Missouri EMS Central Region September 2012 Webinar Case Review Jeffrey Coughenour, MD, FACS Assistant Professor of Surgery Medical Director, Missouri EMS Central Region

Patient 1 Admission brain CT

Patient 1 Repeat 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 2 Admission chest radiograph

Patient 2 Left chest

Patient 2 Posterior view

Patient 2 Bilateral sacral fractures

Patient 2 Extravasation from posterior pelvis

Patient 3 Admission chest radiograph

Patient 3 Brainstem hemorrhage

Patient 3 Ischemia/reperfusion injury of the small bowel

Patient 3 Left lower lobar extravasation