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Missouri EMS Central Region
September 2012 WebinarCase Review
Jeffrey Coughenour, MD, FACS
Assistant Professor of SurgeryMedical Director, Missouri EMS Central Region
Patient 1Admission brain CT
Patient 1Repeat brain CT, 24 hours after admission
Primary Brain Injury
• Direct result of the disruptive forces that are transmitted during impact– Various mechanism of injury– Result: Several types of mass lesions, axonal shear, skull
fracture, etc.
• Best therapy—prevention
Secondary Brain Injury
• Events after the primary insult that exacerbate injury and worsen outcome
• Leading cause of in-hospital death following TBI
• Injured brain swelling reduced cerebral blood flow and reduced threshold for cerebral ischemia more damage worsened functional outcome
Secondary Brain Injury
• Paramount to therapy is…
Avoidance of hypotension and hypoxemia
• Intensivist-based management to manage elevated ICP and optimize cerebral blood flow
Evaluation
• D “Disability” portion of primary survey• Glasgow Coma Scale score most reproducible
measurement of injury– Mild (GCS 14-15): 80%– Moderate (GCS 9-13): 10%– Severe (GCS 3-8): 10%
• Report initial GCS, repeat with clinical change• Motor component most predictive of recovery
Evaluation—GCS
Patient 2Admission chest radiograph
Patient 2Left chest
Patient 2Posterior view
Patient 2Bilateral sacral fractures
Patient 2Extravasation from posterior pelvis
Patient 3Admission chest radiograph
Patient 3Brainstem hemorrhage
Patient 3Ischemia/reperfusion injury of the small bowel
Patient 3Left lower lobar extravasation