying injury associated with them. That's actually 624 00:23:10,089 --> 00:23:12,429 a fairly common injury in kids. 625 00:23:13,049 --> 00:23:15,529 I do worry about them if the fracture 626 00:23:15,529 --> 00:23:16,429 line crosses, 627 00:23:16,730 --> 00:23:19,450 for instance, across midline at the occipital region 628 00:23:19,450 --> 00:23:21,369 because, as I mentioned earlier, you can cause 629 00:23:21,369 --> 00:23:23,484 some venous injury, and so that would warrant 630 00:23:23,484 --> 00:23:25,085 something like a CTB to make sure that 631 00:23:25,085 --> 00:23:26,704 the veins underneath are okay. 632 00:23:27,164 --> 00:23:29,964 And if the fracture is depressed beyond the 633 00:23:29,964 --> 00:23:31,265 thickness of the bone, 634 00:23:31,644 --> 00:23:33,644 then that may in and of itself warrant 635 00:23:33,644 --> 00:23:34,144 intervention. 636 00:23:34,445 --> 00:23:36,625 Usually, that ends being associated with some underlying 637 00:23:36,750 --> 00:23:38,829 injury, and there's also the reality of the 638 00:23:38,829 --> 00:23:40,910 cosmetic deformity of, you know, the crater in 639 00:23:40,910 --> 00:23:41,569 your head. 640 00:23:41,950 --> 00:23:44,670 Penetrating trauma, I guess, a couple of notes 641 00:23:44,670 --> 00:23:46,769 on this. Obviously, these are very severe injuries. 642 00:23:47,150 --> 00:23:50,130 There isn't necessarily a role for going after 643 00:23:50,444 --> 00:23:52,125 bits of something in someone's brain. You can 644 00:23:52,125 --> 00:23:54,684 actually cause a lot more damage than what 645 00:23:54,684 --> 00:23:55,984 has already even happened. 646 00:23:56,605 --> 00:23:59,585 One notable statistic that I found helpful clinically 647 00:23:59,884 --> 00:24:00,544 is that 648 00:24:00,924 --> 00:24:01,585 a biventricular 649 00:24:02,125 --> 00:24:04,980 trajectory of something like a gunshot wound is 650 00:24:05,299 --> 00:24:08,440 universally associated with mortality, with death. 651 00:24:08,819 --> 00:24:10,980 So that can be helpful prognostically in the 652 00:24:10,980 --> 00:24:12,359 emergency department setting. 653 00:24:12,740 --> 00:24:15,380 And one last phenomenon that I've seen happen 654 00:24:15,380 --> 00:24:17,640 and I think is notable prognostically, 655 00:24:18,875 --> 00:24:21,934 Sometimes if you have bad enough skull fracturing, 656 00:24:22,394 --> 00:24:25,434 it can actually serve the same role that 657 00:24:25,434 --> 00:24:26,654 a surgical decompression 658 00:24:26,954 --> 00:24:27,454 can. 659 00:24:27,835 --> 00:24:30,414 If the skull is not actually in continuity, 660 00:24:31,194 --> 00:24:33,934 then it will auto decompress itself. 661 00:24:34,609 --> 00:24:37,330 And I think it's an important thing to 662 00:24:37,330 --> 00:24:38,789 think about as far as 663 00:24:39,090 --> 00:24:41,809 the timeline. I mean, those injuries are very, 664 00:24:41,809 --> 00:24:45,029 very severe, probably almost universally catastrophic, 665 00:24:45,890 --> 00:24:48,545 and it would change what I would expect 666 00:24:48,545 --> 00:24:50,144 from, for instance, the number of hours of 667 00:24:50,144 --> 00:24:50,644 survival 668 00:24:50,945 --> 00:24:53,765 if the brain is auto decompressed. Intraventricular 669 00:24:54,144 --> 00:24:56,865 hemorrhage. So I think the most important tidbit 670 00:24:56,865 --> 00:24:58,144 with these is if you're seeing a lot 671 00:24:58,144 --> 00:25:01,390 of intraventricular hemorrhage, that's not really that common 672 00:25:01,390 --> 00:25:02,690 in a traumatic injury. 673 00:25:03,150 --> 00:25:05,090 That is something that would make me suspect 674 00:25:05,309 --> 00:25:06,690 that there might be a spontaneous 675 00:25:07,150 --> 00:25:09,950 bleed underlying it, like an aneurysm rupture, like 676 00:25:09,950 --> 00:25:10,529 an arteriovenous 677 00:25:10,830 --> 00:25:11,330 malformation. 678 00:25:11,950 --> 00:25:14,445 A small amount can happen with the trauma, 679 00:25:14,505 --> 00:25:16,285 but a large amount would make me suspicious. 680 00:25:16,664 --> 00:25:18,424 In this section of the article, there's a 681 00:25:18,424 --> 00:25:21,305 table, table two, determining the risk level for 682 00:25:21,305 --> 00:25:24,845 critical intracranial pressure, which I find to be 683 00:25:24,984 --> 00:25:27,785 a concept I wasn't aware of before. I 684 00:25:27,785 --> 00:25:29,920 I love this table, but this is taking 685 00:25:29,920 --> 00:25:31,460 a patient who has 686 00:25:31,759 --> 00:25:34,320 an intracranial hemorrhage and trying to determine low 687 00:25:34,320 --> 00:25:36,640 risk versus high risk. This is typically something 688 00:25:36,640 --> 00:25:39,220 I just deferred to my neurology or neurosurgery 689 00:25:39,359 --> 00:25:41,700 colleagues anyway. But I think if you're in 690 00:25:41,759 --> 00:25:43,774 a critical resource 691 00:25:44,154 --> 00:25:44,654 restrained 692 00:25:45,194 --> 00:25:46,894 area working in rural medicine 693 00:25:47,194 --> 00:25:49,434 or perhaps you have an ICU but no 694 00:25:49,434 --> 00:25:52,075 neurosurgery available, this is a concept that might 695 00:25:52,075 --> 00:25:55,349 actually be very helpful, and it's beautifully laid 696 00:25:55,349 --> 00:25:57,349 out in this table. You can actually risk 697 00:25:57,349 --> 00:25:58,970 stratify someone to being 698 00:25:59,349 --> 00:26:01,690 low risk, and that low risk category, 699 00:26:02,230 --> 00:26:03,990 for treatment, when we get into it later, 700 00:26:03,990 --> 00:26:05,430 might actually be someone you could hang on 701 00:26:05,430 --> 00:26:07,589 to and just monitor as opposed to having 702 00:26:07,589 --> 00:26:09,674 to transfer them from, you know, Alaska to 703 00:26:09,674 --> 00:26:11,454 your nearest neurosurgical center? 704 00:26:11,755 --> 00:26:13,275 That was my goal to try and make 705 00:26:13,275 --> 00:26:15,194 it practically useful, and this was probably the 706 00:26:15,194 --> 00:26:16,875 thing that I agonized the most over because, 707 00:26:16,875 --> 00:26:19,994 obviously, you don't wanna misguide anyone. So I 708 00:26:19,994 --> 00:26:21,934 did try to be on the more conservative 709 00:26:22,154 --> 00:26:23,375 side with these recommendations. 710 00:26:23,755 --> 00:26:27,250 But if there's any element of a higher 711 00:26:27,250 --> 00:26:27,750 categorization, 712 00:26:28,690 --> 00:26:31,589 it will be categorized as a more concerning 713 00:26:31,649 --> 00:26:34,289 finding. It's not the average of I've got 714 00:26:34,289 --> 00:26:36,529 some factors in low risk and some factors 715 00:26:36,529 --> 00:26:38,369 in high risk that averages out to low 716 00:26:38,369 --> 00:26:41,494 risk. If there's any feature of higher risk, 717 00:26:41,494 --> 00:26:43,515 then it would get qualified as higher risk. 718 00:26:43,974 --> 00:26:47,015 Lower risk patients clinically are gonna have, 719 00:26:47,494 --> 00:26:50,315 non vocal examination, meaning no neurologic deficits. 720 00:26:50,775 --> 00:26:52,855 The GCS is going to be somewhere between 721 00:26:52,855 --> 00:26:56,119 thirteen and fifteen, so into the mild traumatic 722 00:26:56,119 --> 00:26:57,019 brain injury category. 723 00:26:57,640 --> 00:26:59,799 Minimally symptomatic, meaning maybe they have a little 724 00:26:59,799 --> 00:27:02,539 headache, a little nausea, not more than that. 725 00:27:02,599 --> 00:27:04,279 And it's an important one here that it's 726 00:27:04,279 --> 00:27:07,000 a stable examination. If they're clinically stable, that 727 00:27:07,000 --> 00:27:08,599 is very reassuring. If you have a few 728 00:27:08,599 --> 00:27:10,985 hours to be able to say that they're 729 00:27:10,985 --> 00:27:11,884 not decompensating, 730 00:27:12,265 --> 00:27:14,045 that's a very reassuring thing. 731 00:27:14,424 --> 00:27:14,924 Radiographically, 732 00:27:15,545 --> 00:27:18,445 as I mentioned earlier, isolated traumatic, meaning peripheral 733 00:27:18,825 --> 00:27:20,045 subarachnoid hemorrhage, 734 00:27:20,345 --> 00:27:22,045 I do not find as concerning. 735 00:27:22,825 --> 00:27:25,565 Salcine and tentorial subdural hematoma, 736 00:27:26,220 --> 00:27:29,679 which I'm categorizing differently as convexity subdural hematoma, 737 00:27:30,299 --> 00:27:33,019 a chronic subdural hematoma without shift. Again, we 738 00:27:33,019 --> 00:27:34,700 know that that's not a new finding. That's 739 00:27:34,700 --> 00:27:36,779 something that they've been dealing with for, you 740 00:27:36,779 --> 00:27:38,160 know, weeks or months. 741 00:27:38,605 --> 00:27:41,244 A small volume of intraventricular hemorrhage is really 742 00:27:41,244 --> 00:27:42,544 rarely gonna do anything. 743 00:27:43,005 --> 00:27:45,345 And maybe most significantly, if you have stability 744 00:27:45,404 --> 00:27:47,744 of findings on repeat imaging, maybe 745 00:27:48,125 --> 00:27:50,684 six hours later, that is also very reassuring. 746 00:27:50,684 --> 00:27:52,684 You know that it's not likely to change 747 00:27:52,684 --> 00:27:55,440 at that point. And from the laboratory findings 748 00:27:55,440 --> 00:27:57,619 perspective, there does have to be no coagulopathy. 749 00:27:58,720 --> 00:28:01,680 The higher risk category, I would put for 750 00:28:01,680 --> 00:28:03,460 patients who are clinically 751 00:28:04,240 --> 00:28:06,799 showing signs of moderately impaired consciousness, which is 752 00:28:06,799 --> 00:28:09,220 a GCS qualified as nine to 12. 753 00:28:09,815 --> 00:28:11,194 And if you have any asymmetric 754 00:28:11,815 --> 00:28:12,315 examination, 755 00:28:13,255 --> 00:28:15,434 that implies that there's focal 756 00:28:16,134 --> 00:28:18,714 effect in the brain that's having clinical ramifications, 757 00:28:18,855 --> 00:28:21,414 and there's a more concerning finding. Yeah. So 758 00:28:21,414 --> 00:28:23,519 if they're weak on one side, if you're 759 00:28:23,519 --> 00:28:25,539 seeing a facial droop, if you're seeing 760 00:28:25,920 --> 00:28:27,140 anything that's asymmetric, 761 00:28:27,519 --> 00:28:28,980 that would make me more concerned. 762 00:28:29,440 --> 00:28:31,859 And into the radiographic category here, 763 00:28:32,320 --> 00:28:34,500 acute convexity subdural hematoma 764 00:28:34,880 --> 00:28:37,424 isn't an entity that can certainly change. 765 00:28:37,724 --> 00:28:40,684 Intra parenchymal hemorrhage or contusion, as we mentioned, 766 00:28:40,684 --> 00:28:42,845 is something that you expect to actually get 767 00:28:42,845 --> 00:28:44,464 worse before it gets better 768 00:28:45,004 --> 00:28:46,144 and before it stabilizes. 769 00:28:46,684 --> 00:28:50,224 Epidural hematoma classically is a concerning finding. 770 00:28:50,720 --> 00:28:51,619 Any kind of multicompartmental 771 00:28:52,079 --> 00:28:54,480 hemorrhage that indicates enough brain injury that I 772 00:28:54,480 --> 00:28:56,720 would be concerned about it. And if the 773 00:28:56,720 --> 00:28:58,640 findings are worsening on repeat imaging, you know 774 00:28:58,640 --> 00:29:00,160 that you haven't seen the end of whatever 775 00:29:00,160 --> 00:29:03,599 decline could happen. And any laboratory, if they're 776 00:29:03,599 --> 00:29:04,820 showing any signs of coagulopathy, 777 00:29:05,684 --> 00:29:07,284 that also put in the higher risk category. 778 00:29:07,284 --> 00:29:08,565 You don't know that that bleed is stable 779 00:29:08,565 --> 00:29:11,304 yet. And then finally, the signs of critical 780 00:29:11,365 --> 00:29:13,684 ICP, I categorize separately because this is your 781 00:29:13,684 --> 00:29:16,005 indication that you should be starting medical management 782 00:29:16,005 --> 00:29:18,929 for critically elevated intracranial pressure. These are the 783 00:29:18,929 --> 00:29:21,329 folks who come in clinically with a GCS 784 00:29:21,329 --> 00:29:23,250 of less than or equal to eight, a 785 00:29:23,250 --> 00:29:25,970 declining examination. And that can mean somebody who 786 00:29:25,970 --> 00:29:28,049 starts at a 13, and then you check 787 00:29:28,049 --> 00:29:29,409 back in a couple of hours later and 788 00:29:29,409 --> 00:29:31,409 they're at a 10. It doesn't matter that 789 00:29:31,409 --> 00:29:33,634 they're not at eight yet. If they're showing 790 00:29:33,634 --> 00:29:35,894 that kind of decline, that's highly concerning. 791 00:29:36,434 --> 00:29:38,054 If they've got a pupillary 792 00:29:38,434 --> 00:29:40,595 defect, I mean, the classic long pupil is 793 00:29:40,595 --> 00:29:42,595 sort of an obvious one, but any other 794 00:29:42,595 --> 00:29:45,634 cranial nerve deficits implies that there's, brain stem 795 00:29:45,634 --> 00:29:46,134 pressure. 796 00:29:46,950 --> 00:29:49,269 And vital sign of abnormalities. The classic sign 797 00:29:49,269 --> 00:29:50,569 here is Cushing Triad. 798 00:29:50,869 --> 00:29:53,849 It actually takes quite a lot to have 799 00:29:53,909 --> 00:29:56,149 that effect that is someone who is, you 800 00:29:56,149 --> 00:29:58,089 know, bordering on herniation. 801 00:29:58,630 --> 00:30:00,630 Occasionally, I've been called to the bedside for 802 00:30:00,630 --> 00:30:02,515 somebody who's awake and alert with high blood 803 00:30:02,515 --> 00:30:03,494 pressure and bradycardia 804 00:30:03,954 --> 00:30:05,575 and maybe some irregular respiration. 805 00:30:06,115 --> 00:30:08,194 That is not the Cushing Triad that is 806 00:30:08,194 --> 00:30:10,194 being referred to in this setting. This is 807 00:30:10,194 --> 00:30:11,575 somebody who is comatose 808 00:30:11,954 --> 00:30:13,414 and very injured. 809 00:30:13,795 --> 00:30:15,554 It's pretty rare to actually see in clinical 810 00:30:15,554 --> 00:30:16,054 practice. 811 00:30:16,440 --> 00:30:16,940 Radiographically, 812 00:30:17,480 --> 00:30:19,399 midline shift is sort of a an easy 813 00:30:19,399 --> 00:30:21,500 one to be able to look for. Cisternal 814 00:30:21,639 --> 00:30:23,720 effacement, which can be a little bit more 815 00:30:23,720 --> 00:30:26,200 challenging in the younger population where their brain 816 00:30:26,200 --> 00:30:27,179 is just fuller. 817 00:30:27,559 --> 00:30:30,464 Socal effacement, again, somebody with this who's starting 818 00:30:30,464 --> 00:30:31,664 with a full brain, it can be a 819 00:30:31,664 --> 00:30:33,765 little bit more challenging to look for. 820 00:30:34,065 --> 00:30:36,865 And herniation, and, generally, we're talking about uncle 821 00:30:36,865 --> 00:30:37,365 or 822 00:30:37,664 --> 00:30:38,164 transcentorial 823 00:30:38,704 --> 00:30:40,005 herniation in this setting. 824 00:30:40,384 --> 00:30:42,625 And the coagulopathy is kind of irrelevant here. 825 00:30:42,625 --> 00:30:44,144 This is you know, we're sort of beyond 826 00:30:44,144 --> 00:30:46,359 the stage of treating based on these. 827 00:30:47,059 --> 00:30:49,859 Great. Yeah. And that's table two, page nine, 828 00:30:49,859 --> 00:30:52,339 a fantastic reference, I think, to keep in 829 00:30:52,339 --> 00:30:54,099 your pocket. I mean, obviously, if I think 830 00:30:54,099 --> 00:30:55,859 if you're in a resource constrained area, this 831 00:30:55,859 --> 00:30:57,220 is very handy. But even if you're a 832 00:30:57,220 --> 00:30:59,139 tertiary center and you've got someone with a 833 00:30:59,139 --> 00:30:59,639 hemorrhage, 834 00:30:59,940 --> 00:31:02,875 this helps kinda guide the decisions that you're 835 00:31:02,875 --> 00:31:05,695 going to see from your neurosurgical and neurological 836 00:31:05,835 --> 00:31:07,755 colleagues, so it's not a surprise to you. 837 00:31:07,755 --> 00:31:09,515 You can even prep family members. Oh, okay. 838 00:31:09,515 --> 00:31:11,035 I've got a low risk person. I'm gonna 839 00:31:11,035 --> 00:31:12,955 call my neurosurgical colleague. They're probably gonna say 840 00:31:12,955 --> 00:31:15,019 there's nothing to do here. Or I've got 841 00:31:15,019 --> 00:31:17,660 someone who, you know, is awake, alert, has 842 00:31:17,660 --> 00:31:18,880 maybe not a very 843 00:31:19,500 --> 00:31:22,400 worrisome radiographic finding, but is anticoagulated. 844 00:31:22,940 --> 00:31:24,380 So we're gonna bump them into the high 845 00:31:24,380 --> 00:31:26,140 risk category, and this is why we're getting 846 00:31:26,140 --> 00:31:28,565 all excited about it. It's helpful to understand 847 00:31:28,565 --> 00:31:30,965 that decision making process that goes on for 848 00:31:30,965 --> 00:31:32,345 my neurosurgical colleagues. 849 00:31:33,045 --> 00:31:35,205 There is a great section also following this 850 00:31:35,205 --> 00:31:38,105 table three to try and differentiate the spontaneous 851 00:31:38,164 --> 00:31:40,005 versus traumatic. We don't have to read through 852 00:31:40,005 --> 00:31:42,619 it, but it's a few points of information 853 00:31:42,619 --> 00:31:45,759 to help you differentiate spontaneous from traumatic etiology 854 00:31:45,900 --> 00:31:47,980 because, again, the spontaneous hemorrhage is a whole 855 00:31:47,980 --> 00:31:50,779 different pathway, and I think that table nicely 856 00:31:50,779 --> 00:31:51,279 outlines 857 00:31:51,660 --> 00:31:52,559 some of the characteristics 858 00:31:53,019 --> 00:31:54,539 of those types of patients and how you 859 00:31:54,539 --> 00:31:56,160 can tell them apart from the traumatic. 860 00:31:57,075 --> 00:31:59,394 Next is the section for prehospital care, and 861 00:31:59,394 --> 00:32:01,154 I know we've got some colleagues who listen 862 00:32:01,154 --> 00:32:03,734 to the podcast who work in prehospital medicine, 863 00:32:03,875 --> 00:32:05,255 some EMTs and paramedics. 864 00:32:06,115 --> 00:32:08,115 What are some of the critical things that 865 00:32:08,115 --> 00:32:08,587 we can do in the prehospital setting for 866 00:32:08,587 --> 00:32:10,509 someone we suspect might have a hospital setting 867 00:32:10,509 --> 00:32:13,309 for someone we suspect might have, traumatic brain 868 00:32:13,309 --> 00:32:13,809 injury? 869 00:32:14,109 --> 00:32:16,190 So a lot of it is actually the 870 00:32:16,190 --> 00:32:17,569 same as what we're 871 00:32:17,950 --> 00:32:19,890 targeting in the emergency department. 872 00:32:20,509 --> 00:32:22,349 I think the critical things to be bearing 873 00:32:22,349 --> 00:32:24,589 in mind are and and maybe it sounds 874 00:32:24,589 --> 00:32:27,404 a little silly, but maintaining normal thresholds is 875 00:32:27,404 --> 00:32:29,424 actually really, really important. Normoxia, 876 00:32:29,884 --> 00:32:30,384 normocarbia, 877 00:32:30,845 --> 00:32:31,345 normotension, 878 00:32:31,804 --> 00:32:32,304 normoglycemia. 879 00:32:33,244 --> 00:32:34,144 And they've actually 880 00:32:34,605 --> 00:32:37,005 had studies where they've shown that even a 881 00:32:37,005 --> 00:32:40,044 single reading of an oxygen saturation less than 882 00:32:40,044 --> 00:32:40,865 90% 883 00:32:41,000 --> 00:32:43,559 or a single systolic blood pressure less than 884 00:32:43,559 --> 00:32:44,059 90 885 00:32:44,600 --> 00:32:46,539 has been associated with increased mortality. 886 00:32:47,160 --> 00:32:49,000 So those sound like simple things, but they're 887 00:32:49,000 --> 00:32:52,200 actually very important things, both prehospital and in 888 00:32:52,200 --> 00:32:52,859 the hospital. 889 00:32:53,414 --> 00:32:55,494 Some other things that I think are important 890 00:32:55,494 --> 00:32:56,154 to remember, 891 00:32:56,455 --> 00:32:59,835 there's significant caution reserved against hyperventilation. 892 00:33:00,855 --> 00:33:02,075 As I mentioned previously, 893 00:33:02,535 --> 00:33:04,615 it is something that's going to reduce the 894 00:33:04,615 --> 00:33:06,235 cerebral perfusion pressure. 895 00:33:06,700 --> 00:33:08,559 And so while it can be an excellent 896 00:33:08,700 --> 00:33:09,200 temporizing 897 00:33:09,660 --> 00:33:11,519 measure just to get someone 898 00:33:11,820 --> 00:33:12,320 maybe 899 00:33:13,180 --> 00:33:15,019 twenty, thirty minutes from the ED to the 900 00:33:15,019 --> 00:33:15,519 OR 901 00:33:15,820 --> 00:33:16,880 and prevent herniation, 902 00:33:17,340 --> 00:33:19,019 it's otherwise a pretty dangerous thing to do 903 00:33:19,019 --> 00:33:20,619 to a brain because you are restricting the 904 00:33:20,619 --> 00:33:21,974 amount of blood flow that gets 905 00:33:22,615 --> 00:33:23,515 to the brain and you can cause ischemia. 906 00:33:24,134 --> 00:33:26,775 So in the prehospital setting, it's typically not 907 00:33:26,775 --> 00:33:27,275 advised. 908 00:33:28,054 --> 00:33:30,694 Another important thing that the prehospital providers can 909 00:33:30,694 --> 00:33:31,355 be doing 910 00:33:31,654 --> 00:33:35,035 is having an accurate on scene neurologic assessments, 911 00:33:35,490 --> 00:33:38,049 namely the GCS score. Having the trend there 912 00:33:38,049 --> 00:33:40,849 is actually incredibly valuable. Knowing whether someone is 913 00:33:40,849 --> 00:33:42,150 stable or declining 914 00:33:42,769 --> 00:33:45,009 changes the paradigm of how much concern you 915 00:33:45,009 --> 00:33:48,369 have. So having accurate trends there is really 916 00:33:48,369 --> 00:33:48,869 critical. 917 00:33:49,505 --> 00:33:51,904 Kind of on the same level, if the 918 00:33:51,904 --> 00:33:53,585 patient is intubated in the field, which would 919 00:33:53,585 --> 00:33:56,384 be indicated for a GCS of less than 920 00:33:56,384 --> 00:33:56,884 nine, 921 00:33:57,424 --> 00:34:01,184 knowing which paralytic was given, which sedating agents 922 00:34:01,184 --> 00:34:03,569 were given, and when is also a critical 923 00:34:03,569 --> 00:34:06,210 thing for the providers later to be able 924 00:34:06,210 --> 00:34:08,050 to assess how this might be affecting the 925 00:34:08,050 --> 00:34:09,429 neurologic exam later. 926 00:34:10,050 --> 00:34:11,670 And any notable 927 00:34:12,050 --> 00:34:14,869 elements from on scene can be very helpful 928 00:34:15,010 --> 00:34:18,164 in the determination of was this spontaneous or 929 00:34:18,164 --> 00:34:20,744 not. If it's a really low mechanism 930 00:34:21,125 --> 00:34:23,065 appearing car accident, 931 00:34:23,925 --> 00:34:26,505 but the patient is really neurologically compromised, 932 00:34:26,885 --> 00:34:29,605 that's concerning for there being something else that 933 00:34:29,605 --> 00:34:30,585 caused a crash. 934 00:34:30,900 --> 00:34:32,659 So elements like that from the scene can 935 00:34:32,659 --> 00:34:34,359 actually be very, very helpful. 936 00:34:35,059 --> 00:34:36,280 Other elements here, 937 00:34:36,819 --> 00:34:39,219 TXA, there have been actually a few decent 938 00:34:39,219 --> 00:34:39,719 studies 939 00:34:40,260 --> 00:34:41,639 that have shown that 940 00:34:42,260 --> 00:34:44,179 essentially in the long term, it does not 941 00:34:44,179 --> 00:34:46,454 improve emotional outcome at six months in the 942 00:34:46,454 --> 00:34:47,434 TBI setting. 943 00:34:47,894 --> 00:34:50,375 There are some in the hospital settings that 944 00:34:50,375 --> 00:34:53,335 it seems to improve, but long term, it 945 00:34:53,335 --> 00:34:54,855 does not seem to make a difference. So 946 00:34:54,855 --> 00:34:57,174 that's not a standard recommendation in the TBI 947 00:34:57,174 --> 00:34:57,674 setting. 948 00:34:58,135 --> 00:35:00,099 I think those are the most significant things 949 00:35:00,099 --> 00:35:03,059 from there. Good. And that's nicely summarized. Again, 950 00:35:03,059 --> 00:35:06,280 table four, the Brain Trauma Foundation prehospital guidelines, 951 00:35:06,340 --> 00:35:08,500 really covering all of those items in one 952 00:35:08,500 --> 00:35:09,000 table, 953 00:35:09,460 --> 00:35:10,519 mostly hemodynamics, 954 00:35:10,900 --> 00:35:11,559 but also 955 00:35:11,954 --> 00:35:15,155 critically important in history gathering and in obtaining 956 00:35:15,155 --> 00:35:17,795 a baseline exam for monitoring the trend. So 957 00:35:17,795 --> 00:35:20,055 those are some critical pieces for our prehospital 958 00:35:20,195 --> 00:35:20,695 personnel. 959 00:35:21,315 --> 00:35:23,715 Once they arrive in the ED and it's 960 00:35:23,715 --> 00:35:25,494 our turn to obtain a history 961 00:35:25,929 --> 00:35:28,170 and then perform a physical examination. Let's start 962 00:35:28,170 --> 00:35:30,489 with a history. Is there anything really critically 963 00:35:30,489 --> 00:35:32,409 important when it comes to history assuming that 964 00:35:32,409 --> 00:35:34,489 the patient's able to give me one? Yeah. 965 00:35:34,489 --> 00:35:35,769 So, I mean, it's a good sign that 966 00:35:35,769 --> 00:35:36,890 the patient can give you, but but if 967 00:35:36,890 --> 00:35:39,184 you're also getting it from EMS, establishing those 968 00:35:39,184 --> 00:35:41,525 things that we just mentioned about were any 969 00:35:41,744 --> 00:35:43,125 alertness altering sedating 970 00:35:43,425 --> 00:35:45,744 medications given if the person was paralyzed, what 971 00:35:45,744 --> 00:35:47,284 were they paralyzed with and when. 972 00:35:47,664 --> 00:35:49,585 Any information you have from on scene that 973 00:35:49,585 --> 00:35:51,264 might help you determine whether or not you 974 00:35:51,264 --> 00:35:53,525 think this could be a spontaneous etiology. 975 00:35:54,519 --> 00:35:57,579 And the big piece from the patient history 976 00:35:57,800 --> 00:35:59,400 would be, is there any reason to suspect 977 00:35:59,400 --> 00:35:59,980 a coagulopathy? 978 00:36:00,840 --> 00:36:02,599 And that includes things like liver disease as 979 00:36:02,599 --> 00:36:04,519 well. It doesn't have to be just medication 980 00:36:04,519 --> 00:36:05,340 induced coagulopathy. 981 00:36:05,720 --> 00:36:07,579 Yeah. Is there any reason you'd suspect thrombocytopenia? 982 00:36:08,434 --> 00:36:11,155 And then physical examination, obviously, we're looking for 983 00:36:11,155 --> 00:36:11,815 the neurological 984 00:36:12,114 --> 00:36:15,255 deficits and level of alertness. Anything else specifically 985 00:36:15,315 --> 00:36:16,934 we need to be focused on? 986 00:36:17,394 --> 00:36:19,074 I guess so. This is a lot of 987 00:36:19,074 --> 00:36:21,530 sort of following basic ACLS algorithms. I didn't 988 00:36:21,530 --> 00:36:23,130 go into a ton of detail here. I 989 00:36:23,130 --> 00:36:24,489 think some of the things to note in 990 00:36:24,489 --> 00:36:26,969 the setting of traumatic brain injury, look for 991 00:36:26,969 --> 00:36:29,530 facial trauma that you think could compromise the 992 00:36:29,530 --> 00:36:31,769 airway either at the present or if you 993 00:36:31,769 --> 00:36:33,530 suspect that's gonna be an issue, for instance, 994 00:36:33,530 --> 00:36:35,945 going for imaging. That's something to be mindful 995 00:36:35,945 --> 00:36:37,704 of. And maybe this is a little bit 996 00:36:37,704 --> 00:36:39,545 more of a subtle thing, but if your 997 00:36:39,545 --> 00:36:40,765 patient is already 998 00:36:41,144 --> 00:36:41,644 intubated, 999 00:36:42,265 --> 00:36:44,925 I think that this is a unique scenario 1000 00:36:44,985 --> 00:36:45,485 where 1001 00:36:45,864 --> 00:36:49,244 a, quote, neurologic code in that setting 1002 00:36:49,989 --> 00:36:51,210 can be silent. 1003 00:36:51,750 --> 00:36:53,989 If you don't have intracranial pressure monitoring, there 1004 00:36:53,989 --> 00:36:56,390 aren't going to be any alarms or, you 1005 00:36:56,390 --> 00:36:58,710 know, there's gonna be nothing that tells you 1006 00:36:58,710 --> 00:37:01,369 necessarily that the patient is nearing 1007 00:37:01,750 --> 00:37:04,045 brain death. And so I think sometimes 1008 00:37:04,744 --> 00:37:07,244 I've seen there be maybe less 1009 00:37:07,545 --> 00:37:08,045 concern 1010 00:37:08,505 --> 00:37:11,304 than is warranted because the patient, you know, 1011 00:37:11,304 --> 00:37:13,324 appears comfortable. We don't see anything 1012 00:37:13,704 --> 00:37:16,380 dramatically wrong with the vital signs. That doesn't 1013 00:37:16,380 --> 00:37:19,199 mean that the patient isn't a critical neurologic 1014 00:37:19,339 --> 00:37:19,839 patient. 1015 00:37:20,380 --> 00:37:22,699 So just keeping that in mind if you've 1016 00:37:22,699 --> 00:37:26,319 got a patient that's intubated and appears stable, 1017 00:37:26,460 --> 00:37:28,859 that doesn't necessarily mean that they're stable until 1018 00:37:28,859 --> 00:37:30,239 you've proven that neurologically. 1019 00:37:31,164 --> 00:37:33,324 And if they're already intubated, you're relying a 1020 00:37:33,324 --> 00:37:34,464 lot there on 1021 00:37:34,764 --> 00:37:38,144 brain stem function and reflexes for exam findings? 1022 00:37:38,444 --> 00:37:40,605 Depends on what agents they've already had on 1023 00:37:40,605 --> 00:37:42,545 board. And this is one where, 1024 00:37:42,924 --> 00:37:43,585 I guess, 1025 00:37:43,940 --> 00:37:46,840 knowing what paralytic was used and when, succinylcholine 1026 00:37:47,140 --> 00:37:48,599 versus rocuronium essentially, 1027 00:37:49,059 --> 00:37:51,400 is critical. And if they did get rocuronium 1028 00:37:51,780 --> 00:37:52,440 in the last 1029 00:37:52,740 --> 00:37:54,039 sixty to ninety minutes, 1030 00:37:54,500 --> 00:37:56,579 you may well not have an exam at 1031 00:37:56,579 --> 00:37:58,200 all. You will still have pupils 1032 00:37:58,644 --> 00:38:01,445 because rockeronium does not affect that. But beyond 1033 00:38:01,445 --> 00:38:02,885 that, you're not gonna have much of anything, 1034 00:38:02,885 --> 00:38:05,045 and that is a scenario where, let's say, 1035 00:38:05,045 --> 00:38:06,724 it's been two hours, and now you don't 1036 00:38:06,724 --> 00:38:08,585 know, is it the rockeronium, 1037 00:38:09,285 --> 00:38:11,684 or is this patient really, you know, very, 1038 00:38:11,684 --> 00:38:12,664 very impaired? 1039 00:38:13,500 --> 00:38:15,579 And this is where I actually do advocate 1040 00:38:15,579 --> 00:38:17,260 for use of something called a four twitch 1041 00:38:17,260 --> 00:38:19,119 monitor or a peripheral nerve stimulator. 1042 00:38:19,659 --> 00:38:22,619 They're really commonly used in the OR by 1043 00:38:22,619 --> 00:38:23,119 anesthesiology 1044 00:38:23,739 --> 00:38:26,940 after elective cases to ensure that paralytic is 1045 00:38:26,940 --> 00:38:29,154 off before they extubate a patient. And it's 1046 00:38:29,154 --> 00:38:32,434 a simple tool, and, essentially, it's a shocking 1047 00:38:32,434 --> 00:38:32,934 device 1048 00:38:33,474 --> 00:38:36,375 that it will use the train of four 1049 00:38:36,594 --> 00:38:38,194 feature, which is just a simple click of 1050 00:38:38,194 --> 00:38:40,514 the button and put it generally, people do 1051 00:38:40,514 --> 00:38:41,815 it right here at the eyebrow. 1052 00:38:42,194 --> 00:38:43,974 It will work on any muscle, 1053 00:38:44,639 --> 00:38:47,359 and you're just watching for each shock should 1054 00:38:47,359 --> 00:38:50,079 cause a muscle twitch. So four shocks should 1055 00:38:50,079 --> 00:38:52,239 get you four muscles switches. If you are 1056 00:38:52,239 --> 00:38:53,679 not seeing that, it means that they're still 1057 00:38:53,679 --> 00:38:54,900 paralytic on board, 1058 00:38:55,279 --> 00:38:57,440 and that can help you tailor what you'd 1059 00:38:57,440 --> 00:38:59,655 expect from your neurologic exam and whether you 1060 00:38:59,655 --> 00:39:00,875 should be giving reversal 1061 00:39:01,574 --> 00:39:04,155 to be able to actually uncover what neurologic 1062 00:39:04,295 --> 00:39:06,135 exam is there. So that is the risk 1063 00:39:06,135 --> 00:39:07,974 that I worry about with rocuronium, but it's 1064 00:39:07,974 --> 00:39:10,855 not insurmountable. You have those tools that are 1065 00:39:10,855 --> 00:39:12,934 available to be able to determine how much 1066 00:39:12,934 --> 00:39:15,059 an effect it still has. Great. Yeah. That's 1067 00:39:15,059 --> 00:39:17,140 a great point. And a good pearl there, 1068 00:39:17,140 --> 00:39:19,539 your anesthesia colleagues are going to have those 1069 00:39:19,539 --> 00:39:21,219 tools available. So if you've got an OR, 1070 00:39:21,219 --> 00:39:23,300 you could probably get one pretty quickly. Yeah. 1071 00:39:23,300 --> 00:39:25,219 I I actually grabbed one from the OR 1072 00:39:25,219 --> 00:39:26,340 at some point and hid it in the 1073 00:39:26,340 --> 00:39:27,880 ED so that I had it available. 1074 00:39:28,204 --> 00:39:30,684 And Sugamadex is also really easy to get 1075 00:39:30,684 --> 00:39:32,284 in the OR. They use it all the 1076 00:39:32,284 --> 00:39:34,284 time. So Yeah. Swinging by there and grabbing 1077 00:39:34,284 --> 00:39:36,764 it. Yes. In your airway cart, probably something 1078 00:39:36,764 --> 00:39:39,005 you should have stocked. Yeah. Alright. And then 1079 00:39:39,005 --> 00:39:41,244 there's a whole section in this article about 1080 00:39:41,244 --> 00:39:43,184 brain stem function and how 1081 00:39:43,559 --> 00:39:45,739 important it is when we're talking about reflexes. 1082 00:39:45,880 --> 00:39:47,579 Tell me a little bit more about that. 1083 00:39:48,039 --> 00:39:48,860 Okay. So 1084 00:39:49,160 --> 00:39:51,400 while brain stem function is not typically something 1085 00:39:51,400 --> 00:39:54,039 that's assessed in detail in the emergency department, 1086 00:39:54,039 --> 00:39:55,480 I do think that there is a role 1087 00:39:55,480 --> 00:39:56,860 for it in severely 1088 00:39:57,160 --> 00:40:00,244 impaired patients with, let's say, a GCSF three. 1089 00:40:00,625 --> 00:40:02,385 And part of what you're trying to be 1090 00:40:02,385 --> 00:40:05,125 able to assess and communicate to your neurosurgical 1091 00:40:05,344 --> 00:40:06,324 colleagues is 1092 00:40:06,784 --> 00:40:09,585 how close this person is to herniation or 1093 00:40:09,585 --> 00:40:11,125 have they already herniated. 1094 00:40:11,500 --> 00:40:13,420 Mhmm. And sometimes that's the best exam that 1095 00:40:13,420 --> 00:40:14,539 you're going to be able to give, and 1096 00:40:14,539 --> 00:40:16,219 so you're just trying to trend something. If 1097 00:40:16,219 --> 00:40:18,380 you have one blown pupil, and by the 1098 00:40:18,380 --> 00:40:20,640 time they get to their neurosurgeon, 1099 00:40:21,340 --> 00:40:23,340 they have two blown pupils, that's a very 1100 00:40:23,340 --> 00:40:24,940 helpful thing. Or if they had a cough 1101 00:40:24,940 --> 00:40:26,460 or a gag or were over breathing the 1102 00:40:26,460 --> 00:40:29,244 vent initially and now are not, those are 1103 00:40:29,244 --> 00:40:31,164 actually really helpful things to be able to 1104 00:40:31,164 --> 00:40:34,045 trend to and one pearl there that I 1105 00:40:34,045 --> 00:40:35,505 think can be helpful prognostically 1106 00:40:36,125 --> 00:40:37,905 is if someone has had bilaterally 1107 00:40:38,525 --> 00:40:41,565 fixed and dilated pupils for six hours or 1108 00:40:41,565 --> 00:40:42,065 more, 1109 00:40:42,579 --> 00:40:44,119 that's universally associated 1110 00:40:44,420 --> 00:40:45,559 with brain death. 1111 00:40:46,019 --> 00:40:48,420 So these elements, while we don't necessarily always 1112 00:40:48,420 --> 00:40:50,339 associate them with something that's checked in the 1113 00:40:50,339 --> 00:40:52,440 emergency department, there is a role for them. 1114 00:40:52,659 --> 00:40:54,819 Yeah. That's a a really good point, actually. 1115 00:40:54,819 --> 00:40:56,519 You know, I think of these as critically 1116 00:40:56,579 --> 00:40:59,804 sick patients, lots of high anxiety levels, and 1117 00:40:59,804 --> 00:41:01,085 we get to the point where we figure 1118 00:41:01,085 --> 00:41:03,565 out, okay. This person is dying in front 1119 00:41:03,565 --> 00:41:05,244 of me. I'm just going to call for 1120 00:41:05,244 --> 00:41:08,525 help. And we forget about the subtleties in 1121 00:41:08,525 --> 00:41:10,844 differentiating all of these findings and maybe even 1122 00:41:10,844 --> 00:41:12,500 in writing them down. Like, oh, yeah. But, 1123 00:41:12,579 --> 00:41:14,260 you know, what exactly what time did I 1124 00:41:14,260 --> 00:41:16,099 call you and what was the exam at 1125 00:41:16,099 --> 00:41:18,339 that point versus what it is now? So 1126 00:41:18,339 --> 00:41:20,900 that includes things here listed like doll's eyes, 1127 00:41:20,900 --> 00:41:23,559 corneal reflex, the cough, the gag reflex, 1128 00:41:23,940 --> 00:41:26,819 and, you know, spontaneous respirations and whatever motor 1129 00:41:26,819 --> 00:41:27,914 exam there is. So 1130 00:41:28,474 --> 00:41:30,414 those are critical things to both 1131 00:41:31,035 --> 00:41:34,315 write down and time stamp for your colleagues 1132 00:41:34,315 --> 00:41:36,235 who are then going to take over patient 1133 00:41:36,235 --> 00:41:37,855 care so they can trend. 1134 00:41:38,554 --> 00:41:40,655 Yeah. There is a role. I have seen 1135 00:41:40,949 --> 00:41:43,349 decisions made about whether or not someone goes 1136 00:41:43,349 --> 00:41:45,429 for a surgery based on whether or not 1137 00:41:45,429 --> 00:41:48,469 they still have any intact brainstem reflexes or 1138 00:41:48,469 --> 00:41:50,170 how recently they lost them, 1139 00:41:50,710 --> 00:41:53,050 especially in young people who are really injured. 1140 00:41:53,335 --> 00:41:55,255 So there is a role for keeping track 1141 00:41:55,255 --> 00:41:56,074 of those items. 1142 00:41:56,535 --> 00:41:59,414 Okay. So laboratory studies. Tell me about labs 1143 00:41:59,414 --> 00:42:02,535 in this patient population. Anything important? Sure. Some 1144 00:42:02,614 --> 00:42:04,535 there are certainly the basic labs that you 1145 00:42:04,535 --> 00:42:06,875 wanna be the biggest thing looking for coagulopathy. 1146 00:42:07,690 --> 00:42:09,130 But then there is actually some new and 1147 00:42:09,130 --> 00:42:11,230 kind of exciting research on some 1148 00:42:11,530 --> 00:42:13,869 elements that I'd still qualify as exploratory 1149 00:42:14,409 --> 00:42:16,489 in The US, but I think up and 1150 00:42:16,489 --> 00:42:19,390 coming, the big three being s one hundred 1151 00:42:19,449 --> 00:42:20,190 b testing, 1152 00:42:20,890 --> 00:42:22,110 GFAP testing, 1153 00:42:22,545 --> 00:42:23,045 and 1154 00:42:23,505 --> 00:42:24,804 UHC L one testing, 1155 00:42:25,264 --> 00:42:27,204 all of which in other countries 1156 00:42:27,505 --> 00:42:29,764 have actually some of them are even incorporated 1157 00:42:29,824 --> 00:42:31,125 into standard TBI 1158 00:42:31,425 --> 00:42:31,925 algorithms 1159 00:42:32,545 --> 00:42:34,704 to be able to assess who is low 1160 00:42:34,704 --> 00:42:36,385 enough risk that they, for instance, may not 1161 00:42:36,385 --> 00:42:38,005 even warrant a head CT. 1162 00:42:38,449 --> 00:42:40,549 So I think that they could be clinically 1163 00:42:40,609 --> 00:42:43,809 quite useful. They're just not quite ready for 1164 00:42:43,809 --> 00:42:45,170 prime time in The US yet, but I 1165 00:42:45,170 --> 00:42:46,289 think that they'll need to keep an eye 1166 00:42:46,289 --> 00:42:47,889 on. I think those will be in clinical 1167 00:42:47,889 --> 00:42:49,269 practice in the coming years. 1168 00:42:49,650 --> 00:42:50,630 And this is specific 1169 00:42:51,164 --> 00:42:51,985 to intracranial 1170 00:42:52,364 --> 00:42:55,425 hemorrhage or just traumatic brain injury in general? 1171 00:42:55,885 --> 00:42:57,405 So this is in the traumatic brain injury 1172 00:42:57,405 --> 00:42:59,805 in general category because these are often patients 1173 00:42:59,805 --> 00:43:02,045 who the decision is whether or not you 1174 00:43:02,045 --> 00:43:04,305 actually need to pursue further imaging. 1175 00:43:04,730 --> 00:43:06,730 Gotcha. So it it is in the broader 1176 00:43:06,730 --> 00:43:08,969 population, not people that you know have intracranial 1177 00:43:08,969 --> 00:43:09,469 hemorrhage. 1178 00:43:10,089 --> 00:43:10,589 Gotcha. 1179 00:43:11,049 --> 00:43:13,369 Alright. And then imaging studies, you know, in 1180 00:43:13,369 --> 00:43:16,510 most emergency departments, hopefully, we have CT available. 1181 00:43:16,569 --> 00:43:19,204 But you already mentioned that in some cases, 1182 00:43:19,424 --> 00:43:21,744 a CT venogram might be important. We have 1183 00:43:21,744 --> 00:43:22,244 CT 1184 00:43:22,545 --> 00:43:23,045 arteriograms 1185 00:43:23,424 --> 00:43:25,684 also or angiograms at our disposal. 1186 00:43:26,065 --> 00:43:28,304 How are we gonna differentiate which population needs 1187 00:43:28,304 --> 00:43:28,964 which study? 1188 00:43:29,309 --> 00:43:31,949 Yeah. I think the basic study that hopefully 1189 00:43:31,949 --> 00:43:34,130 everyone has access to is a nonconhead CT, 1190 00:43:34,430 --> 00:43:36,430 and that is quite good to be able 1191 00:43:36,430 --> 00:43:38,369 to see intracranial hemorrhage. 1192 00:43:39,150 --> 00:43:40,849 Nuance studies include 1193 00:43:41,230 --> 00:43:41,809 a CTV, 1194 00:43:42,190 --> 00:43:44,945 which is an appropriate study if there is 1195 00:43:44,945 --> 00:43:47,364 an occipital fracture crossing the midline 1196 00:43:47,664 --> 00:43:50,325 and you're worried about venous injury underlying it, 1197 00:43:50,465 --> 00:43:52,465 or if there's a skull base fracture that 1198 00:43:52,465 --> 00:43:54,325 in infringes on the jugular foramen. 1199 00:43:54,704 --> 00:43:57,069 That's another situation that having a CTV to 1200 00:43:57,069 --> 00:43:59,170 rule out vascular injury would be helpful. 1201 00:43:59,789 --> 00:44:00,289 CTA 1202 00:44:00,829 --> 00:44:03,010 is going to be your go to study 1203 00:44:03,150 --> 00:44:05,409 if you suspect any reason there's a spontaneous 1204 00:44:05,789 --> 00:44:08,210 coverage because you'll be able to see aneurysms, 1205 00:44:08,589 --> 00:44:09,569 vascular malformations, 1206 00:44:10,304 --> 00:44:10,804 Or 1207 00:44:11,105 --> 00:44:13,125 if you have a bony fracture 1208 00:44:13,505 --> 00:44:15,824 that is, for instance, infringing on really any 1209 00:44:15,824 --> 00:44:18,144 of the skull base elements, but specifically the 1210 00:44:18,144 --> 00:44:19,045 carotid canal, 1211 00:44:19,344 --> 00:44:21,585 if you're looking for a lung cerebral vascular 1212 00:44:21,585 --> 00:44:23,344 injury, the CTA is gonna be your best 1213 00:44:23,344 --> 00:44:25,029 bet to be able to find it. The 1214 00:44:25,029 --> 00:44:27,369 other element that you can use CTA for, 1215 00:44:27,429 --> 00:44:29,130 and this is maybe a little bit 1216 00:44:29,670 --> 00:44:32,949 more on the practically useful, but not research 1217 00:44:32,949 --> 00:44:33,849 based prognostically 1218 00:44:34,150 --> 00:44:34,650 useful, 1219 00:44:35,349 --> 00:44:38,549 CTA in the setting of really, really severe 1220 00:44:38,549 --> 00:44:40,545 brain injury with, let's say, someone who has 1221 00:44:41,025 --> 00:44:43,364 no exam or close to no exam, 1222 00:44:43,984 --> 00:44:44,484 CTA 1223 00:44:44,864 --> 00:44:47,105 can be something that shows you, assuming that 1224 00:44:47,105 --> 00:44:48,484 it's appropriately timed, 1225 00:44:48,864 --> 00:44:50,724 if there is no intracranial 1226 00:44:51,184 --> 00:44:52,005 blood flow, 1227 00:44:52,625 --> 00:44:54,545 that is a situation where you can assume 1228 00:44:54,545 --> 00:44:56,840 the intracranial pressure is so 1229 00:44:57,220 --> 00:44:59,860 high, there is no blood that is able 1230 00:44:59,860 --> 00:45:01,239 to access the brain. 1231 00:45:01,700 --> 00:45:02,200 And 1232 00:45:02,579 --> 00:45:04,500 that can be a helpful thing in, for 1233 00:45:04,500 --> 00:45:06,519 instance, talking to a family member 1234 00:45:06,900 --> 00:45:08,920 about how severe an injury is. 1235 00:45:09,385 --> 00:45:09,885 Gotcha. 1236 00:45:10,265 --> 00:45:12,985 Alright. And what about bedside ultrasound? There's a 1237 00:45:12,985 --> 00:45:15,545 discussion there about optic nerve sheath diameter on 1238 00:45:15,545 --> 00:45:18,204 ultrasound. Is that a helpful imaging modality? 1239 00:45:18,985 --> 00:45:20,664 You know, I don't see it in practice 1240 00:45:20,664 --> 00:45:22,345 in the ED often, but I think it's 1241 00:45:22,345 --> 00:45:24,269 kind of a cool thing that I hope 1242 00:45:24,429 --> 00:45:26,610 starts to take more of the spotlight. 1243 00:45:26,989 --> 00:45:29,090 There's pretty good data to be able to 1244 00:45:29,390 --> 00:45:31,949 suggest that if you have an optic nerve 1245 00:45:31,949 --> 00:45:34,349 sheath diameter of greater than 4.8 1246 00:45:34,349 --> 00:45:34,849 millimeters, 1247 00:45:35,390 --> 00:45:37,630 that is something that's consistently associated with an 1248 00:45:37,630 --> 00:45:39,650 intracranial pressure of greater than 20. 1249 00:45:40,325 --> 00:45:42,825 And the sensitivity and specificity are pretty good. 1250 00:45:43,204 --> 00:45:45,684 So I actually think that's something that could 1251 00:45:45,684 --> 00:45:47,285 have more of a role even now for 1252 00:45:47,285 --> 00:45:49,365 providers who are comfortable with using ultrasound, which 1253 00:45:49,365 --> 00:45:51,785 I think is most of my ED colleagues. 1254 00:45:52,460 --> 00:45:55,179 Yeah. And it's pretty quick measurements and certainly 1255 00:45:55,179 --> 00:45:56,940 one that we can repeat at the bedside 1256 00:45:56,940 --> 00:45:58,619 without having to take the patient back to 1257 00:45:58,619 --> 00:46:01,500 CT every time. So Yeah. Quick, noninvasive. So 1258 00:46:01,500 --> 00:46:02,539 I think that there is a role for 1259 00:46:02,539 --> 00:46:04,779 that even now. I'm wondering if that's something 1260 00:46:04,779 --> 00:46:06,880 you have to do bilaterally. If you're suspecting 1261 00:46:06,940 --> 00:46:07,440 intracranial 1262 00:46:08,054 --> 00:46:08,954 pressure increase, 1263 00:46:09,255 --> 00:46:10,775 say they have a blown pupil then, do 1264 00:46:10,775 --> 00:46:12,554 you have to do this in both eyes? 1265 00:46:13,094 --> 00:46:15,514 It should be a proxy for the universal 1266 00:46:15,574 --> 00:46:17,894 intracranial pressure unless you have something really focal 1267 00:46:17,894 --> 00:46:19,815 behind the eye, but it's probably something that's 1268 00:46:19,815 --> 00:46:21,789 better to check on both sides. It's actually 1269 00:46:21,789 --> 00:46:23,469 the same issue that you can run into 1270 00:46:23,469 --> 00:46:26,029 with an intracranial pressure monitor. For instance, if 1271 00:46:26,029 --> 00:46:28,690 you put the monitor directly into a contusion, 1272 00:46:28,909 --> 00:46:30,510 you're gonna get a really high pressure that's 1273 00:46:30,510 --> 00:46:31,170 not necessarily 1274 00:46:31,549 --> 00:46:33,885 representative of the brain as a whole. So 1275 00:46:33,885 --> 00:46:35,885 that that's an issue that wouldn't even just 1276 00:46:35,885 --> 00:46:37,184 be with an ultrasound. 1277 00:46:37,644 --> 00:46:38,625 MRI imaging, 1278 00:46:38,925 --> 00:46:40,605 again, this is not something we can typically 1279 00:46:40,605 --> 00:46:42,525 get in the emergency department in any kind 1280 00:46:42,525 --> 00:46:45,105 of rapid fashion, but there are some EDs 1281 00:46:45,164 --> 00:46:47,759 that can task this to occur pretty quickly. 1282 00:46:47,819 --> 00:46:49,819 Are there instances where an MRI would be 1283 00:46:49,819 --> 00:46:51,359 more helpful than a CT? 1284 00:46:52,219 --> 00:46:55,179 So I primarily have MRI mentioned here as 1285 00:46:55,179 --> 00:46:57,199 something that I would be very cautious 1286 00:46:57,579 --> 00:47:00,460 about using in the setting of acute brain 1287 00:47:00,460 --> 00:47:00,960 injury. 1288 00:47:01,454 --> 00:47:02,755 And that's largely because 1289 00:47:03,055 --> 00:47:04,655 for an MRI to happen, you're going to 1290 00:47:04,655 --> 00:47:06,735 have to lie the patient flat, which is 1291 00:47:06,735 --> 00:47:08,894 going to increase intracranial pressure, and you're gonna 1292 00:47:08,894 --> 00:47:09,954 put them for 1293 00:47:10,414 --> 00:47:13,394 forty minutes, sixty minutes in an unmonitored 1294 00:47:13,695 --> 00:47:15,775 environment, and you don't necessarily know how they're 1295 00:47:15,775 --> 00:47:18,130 gonna look when they come out. Mhmm. Yeah. 1296 00:47:18,430 --> 00:47:20,430 In these patients, I would be very hesitant. 1297 00:47:20,430 --> 00:47:21,710 Even if I had an MRI at my 1298 00:47:21,710 --> 00:47:22,690 disposal readily, 1299 00:47:23,390 --> 00:47:24,369 I would be hesitant 1300 00:47:24,750 --> 00:47:26,750 until I really knew that they were stable 1301 00:47:26,750 --> 00:47:29,070 to pursue that, especially because a CT actually 1302 00:47:29,070 --> 00:47:30,750 gets you pretty much all the information that 1303 00:47:30,750 --> 00:47:32,804 you need. The only element the that MRI 1304 00:47:32,804 --> 00:47:34,885 is really going to help you with is 1305 00:47:34,885 --> 00:47:37,385 if there's DAI, diffuse axonal injury, 1306 00:47:37,684 --> 00:47:40,184 which certainly can be helpful prognostically. 1307 00:47:41,364 --> 00:47:43,844 It doesn't really guide initial management. So I 1308 00:47:43,844 --> 00:47:45,684 think there are very few roles to really 1309 00:47:45,684 --> 00:47:47,864 be considering MRI in this acute setting. 1310 00:47:48,250 --> 00:47:51,210 And then EEG monitoring, is that universal for 1311 00:47:51,210 --> 00:47:52,890 all of these patients, or when would you 1312 00:47:52,890 --> 00:47:54,110 consider that necessary? 1313 00:47:54,410 --> 00:47:56,650 Really, I would only consider that if the 1314 00:47:56,809 --> 00:47:59,469 it seems like their exam is so disproportionate 1315 00:47:59,769 --> 00:48:01,130 to the amount of injury you see on 1316 00:48:01,130 --> 00:48:01,630 imaging 1317 00:48:02,034 --> 00:48:04,454 that you're worried about non convulsive status epilepticus. 1318 00:48:04,994 --> 00:48:06,994 So it's a reasonable thing to throw on 1319 00:48:06,994 --> 00:48:09,315 someone to rule that out in that setting, 1320 00:48:09,315 --> 00:48:11,235 but certainly not something that I would expect 1321 00:48:11,235 --> 00:48:13,795 to need for garden variety traumatic brain injury 1322 00:48:13,795 --> 00:48:14,295 patients. 1323 00:48:14,719 --> 00:48:15,219 Gotcha. 1324 00:48:15,679 --> 00:48:17,839 Alright. Let's get into treatment. So we're in 1325 00:48:17,839 --> 00:48:19,519 the ED. We've got somebody with a traumatic 1326 00:48:19,519 --> 00:48:20,980 brain injury. And 1327 00:48:21,359 --> 00:48:21,859 now 1328 00:48:22,400 --> 00:48:24,179 you have already mentioned how 1329 00:48:24,559 --> 00:48:26,819 a lot of these injuries can be treated 1330 00:48:26,960 --> 00:48:27,460 nonsurgically, 1331 00:48:28,000 --> 00:48:30,545 and that treatment begins really in the prehospital 1332 00:48:30,764 --> 00:48:32,925 setting, but we definitely wanna make sure we're 1333 00:48:32,925 --> 00:48:34,704 giving appropriate treatment in the ED. 1334 00:48:35,164 --> 00:48:37,244 Let's begin with just some of the basics. 1335 00:48:37,244 --> 00:48:38,464 There's a great table, 1336 00:48:38,764 --> 00:48:41,405 on page 16, table seven, the summary of 1337 00:48:41,405 --> 00:48:43,644 actions to consider for patients with traumatic brain 1338 00:48:43,644 --> 00:48:46,159 injury that kinda walks you through all of 1339 00:48:46,159 --> 00:48:46,900 these elements. 1340 00:48:47,279 --> 00:48:49,920 Obviously, they we're gonna get IV access. When 1341 00:48:49,920 --> 00:48:50,900 it comes to hemodynamics, 1342 00:48:51,279 --> 00:48:53,119 what are some of the parameters when it 1343 00:48:53,119 --> 00:48:55,199 comes to blood pressure? Say we don't have 1344 00:48:55,199 --> 00:48:55,859 an intracranial 1345 00:48:56,319 --> 00:48:58,335 monitor. The what are the kinds of parameters 1346 00:48:58,335 --> 00:49:00,434 we're looking for for normal tension? 1347 00:49:00,974 --> 00:49:02,574 Yeah. So this is probably one of the 1348 00:49:02,574 --> 00:49:03,474 biggest takeaways, 1349 00:49:04,094 --> 00:49:05,875 as far as specific numbers, 1350 00:49:07,054 --> 00:49:09,054 and vital signs to be thinking about in 1351 00:49:09,054 --> 00:49:11,135 the traumatic brain injury population. Because I think 1352 00:49:11,135 --> 00:49:13,519 there's a tendency with brain bleeds to worry 1353 00:49:13,519 --> 00:49:14,420 about hypertension. 1354 00:49:15,360 --> 00:49:17,199 And the bigger thing in the traumatic brain 1355 00:49:17,199 --> 00:49:19,460 injury section is actually to worry about hypotension. 1356 00:49:20,159 --> 00:49:21,679 And I mentioned this earlier, but I'll mention 1357 00:49:21,679 --> 00:49:23,380 it again because I think it's pretty significant. 1358 00:49:23,765 --> 00:49:26,085 A single systolic blood pressure of less than 1359 00:49:26,085 --> 00:49:28,344 90 is associated with worse mortality. 1360 00:49:28,644 --> 00:49:31,045 There isn't a clearly defined upper limit for 1361 00:49:31,045 --> 00:49:32,965 what blood pressure is safe in the setting 1362 00:49:32,965 --> 00:49:35,704 of traumatic brain injury and intracranial hemorrhage. 1363 00:49:36,210 --> 00:49:38,769 So it's normal tension that you're shooting for, 1364 00:49:38,769 --> 00:49:40,530 and it does vary a little bit by 1365 00:49:40,530 --> 00:49:42,609 age. For the fifty to sixty nine year 1366 00:49:42,609 --> 00:49:44,690 old population, you're aiming for a systolic greater 1367 00:49:44,690 --> 00:49:45,510 than a hundred. 1368 00:49:45,889 --> 00:49:47,969 And basically, in everybody else, you're aiming for 1369 00:49:47,969 --> 00:49:49,109 greater than one ten. 1370 00:49:49,585 --> 00:49:51,744 And the research does not clearly define an 1371 00:49:51,744 --> 00:49:53,985 upper limit. I would put it somewhere around 1372 00:49:53,985 --> 00:49:55,905 a systolic of one sixty, but there really 1373 00:49:55,905 --> 00:49:58,465 isn't good evidence to support that in the 1374 00:49:58,465 --> 00:50:00,485 traumatic intracranial hemorrhage literature. 1375 00:50:01,025 --> 00:50:03,744 You're aiming for normoxia. You're aiming normothermia, and 1376 00:50:03,744 --> 00:50:05,125 this is where Allegan mentioned 1377 00:50:05,799 --> 00:50:06,859 prolonged hyperventilation 1378 00:50:07,319 --> 00:50:08,539 is something to avoid. 1379 00:50:09,239 --> 00:50:09,739 Hyperventilation 1380 00:50:10,599 --> 00:50:13,000 is a temporizing measure. It is not something 1381 00:50:13,000 --> 00:50:14,359 that I would use in any kind of 1382 00:50:14,359 --> 00:50:15,260 long term setting. 1383 00:50:15,799 --> 00:50:16,299 Gotcha. 1384 00:50:16,599 --> 00:50:19,099 And those blood pressure parameters, again, in distinction 1385 00:50:19,480 --> 00:50:20,219 to the 1386 00:50:20,534 --> 00:50:23,255 spontaneous intracranial hemorrhage, which is a completely different 1387 00:50:23,255 --> 00:50:25,674 population. So we're just talking about traumatic 1388 00:50:25,974 --> 00:50:28,614 intracranial hemorrhage. That's correct. Because there because there 1389 00:50:28,614 --> 00:50:30,795 is good evidence in the spontaneous 1390 00:50:31,174 --> 00:50:31,674 intracranial 1391 00:50:32,054 --> 00:50:32,554 hemorrhage 1392 00:50:32,934 --> 00:50:33,434 category 1393 00:50:34,190 --> 00:50:36,210 for strict systolic parameters 1394 00:50:36,990 --> 00:50:38,369 to avoid hypertension. 1395 00:50:39,550 --> 00:50:41,410 So this is one of the big differences 1396 00:50:41,470 --> 00:50:42,530 between spontaneous 1397 00:50:42,829 --> 00:50:44,769 and traumatic intracranial hemorrhage. 1398 00:50:45,309 --> 00:50:45,809 Gotcha. 1399 00:50:46,184 --> 00:50:46,684 Coagulopathy, 1400 00:50:47,385 --> 00:50:49,085 obviously, if they have a coagulopathy 1401 00:50:49,385 --> 00:50:51,144 and they're on some agent and we can 1402 00:50:51,144 --> 00:50:53,545 reverse it, that's indicated in all of these 1403 00:50:53,545 --> 00:50:54,045 patients? 1404 00:50:54,505 --> 00:50:56,605 I would actually say it's not necessarily indicated 1405 00:50:56,664 --> 00:50:57,164 for 1406 00:50:57,864 --> 00:50:58,364 everyone. 1407 00:50:58,949 --> 00:50:59,609 For example, 1408 00:50:59,989 --> 00:51:02,809 especially if you're considering something like PCC, which 1409 00:51:03,030 --> 00:51:06,070 maybe some places only have in access in 1410 00:51:06,070 --> 00:51:08,309 small amounts, or if you've got somebody, for 1411 00:51:08,309 --> 00:51:10,170 instance, with a thin chronic subdural 1412 00:51:10,710 --> 00:51:12,409 who is also anticoagulated, 1413 00:51:13,505 --> 00:51:16,224 You can consider, for instance, something like vitamin 1414 00:51:16,224 --> 00:51:17,844 k. You can consider slower 1415 00:51:18,224 --> 00:51:20,565 reversals or waiting for something to 1416 00:51:20,945 --> 00:51:21,925 titrate off 1417 00:51:22,305 --> 00:51:24,805 if somebody is really very stable with a 1418 00:51:24,864 --> 00:51:26,485 minimally concerning ridge. 1419 00:51:27,119 --> 00:51:28,019 Good to know. 1420 00:51:28,319 --> 00:51:30,400 Positioning is important as well. Tell me about 1421 00:51:30,400 --> 00:51:30,900 that. 1422 00:51:31,279 --> 00:51:33,519 So positioning, I think it sounds maybe simple, 1423 00:51:33,519 --> 00:51:35,139 but raising the head of bed to 30, 1424 00:51:35,199 --> 00:51:37,039 that can look like a 10 or 15 1425 00:51:37,039 --> 00:51:39,359 difference in somebody's intracranial pressure. It is not 1426 00:51:39,359 --> 00:51:40,179 a small thing. 1427 00:51:40,545 --> 00:51:43,984 And if you're worried about spinal precautions, which 1428 00:51:43,984 --> 00:51:46,244 often in this situation you are, reverse Trendelenburg 1429 00:51:46,385 --> 00:51:47,585 will get you there too. So it doesn't 1430 00:51:47,585 --> 00:51:49,425 mean that you can't do it. You still 1431 00:51:49,425 --> 00:51:51,664 can. You can just maintain spinal precautions at 1432 00:51:51,664 --> 00:51:52,484 the same time. 1433 00:51:52,910 --> 00:51:56,210 And something that is maybe easy to miss, 1434 00:51:56,430 --> 00:51:58,349 if the cervical collar is too tight, that 1435 00:51:58,349 --> 00:52:00,450 can also have a significant effect on intracranial 1436 00:52:00,510 --> 00:52:03,390 pressure by preventing venous outflow. So making sure 1437 00:52:03,390 --> 00:52:05,309 that it fits the patient and that their 1438 00:52:05,309 --> 00:52:07,375 head is square in it actually can have 1439 00:52:07,375 --> 00:52:09,075 a significant effect as well. 1440 00:52:09,535 --> 00:52:11,775 Good. Yeah. That's great. Those are easy things 1441 00:52:11,775 --> 00:52:13,635 to do. Yeah. Also circumferential 1442 00:52:14,015 --> 00:52:15,075 ET tube tape. 1443 00:52:15,454 --> 00:52:17,295 Anything that's going to come across here and 1444 00:52:17,295 --> 00:52:19,055 prevent I mean, there are things that we 1445 00:52:19,055 --> 00:52:21,235 can make sure are not causing a problem. 1446 00:52:21,469 --> 00:52:23,969 That's right. No ligatures around the neck. Correct. 1447 00:52:24,349 --> 00:52:25,569 Okay. Good to know. 1448 00:52:25,869 --> 00:52:29,549 Alright. How about sedation medication? So if they're 1449 00:52:29,549 --> 00:52:30,049 intubated 1450 00:52:30,429 --> 00:52:32,989 and we're sedating them, you know, I'm always 1451 00:52:32,989 --> 00:52:35,385 reaching for propofol in the emergency department, but 1452 00:52:35,545 --> 00:52:38,684 there is an indication for not overly sedating 1453 00:52:38,744 --> 00:52:40,905 these patients so that you can continue to 1454 00:52:40,905 --> 00:52:41,804 perform examinations 1455 00:52:42,105 --> 00:52:43,965 and track reflexes. So 1456 00:52:44,344 --> 00:52:45,804 where are we in recommendations 1457 00:52:46,184 --> 00:52:48,719 for that? Yeah. Propofol is a safe bet. 1458 00:52:48,960 --> 00:52:50,639 Obviously, you're walking the line here where you 1459 00:52:50,639 --> 00:52:52,900 wanna make sure that the patient is comfortable, 1460 00:52:53,599 --> 00:52:55,280 but that you also need to be able 1461 00:52:55,280 --> 00:52:57,359 to trend a neurologic exam. Propofol has a 1462 00:52:57,359 --> 00:52:59,119 pretty short half life, so being able to 1463 00:52:59,119 --> 00:53:00,480 titrate it off and get an exam, I 1464 00:53:00,480 --> 00:53:02,159 mean, there's a reason that it's so commonly 1465 00:53:02,159 --> 00:53:03,859 used, and it is a good option. 1466 00:53:04,385 --> 00:53:07,105 I would argue fentanyl is also a decent 1467 00:53:07,105 --> 00:53:08,405 option because it is, 1468 00:53:08,944 --> 00:53:10,085 pretty short off. 1469 00:53:10,464 --> 00:53:12,244 Others in eating, especially benzodiazepines, 1470 00:53:12,784 --> 00:53:15,344 I would avoid because those really those have 1471 00:53:15,344 --> 00:53:17,824 a much longer half life, and you'll lose 1472 00:53:17,824 --> 00:53:18,964 your exam for longer. 1473 00:53:19,425 --> 00:53:20,280 Good to know. 1474 00:53:20,679 --> 00:53:21,179 Antiepileptic 1475 00:53:21,960 --> 00:53:24,280 medications. So is this only if they have 1476 00:53:24,280 --> 00:53:26,760 obvious seizures or have an abnormal EEG, or 1477 00:53:26,760 --> 00:53:29,260 is this kinda prophylactic for everybody? 1478 00:53:29,559 --> 00:53:31,719 This is a particularly messy section of the 1479 00:53:31,719 --> 00:53:32,219 research. 1480 00:53:32,760 --> 00:53:35,099 There isn't great data on 1481 00:53:35,724 --> 00:53:36,704 especially prophylactic 1482 00:53:37,085 --> 00:53:39,644 use as anti epileptic medications. If somebody is 1483 00:53:39,644 --> 00:53:42,545 obviously seizing, absolutely, by all means, treat it. 1484 00:53:42,844 --> 00:53:44,224 I think the combination 1485 00:53:44,605 --> 00:53:45,905 of the concern 1486 00:53:46,284 --> 00:53:49,405 over possible post traumatic seizures and the fact 1487 00:53:49,405 --> 00:53:50,840 that especially Capra, 1488 00:53:51,460 --> 00:53:51,960 levatoracitam 1489 00:53:52,420 --> 00:53:54,980 is so available and such a benign medication 1490 00:53:54,980 --> 00:53:58,579 overall. Mhmm. It's given a lot. And, I 1491 00:53:58,579 --> 00:54:01,140 don't really necessarily have a problem with it 1492 00:54:01,140 --> 00:54:03,914 because it is a pretty benign medication to 1493 00:54:03,914 --> 00:54:05,675 add on. But the way that I would 1494 00:54:05,675 --> 00:54:07,215 think of it is it's not necessarily 1495 00:54:07,994 --> 00:54:08,494 critical 1496 00:54:08,954 --> 00:54:11,835 unless you actively see someone seizing. For instance, 1497 00:54:11,835 --> 00:54:14,635 I would not opt for Keppra before three 1498 00:54:14,635 --> 00:54:17,035 percent if you've only got access in one 1499 00:54:17,035 --> 00:54:19,159 spot. The Keppra can be put on the 1500 00:54:19,159 --> 00:54:21,480 back burner in the emergent setting unless you 1501 00:54:21,480 --> 00:54:23,099 see that they're actively seizing. 1502 00:54:23,480 --> 00:54:26,059 Overall, the literature does say prophylactic, 1503 00:54:26,760 --> 00:54:27,260 antiepileptic 1504 00:54:27,719 --> 00:54:30,119 for seven days after a head trauma is 1505 00:54:30,119 --> 00:54:30,619 reasonable. 1506 00:54:30,994 --> 00:54:32,614 Even if there isn't phenomenal 1507 00:54:33,074 --> 00:54:35,255 evidence to support it, it's pretty annoying. 1508 00:54:35,875 --> 00:54:36,535 And this 1509 00:54:37,315 --> 00:54:40,035 is necessary to give in the ED on 1510 00:54:40,035 --> 00:54:42,114 presentation, or this is kinda it's great to 1511 00:54:42,114 --> 00:54:42,934 have an antiepileptic 1512 00:54:43,235 --> 00:54:44,755 on board in the first twenty four to 1513 00:54:44,755 --> 00:54:47,280 forty eight hours? Again, there isn't great data 1514 00:54:47,280 --> 00:54:49,360 on it. I would say it's nice to 1515 00:54:49,360 --> 00:54:50,960 have it in there in the first day 1516 00:54:50,960 --> 00:54:54,260 or so. But unless someone is actively seizing, 1517 00:54:54,320 --> 00:54:57,300 it's not one of my top priorities initially. 1518 00:54:57,760 --> 00:54:58,260 Gotcha. 1519 00:54:58,664 --> 00:55:00,925 Okay. And then medications to temper intracranial 1520 00:55:01,304 --> 00:55:03,864 pressure. And you mentioned hypertonic saline, and, we 1521 00:55:03,864 --> 00:55:06,025 also have mannitol in the emergency department. Is 1522 00:55:06,025 --> 00:55:07,945 there evidence between one or the other, or 1523 00:55:07,945 --> 00:55:09,565 is it just kinda whatever you have available? 1524 00:55:09,625 --> 00:55:12,364 Oh, boy. This is another really messy area. 1525 00:55:12,940 --> 00:55:14,880 No one has ever been able to clearly 1526 00:55:14,940 --> 00:55:17,119 show that three percent or mannitol 1527 00:55:17,820 --> 00:55:20,780 is one better than the other. They both 1528 00:55:20,780 --> 00:55:21,280 work. 1529 00:55:21,739 --> 00:55:22,800 And especially 1530 00:55:23,260 --> 00:55:25,954 mannitol, I will say, just sort of from 1531 00:55:25,954 --> 00:55:28,054 my own experience in the OR, 1532 00:55:28,675 --> 00:55:31,315 mannitol, you can actually watch the effect on 1533 00:55:31,315 --> 00:55:33,155 the brain. I mean, in the course of 1534 00:55:33,155 --> 00:55:35,315 a minute or two, you can watch swelling 1535 00:55:35,315 --> 00:55:35,815 decrease. 1536 00:55:36,195 --> 00:55:39,440 So it mannitol tends to be the medication 1537 00:55:39,500 --> 00:55:41,359 that's reached for as the, 1538 00:55:41,659 --> 00:55:42,320 you know, 1539 00:55:42,699 --> 00:55:44,159 can I curse on here or no? 1540 00:55:44,539 --> 00:55:45,679 No. Okay. 1541 00:55:46,139 --> 00:55:47,199 As the oh, damn. 1542 00:55:48,219 --> 00:55:49,519 As the oh, damn medication. 1543 00:55:50,219 --> 00:55:53,244 Because it works fast. That said, three percent 1544 00:55:53,244 --> 00:55:54,785 is probably more readily available 1545 00:55:55,405 --> 00:55:58,285 in the ED in general. And generally speaking, 1546 00:55:58,285 --> 00:56:00,304 like we talked about, we're worried about hypotension. 1547 00:56:01,324 --> 00:56:03,960 As a volume expander, three percent is not 1548 00:56:03,960 --> 00:56:05,400 going to risk that. So if you've got 1549 00:56:05,400 --> 00:56:07,800 somebody who is borderline or hypotensive, I would 1550 00:56:07,800 --> 00:56:10,119 certainly reach for three percent before mannitol and 1551 00:56:10,119 --> 00:56:10,859 then he'll dieretic. 1552 00:56:11,320 --> 00:56:13,239 You're going to risk actually dropping their blood 1553 00:56:13,239 --> 00:56:16,440 pressures. Likewise, if they're very hypertensive, you could 1554 00:56:16,440 --> 00:56:18,599 consider reaching for mannitol to drop the blood 1555 00:56:18,599 --> 00:56:19,099 pressure. 1556 00:56:19,784 --> 00:56:20,444 And similarly, 1557 00:56:20,744 --> 00:56:23,405 if their volume status is, you know, grossly 1558 00:56:23,464 --> 00:56:25,784 fluid overloaded, sure, mannitol is maybe a better 1559 00:56:25,784 --> 00:56:28,425 option where they have terrible heart failure. But 1560 00:56:28,425 --> 00:56:30,505 that said, a volume of two fifty of 1561 00:56:30,505 --> 00:56:33,239 three percent probably isn't going to throw off 1562 00:56:33,239 --> 00:56:35,019 even somebody with bad heart failure. 1563 00:56:35,559 --> 00:56:37,900 Baseline sodium is certainly something to think about. 1564 00:56:38,119 --> 00:56:40,219 Sometimes you have that data, sometimes you don't. 1565 00:56:40,440 --> 00:56:41,960 The only patients that I would really worry 1566 00:56:41,960 --> 00:56:43,900 about are people who are severely hyponatremic 1567 00:56:44,440 --> 00:56:45,099 at baseline, 1568 00:56:45,434 --> 00:56:47,454 and you worry about central pontine myelinolysis. 1569 00:56:48,474 --> 00:56:51,035 That said, it's actually pretty rare in clinical 1570 00:56:51,035 --> 00:56:54,074 practice, and there's never been a case report 1571 00:56:54,074 --> 00:56:55,454 of somebody with normonatremia 1572 00:56:56,155 --> 00:56:58,094 who develops central pontine myelinolysis 1573 00:56:58,875 --> 00:57:01,329 independent of how much 3% they're given. So 1574 00:57:01,329 --> 00:57:02,769 if you know that you're starting anywhere in 1575 00:57:02,769 --> 00:57:03,989 the normal ish range, 1576 00:57:04,369 --> 00:57:06,210 it's not something that I'd really worry about, 1577 00:57:06,210 --> 00:57:10,069 especially if your leading concern is intracranial pressure. 1578 00:57:10,369 --> 00:57:11,489 And the last one to think about is 1579 00:57:11,489 --> 00:57:13,170 patients with kidney disease. I would not use 1580 00:57:13,170 --> 00:57:14,849 Manasol if you know that people have bad 1581 00:57:14,849 --> 00:57:15,670 kidney disease. 1582 00:57:16,194 --> 00:57:16,694 Gotcha. 1583 00:57:17,155 --> 00:57:18,835 Alright. And then there is a section here 1584 00:57:18,835 --> 00:57:22,135 about managing the airway. Obviously, if their GCS 1585 00:57:22,275 --> 00:57:24,594 is eight or lower and we're worried about 1586 00:57:24,594 --> 00:57:26,694 the airway, we're going to intubate these patients. 1587 00:57:26,914 --> 00:57:29,074 Is there something in that process or in 1588 00:57:29,074 --> 00:57:31,094 that management that is more neuroprotective? 1589 00:57:32,329 --> 00:57:34,829 Yeah. The medications that have the most evidence 1590 00:57:34,890 --> 00:57:35,390 behind 1591 00:57:35,929 --> 00:57:38,030 them prior to rapid sequence intubation, 1592 00:57:38,489 --> 00:57:39,789 fentanyl or remifentanil 1593 00:57:40,170 --> 00:57:41,949 probably have the best evidence. 1594 00:57:42,809 --> 00:57:43,949 Induction agents, 1595 00:57:44,454 --> 00:57:44,954 propofol, 1596 00:57:45,255 --> 00:57:47,755 etomidate, or ketamine should all be fine. 1597 00:57:48,295 --> 00:57:49,434 And paralytic, 1598 00:57:49,815 --> 00:57:52,714 there is debate between rocuronium and succinylcholine. 1599 00:57:53,494 --> 00:57:56,214 One has not been definitively proven to be 1600 00:57:56,214 --> 00:57:57,275 better than the other. 1601 00:57:57,639 --> 00:57:59,260 The thing to keep in mind with rocuronium 1602 00:57:59,320 --> 00:58:00,519 is obviously that it's going to be in 1603 00:58:00,519 --> 00:58:01,500 effect much longer. 1604 00:58:01,800 --> 00:58:03,500 So that is where noting 1605 00:58:03,960 --> 00:58:05,719 the dose and the time that it was 1606 00:58:05,719 --> 00:58:07,880 given is going to be critical to be 1607 00:58:07,880 --> 00:58:10,119 able to pass on that information as far 1608 00:58:10,119 --> 00:58:11,565 as when we can expect that the effects 1609 00:58:11,565 --> 00:58:13,164 are going to wear off and whether something 1610 00:58:13,164 --> 00:58:14,625 like secantinibex is indicated. 1611 00:58:15,324 --> 00:58:17,324 Yeah. That debate in paralytics has only been 1612 00:58:17,324 --> 00:58:19,664 going on my entire career, so it's okay. 1613 00:58:19,804 --> 00:58:22,065 I wish I had clarification. I do not. 1614 00:58:22,204 --> 00:58:23,885 I'm very disappointed you did not come up 1615 00:58:23,885 --> 00:58:25,744 with an answer just during this article. 1616 00:58:26,230 --> 00:58:29,030 Okay. Managing intracranial pressure. So we talked about 1617 00:58:29,030 --> 00:58:31,690 medications which can be given. We talked about 1618 00:58:31,750 --> 00:58:32,250 hyperventilation 1619 00:58:32,789 --> 00:58:35,989 as something that is only done very intently 1620 00:58:35,989 --> 00:58:37,910 for a very short period of time, perhaps 1621 00:58:37,910 --> 00:58:39,210 on the way to the OR. 1622 00:58:39,585 --> 00:58:41,984 Anything else? There's a discussion here about shivering, 1623 00:58:41,984 --> 00:58:44,885 so patients' shivering and shivering control. That's important 1624 00:58:44,945 --> 00:58:46,965 because that can increase intracranial pressure? 1625 00:58:47,425 --> 00:58:50,085 Yes. Shivering absolutely can. It increases intrathoracic 1626 00:58:50,385 --> 00:58:50,885 pressure, 1627 00:58:51,184 --> 00:58:53,925 decreases venous outflow, increases intracranial pressure. 1628 00:58:54,389 --> 00:58:55,130 So sometimes, 1629 00:58:55,429 --> 00:58:57,190 paralytic is actually used in that setting. This 1630 00:58:57,190 --> 00:58:59,389 is more of the neuro intensive care setting. 1631 00:58:59,750 --> 00:59:02,469 Paralytic can actually be used to prevent shivering 1632 00:59:02,469 --> 00:59:05,029 in the ICP escalations related to it. And 1633 00:59:05,029 --> 00:59:07,394 then I like that there's on page nineteen 1634 00:59:07,394 --> 00:59:09,954 nineteen there, a description of kinda tier one, 1635 00:59:09,954 --> 00:59:12,934 tier two, tier three interventions for continued 1636 00:59:13,394 --> 00:59:15,875 in elevated intracranial pressure. This is getting more 1637 00:59:15,875 --> 00:59:17,255 into that kinda longer 1638 00:59:17,795 --> 00:59:19,954 neurocritical care, and this is certainly something you're 1639 00:59:19,954 --> 00:59:22,070 doing in consultation with your colleagues. But there's 1640 00:59:22,070 --> 00:59:24,309 an excellent description of that in the article 1641 00:59:24,309 --> 00:59:24,969 as well. 1642 00:59:25,269 --> 00:59:26,809 I also like that you included 1643 00:59:27,190 --> 00:59:30,469 the surgical management. So table nine there is 1644 00:59:30,469 --> 00:59:31,769 sort of a picture 1645 00:59:32,230 --> 00:59:33,769 of the different types 1646 00:59:34,070 --> 00:59:34,570 of 1647 00:59:35,204 --> 00:59:37,385 surgical approaches, things like craniotomies, 1648 00:59:37,765 --> 00:59:38,744 decompressive craniectomy, 1649 00:59:39,445 --> 00:59:42,085 burr holes, and how they're done. That's a 1650 00:59:42,085 --> 00:59:44,805 fantastic image and I think helpful to know. 1651 00:59:44,805 --> 00:59:46,885 Again, hopefully, you're not doing this in the 1652 00:59:46,885 --> 00:59:48,890 ED, but, you know, burr holes are certainly 1653 00:59:48,890 --> 00:59:51,050 something that can be done by emergency medicine 1654 00:59:51,050 --> 00:59:52,910 physicians in a disaster scenario. 1655 00:59:53,369 --> 00:59:55,130 But I like that this is outlined in 1656 00:59:55,130 --> 00:59:57,130 here, again, for completeness' sake so you can 1657 00:59:57,130 --> 01:00:00,090 see what your neurosurgical colleagues may be doing 1658 01:00:00,090 --> 01:00:02,695 in the OR and some of the reasons 1659 01:00:02,695 --> 01:00:03,974 behind them, like, you know, if someone has 1660 01:00:03,974 --> 01:00:06,954 an epidural or someone has intractable elevated intracranial 1661 01:00:07,014 --> 01:00:08,635 pressure. This is helpful to know. 1662 01:00:09,014 --> 01:00:11,335 Yeah. I think my primary reason for having 1663 01:00:11,335 --> 01:00:12,614 it there, I think that it can be 1664 01:00:12,614 --> 01:00:14,054 a little bit of a mystery for people 1665 01:00:14,054 --> 01:00:15,670 on the other side of it. And a 1666 01:00:15,670 --> 01:00:17,690 lot of it is actually fairly simple, 1667 01:00:17,989 --> 01:00:19,750 and a lot of it has to do 1668 01:00:19,750 --> 01:00:22,150 with identifying what the source of the pressure 1669 01:00:22,150 --> 01:00:24,409 is and how you can best address it. 1670 01:00:24,710 --> 01:00:26,809 And I think this is where the limitations 1671 01:00:27,190 --> 01:00:29,349 of surgery also become a little bit more 1672 01:00:29,349 --> 01:00:30,250 evident maybe 1673 01:00:30,554 --> 01:00:32,655 because it all depends on how accessible 1674 01:00:33,034 --> 01:00:35,375 the lesion is. An epidural hematoma, 1675 01:00:35,755 --> 01:00:38,255 right at the surface, very easy to access. 1676 01:00:38,795 --> 01:00:39,295 Contusions, 1677 01:00:39,835 --> 01:00:42,175 especially ones that are deeper in the brain, 1678 01:00:42,680 --> 01:00:43,180 multicompartmental 1679 01:00:43,720 --> 01:00:46,539 hemorrhage causing kind of generalized edema, 1680 01:00:47,079 --> 01:00:48,840 those are not things that you can really 1681 01:00:48,840 --> 01:00:50,460 easily address surgically. 1682 01:00:51,239 --> 01:00:52,460 And the ultimate 1683 01:00:53,160 --> 01:00:54,300 measure that neurosurgeons 1684 01:00:54,760 --> 01:00:56,974 can use is even a bilateral 1685 01:00:57,595 --> 01:00:58,095 hemicraniacomy. 1686 01:00:58,715 --> 01:01:00,075 So that would be, as you see in 1687 01:01:00,075 --> 01:01:01,755 figure nine, not just on one side of 1688 01:01:01,755 --> 01:01:04,155 the head, but decompress both sides, open up 1689 01:01:04,155 --> 01:01:04,815 the dura. 1690 01:01:05,434 --> 01:01:07,695 And those situations are really reserved for 1691 01:01:08,429 --> 01:01:09,329 terrible, terrible 1692 01:01:09,630 --> 01:01:11,969 brain injury that is causing so much pressure 1693 01:01:12,030 --> 01:01:14,510 that is not in an accessible region. There 1694 01:01:14,510 --> 01:01:16,190 is no focal lesion to be able to 1695 01:01:16,190 --> 01:01:16,690 evacuate, 1696 01:01:17,150 --> 01:01:18,909 and you're just trying to give the brain 1697 01:01:18,909 --> 01:01:21,250 more space by breaking the Monroe Kelley doctrine. 1698 01:01:21,534 --> 01:01:23,054 The interesting thing is that the evidence does 1699 01:01:23,054 --> 01:01:24,594 actually not support 1700 01:01:25,054 --> 01:01:26,994 doing bilateral craniotomies. 1701 01:01:27,934 --> 01:01:29,315 That has never shown 1702 01:01:29,934 --> 01:01:32,275 a long term outcome benefit, 1703 01:01:32,735 --> 01:01:34,355 and it's probably because 1704 01:01:34,719 --> 01:01:36,480 the brain is so injured at that point 1705 01:01:36,480 --> 01:01:38,880 that independent of whether or not you decompress 1706 01:01:38,880 --> 01:01:42,160 it, it is beyond recovery. So I think 1707 01:01:42,160 --> 01:01:43,440 one of the things to be mindful of 1708 01:01:43,440 --> 01:01:45,119 with these interventions is just that they cannot 1709 01:01:45,119 --> 01:01:47,920 resolve every problem. And there are certainly people 1710 01:01:47,920 --> 01:01:49,300 who you even do 1711 01:01:49,635 --> 01:01:50,295 bilateral crani, 1712 01:01:51,155 --> 01:01:53,635 and they still herniate Mhmm. Because there's just 1713 01:01:53,635 --> 01:01:55,875 too much pressure. And even just the skin 1714 01:01:55,875 --> 01:01:58,135 at some point becomes a bounding feature, 1715 01:01:58,434 --> 01:02:00,515 and they can still generate enough pressure to 1716 01:02:00,515 --> 01:02:02,275 herniate. So as much as I would like 1717 01:02:02,275 --> 01:02:04,295 to say that neurosurgery can cure everything, 1718 01:02:04,769 --> 01:02:05,809 I mean it when I say that the 1719 01:02:05,809 --> 01:02:08,210 medical management is often the definitive management that 1720 01:02:08,210 --> 01:02:09,670 you're trying to do for these patients. 1721 01:02:10,130 --> 01:02:12,210 Yeah. Yeah. That's good to know. On the 1722 01:02:12,210 --> 01:02:15,110 same kind of wavelengths, external ventricular drains, 1723 01:02:15,489 --> 01:02:18,210 it's kind of an institution dependent practice whether 1724 01:02:18,210 --> 01:02:19,829 or not they use them for trauma 1725 01:02:20,414 --> 01:02:21,474 because intraventricular 1726 01:02:22,094 --> 01:02:24,675 hemorrhage is fairly rare in the traumatic setting, 1727 01:02:24,815 --> 01:02:25,795 and hydrocephalus 1728 01:02:26,255 --> 01:02:29,954 is fairly rare in the acute traumatic setting. 1729 01:02:30,094 --> 01:02:32,675 An external ventricular drain is an excellent intervention 1730 01:02:32,815 --> 01:02:33,554 for hydrocephalus. 1731 01:02:34,500 --> 01:02:36,659 That's not typically the problem in the setting 1732 01:02:36,659 --> 01:02:37,239 of trauma. 1733 01:02:37,699 --> 01:02:39,860 So, yes, it's one of the three elements 1734 01:02:39,860 --> 01:02:41,860 of the Monroe Kelley doctrine, CSF, that you're 1735 01:02:41,860 --> 01:02:43,460 taking off and you can lower pressure that 1736 01:02:43,460 --> 01:02:45,699 way. But I think it's also important to 1737 01:02:45,699 --> 01:02:47,704 note that it ends up not being 1738 01:02:48,325 --> 01:02:51,605 immensely helpful because there's often so much pressure 1739 01:02:51,605 --> 01:02:54,085 from the brain and the blood itself. CSF 1740 01:02:54,085 --> 01:02:55,925 is not the problem. Often, the ventricles are 1741 01:02:55,925 --> 01:02:57,925 really tiny to begin with. You're gonna get 1742 01:02:57,925 --> 01:03:00,244 off some pressure. Sure. Maybe it's enough to 1743 01:03:00,244 --> 01:03:00,744 temporize 1744 01:03:01,640 --> 01:03:03,180 through the critical period, 1745 01:03:03,719 --> 01:03:06,140 but it's by no means a definitive intervention. 1746 01:03:06,440 --> 01:03:09,320 And it can also be higher risk because 1747 01:03:09,320 --> 01:03:11,579 the ventricles are often collapsed under pressure. 1748 01:03:11,880 --> 01:03:14,039 It's a procedure that's often done blindly at 1749 01:03:14,039 --> 01:03:16,724 the bedside by your neurosurgical colleagues. So I 1750 01:03:16,724 --> 01:03:18,965 think it's an intervention that can be considered, 1751 01:03:18,965 --> 01:03:23,045 but it's also not a definitive management in 1752 01:03:23,045 --> 01:03:23,704 the setting. 1753 01:03:24,164 --> 01:03:26,565 Okay. What about bedside burr holes for these 1754 01:03:26,565 --> 01:03:29,204 patients in the emergency department? Is that actually 1755 01:03:29,204 --> 01:03:30,965 a thing? People perform those in the ED 1756 01:03:30,965 --> 01:03:32,460 as opposed to taking them to the OR, 1757 01:03:32,539 --> 01:03:34,460 assuming the emergency physician isn't the one doing 1758 01:03:34,460 --> 01:03:34,960 it? 1759 01:03:35,339 --> 01:03:38,139 So there are actually a couple of case 1760 01:03:38,139 --> 01:03:40,400 reports of ED physicians 1761 01:03:40,940 --> 01:03:44,960 doing bedside burr holes for specifically epidural hematoma 1762 01:03:45,675 --> 01:03:48,015 when they are in a critical access location. 1763 01:03:48,394 --> 01:03:50,394 I think, in those situations, they were several 1764 01:03:50,394 --> 01:03:54,235 hours from definitive neurosurgical care with someone with 1765 01:03:54,235 --> 01:03:57,355 blown pupil and a critical exam. So in 1766 01:03:57,355 --> 01:03:59,835 the literature, there are a couple of reports 1767 01:03:59,835 --> 01:04:01,295 where this was done successfully. 1768 01:04:02,369 --> 01:04:04,609 I will say, I think the biggest reason 1769 01:04:04,609 --> 01:04:05,569 that this is something that there's almost no 1770 01:04:05,569 --> 01:04:09,089 indication for is that it just doesn't work 1771 01:04:09,089 --> 01:04:09,829 very well. 1772 01:04:10,130 --> 01:04:10,710 You have 1773 01:04:11,489 --> 01:04:13,809 a tiny hole, and I think something that 1774 01:04:13,809 --> 01:04:15,974 people don't necessarily think about is that it's 1775 01:04:15,974 --> 01:04:19,095 clotted blood underneath it. It's not actually necessarily 1776 01:04:19,095 --> 01:04:21,414 liquid. It's like Jell O. And so you're 1777 01:04:21,414 --> 01:04:24,375 just blindly suctioning in through your tiny hole 1778 01:04:24,375 --> 01:04:27,195 to try to evacuate whatever you can blindly. 1779 01:04:27,869 --> 01:04:30,509 And it's also not addressing the underlying bleeding, 1780 01:04:30,509 --> 01:04:32,449 which is typically from the middle meningeal artery. 1781 01:04:32,509 --> 01:04:34,289 So you've got active extra 1782 01:04:34,750 --> 01:04:37,150 filling up the space that you just tried 1783 01:04:37,150 --> 01:04:38,289 to suction out. 1784 01:04:38,829 --> 01:04:40,750 And so the two case reports that I'd 1785 01:04:40,750 --> 01:04:43,945 seen of it both reactumulated their epidural within, 1786 01:04:43,945 --> 01:04:46,105 I think, an hour or two. And I 1787 01:04:46,105 --> 01:04:48,605 think in one situation, they were repeatedly suctioning 1788 01:04:48,824 --> 01:04:50,824 while they were in transport trying to get 1789 01:04:50,824 --> 01:04:53,565 to neurosurgical intervention. Wow. And both required 1790 01:04:53,864 --> 01:04:55,085 neurosurgical intervention 1791 01:04:55,465 --> 01:04:57,829 at some point. So, I mean, sure, there 1792 01:04:57,829 --> 01:05:00,309 are very, very few cases where this has 1793 01:05:00,309 --> 01:05:01,610 ever been done successfully, 1794 01:05:02,550 --> 01:05:04,570 and it's a very limited intervention. 1795 01:05:05,030 --> 01:05:07,530 So while I think it maybe sounds exciting 1796 01:05:07,829 --> 01:05:10,070 in clinical practice, I think there are very 1797 01:05:10,070 --> 01:05:12,010 few indications where it would be successful. 1798 01:05:12,594 --> 01:05:13,335 And temporizing 1799 01:05:13,635 --> 01:05:15,574 at best. And and temporizing at best. 1800 01:05:16,355 --> 01:05:18,135 Lastly, tell me about 1801 01:05:18,515 --> 01:05:20,835 goals of care. When is it appropriate maybe 1802 01:05:20,835 --> 01:05:23,474 to start having these conversations with patients and 1803 01:05:23,474 --> 01:05:24,375 family members? 1804 01:05:24,940 --> 01:05:26,300 Yeah. I think this is maybe one of 1805 01:05:26,300 --> 01:05:29,500 the scariest things that ED providers can be 1806 01:05:29,500 --> 01:05:32,460 occasionally tasked with because, no, it doesn't necessarily 1807 01:05:32,460 --> 01:05:33,920 mean that you're an expert in neuroprognostication, 1808 01:05:34,460 --> 01:05:36,320 and these injuries are really challenging. 1809 01:05:36,699 --> 01:05:37,820 But I do think that there is a 1810 01:05:37,820 --> 01:05:39,964 role for at least starting the conversation 1811 01:05:40,344 --> 01:05:43,964 in situations where you do suspect severe injury 1812 01:05:44,105 --> 01:05:46,744 in somebody who you think may well not 1813 01:05:46,744 --> 01:05:47,804 do very well. 1814 01:05:48,105 --> 01:05:49,484 And so even asking 1815 01:05:49,944 --> 01:05:52,800 some simple questions to family members just to 1816 01:05:52,800 --> 01:05:54,180 start the thought process 1817 01:05:54,640 --> 01:05:57,440 can be incredibly beneficial down the road. Even 1818 01:05:57,440 --> 01:05:59,680 when neurosurgery is speaking to the family an 1819 01:05:59,680 --> 01:06:01,760 hour later, if they've even had a little 1820 01:06:01,760 --> 01:06:03,780 bit of time to think about questions like, 1821 01:06:04,239 --> 01:06:06,559 what does a worthwhile day look like for 1822 01:06:06,559 --> 01:06:07,300 this patient? 1823 01:06:07,664 --> 01:06:09,605 What level of functioning would be necessary 1824 01:06:10,224 --> 01:06:11,925 to make life worth living? 1825 01:06:12,385 --> 01:06:14,065 If they've even had a little bit of 1826 01:06:14,065 --> 01:06:15,505 time to think about that for the patient, 1827 01:06:15,505 --> 01:06:17,505 it can really help them make better informed 1828 01:06:17,505 --> 01:06:18,864 decisions. So I think there is a role 1829 01:06:18,864 --> 01:06:20,785 for at least starting that conversation in the 1830 01:06:20,785 --> 01:06:21,684 emergency department. 1831 01:06:22,359 --> 01:06:24,599 Yeah. Yeah. That's a great point. And certainly 1832 01:06:24,599 --> 01:06:26,839 something that can be quite uncomfortable to do 1833 01:06:26,839 --> 01:06:28,920 for me, especially in these settings where I'm 1834 01:06:28,920 --> 01:06:30,359 like, hey. I'm not a neurosurgeon. I don't 1835 01:06:30,359 --> 01:06:31,800 know what your outcome's gonna be, but I 1836 01:06:31,800 --> 01:06:33,400 think it's an important point to at least 1837 01:06:33,400 --> 01:06:36,039 start that conversation and get an understanding of 1838 01:06:36,039 --> 01:06:37,400 who the patient is and what they would 1839 01:06:37,400 --> 01:06:37,980 have wanted. 1840 01:06:38,335 --> 01:06:40,255 Yeah. Even for those of us who know 1841 01:06:40,255 --> 01:06:42,035 at least something about neuroprognostication, 1842 01:06:42,815 --> 01:06:44,974 it's still somewhat of a black box. And 1843 01:06:44,974 --> 01:06:46,414 we do the best that we can, and 1844 01:06:46,414 --> 01:06:48,255 we just try to help patients make informed 1845 01:06:48,255 --> 01:06:48,755 decisions. 1846 01:06:49,375 --> 01:06:49,875 Fantastic. 1847 01:06:50,655 --> 01:06:53,190 Alright. Well, that's a lot of information. Again, 1848 01:06:53,190 --> 01:06:57,269 this is the February 2025 emergency medicine practice 1849 01:06:57,269 --> 01:07:00,570 article on traumatic intracranial hemorrhage. We have covered 1850 01:07:00,630 --> 01:07:01,989 almost all of it, but believe it or 1851 01:07:01,989 --> 01:07:04,070 not, there is more in this article. It 1852 01:07:04,070 --> 01:07:06,655 is just jam packed, and it's a wonderful 1853 01:07:06,715 --> 01:07:08,715 write. I really love it. So I think 1854 01:07:08,715 --> 01:07:10,554 all three of you did an outstanding job 1855 01:07:10,554 --> 01:07:13,675 with this article. There is a clinical pathway 1856 01:07:13,675 --> 01:07:16,795 in it for newly discovered traumatic intracranial hemorrhage. 1857 01:07:16,795 --> 01:07:18,590 It'll walk you through who needs to be 1858 01:07:18,590 --> 01:07:21,150 observed, when to get your neurosurgical consult, the 1859 01:07:21,150 --> 01:07:22,590 critical pieces you need to do at the 1860 01:07:22,590 --> 01:07:25,469 bedside. And there's also a clinical pathway for 1861 01:07:25,469 --> 01:07:28,030 elevated intracranial pressure, both of which will convert 1862 01:07:28,030 --> 01:07:30,349 into interactive formats to help you at the 1863 01:07:30,349 --> 01:07:33,355 bedside, and it'll, I think, greatly inform your 1864 01:07:33,355 --> 01:07:35,674 practice. I wanna say thank you for being 1865 01:07:35,674 --> 01:07:37,434 one of the authors and for coming on 1866 01:07:37,434 --> 01:07:40,074 the podcast to explain the voluminous amount of 1867 01:07:40,074 --> 01:07:42,954 information contained in here. It's a wonderful, wonderful 1868 01:07:42,954 --> 01:07:45,360 article. I highly encourage our listeners to go 1869 01:07:45,599 --> 01:07:47,360 download it, read it, and get your CME. 1870 01:07:47,360 --> 01:07:49,840 I mean, that's four hours of trauma and 1871 01:07:49,840 --> 01:07:50,340 neurocritical 1872 01:07:50,880 --> 01:07:54,000 CME that will be well earned and, definitely 1873 01:07:54,000 --> 01:07:55,059 inform your practice. 1874 01:07:55,519 --> 01:07:56,880 Thank you so much for being on the 1875 01:07:56,880 --> 01:07:58,900 podcast. Thank you so much for having me. 1876 01:07:59,119 --> 01:08:01,005 And that's a wrap. Thanks for joining us 1877 01:08:01,005 --> 01:08:02,545 for this episode of Amplify. 1878 01:08:03,085 --> 01:08:06,924 As always, I wanna remind you of ebmedicine.net, 1879 01:08:06,924 --> 01:08:09,964 your one stop shop for emergency medicine and 1880 01:08:09,964 --> 01:08:10,864 urgent care 1881 01:08:11,164 --> 01:08:12,784 continuing medical education. 1882 01:08:13,164 --> 01:08:17,029 That's three journals, the emergency medicine practice, pediatric 1883 01:08:17,170 --> 01:08:20,210 emergency medicine practice, and evidence based urgent care 1884 01:08:20,210 --> 01:08:22,469 journals along with a multitude 1885 01:08:22,929 --> 01:08:25,649 of courses like the laceration course, the abscess 1886 01:08:25,649 --> 01:08:28,324 course, the EKG course, all available to you 1887 01:08:28,324 --> 01:08:29,925 at ebmedicine.net. 1888 01:08:29,925 --> 01:08:32,265 Until next time, everyone. I'm Sam Ashoo.