00:01
What about the evaluation
of these patients?
How do we diagnose and
workup both the injury
and potential secondary
complications?
Well, the first thing that
should be done is a head CT.
00:12
Non-contrast head CT is the
initial imaging modality of choice
and we're looking for
fractures, skull fractures,
were looking for secondary
injuries in the scalp,
and intracranial hemorrhages.
00:24
Here we see a
non-contrast head CT
demonstrating a lens shape hyper density
consistent with an epidural hematoma.
00:33
Alternatively,
we may want to look in different planes
and here we're looking
at a coronal CT
demonstrating a similar
lens shaped deformity
in the inferior temporal lobe also
consistent with an epidural hematoma.
00:47
CTA or CT angiography is also
important in evaluating these patients,
particularly for
concerned for dissection
or tearing of the intima of the artery
as a result of head or neck trauma.
01:00
Here we're looking
at two CTA images.
01:02
The one on the left is a
CTA in the sagittal plane,
and we're looking at the contrast
filling up the common carotids
and internal and
external carotids.
01:11
The common carotid here is labeled with
the orange and we see the bifurcation
of the internal and external
carotid at the green arrow.
01:20
On the axial, we're looking at
all four of the blood vessels
that supply the brain
with blood supply,
the two common
carotids in the green
and the vertebral
arteries in orange.
01:31
We can see the vertebral
arteries are located
within the foramen
transversarium,
the bones and that foramen of
the bone in the cervical spine
and that does increase the
risk of tearing of that artery
as a result of severe stress on
the neck and selected injuries.
01:47
MRI scan is common to be
performed in these patients.
01:50
And here we're not just looking
for bleeding or fractures,
but also internal injury
to the brain itself.
01:57
This is an excellent modality for
looking for a delayed onset of hemorrhage
or other deficits within the first
24 to 48 hours after a trauma.
02:10
This is a modality that we may use for
more moderate to severe concussions,
but it's not required for all patients
with a mild traumatic brain injury.
02:19
And here we're looking
at a typical MRI scan,
demonstrating a convex lesion extending
over the entirety of the left convexity
with multiple dense
intensities of fluid consistent
with an acute on subacute
subdural hematoma.
02:36
This patient likely due to this
left-sided brain hemorrhage
will have right-sided weakness,
maybe just drift with the arm or
perhaps more extensive weakness,
which could require
surgical intervention.
02:50
We also want to consider monitoring
for increased intracranial pressure
as a result of trauma and swelling
of the brain or hemorrhage.
02:59
We can see increases in
intracranial pressure.
03:02
Intracranial bolt monitoring allows
us to titrate intracranial pressure
monitoring in the ICU
setting for patients
with significant or severe
traumatic brain injuries.
03:12
And patients with a brain injury
can have a seizure not all will.
03:16
But we evaluate for
seizures clinically
and in those who suffer a seizure
treat promptly with an anti-epileptic.
03:24
So what about the
initial management?
How do we manage these patients?
What are some of the
initial interventions
and then longer term
interventions for patients?
Well, the first is this brain
injuries are an emergency
and whenever we're
dealing with an emergency,
we think about
airway protection.
03:39
Intubating those who may not be
able to protect their airway,
particularly those with
a GCS scale of 9 or less.
03:47
Fluid resuscitation
oxygenation are important.
03:50
We want to reduce biochemical
stress to the brain.
03:53
And these resuscitative and supportive
care measures are critical for doing that.
03:58
And then we want to assess and
manage any associated injuries,
injuries to the scalp,
face, or the brain itself,
or anywhere else in the body.
04:06
And patients presenting
with a new trauma
will have a head to toe
evaluation to screen
for any traumatic injuries
anywhere in the body
so that those can
also be managed.