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

2. Patient 1 Admission brain CT

3. Patient 1 Repeat brain CT, 24 hours after admission

4. 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

5. 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

6. Secondary Brain Injury Paramount to therapy is… Avoidance of hypotension and hypoxemia Intensivist-based management to manage elevated ICP and optimize cerebral blood flow

7. 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

8. Evaluation—GCS

9. Patient 2 Admission chest radiograph

10. Patient 2 Left chest

11. Patient 2 Posterior view

12. Patient 2 Bilateral sacral fractures

13. Patient 2 Extravasation from posterior pelvis

14. Patient 3 Admission chest radiograph

15. Patient 3 Brainstem hemorrhage

16. Patient 3 Ischemia/reperfusion injury of the small bowel

17. Patient 3 Left lower lobar extravasation