00:01
What about the clinical
patient clinical presentation?
How to patients typically
present from a brain injury?
Well our first job
is to take a history,
a detailed history
to explore the type,
nature and mechanism
of the potential injury
and then a comprehensive
physical exam.
00:17
In terms of history, we obtained a
history of the mechanism of the injury
prior to the patient's
arrival if possible,
bystanders are very important to question
in evaluating patients around a trauma.
00:28
We want to look for reported
loss of consciousness
and for how long the patient
may have been consciousness.
00:34
If there was a motor
vehicle accident
whether the patient was restrained
or not restrained by a seatbelt.
00:40
We want to perform a
mental status examination
and the Glasgow Coma
Scale as a standardized
and validated measure of
the patient's mental status
after the time of of a trauma.
00:51
We look for scalp lacerations,
palpate for fractures,
we're looking to differentiate those open
head injuries from a closed head injury.
00:59
And then we want to look
for other associated signs
that may herald an
underlying skull fracture.
01:05
Otorrhea or rhinorrhea,
which is CSF fluid drainage
from the nose or the ears
is highly concerning.
01:12
Clear fluid that is draining from the
nose or ears should be evaluated promptly.
01:16
This indicates there's
an open connection
between the outside world
and the cerebrospinal fluid
and could be initis for CNS infection
and needs to be managed emergently.
01:28
We look for ecchymosis in the
raccoon eyes which you can see here
which is bruising
ecchymosis around both eyes
is a specific sign for a base
of the skull base fracture.
01:38
And those findings should
prompt evidence prompted workup
for evaluation of
underlying skull fracture.
01:47
We look for conjunctival
hemorrhages,
blood behind the tympanic membrane or
other evidence of underlying trauma.
01:55
And then a comprehensive
neurologic exam is key,
looking for signs or symptoms that
suggest a focal neurologic deficit
that requires imaging or
other more diffuse deficits
that could have occurred
from the traumatic injury.
02:11
Next,
we want to look at vital signs.
02:13
Vital signs are very important in
evaluating a patient with potential trauma
and significant alterations in
vital signs herald herniation
and point towards the
concern for herniation.
02:25
Neurogenic shock or hypotension.
02:28
Tachycardia require
prompt resuscitation,
we really worry if we see vital signs
that point towards Cushing's triad,
which is hypertension, bradycardia,
and irregular respiratory rate.
02:40
And that combination suggests
brainstem herniation,
or impending modularity
brainstem herniation,
and is a medical emergency.
02:51
When patients present we
use the Glasgow Coma Scale
to stratify those patients who are high
risk for complications or lower risk.
02:59
The GCS exam addresses the level of
consciousness after a head injury.
03:03
Patients receive a score for the best
response in each of these three areas.
03:08
Eye opening, best verbal
response and best motor response.
03:13
Scores in each area combined,
and we get a total
score ranging from 3
which is severe reduction in consciousness
and function to normal which is 15.
03:23
And you can see each
of the three areas,
we evaluate the
level of eye opening.
03:27
Does the patient open their eyes
spontaneously which is a score of 4
or to verbal command or
pain or no eye opening?
We look at their best
verbal responses.
03:37
Is the patient alert, awake, oriented
and appropriate in their conversation
or are they confused?
Are they speaking nonsensically?
Are they mumbling or just
silence not able to speak?
And then in terms
of motor response,
we want to look at whether the
patient is following commands
which is normal and a score of 6
or is localizing to pain,
withdrawing to pain,
has flexor posturing,
extensor posturing or flaccid.
04:03
And the lower we
get on each score,
the more concerned we are about the
significance of the injury the patient
has received and the more urgent
the evaluation is for that patient.
04:13
Let's look a little bit
closer at how we stratify
these scores on the
Glasgow Coma Scale.
04:18
The higher the number,
the better the prognosis
and this is an important
early assessment
bedside assessment to stratify short and
long term prognosis for these patients.
04:28
A Glasgow Coma score of
9 or less indicates coma.
04:33
These patients need endotracheal
intubation for airway protection
and aggressive monitoring
and resuscitation.
04:41
Glasgow Coma scores in the
11, 12, 13, 14 range
indicate minor to
moderate injury
and a change in score is more
important than the absolute scale.
04:50
And so if we see a patient who begins
at 11 and is moving up to 12, 13 or 14,
that patient is trending
in a favorable direction.
04:58
Alternatively,
an initial 14 that is declining to 11
requires prompt intervention
prior to the development of coma.