Nursing Care Plans For Cva

[music playing] ok. so i'm kara. people who come toeval time don't usually have a hard time remembering me. so what happens is i have a veryunorthodox method of teaching. i like to talk a lot. i like this to be interactive. i put some fun picturesand scans and whatnot

into the presentation. i don't like to justlook at you guys, and you're alljust staring at me. and you are post-lunch,i understand, right? mm-hm. yeah. so that's going to be rough. so don't do it. don't give me the nod.

don't give me the slouch down,none of that business, ok? so i-- [laughs] i like it. be persnickety. be rough and tumble. be loud. i enjoy that. be participative,we'll get out faster. i was told that we're heretoday till 1800 sharp.

and we're going to behere till 1800, right? no. oh, my bad. [inaudible] oh! is that how it is? so usually, every gets all kindof mad and stuff like that. so-- we get out earlier, themore you participate, ok?

[inaudible]? you know it. okey-dokey, bert. i also have to say i enjoythe level of disbursement throughout the classroom. do you smell? or what? what is it? why are you all the way--

ah. that's what it is. i like it. very nice. and we've got somegirl representation. chicas, i like, andthe dudes as well, ok? i will caution you this. if you have any questionsat all-- very occasionally, have people say things like,oh, are you being serious?

i'm totally fine with that, ok? so if you're notsure if i'm actually serious about something--usually, i'm pretty clear-- but any-- i love tobe interrupted, ok? i interrupt myselffrom time to time, ok? but everybody is going tobe learning about neural. and everybody lovesneural, right? yes. really?

oh, that's it. your face was dead on. neuro is definitelyan acquired taste. most people hate it. however, it can be really,really interesting. and just know thatyou can absolutely affect someone's abilityto go back to work and mow the lawn, versus goingto the group home and having your droolwiped off your chin,

those kind of sortof things, ok? so enough of that baloney. all right, ourintroduction slides. you know, it's anintroduction, ok? most neurologic patientsrequiring transport are going to have some sortof traumatic brain injury, but not all. there's some stuffin here about stroke, and hemorrhage, aneurysms,things like that, ok?

i really don'twant to ignore you, so i'm going to try toswivel from time to time, ok? i'm not dancing. all right. so we've got some a andp. i know that it's tough. there was a lot ofneural anatomy in here. and sometimes, it canwind up just you get completely overwhelmed andturned off and intimidated. so don't.

we're going to-- i don't want tosee the words, "dumb it down"-- but bring it down a little bitso that it kind of makes sense, ok? ask, if you have anyquestions at all. so a and p nervous system,central nervous system, and peripheral nervoussystem, everybody knows that. these are the basics, right? everybody's had a and p already. and you kind of knowa little bit about it.

when we're talking aboutperipheral nervous system, you have afferent andefferent pathways. so is everybody reallycomfortable with talking about peripheral nervous system,and the afferent pathways, and what that can have to do? it's very dry. it's very boring. it's kind of hard toremember what they do. and i understand you're goingto be tested on this material.

i am a person-- i've learnedover 17 years as a nurse-- adding up a little bit, fiveyears on top of that, that will tell you how old i am,this is really embarrassing-- but i've learned littlemnemonics that help me out. you like them, keep them. if you don't,don't use them, ok? afferent is yourascending pathway. so you get the ato the a, right? your afferent pathways aregoing to be ascending pathways.

these are the tracksthat are going to bring impulsetowards the cns. does that make sense? so six years fromnow, you're not going to remember this at all. right? try to remember. it's not that bad. efferent is obviouslygoing to be the other way.

it's a two-way street,but only a two-way street. there's no roundaboutsin there, hopefully. actually, there's a couple ofexceptions we'll talk about. but efferent are yourdescending pathways, ok? so talking a little bit more, wegot our somatic nervous system, autonomic. your somatic is goingto be your voluntary-- if you kind of sort of breakit down almost like that, ok-- verses autonomic--automatic, involuntary.

see? they're not so ok? these are very generic they'retrying to ease you into, so we won't talk excessively. you don't need tomemorize all these things. the key is not to memorizethe entire periodic table of the elements,right, it's to know where to find yourresources, ok? so here's a nice picture.

i believe you do havethis in your book. your nervous systemis essentially your brain andspinal cord, knowing that that comprises all kindsof cranial nerves and then spinal nerves, ok? 12 cranial, 33 spinal. so just keep these genericprinciples in mind. all right, so you've gotyour skull, your brain box. i like that.

they actually put that there,i did not add that brain box. it's a very lovely,wonderful, wonderful terms that just kind ofhelps us remember. so you've got your neurocranium,brain box, and then your visceral cranium. visceral, we think of what? viscera makes us think? viscera sometimes has todo with smooth muscles and organs and stuff like that.

what's kind of-- it's not the same thing up here. so your visceralcranium is really talking about yourfacial bones, ok? neurocranium makes sense. if it's a brain box, itencloses the brain, ok? we've got lots ofdifferent pictures there. and you've got your foramina. nice picture here.

again, we're not going to dwellexcessively on the pictures. you have these in your book. but this is kind ofnice to, maybe, go back to when you're confused or youneed a nice colorful picture, or you can't goto sleep at night. ok, anyways. the meninges. everybody enjoys the meninges. maybe?

maybe not? your meningeal anatomyand physiology. for your meninges,everybody always remembers what thedura is, right? what do we think of whenwe think of the dura? or what do i want you--that's exactly it. she made like amotion like this. it's a covering over the brain. so one thing, the way that ilike to kind of describe this

is you have your brain. we'll pretend yourbrain is my fist. and then you have this balloonaround your brain, which is, technically, all threelayers, but essentially the dura, ok? where would you, say, findcerebral spinal fluid, or csf? outside the balloon? or inside the balloon? inside.

inside the balloon. so that's very, very,very easy, right? brain. balloon. csf's inside the balloon. it's really notthat hard, honestly. the meninges, youhave your dura mater, your arachnoid, andthen your pia mater. we'll talk very briefly aboutwhat each of them are, ok?

your dura. so outermost layer--so we'll kind of go outward and work inward, ok? you've got theoutside, what you can touch on the balloon andkind of feel, all right? so it's two layers. if this kind of makes sense,one goes out, one goes in. it's all the dura, duramater, the meningeal layer. you've got your arachnoid, whichis a little bit inside of that.

why do you think we calla certain type of bleed, when we have a brainbleed-- and there's lots of different kinds,we'll talk about all them-- but you call it asub-arachnoid hemorrhage? medicine is so cool. if you take the words apart,you can totally get it, right? so you started todo something again. under. sub is under, so beneath.

sub-arachnoid hemorrhage,so beneath the-- arachnoid. oh, gosh. you just determinedwhere-- remember, this can happenall over the brain, because it kind ofencloses all over-- but you just determinedwhere that bleed is, ok? that'll come in handy when wetalk about sub-durals, as well, and epidurals, andother sorts of things.

so then we'll goto the pia, which is like, it's the smallest word. it's the smallest layer. it's the closest layer. i use all kind ofreally funky things. but your dura is your outside. that's the one thateverybody talks about. the other two just kind ofride underneath there, ok? the pia has a lotof blood vessels

that supply blood to the braintissue, to the parenchyma, ok? so we're going to talkabout our ventricular system and our csf-- ok, i knowthis is all going on camera, be quiet-- so our csf. so in your brain, didyou have ventricles, just like in this big thing here? how many do we have? four. oh, he's very good.

he's all alone with armscrossed, and laid back and relaxed. and he's doing great. and you're right! you smarty pants. it's perfect. you've got four. how did you know that? oh, i was going to say,because is it up on the screen?

it says third andfourth ventricle? no? nobody? fine. very well, then. you have your ventricles. one and two are very large. and they kind of look like that. and certain parts ofit is called the horn.

so those kind of go up and over. and the lateral, thoseyour lateral ventricles. your third and fourthare most central. and then, afterthird and fourth, there's actually a coupleof foramens, or holes, that they go down. and actually, thecsf goes all the way around your spinal cord,your spinal column, and kind ofcontinuously circulates.

how do we get csf? do i go to walmart and grabsome because it's on special? oh. oh, you're so smart. i just absolutely love this. you actually create itcontinually around the clock. we have drugs that can actuallyreduce and slightly enhance production. about how much do we make?

does anybody have any idea? it'll be in a later slide. we'll let it be fora little bit, ok? we'll come to it. so each hemisphere has a lateralventricle, that's one and two. we talked about that alittle bit, the ventricles. when we put in aventriculostomy or evd, this is wherethat's going to go. essentially, that's a straw.

that then sucks fluid out. if you've heardsomebody has a vp shunt, like a ventral plural or aventral peritoneal shunt, that's what that is. we put the one endof the straw in there and either bring it to theoutside, if they're really sick and in transport, likeyou guys, or in the icu. and then if theyare going to need this long-term-- young onesused to have-- hydrocephalus

used to be a reallybad sentence to have. and they would go offto different areas. the camera's on. we're not going to gowith some of the stories i was going to tell. but having the abilityto shunt that now, actually, willdrain that fluid-- it's all sterile-- eitherinto the lung, the pleura-- or into the peritonealspace, where

it will be reabsorbed, ok? and this is if the bodycannot reabsorb it on its own. we don't want to talkexcessively about hydrocephalus right now. but that lateralventricle, either side, is where we're going to put thestraw, the shunt, if we need to monitor icpand/or drain csf, ok? so very, very briefly, we'lltalk about foramen of monro. that's one of those holesi was telling you about.

things go downward tokeep things flowing. if you happen to haveblood in your ventricles, do you think thatwould really help the absorption and flow of csf? definitely no. definitely not. really not, right? that can plug things up,because blood does what? clot.

and a clot is very likea clog in your toilet or in your bathtub drain orsomething like that, right? so then you canhave hydrocephalus or that can either be very, veryeasily corrected with a shunt, the blood reabsorbs after,say, a bleed, a stroke, or a traumatic sub-arachnoid. we'll talk about differentthings, as they come up. i put some interesting slidesin here with different bleeds. but as they come up, you mightneed a shunt just to drain it.

and then the blood reabsorbs. we sometimes try to manageoverproduction of csf or under-absorption of csf. initially, you'realways going to try to manage things medically. what does that mean? we used to call itconservative management. that gives the wrongimpression, so that's why we don't callit that any more.

what do we try to do? when we treat itmedically, we give drugs. so we try to treat itnon-invasively, ok? kind of exactly what youwere saying, all right? so we try to give them drugs. diamox is a big one, all right? it's a very old drug, but itworks really well, all right? if needed, then we can gointo more invasive methods. you would do a temporary shunt.

and then you mighthave a permanent shunt. i don't want to say acrossthe board, because it can vary from person toperson, and depending on the degree of spina bifida. there are some that have partof the actual spinal cord and spinal roots exposedoutside the body. that's definitely very,very, very serious. [mumbles] ok. so your cerebrum is themajority of your brain.

you have your cerebrum. you have your cerebellum. you have your brain stem, ok? it's really not ashard as, sometimes, we make it out to be. so it's the largestpart of your brain. so you have thetwo hemispheres-- we kind of know about that--separated by the fissure. anybody ever heard ofthe corpus callosum?

so these words are kindof-- you know, oh, it's very intimidating. these are very big words. what does it actually mean? it's just almost aconnecting structure, ok? it's where the two halvesof your brain get connected. we'll talk about the brainstem, and the cerebellum, and what each thingdoes, as we go through. cerebral cortex, sothis is really thick.

it's the outside. you've got your dendrites,your neurons, your gray matter. we had a absolutelywonderful-- and i'll call him a coupleof times in here-- a wonderful britishneurosurgeon, who went through his entireresidency over at froedtert. and then they couldn'ttake him on as staff. they didn't have aposition, so he left. but he taught me all kindsof interesting things, which

i'll quote him a coupleof times throughout here. but your gray matteris your second grade, the majority of yourbrain tissue, ok? oh, boy. my goodness, gracious. i'm fumbling here. it's just absolutely terrible. underneath your cortex,you've got your white matter-- there are all kinds ofjokes about gray matter

and white matter--communicating impulses from the cortex to theother areas of the brain. essentially, you've gota lot more gray matter than white matter. but the white matter is a littlebit more important, sometimes, is one way certain peoplethink about it, ok? so these are areas of the brain. so which side of the screenwould your eyeballs be on? good.

very good. it's your occipitalthat's your back end. incidentally, providing sight? your eyeballs. kind of connecting there. it was kind of funny. on the next fewslides, we're going to go through whateach one of these does. and i believe you havethis in your book as well.

so your frontal lobe--anybody ever taken care of a patient with frontallobe contusions or frontal lobe bleeds? because it's notso bad immediately, as far as what you'regoing to see clinically. but after these few hoursto days after someone has damage to thefrontal lobe, they get extraordinarilydisinhibited, extremely disinhibited.

often, you seehypersexuality, enormously so. and they have no control. so if you think about it,you've got a 20-year-old male or female who has beenin a multi-vehicle crash. wasn't belted. whaps there. and you've got thespidered windshield, so they've whappedtheir head there. your frontal bone isactually extremely thick.

and it's very hardto actually break. you never get a skullfracture there, practically. you talk about the coupand contrecoup injuries. but you wind up withbifrontal contusions, or a frontal subdural hematoma,something like that, right? these are patients who are, oncethat has a little time to kind of-- because you'vegot edema that happens after an injury, any of thesekind of things, what happens is that they getvery disinhibited.

they get angry, noimpulse control. looking at what'sin there, you've got concentration, abilityto think abstractly, memory, your autonomic nervous system. really, essentially,why are 18-year-olds excused-- especially18-year-old males-- excused from some of theirbad behaviors? and we say boys will be boys. what is the last areaof the brain to develop?

frontal. fully develop? is that frontal lobe, right? so it takes time. so up until like22, 23 years old. so boys will be boys. never heard that? a lot of boys in here smiling. your parietal lobe is justpast-- not the temporal lobe,

but your parietal lobe. and you've got differentsensory functions. so if you have leftparietal stroke, ok, everybody thinksleft side of the brain. what's the number one functionthat's going to be impacted? if i had a lefthemisphere stroke, what am i really worried about? or speech, right? so we're talking about speech.

but it depends whereon the left side, ok? so we're not temporal,we're talking parietal. anybody ever-- of course,no one would ever do this. you're drivingdown the freeway-- or well, let's makeit a lower speed. you're driving down thestreet in your neighborhood. and you really need to getsomething in your bag or purse, if you're a lady. and you go in there,and you're looking

for the wallet, or thewatch, or the lipstick case, or whatever it isthat you guys get. you know, that abilityto tell without looking? you can tell a quarter from anickel, or quarter from a dime. so you've got parietallobe injuries. it's a lot of sensation. you may lose thatability to determine. you're not losing nerveendings and unable to feel, you're unable to processthat information.

so very, very benign. and i didn't change this slide. there's was justone line item on it. i'm not sure why itsuch a lonely slide. but yeah, that's a lot of timeswhere you can have blindness as a result, if you havean occipital stroke. so i'm talking alot about stroke. we'll get it to beingmore traumatic injuries and talking abouttransport and trauma,

when we get through in here,after this a and p stuff. so temporal lobe-- so thisis actually on the side. so this is wherewe're really, really, really talking about speech, ok? so there's multiple different. and there's a couple ofslides on here regarding aphasia and speech, knowing thatspeech and language are not, absolutely not the samething, not even close to being the same thing, ok?

and a lot of us tendto group them together. you can have problemswith one, and/or both, so sound impulses, speech. your limbic lobe-- sowhat is the major thing that this area of thebrain is known for? limbic system, your limbic lobe? maybe a little bit emotionsand pleasure, right? so pleasure center. so certain drugswe give are going

to stimulate thisarea of the brain. i love words. there's some neatwords out there. medical terminology, wehave way too many words. but anhedonia, youheard of that one? so inability to feel pleasure. that's like a majorbummer, right? so we do things like go outand take drugs, like ecstasy. well, not me, you know?

but we take all kinds ofdrugs to give ourselves those emotions and stimulatecertain part of our brains and stimulate the releaseof certain chemicals, endorphins, yada, yada, buta lot of moods and emotion and pleasure, ok? so i know i said the frontallobe with the disinhibition and impulse controla little bit here. just remembering,pretty much everything with limbic system, limbic lobe,has to do with how you doing?

versus like the temporallobes are for speech and stuff like that. so your diencephalon--again, these are really annoying words. they're very big words. there's a lot of stuff there. but it's just anarea in the brain. really, what's thenumber-- there's four different words on there,four different structures

on there. what's one of those fourstructures in the diencephalon that we hear about andcare about the most? thalamus? hypothalamus. so what do you think ofwhen you hear hypothalamus? what does it do? we automatically go rightto temperature control, ok? so it's hypothalamus.

we want to affectthe hypothalamus when we're doing inducedhypothermia and all these other kind of funtherapies and whatnot. we will talk, mostly, alot about the hypothalamus. it does a lot more thanjust temperature control, what you're thinking, ok? your thalamus is kind of there. it's more like agate, a relay station. it kind of passes things along.

not so much-- i don't wantto say, as important-- but it doesn't do as manythings or is not responsible for asmany things, ok? your hypothalamus-- you dolots, and lots, and lots of different things in here, ok? so it's underneath. hypo means? below. it's the easiest thing ever.

so below the thalamus,is your hypothalamus. but then there was subthalmus. there was all kinds ofother things, right? but it forms the floor. it's below-- just kindof thinking about below. has a little bit to do with thepituitary gland and secretion of different hormones andwhatnot in the pituitary gland. mostly, internalbody environment. do you know that whenyou're feeling full,

that feeling of satiation,that feeling of, oh, i feel really good now. i had eight pieces ofpizza, i'm good to go, ok? that usually comes fromstimulation or release of hormones withinthe hypothalamus ok? it's not just about temperature. so we should come up witha good drug, at least in my case, a really good drugto stimulate my hypothalamus. so then i would stop eating.

and then i wouldn't be so big. it's like dang it, you know? so this is another slide. i believe you have thistable in your book. but this is reallyall functioning on the hypothalamus, ok? so the big one, temperatureregulation, everybody thinks about that. but your level of feelingsatiated, your regulation

of water intake-- who's evergone out on a friday evening-- don't lie. i know we're on camera, dang it. dag nab it, right? but who's ever gone outon a nice friday evening, and just passed a giant test,everybody's in the class right now, it's very annoying,you passed a huge test. and you're going to go relax. and you're going to go havea couple of beverages, huh?

waters. absolutely. so maybe you have somethinga little stronger than water. maybe water with some whiskeyin it or something else, right? did you ever notice--[laughs] that's good. did you ever notice, whenyou're out there drinking and whatnot-- ifyou were the type to do that, nevermyself, absolutely not-- but if you were thetype to do that how, how

your urine output increases? gosh. i just went, and i'vegot to go pee again. i can make it througha 12-hour shift at work just fine anddandy, but my goodness. i'm going out to have a goodtime with my girlfriends or my boyfriend--- guy friends--you guys don't call each other boyfriends-- and you're havinga run into the bathroom every hour.

that's because your osmoticpressure-- your alcohol actually induces--ok, what is released that makes you pee a lot? there's a hormone,antidiuretic hormone, ok? coming fromhypothalamus, actually has some control overthe release of this. if we take the word apart,antidiuretic hormone, alcohol specificallywill inhibit or increase? thinking about you pee more, sodoes alcohol inhibit or release

the production ofantidiuretic hormone. [interposing voices] if it's an antidiuretic,it will inhibit it. a lot of the brain-- theconversation works itself-- it's very backwards,the way that we talk. i'll let it be a little bit. it's going to come up againin a couple of slides, ok? and then we'll talk aboutit again a little bit more there, ok?

why do you get a headache,a hangover the next morning? that's it, ok? it's not that you need yourvitamin b12, all this, that, the other kind of stuff. you are massivelydehydrated, because you peed out way too much, ok? so we'll let it befor a little bit. we'll come back to it. but again, that controlof those pituitary gland

and all those other thingsthat come out of there. and again, you have thattable in your book, i believe. i'm not sure of the page. it wasn't included on here. 373. 373? fantastic. good stuff. so your basal ganglia--this is a very fun

sounding kind of word. not very fun when you haveproblems with it, though. so these are deep within. people see basal, and they'rethinking like brain stem. but no, it's not. basal, kind of like thebottom, but it's not within the brain stem itself. but your fine motor function,so hands and lower extremities, your fine motor, so yourability to pick up a pen

and write with it. so basal ganglia,fine motor function. bad place to have a bleed. bad place to havehypoxia, as well. every place is, really. so now we're going toget to the brain stem. so the brain stem isextremely important, right? everybody knows a lot oflife saving, life producing functions take placein the brain stem, ok?

so you've got yourrespiratory center. a lot of other things kindof butt up against there. but in the brain stem, so thisis cerebrum, cerebellum, brain stem underneath. coming down, you've gotmidbrain, pons, and medulla, so i was going to doall sorts of references to popular culture, but we'regoing to hold on that for right now. the pons, you've gotyour locked-in syndrome.

this is horrible. anybody ever heard oflocked in syndrome, or cared for apatient like this? so if you strokeyour pons-- and it's very hard to gettraumatic injury there, but very easy to causedamage resulting from edema, things kind of pressing down. and you can have astroke in your pons. a pontine hemorrhage isterrible, and very often will

result in a locked-in syndrome. so it's low in the brain. so you have all yourcognitive abilities there. and a lot of times,what happens is you have an absolute inabilityto move, completely locked-in. it's horrible. everything. respiratory is gone,because, remember, brain stem and what's controlledall in there.

but often, they havecontrol over their eyes. and this is normally howwe communicate with them. so they can blinkand move their eyes. depending on thelocation within the pons and how severe thesecondary-- we'll talk about primary andsecondary-- injury is, a little bit offunction can come back. but it's usuallyfrom the neck up, ok? so you think, oh, it'slike being a quadriplegic.

no, it's much, much, much worse. so they have the ability tomove their eyes up and down. rarely, they willhave the ability to move eyes side to side. but that's how we communicate. are you in pain? look up. you know? do you want to see your son?

look down. these kind of things. very, very, very, very,very, very bad thing. so if you ever hear or read inthe history of your patients about a patienthaving a pontine-- and often, it is from a stroke--having a pontine hemorrhage or damage to the pons,look for absence, almost complete cessation ofmuscular movement, and ability to control.

it's not from thespinal cord, right? why is it having aneffect like that? because it's withinthe brain stem, so it kind of affectseverything, ok? the brain does rule all. so i'm a formercvicu nurse as well. and we could transplantone of these, and we can't transplantone of these, right? no, we just haven'tfigured it out yet.

that's not a popular view. but i was a neuro icunurse and a cvicu nurse, so i can kind of saythat and make fun. so you've got your midbrain. we'll talk about themost important feature within the midbrain is goingto be your reticular activating system. does anybody remember thatfrom anatomy and physiology way back?

your ras, what'sit important for? everything in thebrain is important. i know that, ok? but your ras, does thateven sound vaguely familiar? so it's your levelof alertness, ok? very, very, very closelyassociated, damage to the ras is a result, a lot oftimes, of something called a dai, ordiffuse axonal injury. has anybody heard of that?

i've got some slidesin there later on. this is another very sad--everything in there always sad. there's a lot ofsad-- i tried to put some happy faces inthere as well, ok-- but a lot of kind of sad cases. when we talk about yourwhole brain-- brain stem, spinal cord wind upbeing back down there-- but let's just brieflygo back to the pons, so looking at where it is.

and this entire area,there's not a lot of room to allow for swelling. so swelling can be thehuge, huge, huge enemy, ok? so let's say you've gotsomebody that's really, really, really sick. and they've got damage to thepons, or a cerebellar injury. you can have swelling that kindof push things in and what not. but we might havean icp monitor in. what do you thinktheir icp would be?

normal. it can be completely normal. you can actually herniateand become brain dead with a normal icp, dependingon where the injury is. so one of our biggest problems,as health care providers, no matter where wework, pre-hospital, in hospital, doctorto emt, we all get very reassuredby numbers, right? what's your favoriteblood pressure?

120/80. 120/70. 120/60. we like whatamerican heart likes. what's your favorite map? 60, 65, if better, ok. systolic. american heart likes 90. all these kind ofnumbers we get result.

what's our favorite icp? oh, good. we're going to talk about this. so it should beless than 15, ok? really want to see it lessthan 15-ish, right around 15. so we get happy with numbers. but remember that it's afull clinical picture, ok? don't get reassured by numbers. so more informationabout the pons,

we've got going back and forth. so damage to thepons, even though you don't have any damage tothe spinal cord itself, will result in-- becauseit passes things along to the spinal cord,so this is why you have that full, absoluteinability of being locked-in. it's just the absolute worstever, full complete awareness. i've seen it several times,and it's absolutely horrible. it's usually older patients.

i haven't seen itin someone younger. but whether it's a45-year-old or an 85-year-old, only the ability to move youreyes up and down is just, oh, completely terrible. so you've got yourapneustic center. apne, right there, whatdoes that word kind of make you think of? i know it's allup on the screen. it's in your book.

no breathing, apneustic center. it's really kindof-- getting that? so the little thing hereis, very frequently, you have a pontine stroke, ok? you've got your pontine cva. you will be unableto wean the vent, ok? this is no respiratory issue. it's all because ofthe drive, and even in the brain stem, specifically.

you're just notgoing to trigger. your diaphragm willbe working fine, ok? and we won't even talk aboutdiaphragmatic stimulators. but just you'renot able to produce good, sustainedrespirations, ok? different than spinalcord injury, ok? we always want to kind ofdivorce and or lump together the brain and the spinal cord. they are kind of together, butwe have to be careful that we

don't-- mechanismis really important, the patho as to what'sgoing on behind. ok, either way. so we'll talk verybriefly about the medulla. so i was going tomake a reference here to what comes intoeverybody's mind when you're medulla oblongata. what was that? thank you.

i'm not the only one to say it. i didn't say it myself. i asked the question,and they came up with it. they didn't tell me i wasgoing to be on camera. but yeah, the waterboy and the guy that looks like colonelsanders and he dumb, medulla oblon-- yeah,it's very funny. so maybe, kind of,i was going to put a picture of colonel sanders inhere, but i couldn't find one.

darn it. kfc bucket and see if youguys got that reference. but you did all by yourself. you're good stuff. so it connects throughthe foramen magnum. magnum is big, the big hole, ok? it connects withthe spinal cord. it's not the hole. it's the structure thatconnects to the spinal cord

through the big hole. it is quite important. this is a huge cue. so if you get askedto transport-- you're not going to know this. if they're in the field, you'repicking them up and taking them in. but often times, wewill transport patients from one facilityto another, right?

because we always have tokeep in mind mtla and all those very serious regulations,and best level of care that's most appropriate for thepatient at the right time, ok? you always want to know thediagnosis of your patient, right? you want to get some reporton what's going on, right? so if you heari've got a stroke, ask for the locationof the stroke. you're going to, hopefully, knowa little bit more about this.

you're going toforget a lot of it. but if you ever hear the words"some ventricular blood," immediately ask! or if you see that straw comingout of their head and the fluid is bloody, ask! where is the blood? if the blood is inthe fourth ventricle, the fourth ventricle is quiteclose to the medulla oblongota. yes, kind of emptyingthere, right?

your vomit center is there, ok? your patients that have bloodin the fourth ventricle-- so this is deep blood,so it won't always be bloody fluid, becausethis is deeper down blood. blood is heavy, and it'ssinks to the bottom. but blood in thefourth ventricle equals lots and lots of highpressure, high enthusiasm, barfing. and just because theyhave an et tube in,

does not mean thatthey won't barf, right? and will all the zofranin the world help this? no, because it's aphysical stimulation. so then, hopefully, you takeone little tip away out of here, are you with me a little bit? a little bit? ask for report. you deserve report. but it does lots ofother things as well, so

your coughing and allthat kind of stuff. ok, so we had cerebrum,midbrain, cerebellum. so it's a different color,different kind of texture, looks different. but it's in the back, not theoccipital lobe, but underneath. and really hugely,majorly, has to do with coordinationand movement, ok? so you have somebodywas cerebellar damage, they will haveherky-jerky movements

and not be able to have nicesmooth, coordinated muscle function, soespecially with gate. so this is not like yourpatients with essential tremors or anything like that. really definitelylooking at that gate, ok? so not like the gateyou open and close, but how good am i walkingdown the hallway or whatnot. ok, great. so what's that called?

oh, you're so good. so great. and this is called the? oh, yeah. that's your cerebellum. it's colorfully enabledon the slide here. it's not usually blueand green and red. so anyhow. so now, we're goingto talk really heavy

for just a moment aboutreticular activating system, or your ras. so hopefully, i'll justcall it ras from now on. so you have asystem-- really, this has to do a lot withyour level of alertness. does a couple ofother things, as well. so i put thislittle footnote here to just kind ofremember to watch for dai in rapiddeceleration injuries.

give me an example of arapid deceleration injury. rapid deceleration, right? car decelerates, and thenthe person decelerates. and then the head decelerates. and then, finally,what decelerates? the brain. the brain within the head,because it's got that nice, cushy back and forthkind of stuff there. ok, so another frequent timethat you would see this.

so that's like, it's notthe fall that kills you, it's the sudden stop, thatkind of sort of thing. but you've got arapid deceleration, but maybe not as abruptas a car versus tree, which is a great example. a fall. a fall, anotherreally abrupt stop. it's season out-- youguys saw me, some of you saw me walk in with some gear.

football? [laughs] i didn't bringshoulder pads today, guy. come on, now. but a helmet,indicating i may ride a? moped. so motorcyclists, they aregoing really fast or, hopefully, the speed limit. but a lot of times, these youngmales, the like to impress us girls.

and statisticallyspeaking-- mark is smirking over there--statistically speaking, who is injured most frequentlyin traumatic accidents? males under age 35. has it gone up ordown over the years? no, it's kind of like the same. well, it ticks upand down, you know? we find very interestingways to injure ourselves. we're the weirdest species ever.

i can't imagine sometimeshow we are able to survive. but you are driving along. and then your bike, whatever. and then you go and youtumble, tumble, tumble, tumble. and maybe you suddenly stop. but rapid deceleration. maybe not as fast as thatinstantaneous deceleration when you hit a tree or abuilding or another car, but that still really fastdeceleration, those guys

and girls-- i am one-- very,very, very prone to dai. so dai. and i have a nice-- what'sthe word-- animation to show you after. i can't remember. it's in here, acouple of slides. but it's a shearing injury, ok? and it is very,very, very dangerous. you made a reallynice face there.

shearing, what do you think of? what do you think is happening? tearing apart. exactly. and it doesn'ttear things neatly. so you've got-- everyone knowwhat a neuron kind of looks like? axon, dendrites, ok. so you've got your axons here.

so if this is brain cell numberone and this is brain cell number two, what happens toget the impulse from my brain to my left foot, we'll say? does it walk across? no. [inaudible]. it jumps across, right? so it jumps across, ok? and if you do this to yourbrain cells, maybe the neuron itself is possibly,partially still fine,

but it strips off thosefingers those projectiles. and now that impulse has avery, very hard time-- i just spit on the table alittle bit, good thing nobody's in the front row--but it jumps across, right? but if now this middle one,there's not a receiving finger, instead of jumpingover a little puddle, you're now jumping over likethe potomac river, right? so it gets harder, andharder, and harder. you're dai, your diffuse axonalinjury, diffuse means what?

all over. axonal is? damage to the axon. smart. an injury is an injury, right? so you've got a lot ofdamage to the axons. and it's almost neverlocalized in one area. it's very spread throughout. i know the nameof it is diffuse.

but depending on howmany are injured, you can have mild,moderate, and severe, these patients, becauseof the damage to the ras, will not wake up. this is a patient thatthat subdural has resolved. that subarachnoid has resolved. their bones have knit. their ex fixes are coming off. and you still can't get themweaned from the ventilator, ok?

so clinically, what you mightsee is a lot of yawning. you'll see a lot of chewing. these patients will live a verylong life in the group home, very sad. there's absolutely noway to fix that, ok? i know there's aslide a little bit further down about dai as well,so we won't go heavy into it but does that kind of makesense, that rapid deceleration injuries really,really, really, that dai

comes from rapiddeceleration injuries. very closely associatedwith damage to the ras. sleep-wakefulnesscycles, makes sense. you just can't getthem all the way awake. a lot of yawning. can't wean them from thevent, because they're not having enough of alevel of consciousness. so your brain, is it this? i'm trying to say that yourbrain is a-- what is this?

it's a piggy bank. is your brain a piggy bank? but you put all kindsof information in there. is it? so your brain is notthat, your brain is that. your brain is a hog, ok? it is a pig. what do i mean by that? your brain consumes20%, truly, 20% percent

of your resting cardiacoutput every minute. but it's only 2% of yourtotal body weight, ok? it's very, veryimportant, all right? you will sacrificeyour fingers and toes, without meaning to, yourintestines, then your kidneys, then your liver, then your heartand lungs to save this, right? so your brain really,really, really is important, but it's definitely a hog. 20% of your resting cardiacoutput every minute, ok?

and it's only 2% ofyour total body weight. it is supplied by yourvertebral arteries and your carotid arteries. you guys are all way too young. i knew it was upon the tile there. most of you are way too young. there's a couple of youthought it was funny. did anybody get that? sorry.

"what you talkin''bout, willis?" it was a show called,different strokes. it was great! it was wonderful. back in the '80's, it was fun. all right, moving on. let's talk about thecircle of willis, ok? so your circle of willisis really important, ok? i also want to getthat t-shirt real bad,

but i can't find it anywhere. i just could findpictures of it. but i would buy one, ifanybody can ever find that. i'll buy it off you. it's a very importantsystem of arteries where things branch off of. and really, this is where allof your aneurysms come from, ok? damage here, we'll talkabout them, specifically, as they come through.

so you've got yourbasilar artery. i know this is alittle bit fuzzy. and i don't know how well it'sgoing to come up on the camera. but i tried to make it bigger. and then it got kind offuzzy, but still big enough so you could see it. but the little ballshere with the numbers are telling where your mostcommon aneurysms are present, so you've got your carotids.

you know, it kindof branches here. you've got your basilar artery. you've got yourcerebral arteries. so give an example here. so when we weretalking about the lobes of the brain, yourtemporal artery. so you have an arterythat runs there, called the middlemeningeal artery. so 93% of all epiduralhematomas come

from a tear in your middlemeningeal artery, ok? that's a reallyinteresting statistic. what does that mean to you? are you going to see anepidural hematoma in somebody that has spideredthe windshield, or when someone was hit upsidethe head with a baseball bat? mechanism, right? go patho, kind oflike what to expect, this, that, and the other.

but your aneurysms,about 40% of them come from tears in youranterior communicating. very, very commonplace forthese aneurysms to occur. aneurysms are bad things. not so bad until they blow,and then they're really bad. but just a nice,interesting slide. actually, you have that now. i was going to send that,but i don't need to now. so you've got your verts,your vertebral arteries.

they come off ofthe subclavians, entering up throughthe big hole. and then, at the pons,you've got your two verts that join to form thebasilar artery, which then goes into that circle of willis. everybody sees why it's thecircle of willis, right? what you're talkingabout, a big circle. everything importantcomes off it. it's great.

it's like the olympics with thecircle of rings and everything. so basilar arterydoes divide then. and we just saw in thepicture of what all that is. just sometimes, a visual is alot better than just words up on a screen, ok? moving along. so then you've got yourinternal carotids, ok? so they kind of come off. this is essentially that slidedescribing piece by piece.

this is what thecircle of willis is. it's hard a and p. youhave to memorize it. there's not really muchi can say about that, ok? it's just it is what it is. circle of willis is good stuff. it's really important! incidentally-- becausei like stories, i think they kind ofhelp sometimes-- a dog, it is virtually impossible--as soon as i say never,

something's going tohappen-- but it truly is virtually impossiblefor a dog to have a stroke. any idea why? their circle of willisis very huge, ok? the shape of their skull,the shape of their brain. so if you see dogleaning drunkenly, he probably had beer,instead of having a stroke and having left-sidedweakness or something. often, they can getspinal plexus injuries.

i know this iskind of weird, ok? but i love dogs, and i liketo help dogs out and stuff. and it came througha neurologist, as well, just soyou know i didn't go investigating any dog brains. but having a dog, it'svirtually impossible for them to have a stroke of anysort, clot or a bleed. they aren't tending to bleed. but their circle ofwillis is really gigantic.

so lots of theirvessels are very large. lots of blood flow canget around any plaque. so feel free to give your dogall the mcdonald's he wants, i have 210 poundof labs at home. i love them very, very much. but yeah. and they're "flabradors." no joke. i can't help it.

but yeah, labradors--no, rotties, actually, have the largest heads. bigger than a pit bull. rottweilers, that wouldbe for akc-type people. ugh. is it time for a break yet? so venous drainage-- so yourveins, arteries and veins. everybody know whatartery does, right? artery takes bloodunder pressure,

gives it out, makesthe masses happy, the masses being our fingernailsand teeth and brain cells and all that, ok? and then veins take theblood passively back, right? to do that wonderful cycleand get re-oxygenized and kind of broughtback out there again. so this stupidneurologist-- did you ever take a patient in transport yet? if you haven't, justwait a little while,

when they're going fromone icu to another. so as they come in withtraumatic brain injury, or a stroke, orsomething like that, and they always want to putthose stupid subclavian central lines in, instead of a nice ij. give me a big old ijany day over a cvl. why do you thinkthey prefer that? i mean, over a subclavian cvl. why do they like that?

let's take a look and see. venous drainage-- so thingsgetting out of the brain can really affect your icp. this is a wonderful slide. it was actually in here. i didn't put this picture in. but you've got yourej and your ij, ok? so i can go ahead and slip a 16gauge into his ej, no problem. don't need an x-ray, noneof that stuff, right?

great. wonderful. you'll even have neurologiststhat will do that, ok? but an ij, which is where--every cardiac, every ct surgeon in the universe want anij swan, not a subclavian swan, catheter? creaking silence? you guys are kind of freaking meout there a little bit, but ok. why do we not want-- lookat the size of it, verses

your sublavian's kindof coming in here. still central, ok? but why do you thinkthe neurologist, the neurosurgeons don'twant to plug up that ij? by what method? and not so much directlycause an increase, as prevent a decrease, because? it's big. it's huge.

so you get a lot of--remembering both sides ok? most people areright-dominant, ok? so the right is bigger. but look at thesize of the ij, ok? it's responsible for draining--where does the ej drain from? right. where does the ij drain from? can you see it,maybe, a little bit? inside?

so we will talk in a little bitabout this wonderful doctrine, the monro-kellie doctrine. people have heard of that? it's one of myfavorite doctrines. it really is. not doctor, but a doctrine,school of thought. it's good stuff. but having a big honkingcatheter up there, either just a central line or a swancatheter or something,

and anything that'sintroduced or anything that's really, really big canplug a lot of drainage, slowing drainage from the brain,thereby, slowing the reduction in fluid out of the brain,thereby, kind of increasing, or maybe not allowingfor the reduction of icp. blood-brain barrier--it's very selective. it's very choosy. it's a diva. your blood-brainbarrier is a diva, ok?

think of it like a princess,a really snotty princess, ok? so you've got yourblood-brain barrier, right? you've got this reallyhot club everybody wants to go to on friday nights tohave ice water, like we were talking about earlier, right? and there's a line all theway down the block, right? who gets in? only very, veryfew people get in. i would never get ina place like that, ok?

no worries. so your blood-brain barrieris that selective, obnoxious nightclub, only lettingcertain things in, certain drugs-- too many ofthe wrong drugs in, right? and we have totailor antibiotics and all sorts of otherthings to what will actually affect and get throughthe blood-brain barrier. really impressivelyimportant aspect. only took up one slide.

it's kind of like, hm. ok, so we're going to talk alittle bit about your spine. you've got bones, sothey call it vertebrae. neurosurgeons will always referto it as the vertebral body, almost always. but they're stabilizedby ligaments, by muscles. that's the i brokemy back, and yet i'm still walking around, ok? the vertebral bodyand the spinal cord

are two completelydifferent things. please keep that in mind, ok? so they're just cervical,thoracic, lumbar, sacral, cox coccyx. so you've got thevertebral body itself, weight-bearing, very heavy bone. incidentally, youcan tell on a ct scan what level of thespine-- even if you can't see anycurves present, you

can tell what level ofthe spine you're at, based on how large they are. where are my largest vertebrae? lumbar. why is that? yep. because that's where youcarry most of your weight, ok? don't judge me. how do you get yourcurves in your spine?

how did you getyour thoracic curve? when you were a littlebaby in the tummy, you were curled up in a ball. thoracic curve, ok? and then, when you'reout learning to crawl, and you hold upyour head, that's how you get yourcervical curve, right? and then we graduallylearn to walk. and that's how weget our lumbar curve.

so you've got aspinal cord injury without radiographicabnormality. what in the heck does that mean? what they're talkingabout is like a stunner. or he probably concussedhis spinal cord. did you know you cancause a spinal cord concussion, the same asyou can a brain concussion? so that's likely what that was. so i always thinkabout jerry maguire,

you know, whendude's running down and he catches atthe end of the movie. and he goes from beinga crabby, [growls] into like this great person thateverybody loves at the end, how he was knocked out, but then healso couldn't move or anything. and then, finally, he got up. you hear about this a lotin youth athletes, ok? so that stunning orconcussion can happen. sciwora is different.

[inaudible] long time? that's it. and that's not entirely,but almost exclusively related to what population? take a guess. young ones, really, reallyyoung patients, right? kids. so you think about kidsas being like 10 or under, and old people as being-- itgets older for me every year--

but old people, for me, aregoing to be over 80 now. so having a-- don't judge me. i just had a really big birthdaylast week, which made me sad. but why do you think a child,say, an eight-year-old, would be more susceptibleto having a spinal cord injury withoutradiographic abnormality? what does that mean,radiographic abnormality? you can't see iton the [inaudible]. we can't see it on--and incidentally, you

can't see cordinjuries ever on ct. they always need to go for a? mri. you got it, mri-- themost annoying road trip-- because mri willactually show the cord. i don't think iput it-- i didn't. i put a bunch ofcts in here, but i didn't put any mri pictures. i kind of ran out of time.

i wanted to do some cool stuff. but hopefully, you'llthink it's somewhat cool. anyway, but getting back. we couldn't see iton x-ray either. because we can see thevertebral bodies on x-ray, and they will always dox-ray films, as well, ok? but the one right off,when they're sick, they have to get an mri. everybody goes to ct now, right?

sure. they'll ct you fromhere to here, right? just because wedon't get sued now, so we kind of ct everybody. but we'll ct you, butthen they will also, if they have any cardinalsigns or mechanism hinting at a spinal cordinjury, they will absolutely get that mri done,as soon as possible. and then they do serial exams.

and the reason forthat is your spine will swell, just like yourarm, if you get punched. and there's not alot of room in there. and we have a picture ofa vertebrate coming up, so i won't talkabout it right now. but anyway, back tothe original question. why would a kid be moresusceptible to this than, say, an 80-year-old? less developed?

what specifically isless developed in them? i can be eight yearsold and be run over and not have any rib fractures,but be all squished inside, because my bones havenot fully ossified yet. so they're very flexible. so when my kid was fiveand he broke his arm, what kind of breakdo you think it was? greenstick. they're not fully ossified.

they're not hard. they're still kind ofgrowing and everything. so you can have-- you needto think about it in terms of stroke, tia versus cva. you know what i mean? so you've got yourstunner, or your bruise, or your concussion. which incidentally, is arule-out sort of thing. you can't see a concussion.

it's a set ofsymptoms that you get by exclusion of everything else. but versus sciwora. you can have somebody, vertebraelook just fine and dandy, usually the kids. and then they can have notjust numbness and tingling, but they can have all the waythrough actual complete loss of sensation and motor,so being paralyzed. terrible stuff.

i think that was all iwas going to say on there. so here's some little pictures. again, no patientidentifiable information here. so this tells you, just lookingat it, how old it is, right? but when i first started, wewould walk in and have a chart. and you can flip up andsee the pictures in there. they would put the crash scenepictures in there, right? we're not allowed to do thatanymore, because it's uncool. but hearing about amotor vehicle crash,

roll over at 45 miles anhour is a little different than actually seeing that. and that guy is going home? or you get thevery barely dented this, that, or the other. and that guy didn't make it? i keep saying guys. i mean girls too. so just a littletrying to kind of spice

up the presentation for you. ok, so here we go. we've got our vertebral body. so the front-- where'smy belly button? yeah, very good. so looking through-- don't judgemy belly button either-- ok, so we've got our vertebral body,and then this little hole-- so this is us looking down,ok-- this little hole where the spinal cord is.

so this is your cord. these are the nerves thatkind of come off of it. and no, i don't wantto talk about that. but kind of moving and,as far as space-wise, do you see a lot of room there? really, not a lot of room, ok? and certain areas haveless room than others, ok? so there's really, really,really not a lot of room to allow for those naturalcompensatory mechanisms.

we have auto-regulationintact, ok? that means that, if icome across and smack you upside the head, or smackyou across the face, your face is going toget swollen a little bit, as the injury and the bodytries to help things out. normal internal mechanisms. when you have a scratch hereand you get a scab, inside, what's going on? your body is increasingvasogenic edema,

bringing extra good littlesoldiers there to kind of clean up the bad stuff and thedead stuff and get it away. that stuff goes on notjust on your hand and arm, but inside throughouteverywhere. the only reason it'ssuch a horrible thing in the brain and the spinalcord is that there's no room. remember, that brain box? there's not a lot of room, ok? and definitely, there'smore room in the brain box

than there is going allthe way through, ok? so we've got to really,really, really be careful. then, over the last 10, 20,30 years, a lot of therapies have gone in and out of vogue. very briefly, what'sthe one therapy that used to be astandard smack automatic, we had to get it up and getit going as soon as humanly possible when someone had aspinal cord injury, that is now huge brakes, ok?

we're talking within15 years, it's gone from the goldstandard to being, don't you dare, unlessyou have good reason. it's a very shortamount of time. spinal cord injury, good. steroids, so yoursolu-medrol drip, ok? so it used to be, when ifirst started in the field, it was, oh, ok, we'regetting this guy going there. if we had to exactlyto the minute

know time of suspectedinjury because, if he was started that steroiddrip three hours or less from time of injury, he wouldonly need it for 24 hours. but if it was morethan three hours from the time ofthe actual injury-- kind of almost soundslike a stroke nowadays, doesn't it-- then he wouldget the 48-hour drip. why do you think we-- andit does do its job-- why do you think westarted doing that?

why did everybody have anautomatic, hair-trigger, knee jerk response? if somebody had aspinal cord injury, why did we give thema solu-medrol drip? keep the swelling down. boom! because there's not alot of room there, right? did it work? most of the time, ithelps a little bit.

it's going to do its job. brain injury patientsoften get steroids after, they get decadron, right? and especiallypost-surgicals, they always get decadron scheduled, ok? it works. it does its job. not all the time, but it works. why do we not--and incidentally,

practice has not fullykept up with the literature throughout the countryin this-- but why do we, whoa, don't do that! why don't we want to dosteroid drips anymore? what do steroids do? both of you are right. anti-inflammatory? anti-inflammatory, so theywill reduce the swelling. what is the flipside of steroids?

non-discriminant. what do they destroy? your ability tofight off infection. your immune system. it's gone. not forever, but it's gonefor the length of time that you're on it, right? what else do steroids do? anybody on prednisoneor decadron,

dexamethasone, solu-medrol? what happens? pressure? something goes way high. and somebody thatdoesn't look like me, this number would go way high. your weight? not weight. well, weight, incidentally,because it increases hunger.

it's a lab. it's a number. it's really easy to get. it takes like 20seconds or less. finger stick. it will drive your glucoselevel through the roof. why do we not likethat in any patient, especially not intrauma patients? it increases [inaudible].

ah! so steroids are good? but they are bad. so a healthy 20-year-old,truly-- and i work at froedtert'slevel one trauma center, worked in our neuro icufor seven years full-time. still staff up there. i was up there three weeks ago. so looking at that,we get patients

in the from other hospitalsand started in our own hospital when they presentto us, and we still do steroid drips sometimes. you don't see a 48-hour drip. i have yet-- i don'twant to say that, because as soon as isay that, somebody-- you know, as soon as you doalways or never, it's done. but you really don'tsee two-day drips. but you will still occasionallysee a 24-hour drip.

why do you think we'rewilling to take the risk? who would we start that on? 20-year-old? or an 80-year-old? why the 20-year-old? they're probably goingto be able to fight off the rest of the nonsense, right? they're going to be able to suckit up and soldier on and get through, ok?

and if they take a little bumpto the kidneys or a little hit to the liver, you know,they'll be able to get over it. they don't have as many co-? morbidities. they probably don't haveadvanced atherosclerosis going on and diabetes type iiand things like that, ok? incidentally, americanheart has done some studies showing advancedatherosclerosis in 16-year-olds, in 30-year-olds.

we're like a mcdonald's society. me too. i'm sorry. but it's a bummer, right? but they're more likely to doit in a 20-year-old than a 60 or 80-year-old, ok? but still, not ahair trigger thing. but you will still see it done. the literature says youreally, really, really

should not be doing it,unless there's absolute proof. but in practice, we're lagging. we're still seeing it started,not with full regularity, but with some regularity,which is kind of a bummer. so never be afraid to ask thequestion or speak up and say, do we really need that? because sometimes, theylisten to us, right? oftentimes, traumaticspinal cord injuries-- which are the ones thatare most likely going

to get this--traumatic injuries, your diving accidents-- i tookcare of a guy who fell off the second levelof-- moron, idiot-- got drunk and went offof miller park shortly after it opened, and walkedout of the hospital, mind you. holy moly, ok? but traumatic injuries, often--especially with spinal cord injuries-- whathappens, and may hasten the arrival of atelectasis,which then leads to pneumonia--

traumatic injuries,not protecting there. and then, what happens often? people don't usually goout and diet and then get in a traumatic injury. they go out and have what? lots of ice waterand beef brisket and all those otherinteresting things. and then they go whoops,and it goes whoops. yeah, that's bad stuff.

so a lot of times, a neuroinjury, head or spinal cord, you're almost guaranteedto get a pneumonia, really. they are allowed by-- ok,without getting too much into it-- but brain andspinal cord injuries are allowed a higher levelof pneumonia before medicare and all those otherkind of things start withholdingdollars, only because they have a lack ofprotecting airway. it's not significant, ok?

but i mean, it is significant,when you're talking dollars. so spinal cord, we'vegot, starting up in the base of the brain,and then going on down. it is your centralnervous system. when you start talking aboutnerves off of it, that's your peripheral, right? so your central nervous system. anyway, so you've got your31 spinal nerves coming off of that.

incidentally, your corddoesn't go down to your coccyx, but your nerves do. so you have thatclassic-- and some of you are in my age rangewhich could say-- so you've got thatoh, ah, my butt hurts! and my second and thirdtoe are numb and tingly. what's that? sciatic. sciatic pain, because ofmy sciatic nerve coming off

my spinal cord. i don't have a spinalcord injury, right? but you've got a disc that'sslipping out, putting pressure on that nerve, resultingin those symptoms. use your lifting machines. that's good stuff. so we talked aboutwhat this was. kind of looking at a view,you've got the butterfly shape. it's a very prettyshape and whatnot,

but it does all kindof sort of stuff. when you talk about dorsalhorns and ventral horns back in front, sosome of those things. throw it away, ifyou don't want it. don't worry about it. but i find it helps me a lot,because i have like cabinets up there in my head, and i can'talways remember everything. so when i want to knowwhat does what, perchance if i were askedlater at some point,

somebody comes up and says,well, hey, what happens, and what does the dorsalhorn with your spinal cord, those dorsal horns versus theventral horns, what does what? i think about dorsal horns. i go to dorsal fin. where's a dorsal fin on a shark? on the back. and if you rub my back,i'm going to feel good. don't judge me, ok?

we all do what we do, ok? but my back-- dorsal horn,ok-- carries the sensation, all right? so it feels good if yourub my back, the dorsal. whatever. so then you've got youranterior, or your ventral, is going to be justlike the opposite. so that will be your belly. but you've got your ventral,so your ventral horn, which

then has movement, ok? so it's kind of like sensation,movement, if that helps. if it doesn't, whatever. it's just how iclassify it in my head. use your own stuff. it's fine and dandy. anyway, that's whathappens with those nerves. ok, here's a nice pictureof the cord itself. so i like this.

this from your book. so it goes, whoops, thenit kind of cuts it out, so you can see where it is. incidentally, what arethese things called? words? they are words. i like them a lot. so they are meninges. so we all think aboutthe dural, you know,

the dura, or the duraltear or what not. so you've got your dura, yourarachnoid, your pia mater. and then inside of that,you've got your spinal cord. just like up here you'vegot that brain and balloon, you've got spinalcord and balloon, ok? all right, so moving on, lookingat how things are coming out of it. so you have your cord. you've got your central canal.

you've got your cord, your greyand white matter that comes out. you've got thisbeing your dura, so the outer edge of the balloon. so we talked about whatyou can do your spine. you know you can concussyour spinal cord, right? you can stun, numb this thing. and then, hopefully, itwears off, hopefully. about 20 minutes is agood rule of thumb, ok?

longer than 20 minutes,it's kind of bad. loss of consciousness,it's five minutes. if you're out, ok. but if you're out morethan five minutes, the neurosurgeon's ears perk up. what? those kind of sort of things. but did you know you caninfarct your spinal cord? what are you thinkingof right off the bat,

if you have a patient come in--i'm sorry, if you-- which talk am i giving here? so you go to thepatient in the field. you block and strapthem and tape them. find and dandy. low blood pressure. having a little trouble. going in and outof consciousness. you get to the ed.

you're taking them over, andthey start undoing the clasps. and if you haven't seen ityet, you're doing your buckles, and his legs kindof go like that. what are you thinking? he's got a spinal cord injury. that's honestly whereall of us go to, bilateral externalrotation of the legs. if you see the littlehallmark indicator in the gents that's not there,present, with us ladies,

what's that called? priapism. they're not happyto see you, right? that usually indicates a? ok, it's a funny joke. is it the camera? it's not my joke, but i tell it. and usually, i getmore of a giggle than that, even when there'sboys and girls in the class.

but fine. so you've got priapism andbilateral external rotation of legs. you're kind of thinking,oh, big hallmark indicator. and really, the major thing ismechanism, diving injury, fall, sudden stop, thosekind of sort of things. but infarction isreally more rare. when is one timewhere, maybe, you would present tosomebody's house.

bilateral or external,they're not moving their legs. they're kind of notwith it mentally, so they're not really makinga lot of sense either. and their bloodpressure is tanking. and they're crumping fast. and they can die ina matter of minutes. and they can present likea spinal cord injury, without the mechanism. where does the spinal cordget its blood supply from?

mm. what if you had a patient--let's work it backwards. you have patientwith a-- john ritter. does anybodyremember john ritter? so he died from a? where? so if you have anaortic dissection, usually, it's goingto happen fast, because that's under awhole lot of pressure.

so once you pop the skin inone area, it goes, whoosh, and a zipper opensright up, right? so usually they die,and they die real quick. but you can have dissectiona little further down. under the arch, i mean,unless you're already open on the operatingtable, you're gone, right? that's under enormous pressure. and everything that'scoming in is going out, and not to the right places.

it's just you're gone, ok? so less than five minutes, bam. but if it's alittle further down and you start having alittle bit of a tear, it's under less pressure. again, usually, theykind of open up. but say you've justgot an aneurysm there, or it's a slowleak, or it's just an aneurysm that's areally big aneurysm.

it's not getting bloodsupply to the spinal cord. you're going to infarctyour spinal cord. so they're goingto present looking like they have a spinalcord injury, because they don't have sensationor movement. and they have thatrolling out, ok? so this is where mechanismreally comes into play. and as field people--the in-hospital people get very, verylazy and don't care

about what happened,until you get to the icu. and they want to know what thesecond cousin's former roommate did in college. you know, that's the icu nurse. yes, i know. and the ed nurselike the add nurse. oh, great. what's this? i've done all that,so no judgment, ok?

ocd as well, mark can tell you. but knowing the mechanismbehind is really, really, really important. you guys usually paya lot more attention to that than the inpatient. well, i don't care whatthe original presenting injury was, we onlycare about now. what's his white count? what's his blood sugar?

what's his crit andall these other kind of sort of things, right? but you guys careabout the mechanism. so when you'representing, when you're seeing somethingclinically in front of you, always try to think, ok? so this is just maybe anotherone of those things-- sorry, it was a long talk--but one of those things that, maybe, wouldgive you a tip.

you have somebody with anunexplained non-traumatic appearing to bespinal cord injury. and yes, there canbe priapism, ok? don't think spinal cordinjury primary, think spinal cord injury asa secondary injury. again, it's not very common, ok? but you never know, you mightbe that one person to see it. detect. ok, so you've got yoursympathetic, your fight

or flight. we talked about thehypothalamus and how important it was and all these otherkind of sort of things. we will not excessively go intothe alpha and beta receptors. this, you could sit andtalk for, oh, my goodness. and i started putting insome stuff here about drugs. and it's just way morethan is necessary. and i'm sorry, i kind of geekout about it a little bit. but sympathetic nervoussystem is really

going to be yourfight or flight, ok? so what is the oneindicator that you get in a healthy20-year-old who's got four gunshots-- you knowwhat i mean-- to the periphery. there's no indication of spinalcord involvement, whatsoever. and you know he'sgetting shocky. how do they look to you? how do i know fromacross the room that you are perfusingyour brain well?

so the patient lookingshocky is going to be pale. how do they feel? cool and? pale, cool and clammy. anxious, definitely,that mental status. you're the one that gotit right off the bat. level of consciousnessis actually the very firstthing that changes. oftentimes, either we'vedone things to them,

or they've donethings to themselves that make us losethat indicator. but your indicationof shock in someone usually is, oh, you'renot looking good. you're looking the samecolor as the bed sheet. can very dark-skinnedindividuals become pale? so are their lips bloodless? nail beds? can't breathe, all theseother kind of things.

you can tell ifsomeone's shocky, right? i'm sweating. why do we get sweaty like that? why do we get pale? why do we get cool and clammy? how? what's fight or flight? what's compensating? what's the mechanism?

shunting. the blood is going from my? periphery. to my? right here, ok? and then, first,you lose the gut. and then you lose the kidneys. and then you lose the liverand all that good stuff, right? and that whole cascade setsoff your whole-- oh, my gosh,

shock is so much fun. but that's not whati'm talking about, so we're going togo back to this. so that's how you knowsomeone looks shocky, right? you have somebody with ac6, they'll be breathing ok. c6 transaction of thecord, you go to the field, and they'representing like that. what do they look like? do they get pale,cool and clammy?

they do not get pale,cool and clammy. why? you lose that prognostic,that quick, oh, i look at you and i don't like that. no innervation is left, right? there's no communication,so they can't clamp down. they don't have fight or flightbelow the level of the injury. remember, incompleteand complete are two different things.

it goes into it a little bit. we'll talk about it. but just keep inmind that you've lost that immediate-- theywill have what kind of pulses? bounding pulses, greatbig old pulses, ok? your 20-year-old's, you canfeel like in their fingernail, you can feel their pulse. in their ear lobe youcan feel their pulse, because they can't clamp down.

they look very puffy, becausethey are in distributive shock. very, very, very,very, very dangerous. all right, so we'vegot our sympathetic. so we're talking, really,like spinal cord injury here, so stimulation ofsympathetic nerves, which can happen artificially. so we'll say like,i.e., a foley catheter, or a distended rectum,without parasympathetic input, will causesympathetic overdrive.

what does your sympathetic do? fight or flight. what does yourparasympathetic do? anti-fight or flight, right? so it kind of calmseverything down. your pupils constrict. your heart rate lowers. your blood pressure lowers. urinary output kicks up.

you're no longerrunning from the bear or running fromthe dinosaur, ok? so if you have sympathetic,without parasympathetic, which is the case-- youknow, they have nothing in completespinal cord, ok? and they have somekind of bad stuff we'll talk about inincomplete injury-- but can result in autonomicdysreflexia, so ad. this is very under-appreciatedoutside of the neuro world.

very easily remedied andcompletely preventable, almost all the time. autonomic dysreflexia will leada very, very, very straight line to dead, in a 20-year-oldor an 80-year-old, ok? so what do i mean by that? you're transporting a patientfrom-- usually not fresh. so when you're getting themin the field and going in, you don't have toworry about this. but let's say you'retransporting somebody

from hospital to skillednursing facility, and they're vent-dependent. they're going toneed als, right? or hospital to hospital,community hospital to trauma center or spinalcord center, right? if that foley is not-- andwe're not talking about the bag, nobody cares about thecatheter bag, right? if you do, you need tostop it and smack yourself, because you should notcare at all about the bag.

you care about what'sgoing on internally, right? but if that foley iskinked and they're having bladderdistention, they're going to havesympathetic stimulation. and the body's like, woo. but the body can'trespond to it. the body can't empty it. it can't controlits own sphincter. that foley is kinked.

it can't do anything about it. and the guy doesn't evenknow anything's going on. all of a sudden, he'sgot a bad headache. you check his vitals. his heart rate's 250. his blood pressure's250/140, ok? he's very flushed. he will stroke andhe will die, ok? and i said man again.

but the same thing,woman, man, all that kind of stuff, all right? so very, very, veryclear progression. autonomic dysreflexia, theywill have a cerebral hemorrhage and then die, ok? it's very, very bad. so we'll talk a littlebit about parasympathetic. remembering that yoursympathetic is your fight or flight, yourparasympathetic is you're?

you guys are sosuper duper smart. so we're talking aboutwhat they really kind of do is really sort ofslow things down. have a lot to do, a lot todo with bowel and bladder tone and sexual function, ok? so a very brief segueway, just talking about those twoparticular things. people have an expressionthat sometimes comes out. well, that scared the--

shit. --out of me. she said it, i didn't. i love it. uh-huh. but if you literallysee that-- you might have urinaryincontinence, but if you have rectal incontinenceat the scene of anything, your suspicion-o-meter goesto 99 on a scale of 100.

that's a spinal cord injury,because that sphincter usually puckers right up inevery other instance, ok? so if you have somebodythat loses bowel control, huge suspicion. regardless ofmechanism, they have some sort of-- eitherprimary or secondary, usually primary-- injuryto their cord, ok? so really, really, really,really interesting. and sexual function,so does that mean

that somebody who's a paraor quad can never have a kid? not at all. there are all sortsof-- i could tell you some interesting stories, aswell, things we did at the va to enhance, so that peopledon't think that life is over. life is different, butlife is not over, ok? neurologic examination,what are we going to do? so i underlined oneword on this slide. and i underlined it inthe next, i don't know,

five slides or whatever. what word is that? history. history, history,history, history. so in all systems, and allinjuries, and all everything, you always need toknow history, right? mechanism of injury. what was going on prior to--oh, they crashed the car. but were they havingan mi, and that

caused them to crash the car? did they fall off thebuilding because he was high? did he get shot becausesomebody was mad at him? history, history isreally important. but in neuro, it's doubly so. we don't care aboutjust event history, we care about prior history, ok? you know how ifyou get frostbite, you're more susceptible again?

heat and cold injuries,neuro is like that. if you have a historyof a neuro injury, you are more susceptibleto another one, ok? it's very sensitive. it's like a teenage girl, ok? your lungs and your neurosystem, brain and spinal cord, they're very, very sensitive. they're easily injured. they're easily offended, ok?

so history is super important. what are they normally? do you have a problem respondingto a motor vehicle crash-- and the guy can't move hislegs, and he's out on the grass. was he a para prior? and some good samaritanpulled-- oh, my god. seriously? yes, that happens, ok? so pay attention.

oh, he's got a-- no, he'sbeen a para for 25 years, ok? so remember that. it's hard for allof us in our field to remember that theyexisted as a human being before they metus, or we met them. so what is theirnormal baseline? talk about event history. what has gone onthat could affect the nervous system,specifically?

did they have a seizureand crash the car? i actually respondedas a good samaritan to a patient who had a seizure. oh, my goodness gracious. would i ever considerdoing that again? i'd have to think about it,because it tied myself up in court for two years, becausethis guy couldn't get his job to pay. he had a seizure,crashed his car.

i responded. and he turned outjust fine and dandy. but it was a company car. and the company wasmaking him pay for it. and i had to go and getdeposed, and testify, and all theseinteresting things. i think law and order'sreally cool, by the way. i think it's really neat. i hate all medicalshows, because they're

fake and stupid. and i'm sure cops think thesame thing about law and order. but it was not fungoing through it. and this was like 15 yearsago, so it doesn't matter. and i'm going to stoptalking about it now. so recent infections? remembering infection,infection, infection, ok? very, very important. did you recently have anysort of-- i don't know--

sinus surgery? that's going everywhere. ear infections can cause issues,mouth and tooth infections. so nowadays, you can'thave a cardiac bypass if you had dental work donein the last 90 days, right? your mouth is filthy. my dog licks his butt andthe neighbor's dog's butt, and his mouth iscleaner than my mouth? and i brush and floss.

what's the deal with that? but it's true. so just thinking aboutall kinds of everything. history, witheverything, is important. but with neuro, it super,duper, duper important, ok? history of headaches,migraine headaches. have you had difficultyconcentrating recently? who has a headache and doesn'twant to listen to me anymore? don't lie.

so it goes in accordancewith mechanism, ok? but history is really important. on any given day, weall feel like this. i don't know. oops, i almost fell down. and i didn't hear whatyou said, you know, those kind of sort of things. they're interesting. so what do you want toinclude in your history?

this is all commonsense sort of thing. clumsiness, numbness, tingling. when we talk aboutweakness and whatnot, what is very, veryoften forgotten in the field and outsideof the neuro world? so sometimes, even inthe ed-- sometimes, i'm not going to saythat-- but sometimes, it gets forgotten tobe fully assessed. we really look.

ow! so they're looking at this arm. and then what couldpossibly happen? we forget to assess equality,so both extremities. so in neuro, it'sreally important. if i'm having numbness andtingling in my right leg and foot, i need to also notjust worry about that one, but worry about theother one as well, ok? you guys are critical,ems is beyond

critical in knowingwhat the first exam was, because it can changedrastically just in the back of your rig, right? but it can changeover courses of days. and in-hospital,again, we sometimes tend to minimize what happenedpre-hospital, because now it's the real world, right? the hospital is where it counts. not intentionally.

everybody does that. you care about whatyou are doing, right? but it's really,really important to have that baselineexam documented in everything, butespecially in neuro. you have a brain injury,baseline pupil exam. you know, some drugs affectyour pupils and some don't. i'm talking about thedrugs that we give. yes, their own drugs, ok?

but knowing what drugs yougave, what was their exam prior, and what was their exam after. and then, did they havenumbness and tingling in their left foot? but i've had that forfive years, on and off. oh, that's reallywhat's going on. so the baseline examis really important. stop talking about it now. impotence, we talked aboutthe really, really bad type

of impotence. i said impotence. incontinence, is thatfecal incontinence? if you poop your pants,something really wrong, neuro-wise. and then impotence. incidentally, impotencecan be something that people are not comfortabletalking about, right? who would love to justhave a whole conversation

on their ability toperform sexually? of course, no one would, ok? and one particulardrug-- ok, it's a particular class ofdrugs-- is given out to lots of males ofa certain age who have a certainmedical diagnosis. we're not talking about viagra. i'm not going there at all. i'm talking abouta class of drugs

that has impotence as almostit's number one side effect. and lots of people are on them. and lots of people,lots of males, stop taking them becauseof this side effect. met-- oprolol? oprolol, yeah,your beta blockers. did you know that? ooh, yeah.

so if i'm happy and go-lucky,and now i've got hypertension, and they put me on lisinopril,a nice little ace inhibitor, initially. and i take that. but then i don't wantto get up and pee. or for whatever reason, theyadd a beta blocker, metroprolol. it's really cheap. it's 1,000 years old. everybody gets it.

very effective too, ok? and a huge sideeffect that men do not like-- some men do notlike-- is impotence. so they stop taking it, ok? and then they havehigh blood pressure. and they have an mi or a stroke,calling you to the scene. so history, history. history is really important, ok? so we're going to talkabout vision, remembering

vision really comes fromwhat area of the brain? occipital lobe? occipital lobe, so theback of the brain, ok? so are you havingvision problems? not just let me lookat your eyes and are they perl, but are youhaving vision problems? are you having floaters? are you having diplopia? whatever it is, ok?

did you do anything ordid you take anything? and do people usually givea nice, honest response to that question? absolutely not, ok? so always kind of trying tobe sensitive to this, that, and the other. i don't care what you do. you want me. i'm here.

i'm here for you. you don't tell me? i'm not going to beable to help you, ok? i'm not the police,but i've got to know for this, that, or the other. so slight segue way. do you guys member themovie, as good as it gets? anybody see it? jack nicholson and diane keaton.

awesome movie, by the way. so in that movie, he getsa nice young girlfriend. and he starts takingviagra, right? and so then he cankeep up with her. and everything's all funand happy and going on. ooh, i've got some chest pain. so he goes in the hospital. and they ask himlike, oh, my gosh. they didn't say, oh, my gosh.

they said, have you takenany erectile dysfunction meds lately? have you taken any viagra? he's like, absolutely not. i never take that. who are you to ask me that. and they said, oh, ok. because otherwise, this drugthat i'm putting your arm will kill you.

and he rips the iv out. and he sits up,and he's like, no! because they're giving himnitro with the-- you know? and then the next time he comesin with the same symptoms, he says i just took my viagra. it was really funny, ok? so not judgmental, but importantto tell them why you're asking. troubles with adls. check your sample.

and you guys are pre-hospital,so you know that, right? very important acronym? why are there so many acronyms? but very, very, very,very, very important. and then some islast [inaudible] or last menstralperiod, remembering to ask the ladies that as well. let's see. what do we want to look at?

their mental status,their emotional status, is it appropriateto the situation? and we'll get into all of these. we're checking theirthought process, what is their general behavior,what is your avpu score. actually, i was happy tosee that you guys have avpu. everybody familiarwith the avpu? use it. very, very wonderful.

it's a very reliable tool. it translates veryeasily across disciplines and across countries. and it's great. a level of consciousnesson all patients. so it's not just awakeor unconscious, right? there's all those littlethings in between. so are you awake, butare you lethargic? are you stuperous?

not stupid, butare you stuperous. are you obtunded? and being able to communicatethose to the receiving end, because you're going totake them somewhere always. so arousal, talkingabout arousal. when might a patienthave a problem maintaining alevel of alertness? or their level of consciousnessmay be decreased due to-- i'm trying to go back to,i don't know, 35 slides ago.

we were talking aboutone particular injury that really affectsa certain system. you might have a diagnosis. but they might not be ableto maintain full wakefulness. that's it, damage to thereticular activating system. so it's because i'mstanding close to him that he's gettingthis osmosis from me. yeah, it's good stuff. you got it.

so just kind of trying tore-tie things in here and there. so glasgow coma scale, isevery familiar with this? it's a good tool? it's a good tool, because it'svery reliable, not meaning that it always shows upon time, but that you get, usually, the same score across atrauma surgeon, a neurosurgeon, an emt, a nurse, a paramedic,a respiratory therapist. however, it is avery dangerous tool. we get reallycomfortable with numbers,

like we were talkingearlier, right? so you have a gcsof what, normally? what do you hopei have right now? and what does a table have? so there's no zero, right? so that's alreadykind of negative. i'm not a real big fan ofthe gcs, unless-- and i challenge you from this dayforward to always do this, ok? when you get reportand you get a gcs,

not just asking thescore, but asking what particularcomponent of the score, because it can be different. you can actually have ahuge change very rapidly, based on whatcomponent of your gcs, because it affectsthe total score. so let's back it up. that was too big of a question. your gcs is-- whatare the things

that we measure in a gcs? score of 15. eyes, verbal-- eyes, verbal, and motor. i actually don't like it. but other peopleseem to like it, so i'm going to passit along to you, ok? so how do we remember withthis, that, and the other? maybe you guys already know,and you don't need it anyway.

but ev and m, so yourextra value meal is $3.56. have you guys heard that? it's not, by the way. it's a lot more than that now. it used to be. when i worked at mcdonald's,we made the biscuits by hand. anyways. but gcs, eyes, verbal and motor. so what's the perfect eyes?

and the verbal is? and then the best scoreis a six, for motor. what does a six mean? obeys simple commands ornormal complex commands. so i'm not asking you to quantumphysics, or go backwards-- i know the mini-mentalexam, but i hate-- try to findthe average person and ask them to sequentiallycount backwards by sevens. ok, so don't necessarilycount on-- but anyways.

so not talking aboutsomething really complicated, but are you oriented times? so that is the new norm. your book does notreally reflect that yet. it still says times 3. i did add a littlespot in there. it should be times 4, ok? so following complexcommands, you should be able toshow me two fingers.

take your left indexfinger and touch your nose. you know, a complexcommand, but that's not too ridiculously complex. and don't ever sayshow me thumbs up. this is a very common,frequent problem. doctors are notoriousfor doing this. show me thumbs up. what did you just do? so if they then do this--90% of our communication

is nonverbal, right? so if i go in and go-- you know? you can't understandanything i'm saying, but you know whati want from you. you're going to dothat too, right? so absolutely do not demoanything for them, ok? give them a complex command. close your eyes. so you see how that-- andyou're making eye contact.

i didn't mean to pick on youlike three times in a row there. so a complex command, butdo not demo it for them, ok? but then the numberfive is what? localizing. so what does thatmean, to localize? to be able to takean extremity and try to remove-- notextremity-- a stimulus and try to go directlyto that stimulus.

usually, the rule ofthumb is to cross midline and try to remove it, ok? so we want to see peoplegrabbing for their et tubes, and grabbing for their-- cathether. the boys do it morethan the girls. but it's still not comfortable,so we want that, right? we want to have to tie themdown drug them into submission, no, i didn't mean that.

i just meant thatwe want to see that, because that's a good status. you can't talk to me. you've got a tube in your mouth. i want to see youtry to rip it out. you don't like that, right? localizing is good, usuallycrossing midline, ok? so not pinching here and tryingto get them to grab you here, pitching over here.

you want a good, brisk response. that's a number five onthe motor score, right? what's a number four? withdrawing. demonstrate that for me, please. trying to remove thebody from the-- you know, someone takingtheir arm [inaudible]. not trying to go towards it. or it's a nonspecific action.

nonspecific, so like, evenif i'm pinching right here and my hand's right here, ah. but it's not able to bespecific to that area, ok? so you pinch theirarm, it's a-- what i want to see is the other armcome over and grab me, right? but this, they're justlike going [grunts]. so they can feel something,but they're not good enough to be able to go up and get it. that's a four.

what's a three? hm? moaning and groaning? well, that's verbal, ok? so actually, a two is posturing. so flexor and extensorposturing, decorticate, decerebrate. so flexor is the new term. i don't know why wehad to change terms.

decorticate, youdemonstrated it. so everybody do decorticate. i'm lovey dovey. i'm decorticate. so you're going tothe core of the body. you're trying to come inward. toes can flex upwards,and the knee might bend. and we really gradeall of these movements on the upper extremities, right?

you kind of don't carewhat the lowers do, right? but this is important. so are they flexor posturing,or decorticate posturing? what's the number two? extensor or decerebrate. extensor or decerebrate,so demonstrate that for me. so we're stretching,because we're really tired of beingin this classroom. it's hot and all thisother kind of stuff.

ok, so decerebrate, ok? so you might see a twisting out. they might reallyrigidly kind of do that, often, with a rightor left deflection of the head, as well. and the toes very frequentlywill point downward. and you'll have a veryrigid extension of the legs. decerebrate posturing, youhave brain stem damage, ok? do you come backto mowing the lawn

and going back to work, ifyou are extensor posturing? no, you don't. you might come back to acertain extent, but no. brain stem involvement,really serious. i mean, it's all really,really serious, right? and then a number one is? and why are they not? did we paralyze and sedatethem and try to get an exam? don't do that, ok?

did you ever givesomebody a bunch of drugs and thenhave somebody go in there try to get a reaction? that's not nice. so don't let anybody else dothat to your patients either. but anyways, so canyou have mixed-- this is why motor isso important-- can you have mixed items on either side? this is where the score isvery, very dangerous sometimes.

a gcs of less than eight? then we have to? intubate. somebody always fills it in. you make me very happy. thank you, very much. so we have intubate, if wehave a gcs less than eight. that's pretty much therule of thumb, right? so you're thumbs up.

everything's all goodwith a gcs of nine. hm. maybe, because their motorcould be the difference, the motor score. eye and verbal iswhat it is, ok? but motor, i could belocalizing on this side and, yes, i could possibly beflexor posturing on this side. it's not common, but you canhave a two point difference, but i could very easily,and it frequently

happens, withdrawingon this side and localizing with this arm. that's my one point difference. i have two more ccs of blood inthat bleed-- my epidural that's continued to bleed now--and that drops my gcs. and now you're trying tubein the back of your rig. is that a very easy thing to do? you guys will be, if you're notalready, ok to intubate, right? do you?

or do you not? so is that a prettyeasy thing to do? absolutely not. whether it's a kingtube-- nobody's using combitubes anymore, right? but whenever you're using,that's still hard to do, even if you don't need tobe able to visualize cords. it's still hard to do. so i challenge you.

get the motor-- soi've got a gcs of 13. what's their motor? oh, he's a solidfive on both sides. well, with 13, hewould be a six. and always, your receivingdepartment, the physician and the nurses in the ed thatyou're going to transfer to, or the unit, if it'sa direct admission, will be very, veryimpressed with you, if you providethem his gcs is 10,

he's got a for motor onthe right, and a four for motor on the left. and they're going tolook at you like [gasps]. like that. like just [gasps]. you take a picture. don't be reassured by the score. that's avpu. you guys already know that,so i won't talk about that.

ok, so physical exam. here's where it is, awake, andalert, and oriented times 3. no, it really should be times4, so person, place, and time and then situation. and don't ask them thestandard stuff, right? what's your name? what's the date? and who is the president? come up withsomething different,

because they will be veryaccustomed to hearing those questions, not if youcatch them in the field. but if you're doing transportfacility to facility and you need to doan exam, they're going to have been askedthose things about 75 times. mini-mental exam,right here, there's a couple of slides on it. these are tableswithin your book. it really talks about, forlevel of consciousness,

this is often-- you know,you're awake, your lethargic, or you're unconscious. no, there are levelsin between that, ok? so it's good to be alittle bit more familiar with more than just, i'mdoing fine, i'm not fine, or i'm dead, kind of gettingthose nuances in the middle so obtundant, being obtunded,something's probably going on. but you can be obtundedfrom not a brain injury, but from all that heroin.

holy cow. that's a big thing in ourcommunities now, isn't it? the parent of a teenager whodoesn't do drugs, i think. i'm pretty sure. but the high schools are havingall these talks about it. it's expensive, isn't it? and it's a downer. but anyway, enough of that. patient orientation,so here they

have time, place and person,remembering situation. where are you? well, i'm in wctc. why are you at wctc? can you tell me about it? oh, i'm here to take a classtoday on this stupid neuro lecture that's never-ending. and it just keepsgoing on and on. and there's so many slides,i can handle it any more.

you know, that kind of thing. so why are youwhere you are, ok? why were you in the car? because that's avery early indicator. that will go away first. i'm in the car. i'm on highway 16, you know? oh, but why? i was going to wctc.

that's right. so the earlier you cancatch things, the better. and here's yourmini-mental exam questions. i get really, really, reallyfurious with some of these. so this is very difficultfor lots of people to do, ok? i know it's says by sevens. it's a little easier tohave them count sequentially by threes, and it's still kindof more than just count to 10, you know?

so sometimes, i will ask them togo backwards by threes, things but the registration and recallis very good, very important. have you ever been presentwhen someone else was trying to do this, and thenyou try to remember? so somebody's in the room,and they're saying, hey, remember bottle,computer, and pen, ok? bottle, computer, and pen. can you repeat those back to me? probably.

hello? [laughs] ok, so that'sour registration. do you understandwhat i'm saying? and can you parrotit back to me? can you regurgitate it? and now these other things. we've got language. you know, what is this? what color is my shoe?

did you notice,by the way, i put on the bright whiteshoes for you guys today? yeah, i changed out of my boots. i was going toleave them on, and i figured i would trip andfall and be embarrassed. so that's actuallyreally why i changed. but look, they're bright white. yeah, they're pretty good. i haven't stepped inpoop yet with them.

all different sortsof kind of things. ok, so now we're goingto talk speech function. so what i do is add this littlething over here of language. everybody assumes all this thati'm doing right now is speech. it's not. speech and languageare different, ok? you can have dysarthria, whichis different than dysphonia, which is different than aphasia. and there are no fewer thanfour types of aphasia, right?

aphasia is not aphasiais not aphasia, ok? can you guys tell mewhat those three items were that i said toyou a few minutes ago? but you all had a little bitof a minute there, didn't you? it's hard. and usually, they letmore time than that go. they'll let like, atleast, 10 minutes go, and then want to know again. it's very interesting.

some people canonly get one or two. do you ever watch thatshow, brain games, on national geographic? oh, you totally should. it's so interesting. yes, i absolutely love it. but it kind of shows you howlowly functioning we all are, and how much by routine wefunction most of the time. you ever driven home andnot remember doing it,

but you got there ok? we need to pay attention. night shift. but we're going to talk aboutspeech and language, ok? [laughter] so dysfunction in any componentor process of communication, aphasia, aphasiaequals language. and this is very,very misunderstood outside the world ofthe neurologist, ok?

we all do it. you have all doneit at some point. so we want you to repeat back--what's that sentence we always want them to repeat back? can't teach andold dog new tricks. no if's, and's or but's. today is a sunny day. today is a cloudy day. those are the bigsentences that we

want to hear him say back, ok? and [mumbles]. so what? you couldn'tunderstand what i said? so you're going tosay i'm aphasic? i may have trouble actuallyarticulating the words, because i have muscle problems,but my language function is still dead on. and how do we assess that?

without me demoingit for you, i would like you to take yourleft pinky finger and raise it high in theair, and then touch your ear, and then touchyour nose, please. and i'm making eye contact,so i want you to do it. very good, but youdid it backwards. i said touch your ear,and then your nose. it's horrible when you'rearound a neuro person. it's so annoying.

i fail that a lot, too. don't worry. but that's how you'reassessing everything. dysarthria is not thesame thing as aphasia. don't classify those. and frequently, we say they'reaphasic when they're not, ok? and if they areaphasic, they are, but we need to know what kind. so here we go.

articulation, that'sthe mechanics of speech. that's a muscular issue, ok? so you can be completelyunable to express, and that's expressive aphasia. or you can be, ok, ifyou really understand, because my floppy lipsand my floppy tongue now aren't cooperating,[mumbling] that i'm really saying, no if's, and's or buts. that's enough of that.

to assess cranial nerves. how many cranialnerves do you have? 12. so they're very, very easy, butyou have to have participation in order to assess, atleast, the first one, ok? not all of them,but the first one. your olfactory nerve, sowho's got a good mnemonic. let's hear them. there's always suchinteresting ones.

to remembering what the12 cranial nerves are? ok, but really,it's more important that you know-- ratherthan remembering the exact name of it, becausethe glossopharyngeal one is one then we kind ofsometimes forget-- but trying to remember howto assess for them, right? olfactory, how do you assesssomeone's olfactory nerve? you have to be awakeand coherent enough to participate in this.

so if you see anydocumentation, cranial nerves, blank through blankintact, 98% of the time, it's going to be cranialnerves 2 through 12 intact, ok? and only in a clinicshould someone really be writing 12 cranialnerves intact, because no one takes the timeto go get-- i mean, not no one-- but really, no one takesthe time to go get something to help assess their levelof their olfactory nerve, ok? but if you happen to bechecking somebody in the home,

remember that, if you'retesting their olfactory nerve, you cannot let them see. you have to cover their eyes. but citrus, oranges, is avery, very good one, ok? and a lot of people haveoranges around the house. okey-dokey. your optic nerve,so are you perl? so when do westart freaking out? we've got, oh, my gosh, there'sa bad brain injury going on.

something's happening right now. we've got to get thisguy to the hospital so they can get him intothe or like super stat. and it has to do withcranial nerve number two. what doesn't work anymore? pupil contraction. very, very good. we get all freaked outwhen, suddenly, someone has a fixed anddilated pupil, right?

that's a pretty good earlyprognostication, right? is that a pretty goodearly warning sign? no, it's not. huge frowny face here, ok? you guys nod alongbecause i'm nodding. and you've checked outmentally, haven't you? i don't want to see it. it's really hot in here. it's hard to standhere and talk too, ok?

no! you haven't missed the bus! it is a very late sign ofneurological compromise. you, at this point,have pressure, barring any baseline issues, ok? so we're not talking aboutsomebody that has issues prior. we're talking about, oh,my gosh, they were working, and now one's not. or both are not, ok?

it's very late. that's the person that's alreadygoing [breathes loudly in]. i know, that wasnot very attractive. i'm sorry about that. but that's really bad. why does that happen? you have pressure oncranial nerve two, ok? so pressure from what? from either swelling, fromblood, from pieces of bone,

if they have a depressed skullfracture, anything like that. a tumor, a lesion, couldbe causing the pressure. and suddenly, that peoplewill not constrict anymore when exposed to light, ok? so we care about perl. but what we really careabout is are they as perl as they were an hourago, or two hours ago, or yesterday, or10 years ago, ok? and we'll talk a littlebit later about-- yeah,

it's not on this one--what we do to fix that, if it's not working anymore, ok? so optic nerve, rememberingto look at both eyes. and to be honest,so pupil exam is not part of the score in the gcs,but it's part of the gcs, so remembering it'seye, verbal, motor, but also check the pupils. and then be honest, i don'tknow if that's working or not. if someone comes to youreally, really, really high,

and they've had a lot of drugs,and their pupils are this big, can you assess them? you've seen pinpoint pupils? do they contract? sometimes they are maximallycontracted already. so don't write perl if youhaven't seen it contract. you're not tellingthem what they are, you're just saying what you see. it's ok to be differentfrom someone else too, ok?

so then you've got this--oh to touch and-- so three, four, five and 6 usuallyare examined as a group. so that's follow myeyes, follow my finger, and all that goodness. position of the eyelid, checkingfor lid ptosis, not pitosis. not like pitocin either. really watching for nystagmus,so this is an extra one here. so nystagmus is really,really a good indicator that something pathologicalis going on the brain, ok?

and it could be avery early indicator. i do know one humanbeing-- i've have met one in my entire life--and she's really weird. so i don't know if thisis her makeup or what, but she can demonstrate--she's perfectly normal, she functions, she's anicu nurse at froedtert-- and she can demonstratelateral nystagmus. it's the weirdest thingin the universe, ok? i've never met anybodythat can do that.

so what is nystagmus? bouncing. they either bounceback and forth-- she can demonstrate horizontalor lateral nystagmus-- or there's verticalnystagmus as well, ok? and depending onwhat type it is, that's why you need to watch. do they bounce back and forth? or do they bob up and down?

or do they bounce up and down? you know what imean-- because that can tell the-- andknowing you're the first, you're the baseline-- that cantell the neurologist a lot, ok? and then they'llmaybe do this, that, or the other exam quicker,radiologic exam quicker, than they maybe would have, ok? so everybody gets a ct. but in some cases, anmri is warranted, ok?

all right, yourfacial nerve, beware. the facial nerve, cranialnerve seven, it's a lot of fun. so let's say this. i'm going to go over to--this is really good, again, people will really be superduper impressed with you-- so let's say yougo over to respond to a call down the road. and you go into the house, andit's an 82-year-old who says, i've got a really,really bad headache.

and she's 82 years old,and vitals are fine. so you do a fast exam, right? everybody knows what that is? i'm not talking about fastfor trauma and ultrasound. i'm not talking about that. they're starting to havecommercials for this out on the radio, which iswhy i'm kind of testing. american strokeassociation is doing it. f-a-s-t stands for face,arms, speech and time.

so that's kind of wherei'm going with that. so it's very quick. i know there's cincinnatipre-hospital screen. and then there's like87 pre-hospital screens we'll talk about. i can't remember whichone is in your lecture, but there's a ton of them. american heart uses cincinnati. i'm really blanking.

i think it's an l-- los angeles? but we'll get to it. but you do a quickface assessment. and she smiles andgoes like this. she's 82. she smiles and goes like that. she's got a bad headache. what do you jump to instantly? stroke.

she's having a stroke. so after working up and reallyquick doing what you're doing, you package her up. you get her, and you tellgrandpa to come with son later on. you get her overto the hospital. and they are goingto diagnose her. they're going toquick, do a ct scan. and you think they'regoing to give her what?

tpa, because you'rethinking she's got a stroke. they do a ct scan, andthey say, holy crap. what else happened to you today? and she says, oh, iwas downstairs to get some preservesfrom the basement, and the dog ran through my legs. and i tripped andfell down the steps. yeah, i know. i'm taking a littlebit of liberty

here with the scenarioand whatnot, ok? and she fell down acouple of steps, ok? she has a basilar skullfracture, facial nerve. cranial nerve sevenis your facial nerve, and it runs through-- andcertain areas prone to fracture in the ring. just like your pelvisis a big ring-- i have a nicepicture of it later on-- the base of your skull,if you're looking down or up

through it, is itshould be a nice ring. and depending onwhere the fracture is, it can pinch facial nerve,cranial nerve seven, giving you a facial droop. don't always assume that theold person with a facial droop has a stroke, because it couldvery easily be a basilar skull fracture, resultingin a facial palsy, ok? how do you figure it out? who's ever done annih stroke scale?

oh, my gosh. that 40-item exam,it's really painful. but they ask you to doall sorts of things. they want to raiseyour eyebrows. they want you towrinkle your forehead. they want you to closeyour eyes really tight. they ask you doall those things. and this is how youdetermine whether or not they've had a stroke, ok?

it's a little bedside thing,not well known, hopefully. hopefully, i'm going to showsomebody something new in here. so you want them towrinkle their forehead. please wrinkle yourforehead for me. some of you are alreadydoing it already. ok, you can go down or up. and you've got the lineskind of like there. i usually wrinkledown like this. what are you talkingabout, willis?

all those other kind of things. so you wrinkle the forehead. but a lot times try towrinkle it upwards, ok? and then have their eyes closed. smile, but wrinkle the forehead. if the forehead wrinkles onthe side of the paralysis-- so if i smile andgo like this, ok, and this side isn't working,and i wrinkle my forehead up or down, and you cansee that it's wrinkling

across both sides, youhave a stroke, rather than a facial nerve palsy. and the reason is that thecentral root of the nerve gets blood from bothsides of the brain, ok? so if you have a stroke,this part of the nerve is being damaged. it's not working. so that's why you'rehaving the facial issues, the facial droop.

but the forehead part willstill work on both sides. and that's part of the reasonwhy, on the nih stroke scale, they have you do both. you get a pointif you can smile. you have to close your eyesand raise your forehead. and eye-closing andforehead-wrinkling is a separate line itemthan the smile, ok? doesn't that make sense? it's kind of cool.

ok, let's move on. number eight,vestibulocochlear nerve. so has anybody heard of atest called cold calorics? ok, so don't judge, but we workin a facility that's large. we have lots of levels. i work at a facilitythat's large. and we have lots oflevels of physicians. and sometimes doctors,just like emts, and paramedics, and nurses,can be really stupid, right?

and we had a couple of residentsseveral years ago, this was. and one of the first-yearsdecided to, well, i really want to see whatcold calorics feel like, ok? what that is is you'restimulating the vestibular cochlear nerve byinducing ice water, pushing ice water intothe ear canal, ok? so in order to dothat-- we're not going to do that ina regular person. how do you test cranialnerve eight in me right now?

have me close my eyes,and put your fingers, or some clothing, orsomething like that-- close my eyes so i can'tsee which one, and tell me, am i rubbing outsideof your left ear? your right ear? both ears? neither ear? that's how you test itin a normal person, ok? but in a person who has severelyaltered level of consciousness,

what we're looking for is eyedeviation with the stimulus. what we do is we put icecold ice water directly into the ear canal. and then we will eye deviation. and that's a good thing. it's a bad thing-- we won'tgo into that excessively. however, in a conscious person,what you get is-- take a guess. just really take a guess. what do you think happens?

vomiting? you get really badthings happening. so you have instantaneous[makes retching noise] everywhere. it's really bad, ok? they vomit all over the place. so next time you're at a partyand it's boring, say, oh, i learned this reallycool new trick. and do it to somebodyyou don't like.

i mean do it to-- not that, ok? but they barf everywhere. and they fall down, becauseyou have seriously, seriously messed them up, ok? but we are looking for,actually, eye deviation. it's a true medical exam. and it's required, actually, tocheck cold calorics when you're checking for-- it's one ofthe requirements for one of the pathways of brain death,when we're assessing that.

but ok, that'scranial nerve eight. so let's go on. we're going to talk aboutglosso means tongue. it's kind of a fun word. you think of thetongue as really gross. glosso. so glossopharyngeal,so swallowing, and tongue, and whatnot,your vagus nerve, and all those kindof sort of things.

very, very easy. and usually quick. and the doctor does thisto you all the time. open your mouth. say, ah. and you want to see the palaterise and things like that, checking for swallow. and that's just checkingmuscular movement and stuff your spinal accessory,it's very easy.

you've probablyhave had this done. you may or may not have. some primary care docs aremore thorough than others. but you turn and havethem push against, ok? and you have todo it both sides. remember, both sides, ok? it's always equal. both sides and trying to see. so hypoglossal, so thisis below the tongue

kind of sort of thing. so we're really checking thetongue, especially underneath. so your tongue and cheek, youmay or may not have had this. so tongue-in-cheekis like saying, oh, i really don't-- it's adouble entendre, right? i'm saying, well,that's a nice chair. so i'm saying something else. that's tongue-in-cheek. does anybody ever--

but this is reallyhow you check it, ok? providing pressure, seecan they push against it. you have to check bothsides, because it's not just open-- i havegum in my mouth-- but, ah, does my tongue, ah,want to deviate that way? that's not good. and that will be presentin stroke patients, some of the time, dependingon where the stroke was. but it's not just checkingfor drift, it's actually,

can you respond to pressure, ok? how strong are you? that's your cranialnerves in a nutshell. ok, so motor function,we will check all parts of range of motion,normal range of motion, remembering that certainpatients will not have full range of motion. so those baseline exams,what do you do normally. how is this normally?

abnormalities are spasticity--flacid extremities are obviously a bad thing. spastic muscles and rigidmuscles are different, right? so rigidity is an absolutelocked, you know, there. but a spasm-- when can aquadriplegic look like he's running down the road? does that ever happen? maybe not down theroad, but oh, yeah. long-term quads, they can havemuscle spasms that are so bad,

those legs are jumpingin the bed, ok? so it has to do with nerveresponse and reflex response, depending on the type of injury. so spasticity is also a badthing, not a spastic person. anyway. assessment of sensory, whatis one thing that's sometimes a lot of us do is weequate motor and sensation as the same thing. they're not.

they're completely different. it's like the spinal cordand the vertebral body, ok? so can you feel and not move? can you move and not feel? you actually can. we'll talk about central cordsyndrome and what that is, ok? so sensory is testing thepatient's ability to perceive. and they do not get to cheat,it's i'm feeling your toes. i'm going to pointyour toe up or down.

you tell me where i end up. if i end up withyour toe pointed up, i want to hear yousay the toe is up. and eyes closed, always. they can't cheat, ok? and if they can tell if i'mtouching right or left leg, and they can tellif i'm touching the right or leftfoot, but they can't tell if the toe ispointed up or down,

these are all differentdermatomes, ok? the level ofdermatome involvement is crucially importantin spinal cord injury. the neurosurgeon wantsto know that, ok? we want to spare everydermatome we can, because that could be thedifference, ultimately, between a sip andpuff wheelchair, and a chair that ican knock with my arm and still havesome movement, ok?

what should you do mr.and mrs. fancy pantses? you should examine pain,temperature, and touch, ok? so you're goingto put the "i was joan of arc in my former life"lighter under their hand. of course, not absolutely. but do they feel warm? do they feel cool? is it the same on bothsides, so patting down, remembering that a patient withspinal cord injury is not going

to get, incomplete or complete,to different degrees-- we'll talk about shockin a little bit-- but they are not goingto usually get pale, cool and clammy, because theycannot mount that response anymore, ok? reflex testing,very, very briefly. deep tendon reflexes,or dtrs, routinely are done by physicians. honestly, ok?

we will do some of them, aspre-hospital and in-hospital providers. but primarily, really, thisis a physician's realm, ok? and they've got to do it. and they really, really careabout it a lot, a lot, a lot. we care abouteverything as well. so examining thedtrs will tell us lots of things aboutthe spinal nerves and what might or might not begoing on with lesions, possibly

with bleeds, withedema in the brain. we talk about the ponsand stuff like that. tendon reflexescan be increased, which is more seen likespasticity, or rigidity. and upper motor neuron, and thenyou are going to see atrophy, and wasting in lowermotor neuron lesions. i am going to cap it rightthere, because upper and lower motor neurondisease and lesions, we could sit andtalk for 10 years,

really, like for twowhole days about it, ok? very confusing andtruly beyond this. not really relevantto any of us, as first-line providers, ok? but if you're ready togo to medical college and start yourneurosurgery residency, you'll need to know them. so there are smileyand bad faces on here. so pathologic reflexes,pathologic is good.

is that a question? it is a question. pardon me? pathologic is good? pathologic is bad! you're like myfavorite one there, ok? i'm serious. but no, pathologic is bad, ok? no, no, no, no, no, no.

but usually,pathologic reflexes, we want to see certain things. we don't want tosee other things. but pathologic, no,it's just what's behind it, that kindof sort thing, ok? plantar response, pleasedescribe for me-- i have a smiley face there,so you can tell i'm being honest there. i'm not faking you out.

we want to see aplantar response, ok? what is a plantar response? the book hadmultiple definitions for exactly the same thing. so sometimes, these arethe two most common ones that you'll see. they had a plantar response. you run an object ontheir foot. [inaudible]. so flexion downward,curling downward, ok?

so you're both exactly right. and do you wantto run it right up towards the ball of the foot? i wish i had a foot. so you want to--no, i'm not even going to crank myleg up on this thing. so pretend these are mytoes, and this is my heel. this is my right foot, ok? so it's like this ismy arch is right here.

so you want to run itlike this, up and around. and always more than once,usually on an inward basis, as you do them insuccession, ok? so you want tosee-- your scraping. and you always wantto use a sharp object. so you don't usethe nice toothette, because we all havesensitive feet. nobody likes to touch or feetor do anything with out feet. everybody hates feet.

but we want a sharp objectto be able to really elicit this response. and a normal planter response--or a negative babinski's is how, usually,we document it-- is you will run it up andover, so under the toes. you don't strokethe toes, but you stroke the sole of the footin a movement like this. so remember, thisis my arch here, ok? and so one, two, three times,but at least two times,

the first time more outer, thesecond time more inner, so more lateral, and thenmore medial, ok? and you want tosee my toes flex, big toe especially,curl under, ok? so if my big toe flexes upward,that is a babinski sign. normally now, all we dois we call babinski's, either positive or negative. we've got a positive babinski. that's a bad thing, if youare greater than one year old.

so what if you'resix months old? it's normal, because yourbody is still developing. your brain is stilldeveloping, ok? everything is still developing. but by six to 12 monthsold, so like a year, you know what i mean-- butif you are 10 years old and you have apositive babinski, bad stuff's going onin your brain, ok? so that's a sad face there.

grasp and superficialreflexes, there's actually a separate slide for each one,so we'll kind of go into that. so the grasp reflex, this issomething that sometimes we unconsciously help our patients,which we need to not do. it feels mean, but you needto not help them out at all. don't say, give mea thumbs up, ok? we talked about that. that's bad! don't give them any help at all.

we want to see them struggle. hopefully, they won't struggle. but we want to see themstruggle and then get it, because that meansthings are just delayed, but they're still happening. but you will place yourfingers in their hands. so this is an infant grasp. your grasp reflex is one ofyour very, very basic ones. you go and see the baby.

and you're like, oh, you're socute with your little hands. and their whole hand takesup just around my one finger. and i don't feel likei have fat fingers. but their whole hand iswrapped around my finger. yes, that's a very, verybasic brain response, ok? so they will grab it. they don't like you. they don't know you at all, ok? well, they can knowyou a little bit,

you know, your smell andeverything like that. but normal responseis to grab here. but they have tobe able to let go. so you don't countsqueeze my fingers. that does not count, ok? i've worked with dozensof neurosurgeons, hundreds of residents over my career. and my career has along way to go yet. and they will say,follows commands

when they squeeze my fingers. do not give themcredit for that. you only get creditif you let go, ok? and don't help them out. don't pull away, all right? i know [inaudible] pull away. just try to get themto command to let go. and if they don't, then pullaway and see if they let go. and then they still kind of getcredit, you know what i mean,

if they can let go. but the grasping does not count,because that's a baby reflex. a two-day-oldinfant will do that. but if i keep going-- youpull away from a baby, and he's going to-- youknow, it takes a lot. you sometimes have to wrenchyour finger out of their hand. so i have five years ofpre-hospital, 17 years of in-hospitalexperience under my belt. seven years of that wasfull-time in a neuro icu

at a level i trauma center. i have never performedthis exam, ever. have any of you? let's read this. [laughs] it feelsa little personal. and i do all kinds of things toall parts of people's bodies, you know, these things are justlike elbows to us now, right? its whatever. it is.

it's just like your wrist,or your knuckle, or whatever. but i have not everdone this, so i can only read you the slide. so i have also neverseen a physician attempt to elicit this response. that does not mean it doesnot happen every single day, and i've just never seen it. but-- ok, we'regoing to move on. meningeal irritation,and why do we care,

and what are wegoing to do about it, these kind of sort of things. your meninges, meningitis isa really, really bad thing, so meningitis, youknow what that is now. "itis" is an inflammationof the-- so inflammation of the balloon, right? so that's kind of great. so it can result fromall sorts of things. we really need to identifythe causative reason, so

the causative agent, if it'sa bacteria, if it's a virus, or whatever. viral things, likeherpes encephalitis, is really, really bad. people talk aboutmeningitis, but meningitis can be bacterial or viral. some cases can be treated. like herpes encephalitis,management of it, there's no real cure for that.

all the acyclovirin the universe, it's kind of like,eh, is it going to? is it not? so we really, really,really don't like it when our balloon, our meninges,so balloon around the brain, gets irritated, ok? often, you can see meningealirritation as a direct side effect several days toweeks after a patient has a sub-arachnoic hemorrhage.

so we're thinking aboutsub-arachnoic hemorrhage. now almost all of those comefrom an aneurysm bursting, so a hypotensive crisisresulting in-- you know, they pop their aneurysm. they have asub-arachnoic hemorrhage, all sorts of things. we could go onand on about that. but a traumatic sub-arachnoicis possible, ok? so you'll have somebodythat crashes, spiders

the windshield, falls outof the car, hits the tree, whatever they decide to do. and they've got multiplethings going on in their brain. they've gotbifrontal contusions. they've got a left subdural anda left traumatic sub-arachnoid. and they will always--i won't say always-- almost all the time,they will identify it as a traumatic sub-arachnoid,versus a sub-arachnoid, because it's not the resultof an aneurysm burst.

it's a result of a vesselrupture, but it's from trauma. you smack somethinghard enough, it's going to have issues, right? it takes up to 10 to12 weeks for blood to be broken downand reabsorbed, but it starts atabout 7 to 10 days. your body starts breakingdown that blood, ok? because blood clots right awayup here, just the same as it does as if you have a littlescab here on your forearm,

so as this bloodstarts breaking down, it releases enzymesthat are excruciatingly irritating to themeninges, resulting in all sorts of bad stuff. you can get vasospasm. you can get photophobia. huge hallmark. bing! i cannot tolerate anything,any light whatsoever.

and then they can alsoirritate the meninges, be one of the causativeagents of meningitis, ok? not usually to thatlevel, but it just gives the worst,worst, worst headaches. these are not drug-seekers. that is not a realdiagnosis, right? but these are not patientsthat require 100 or 150 of fentanyl everysingle hour, they're asking for it at 45 minutesbecause they are seeking out

a fun stay. they really need it, because itis that excruciatingly painful, [sighs] i'm talking a lot. so we talked about all this. i think we're comingto the end of something and getting ready tosegue way into another. nice hairdo, by the way. but you can see hisskull, his brain. all right, respiratory system.

abnormal, oh yeah, becausethe brain rules everything. so if you are havinga brain injury, you need to be very, veryaware that you will likely need-- brain or spinalcord, especially-- you will need aggressiveairway management, ok? be on top of that right away. so there can be absolutelyno airway problems, but big ventilation problems,because you cannot protect your airway, ok?

just remembering we haveall our non-invasive options and ourminimally invasives. so we have bipap. and then we haveoropharyngeal airways, nasopharyngealairways, before you have to go all theway to an et tube. rate and rhythmiccharacteristics, so inspiratory andexpiratory phases. ok, so a c4, a c3 quadriplegicpatient, fresh injury.

are they going to bebreathing in the field? ok, let's make it c4. it's a c4 injury. are they going to be breathing? not the plastic explosives. they can breathe. how will they be breathing? not well. demo for me.

you're right, it's not well. what do you think? [gasps in and out][gasps] is it like that? no, it isn't. panting? so it's going to be morelike panting, right? [pants lightly] so they canhave a decent-- and remember, they don't clampdown, so they can have a decent-- what's thatthing we put on their finger?

and we're reallyreassured by a number. it's the most useless pieceof equipment in any facility, anywhere, ever. pulse oximetry? that pulse ox, right? because it just reflectsoff of how much blood. that's purely what it is, ok? so it can be good. you've got yourcarbon monoxide or

your myastheniagravis patient who dies with a pulse ox of 99%. yes, it has its place. i'm not being like that. but making sure to pay attentionnot just to the number, but the rate and pattern. because this[pants lightly] you're not expelling allthe way either. you're not inhalingand not expelling.

some air is changing up here. but what's happening to themajority of this dead air down here? what hangs out, ifwe don't [blows out]? co2. co2, a hypercarbic patient,meaning a high co2 level. what's a normal co2 level? about 35. 35 to 45.

so hypercarbic patient, thiscan happen relatively quickly in a healthy personwho's not used to it. we're not talking aboutthe 90-year-old copder who, oh, my god, don't givethem two liters of oxygen, because they'll die. but going on with yourpainting respirations, your co2 is climbing. your co2 was 45, now it's 55. they still looknice and pink, ok?

and they still havesome circulating oxygen, so their pulse ox maybereading 94% or 95%, ok? but the hypercarbia is goingto cause what, mentally? as your carbon dioxide goes up,your mental status goes where? down, right? definitely, ok? so it definitely goes down. so trying to keep in mind thatit's not just this number, you are criticallyimportant in watching

how they are breathing. is it 25 times a minute? well, that's still kindof a normal number, right? but is a 25 pantingbreaths, or 25 real breaths? so you may need to intervene. all right, so thepatient's heart rate could indicateneurologic injury. we're really talking aboutcardiac decelerations. those are really big, scarythings, because you remember,

the head rules the heart, ok? you should payattention to tachycardia and any other kindof arrythmias. definitely. but tachycardia is goingto be present in how many trauma patients? like almost all of them, right? in how many patients? lots.

you're kind of nervous, so yourheart rate kind of goes, right? bradycardia issuspicious, definitely, in your trauma patient. what if you have an85-year-old trauma patient? there you go. it depends, because of why? you just said it. beta? they're beta blocked, right?

everybody's on it. let's give them all a statin,a beta blocker, and an aspirin. everybody gets it now. holy trinity. so moving on and knowingthat your heart rhythms-- i know, you guys alreadyknow this-- but really kind of watching them. but in spinal cord, whydo they get bradycardic? no fight or flight.

no sympathetic, ok? no innervation. so their heart rate willdrop because of that. all right, we've gothigh blood pressure. oh, this is good. this is a wonderful, wonderfultriad, the cushing's triad. i know i've got alot of fun things, but cushing's triadis my favorite triad. it beats beck's by amile and a half, ok?

cushing's triad,you've got to know it, because it's reallybad, if it's happening. and it can happen overa series of minutes or a series of hours, ok? so it is-- what are they? what are the three parameters? hypertension-- it'sright on the screen-- bradycardia. bradycardia, and?

abnormal respirations. usually, respiratorydepression, ok? so a lot of times, themost severe head injuries, we said, "gcs ofless than eight, then we have to intubate." excellent. so we are controllingtheir respiratory rate, so sometimes we lose that. but hypertension andbradycardia worsening,

especially a wideningpulse pressure. you are very close, on theprecipice, of herniation. and that's a reallybad thing, ok? so widening of pulse pressure,it can be very, very gradual. or it can be withinfive minutes. and then they're dead. and that's very bad, ok? so body temperature, wetalked about thylamic injury, and subthylamic injury,and hypothalamic injury.

so yes, thehypothalamus is really going to control ourbody temperature. just remember that youmight not realize it, because, even if it's--ok, it is july, right? so i had to wear a sweaterwhen i was riding in today. it's july. it's going to beaugust next week, ok? it's been a weird year, i know. but even in july,if you're laying

on the ground on concrete,and it's 80 degrees out, the concrete is colder than80, so you can see hypothermia as a result of that. and you might not attributeit to a brain injury, but just keep it inthe back of your mind. all right, what do we dodiagnostics for brain injuries? everyone gets a ct scan, right? has anybody delivereda patient to any area that did not have act scan available?

now that it was broken,because sometimes they do that. never? so a ct scan is really nice. it's a very quick,very good exam that can tell you a lot abouta lot of different things, but it is not any good forligaments or a cord, ok? so spinal cord injurieswill get the ct, because head and spinalcord, if you have one, you automatically willassume another is present,

until radiographicallyproven otherwise. you have somebody that comesin or that you go and get who has a spinalcord injury, you assume he has a brain problem,until the ct tells you otherwise. same thing in reverse. they had a head injury. they stay collareduntil the ct scan shows that theirc spine is clear.

we kind of don'tcare after that. but no. but every spinal cord injurywill absolutely, absolutely need an mri. and they'll need itquicker, rather than later. and the reason they needthat is because they watch the degree of swelling. they do serial exams. so like a polaroid, if youthink about it, and an hd movie.

so it used to be knee jerk. oh, we've got aspinal cord injury. bam. get the surgeon in here now. we're going to fix himtomorrow morning at 0600. sometimes now, theywill wait several days. because when you go in andcause surgical trauma-- surgery is trauma, just planned trauma--you can increase the swelling. and that, on top of the initialswelling, which usually takes

two to three days to peak,sometimes three to four days to peak, depending onthe area of the spine, they may do one, andthen another one. if it looked verytight initially, they know what'sgoing to happen. and they'll just watchthe exam, clinical exam. is your tingling higher? do you now have only, i can'ttell if it's sharp or dull, but i can feel you pokingsomething back there.

and they'll watchclinical exams. usually, you will not see asecond mri, until post-surgery. so sometimes, it'll be aweek or even a month later. and they'll go off of ct scans. and when they'relooking at the ct scans, they're not looking at thecord, because you can't. but you can see other associatedstructures and get an idea. and then those clinicalexams are so important. serial exams, it'snot captain crunch.

it's not fruit loops, ok? it's over, and over,and over again. and it's excruciatingly painful. i'm going from here to there? i have to do anexam with you here? and i have to do anexam with you here? and it's like a40-minute transport? do it, ok? really, really,really important.

if they see anythingdifferent, they may decide to, oh,he's not doing well. we're going to bump himup and do him tomorrow, instead of waitinguntil thursday. ok, other diagnostics. we might do a cerebral angio. really good. they can do so much stuff there. but really expensive.

you're paying doctors, verywell-trained doctors, and lots of them, an entire team, to doa cerebral angio, versus a tcd, super cheap. you're paying a tech to do that. and a neurologist willthen interpret the results. what are they? a cerebral angio-- so when ifirst started at froedtert-- and it's going on13 years ago now-- we had one of full-timeneuro interventional guy.

we now have six. so i've not evenbeen there 13 years, and we havequintupled-- sextupled? i don't know-- our amount. and we are one hospitalin this area, ok? remember, st. luke's isanother huge one, ok? they do just about as manythings as froedtert does. enormous. the amount and theability of things,

without fully crackingsomeone's skull-- we're not talkingabout cardiac, we're only talking aboutthe brain right now-- but the things thatthey can do now-- they can correct vascularabnormalities. they can stent. they can plastivessels in the brain. they can injectintraarterial verapamil and resolve, almost completelyresolve, someone's vasospasm

and cause them togo back to work. whereas, if you hadleft it untreated or tried to do otherthings-- like we're giving oral nimodipine-- theywould go to the group home, because their cerebral vasospasmgot so bad that they stroked out a part of theirbrain because of it. a vasospasm, justlike you can have if you're trying to put an ivin, and then they clamp down, and then you can'tget that iv in.

and then somebodyelse comes along, and they poke, andthey get it just fine. and they're like, you'redumb, and i'm great. no, that's because they werevery likely in spasm, ok? wait it out, by the way. don't always yank the catheterout and say, oh, shoot. i missed it. give it a second. and sometimes, it'llloosen up on you.

really. seriously. ok, that's enough about that. but that same thinghappens in the brain, ok? only in the brain, you're goingto constrict enough, and then cause distal hypoxia,which will be a stroke. anyway, that's withcerebral angio, they can do all kindsof stuff of that. they can do so much stuff inthe brain that we couldn't even

five years ago. and they can go up with aclot-- the merci retrieval gun, anybody heard of this yet? it's fantastic. you go up there, and itgoes [makes motor sound]. and it goes [makes suck noise]. and it sucks that clot out. sometimes they dostill put a stent. but it sucks it out.

they withdraw the catheter. and suddenly, within twohours, i'm now like, wow. i was over thetime limit for tpa, so they've consideredme a goner. but some blood was stillgetting past there, and the damage isn't bad enough. we were able to get inthere and vacuum out the clot quick enough that,now, i'm fully back to normal. maybe a little speech problem,or a little residual weakness

in one hand or whatnot, ok? oh, it's just so coolthe things they can do. but tcds, it's adoppler, just like an ultrasound of the belly,the pregnancy, you know, things like that,where you're checking for blood and allkinds of other things. but the tcd is very cheap,but it's very limited. so you can only look at certainblood vessels, the ones that are close to the surface.

so we can very easily viewtemporal, carotids, lower ones. and then you start tolose some of the vessels that you can evaluate with it. but you can tell, basedon the temporal-- they're distal by the time theyget out to surface, right? the important stuffis deeper, and then it kind of branches off. but they can tellif they're starting to have any sort of vasospasm.

and that might leadthem-- if his velocities, or how much theblood vessel is doing this is getting worseon this cheap study, then they'll take himdown right away to and do the expensive stuff, ok? eegs, everybody knowswhat an eeg is, right? nest forest of wiresthat's going on up there. and now, it's so wonderful. we have mri-compatibleeegs, so you

don't have to rip thatwhole mess off their head. go down, do the mri, come backand glue them back on again. it's awesome. you can just go down there. so this is just a funny,little, silly thing. so diffuse slowing, hasanybody ever seen or heard that diagnosis onone of your patients? perhaps, on yourself? like 90% of the populationhas diffuse slowing.

but the neurologistgets to charge for it, if he puts it in the chartand he did a read of the eeg. i almost went forwardwithout talking about the lp, the spinal tap,all that kind of good stuff. so everybody's seen,perhaps, possibly somebody's experienced an lp? it's very easy to do,very bedside, very cheap. you do need a doctor,but very quick and easy. and you can get thatgood, perfect fluid

that you can thensend down to the lab and tell all sorts of stuff. once you get csf, theycan do all kinds of stuff and tell what's going onwith you, a lot of the time. so we'll talk aboutradiology exams. can anybody seeanything wrong here? but it's not, believe it or not. yeah, something'swrong there, ok? so we're kind of likecombining a little bit.

but we've got seriouscranial defects here, ok? we're also missing some-- incidentally, that's agreat kind of patient. you can only suction them. they can't bit downon their et tube. i'm being cavalier. i didn't mean to be like that. so we'll talk about radiology,and then i have some x-rays and some cts in here.

primary brain injury, you cannotdo anything about their primary brain injury. that's what broughtyou to them, or that's what brought them to you, ok? period. it's done. what we have a hugeimpact on and what we need to take seriouslyis our direct impact on their secondaryinjury, either

to the brain or spinal cord, ok? hypoxia and hypotension are thetwo most incredibly dangerous things for any brain and spinalcord injury, that brain injury. really, really,really important, ok? we'll talk about thatwhen we get to that slide. so occur as a resultof contact injuries. you've got your acceleration,your deceleration. so your rapid slowing down. so you've got, i wasthrown off the bike.

my car hit another car. i fell off the bunk bed. and i was fine, untili hit the floor. those kind of things, right? a contact injury is going tobe a direct result of trauma to the head. sudden changes in velocity,we talked about this, right? because it's sittingin a nice bath. it's not fixed.

it moves back and forth, ok? describe for mecoup-contrecoup injury. who knows what that is? oh, you're demoing it. so coup means? it's french. it's funny. it's not coupe. it's always funny whensomebody says coupe.

and i'm really nota cultured person, if you haven't pickedthat up by now, ok? but i really likeit that can say some french words,like coup-contrecoup, blow-counterblow, ok? so it is you havea direct injury. and then the headwill move back, and you'll have an injuryto the opposite area of whatever was hit.

is it only this? it's this as well. this is more common. it's kind of funny. kind of dizzy now. but your blow, and then yourcounterblow, as the brain bounces back, ok? and then, if you are--say you're t-boned. bam!

and then you snap like this. and then your headsnaps the other way. so this is talking, really,about the rough portions of the skull. so on the outside, ifwe shaved our heads, we would see a nicesmooth surface. it might be bumpy,but it's not jagged. on the inside of yourskull, it's very jagged, especially the baseof your skull, ok?

it's like little mountaintops. [growls] little fingernails arescratching down there. so that's what it lookslike on the inside. so that's why thecoup-countrecoup can be very, verydamaging as well. but we just talkedabout what that is. contrecoup injury ison the opposite side. secondary brain injuries,so we talked about this. you can have swelling.

you can have edema,cerebral hyperemia. what is hyperemia. take the word apart, high emia. emia is blood, right? high blood? much blood, too much blood. so cerebral hyperemia, you'vegot too much blood up here. is that possible? it is possible, ok?

we all normally have intactauto-regulatory mechanisms. at the point of one devastatingbrain injury, or even a mild brain injury thateither isn't maximally treated or just kind ofprogresses over time can result in lossof auto-regulation. at that point, you have noability to clamp down anymore, to control yourcerebral blood flow. and sometimes whatcan happen is, if you're-- let's say i'mgoing to drive home from here.

and i'm getting on thefreeway, and somebody cuts in front of me. and i'm, why did youcut in front of me? [unintelligible angry voice]you know? i'm getting very angry right? my blood pressure's going up. i really don't get that bentout of shape in the car. it doesn't matter. i do at work, butnot in the car.

why don't i pass out? why don't i die? why do you think? my blood pressure goes up, ok? why doesn't the bloodpressure in my-- we're going to call itblood pressure for right now-- in my head go up? or you're yelling at your kid. eat your peas!

why doesn't yourhead blood pressure-- ok, it's your icp, yourintracranial pressure, why doesn't thatgo up to the point that you blackout and die? in a normal person? normal would be-- you have normal auto-regulatorymechanisms in place. so when the bloodpressure goes up and maybe my cerebralblood volume goes up,

so i have more blood up there,my brain is going to say, whoa, my icp is going up. i don't like myicp over xyz number for a certain amount oftime, or i will pass out. that's a malignantissue there, ok? and then your carotidswill start to clamp down. reduced blood flow up. and your jugularswill, hopefully, promote venous drainage out.

you have justaffected monro-kellie. incidentally, pronouncedmonro-"keeley." i'd never say that. that was that british residentthat i was telling you about, who was so awesome. he's like, you know, kara, itis pronounced monro-"keeley" doctrine. i said, ok. thank you, dr. beaumont.

i appreciate it. so he's a good guy,you know what i mean? incidentally, does anybodyknow what opisthotonus is? i learned how to saythis word, as well. it's such a cool word. i know. it sounds like a religion. that's funny. opisthotonus iswhen you are seizing

so hard-- so you are maximallyseizing, so much so, that only your shoulders andyour heels are touching the flat surface thatyou're laying on, so status epilepticusto the extreme. and you've all seensomebody seize. we've all seen that, right? but opisthotonus,that's another word i learned from dr. beaumont. so you can quote him on that.

it's really interesting. but i pronounced thatincorrectly as well, until he taught me. now i say correctly. let's go back over here. so we've got our goodauto-regulatory mechanisms intact. so when i get all angry,and my icp starts to go up, my brain says, i don't wantyou to pass out and die,

so let's slow down. it clamps down, doesn'tlet as much blood flow up, hopefully, improvesdrainage out. and i get a littlelight-headed, maybe, so i'm going to stopfreaking out, ok? and my icp's going tostay in a normal range. that's auto-regulation, ok? after a big bad injury,or lot of small injuries, you lose that ability, orit's impaired somewhat.

so what can happen is, withthe more serious injuries, is that when yourblood pressure goes up, you can't compensate anymore. your icp goes up,as a direct result. so you can watch as theirblood pressure goes up. a normal blood pressureof, say, 130 systolic could cause their icp to goto 40-- which is really bad-- and stay there. so then we would put them onblood pressure medication,

like nicardipine,to drop it down, so that we can keep theiricp somewhat normal, and just get them pastthat first critical three to four days of swelling, ok? so that's cerebral hyperemia. this is what i wastalking about also. the carbon dioxide retention,that's when your co2 goes up. so when you don'tbreathe effectively and don't clear co2, you havecarbon dioxide retention.

that's called hypercarbia,too much carbon dioxide in your blood. that will cause cerebralvasodilation, ok? we'll talk about how wefix that in a little bit. all right, scalp injuries. you guys have seen these. everything above theneck is very vascular, so they get a lot of attention,because they bleed a whole lot. and people freak out, right?

but they're easily fixed, right? pretty much. maybe. you've got yourcontusions, remembering that if you have thebig goose egg there, the contusions, whatyou have on the outside can be present onthe inside as well. you can bruise the outside, justlike you can bruise your brain. ok, so we'll talk a littlebit about skull fractures.

these are the nice picturesof the different types. this is a really,really bad one. that's a really bad one. this one's kind ofbad, kind of depending. you've got hemo on tympanum. that's kind of cool, right? but this one isreally, really bad. and we'll talkabout each of them. all right, linearskull fractures.

are these common? do they happen? what do we do for them? absolutely nothing. we give them, maybe, sometylenol 3 or some percocets or something likethat, send them home, and have somebody hangout with them, right? and tell them to come back,if they need anything, ok? so that's pretty much it.

there's nothingyou can do for it. sometimes they're anincidental finding. it means, oh, let'slook at this brain. oh yeah, by the way, he'sgot a couple of linear skull fractures over hissagittal region, or i mean, parietal region. ok, here's a nice picture of it. depressed skull fractures,what do we do for these? are they sad?

do we leave them alone? do we give them some zoloft? they're depressed. ok, finally. [laughs]what do we do for them? so looking at whatit is-- and let me show you a picture-- whatdo we need to do for that? depressed means--he might be sad, i don't know-- but for sure,his skull is depressed, because it's below thesurface of the skull.

so each and every one ofthese, how small or how big, has to go to surgery. they typically dovery, very well, ok? but why do they haveto go to surgery? bone on the brain? so bone breaks nice andsmooth and soft, right? it's jagged. it's got to be difficult. it's got to be temperamental.

and it will shred theballoon, the dura, resulting in a csf leak. is that a good or a bad thing? that's a horrible thing,because what do you really get a super, sky high risk for? infection. meningitis. bad, bad, bad stuff, right? so csf is really high in what?

sugar. really high in sugar. whatever your blood glucoseis, csf has a sugar count. it's a measurablesugar count, ok? so it's really, reallyvery attracted-- bacteria are veryattracted to csf. so they will go on in andeat up all the good stuff and give you a raginginfection in your brain. and that's really,really bad stuff, ok?

so you're also causing damageto the parenchyma, or tissue, of the brain, right? so you've got damage here. so they have to go in,they lift the pieces out. sometimes, they put alittle plastic piece there. or sometimes, they can putthe bone itself back in. pin and screw it. they don't rod your skull, ok? it's not long enough for that.

but sometimes, they puthardware-- not usually. they'll come up withsomething else, ok? or they have niceglues nowadays, ok? and they'll stay in thehospital for a couple of days. and then they'll go home, ok? so clinically, soyou can see this one, he's got a bit ofa goose egg, right? so he's got some bloodaccumulating under there. so when you'rechecking your head

to toe and all thatkind of goodness, and you're checking dcap-btlsand all this wonderful kind of sort of stuff, andyou start at the head, and you go down to thefeet, we start at the head, and we're like,ooh, that's squishy. what do you do? don't push too hard. but what do people actually do? can you come for--what did i just feel?

do you feel that? yeah? and then you get to theed, and they feel it. and the nurse says,uh, dr. jones? come over here. and he feels it. and then he gets his senior. and then he gets his chief. and then, finally, theycall the neurosurgeon in.

meantime, we're all doing this. so what's going onunderneath that? yep, bad stuff. so if you feel a truly mushypart, if you feel crepitus up here, there should neverbe crepitus up there, ok? never. don't touch any more. err on the side of caution. don't block them in extratight, because now you're

really increasing things there. be careful. and tell them that. be very sure to tell them that. and tell them don'ttouch it either. oops. wait. let's go back here. so we talked about this.

the skull is depressed. it's not sad. that means it's below the level. and then the dura mayor may not be torn. oftentimes, is. not always, but oftentimes is. and it depends. you can have soft tissueswelling, like the picture i showed you hasthe goose egg there,

and bony step-offs orcrepitus deformities. these are all bad things. open or closed isself-explanatory, right? if it's open, it's muchworse than if it's closed. so a comminuted,this is just like any other comminuted fracture. phew! it went all over. there's multiple.

this one is, really,not too bad, whatever. but big fragments, not liketons of tiny little fragments. ok, basilar skullfractures, all right? so this is thebase of the skull. so this is thebottom of the skull. and it should bea nice round ring, just like your pelvic ring, ok? i put a picture in here as well. so this is not a good problem.

can you see wherethe issues are? is it there? everywhere. everywhere, kind of? particularly, righthere and right here. it should be a close ring. so we've got a problemthere and there. i know we don't needto read cts in our job. i don't need to, but i like it.

so i like whendoctors tell me things that i can understand, say, oh. so if you don't want, you don'thave to pay attention to this. but it should not belooking like that, ok? so this is huge, hugerisk for a dural tear. i've yet to ever see a basilarskull fracture that did not have an associateddural tear and csf leak. why would you be moresusceptible at the bottom of your skull oftearing that balloon,

than if i got a depressedskull fracture up here? gravity. pushing it down, more weight,more sloshing, more movement, that kind of sort of stuff, ok? so you're going to bereally suspicious [sniffs] of a [sniffs] [sniffs] [sniffs]. sniffing? ah, you know it. so otorrhea, rhinorrhea, right?

people get reallysuspicious of otorrhea, because we shouldn't have fluidcoming out of our ears, right? but in january, you walk intoany emergency department, and there's just as manystaff going [sniffs] as there are patients, right? it's january. we all have coldsand we're grossed out and stuff like that. if history, mechanismis telling you

this might be, any questionthat it might be a csf leak, what do you think you could do? can you do somethingin your rig? the halo. halo. the halo test. love it. so the halo test is perfect. so you put a drop of thatfluid on something white, linen

is better, not the pillowcasewith all the flowers and junk, but a plain white pillowcase. but a two by two will do, ok? something that's absorbent. and after it dries-- it driespretty quickly-- then you see that golden halo, right? so it does show up. sometimes, it's very faint. what do you do with that,once it dries and you see it?

i was right. throw it away? save it for the neurosurgeon. he's going to want to see it. we want to mess with thatas little as possible. if you can't tell-- becausesometimes it's very faint, and you're not sure, and itlooks like snot coming out, but it doesn't makesense, it's july, why would they have a runnynose-- what else can you do?

bedside test. point-of-care test. does require a littlebit of a machine. a blood sugar. why a blood sugar? snot does not have ameasurable glucose, csf does. that makes me happy. a light bulb went off. ok, maybe if i only do thatonce, then that makes me happy.

it affects all the rest of theblathering i've been doing. and then tell them. tell them, and thenthey'll know too. so again, that parietalregion, ok remember-- oh yeah, when they have abasilar skull fracture, what do they always get that youalmost never see in the field, because there's nottime for it to happen? raccoon-- raccoon eyes!

means the periorbital ecchymosisand the-- what did you say? battle sign, mastoidecchymosis, yes. but you never see thatright away, do you? so it's like hard to do the samejob with less resources, right? so that's why you're the bomb. oh, and i answered this earlier. i didn't mean to. but what else isvery, very common when your hit upside the head?

when you hit alongside the head,so it's usually a blunt trauma. the ear trauma. i was talking about it earlier,a specific type of bleed. so mechanism-wise, you'regoing to be watching when you have parietal,or even temporal. it's a bleed within the brain. it's a epi? epidural. epidural bleed.

because of that middle meningealartery, 93% of epidurals come from a hit here, ok? so almost alwaysa traumatic event. facial fractures, people thatusually have facial fractures, oftentimes, will havebrain injuries as well, ok? you can punch somebodyaround the face, the nose, the whatever, butit's really hard to break a bone uphere anywhere, i mean, really, anywhere, if you'renot 85 and osteoporotic and

whatnot. but it really is kind of hard,so watch for other injuries. if you have anysuspicion-- possibly, if they have oneblack eye, not two-- but if you have any suspicionthat they might have any injuries here-- i just hitmy own nose-- that might also lead a basilar skull fracture,what are you never going to do? don't put anything longer than anasal cannula in that nose, ok? and i don't thinki included it here,

but i have a fantastic,blessedly old, x-ray of a skull with a-- i haveit, actually, on my thing. i can show youafter, if you want-- of a ng coiled up in the brain. bad. you not want to bethe person doing that. upper right? so it's actually like thepatient's left, right? so that's it.

so what do they dofor a contusion? depending. if it's a big one, they'llgo in with an ice cream scoop and scoop it out. if it's a little one,they'll wait a little while. and the terminologyfor contusion is they watch it blossom. it's a very pretty wordfor a very ugly thing, because there's swellingassociated, right?

if it's small enough,then the patient is, maybe, going to be ok andcan deal with the other stuff. but they'll just goin with the ice cream scoop, if they needto, and get rid of it. and there goes your secondand third grade memories. and then-- you know, i'mjust joking about that, ok? and then the skull closes backup, and they can do just fine. they could do just fine. where is this in the brain?

so what is this patientgoing to be clinically? inappropriate. for a while, he's goingto be inappropriate. he's going to have no judgment. he's going to betotally disinhibited and, often, hypersexual. not like trying to be. you can't hold himresponsible for that stuff. they're very difficultpatients to care for.

lacerations thatpenetrate the skull can cause tearing tothe actual surface, the parenchyma, corticalsurface of the brain. we talked about epiduralhematomas kind of a good bit. it's the epidural hematoma,epi-dural, where is it? above the dura. so it's outside the balloon,inside the brain, right? it's between thedura and the skull. is that a venous oran arterial bleed?

arterial, ok? these are very, very seriousthings, if they're big. very serious, becauseyou will either die, or you will be just fine. the only thing youneed is a neurosurgeon, so they can go and fix you. and then you're fine,and you go home. i have some pictures here. so epidural, do yousee how pretty it is?

so we've got ouch. you know, that's skull. that's blood. that's bad stuff. but do you see how it'svery clearly defined? because it's outsidethe balloon, ok? so this is actuallya further back, ok? they usually windup being like here. so this would have beena little further down.

very likely, the middlemeningeal artery. not right smack in themeaty middle of it, right? so the classic presentationyou, as ems are going to be the number one people thatcould save somebody's-- i know it's every day you could savesomebody's life and junk. but seriously, the epiduralhematoma, classic presentation. an initial lossof consciousness, followed by a brieflucid period, and then a rapid neurological decline.

those are big,fancy, stupid words. i crashed my bike. i call 911. by the time youget there, i'm out. what's going on? this is an arterial bleed. so you have anopening in the vessel, causing a big, huge,sudden jump in icp. so my brain says, whoa,let's turn the lights out

for a little bit. my icp went up too high. i lost consciousness. and then, gradually, thepressure of the brain kind of tamponades off thatbleeder, if possible. not all of thempresent like this, ok? but this pressure willovercome this pressure. and it'll hold on for aminute, thereby stabilizing. and auto-regulation'sstill sort of intact,

so it'll sort ofstabilize your icp. and then you cancome to again, right? but it's an arterial tear. it's under a lot of pressure,or a little pressure? lot of pressure, so eventuallyit's going to overcome. and then you go down again, ok? and a lucid periodor a with-it period does not mean you're alertand oriented times 4. it means you're awake.

but not everybodyregains consciousness. again, it depends onhow big the initial tear is, how big theinitial bleed is. and again, small ones, they'llmedically manage, watch them. they'll watch them inthe hospital, though. and then they may go home. big ones go to the or. and usually, they're homebefore the small ones are, because they can justfix it right away.

but it's not worthopening someone's brain. you don't want to do thatever, if you don't have to, ok? brain stem herniation, wetalked about that a little bit. expanding brain herniation isthings are getting squished. and most commonly-- well,there's two different-- we're not even goingto talk about that. but the brain gets squeezedenough that, sometimes, it pushes down through thebig hole, and pushes down, and then you have no bloodflow to the brain, ok?

so it goes down through towhere the spinal cord is. we're just going toleave it at that. that's bad, ok? you are brain dead. contrary to whatthe news tells you, you are dead whenyou are brain dead. you're not, oh, i'm brain dead. and now he's back at work. those crummy doctors.

no, that's not it. you do not ever, ever, evercome back from brain dead. everybody knows that? okey doke. subdural hematoma results froman injury that is subdural. where is it? below the dura. so subdural, below the dura. so it's between the duraand the brain, the balloon

and the brain, theballoon and the brain. here's your subdural. do you see howdifferent it looks? it's infiltratingthe brain tissue. it's not pretty. it's not neat. none of it's pretty, right? but it's infiltratingthe brain tissue, ok? it's bad.

it looks kind of really bad, ok? incidentally, let'sgo back to right here. what is this? that's your lateral ventricle. where's the other one? you should have one or two? it's shifted. how do you know it's shifted? you can kind of seethe outline of it.

a little bit right there, right? incidentally, atthis level, you can tell by how much isshowing how high up. these both shouldbe much bigger, ok? but you can watch themidline of the brain, ok? and on ct scans, theyalways draw a little line. and sometimes, they make alittle arrow or something. i couldn't get it to comein on this one either. but here's your ventricle.

this is pushingall this over, ok? if we look at thesubdural, so we're a little off of rightsmack in the middle, looking where everything is. but can you see, a littlebit, the back horn of one, ok? and we've got anotherone that should be, but again, it's pushingthings over, ok? did we talk about-- yep, we did. a concussion isa diffuse injury.

remember, a concussion isa diagnosis of exclusion. there's nothingelse wrong with you. we can't prove itradiologically-- i keep standing right inthe middle of you there. but it's, again, theclassic definition. it can or cannot includea loss of consciousness. but oftentimes, it's aloss of consciousness. and then, when youregain consciousness, it is with, usually,no more than two

focal neurologic deficits. so what does that mean? having speechproblems or, i've got a little numbness in my lefthand, i'm having double vision. and again, youcannot prove this. history makes it make sense. either i was or i wasn'thaving a loss of consciousness. but now, i'm havingtroubles doing simple math. or if i'm a fifth-grader,i've got a bad headache.

so it's a concussion. you can't do anything forthem, except supportive care. and they get over it eventually. anybody had a concussion? usually, a lot morethan two people. so three. and they're additiveas well, right? they're additive as well, right? thank goodness.

the nfl, everybody'swatching all that business. so too many, and you'redone for the amount of time. and then you'redone for the year. and all those lawsuits going on. my goodness. any loss ofconsciousness, remember, that does not alwayshave to happen. amnesia, this can be eventamnesia, retrograde amnesia. it's not, i forgotwhat my name is,

and i don't knowwhere i go to school. it's not that kind of amnesia. it's more relatedaround the event. any alteration in mental statusat the time of the injury, we talk about, yep, thesefocal neurologic deficits when you're not unconsciousfor longer than 30 minutes. so i have to tell youa loss of consciousness for more than 30 minutes,you are really bad off, ok? you are not going to behaving just a concussion.

you're out for 30 minutes? you either did some drugs,that's like a totally reason, that doesn't have anythingto do with the brain itself. but more than fiveminutes, the neurosurgeon gets very concerned, truly outfor more than five minutes. and then they may havethe gcs score of 13 to 15. so i will briefly talk aboutthis post-concussive syndrome. i just wanted to mention this. because you get called tothe home of george smith,

and he's 24 years old. i've got this splittingheadache, man. i couldn't even drivemyself to the ed. and it hurts so bad. and last time i went in there,they gave me this stuff. it started with a d. andthey put it in my iv. and it really helped. and i need it. can you give me some of that?

drug-seeking. oh, yes, you are. however, you are good,good health care provider. you are a good person. and you do a full history. and you find out that hewas in a bad car crash six weeks ago, two monthsago, six to eight weeks ago. post-concussive syndrome isa true, real diagnosis, ok? and it's totally non-specific,so check history.

have him go to the edand get his dilaudid that he wants, or hismorphine and his iv benadryl that he wants. not the pill form, but allthat kind of good stuff. but no, absolutelydon't dismiss them. it really is truly,absolutely like real, ok? so honestly. and it can persistfor up to six months. remember, the moreoften you have them.

who has them all the time? athletes. young, healthy males,possibly over, and over, and over again, ok? so they're notjust drug-seeking. we talked about daia lot back then. i couldn't get thatdoggone animation to work. i'm really mad about it. occurs over a wide area.

there's absolutely nothingthat they can do for these. most common inrapid deceleration. fell off the motorcycle. was in the crash. had a seat belt on,but still my head snapped forward, thosekind of sort of things. these statistics areslightly out of date. all the time, butalmost all the time, the dai is associated withanother bleed, most frequently

a subdural, traumaticsubdural, ok? so dai is never a diagnosis,ever, that is made in the ed or in the field, ever, becauseit needs an mri to diagnose. it does not show up on ct. you have to have an mri. and so, usually suspiciouslater on, they're like, well, his brain has healed,his subdural's healed. he won't wake up. we can't wean him from the vent.

let's go down do and an mri. ooh. he's got severe dai. so we will supportivelycare for him. he will get a trach,and a peg, and go off and live for a long time. all this heals. wear your helmets, if you'redoing anything at all, ok? so physiology of icp, wetalked about this a little bit.

so zero is-- it's reallynot like your cvp is supposed to be 0 to 2. nobody has a cvp at 0. nobody has an icp of 0. but it's possible, so usuallyless than 15, less than 20. does your icp evergo up above 20? does it go above 25? does it go above 30? not unusually, ok?

really, not usually. so when does it go up? when i was talking like,hey, eat your peas, or why'd you cut me off, youlittle razza frazzit, you know, all that kind of sort of stuff. we compensate. we will do other thingsto reduce our icp. and eventually,you'll either pass out and stop whateveryou were doing.

or you won't, and you'll havethis big, bad brain injury. so no. but we talked about csf. around the clock, you produceapproximately 20 to 22 cc's of csf an hour,continuously, forever. we have drugs that cantry to reduce the amount, if you need to. if you have something called,normal pressure hydrocephalus-- which i was very happyto see was actually

in here-- but either way, csf,if you are having malignant icp issues, we might temporarilydo what i was talking about, put a straw, an evd. so that's just a strawthat externalizes. and we will do the absorbing,until the blood resolves, or all the swelling resolves. and eventually, wewill cap that off. and they put a couple ofstitches in your scalp, and you're justfine and dandy, ok?

obstruction to venous outflow. so way back wheni was showing you that picture of the skullwith the blood vessels that were coming,so venous outflow occurs primarily with those ijs. so that's why the brain doctors,neurology or neurosurgeon, does not like to clogup those jugulars. so try hard not to, ifyou have any suspicion. you know, ej's alittle bit different.

but even there, wereally shouldn't do that. as the icp increases,the venous pressure will increase a little bit-- iput this little comment here-- if auto-regulationis intact, ok? so this is to a certainextent possible, to a certain extentnot possible, ok? if you have a person with areally devastating closed head injury, their icp is goingto go up to 20, 30, 40. you can't, at a certainpoint, get your blood pressure

high enough. you can't get your cerebralblood volume high enough. eventually, that'swhen you start to have cerebral death, ok? and eventually, you can havefull-on herniation, all right? so it's kind of like a spectrum. so increase in icp can resultfrom changes in the csf if they're making too much csf,or if they're not reabsorbing at the same ratethey used to be,

or if they're not--i don't know what i was going to say with that. but edema related toa lesion, a bleed, anything, any expandingmasses or lesions that are in there,changes in vessel size, this all kind of makes sense. if you alter onepart, you're going to see changes in mentalstatus, up until death, ok? that's monro-kellie.

cerebral blood flow,we talked about that. the brain uses a whole lotof blood and blood flow. cerebral blood flow, cbf,remains usually constant between 60 and 150. it's a very wide variance. you're not caring about the cbf. what you're caring about is thecpp, which we'll talk about. cpp stands for cerebralperfusion pressure. incidentally,cardiologists will tell you

it's coronaryperfusion pressure. totally different formula, ok? we're talking about the brain. it's your map minus your icp. a normal map-- where areyou happy with a map? map of 60, i'mvery happy, right? map of 60. and a normal icp, i said was? 15?

let's make it real easy, andwe're going to say it's 10. my icp is 10. my map is 60. what's my cpp? 50. so is that a good cpp? no, that's a bad, bad,really bad cpp, ok? but that's normal. so why aren't i dead?

multiple studies have shownthat a cpp of less than 50 millimeters mercuryfor five minutes results in a 50%greater mortality, ok? five minutes is nothing. i know it takes foreverin a class like this, but it's really, really nothing. so why aren't we all dead? because we have a wonderfulthing called auto-regulation. so we will auto-regulate.

we will clamp downon blood going in. we will open up, hopefully,and help blood go down. and then we will justturn the lights out, so that you are reducing theamount of demand on your brain, and you go night night. then you don't have to yellat the guy in front of you in traffic and whatnot. remembering these mechanisms areoften lost after head trauma. 50 and 70, so thebare minimum is 60.

much literature inthe last 10 years really points togreater than 70. so if a cpp of greaterthan 70 is good, is a cpp of greaterthan 90 even better? so more is notalways better, ok? so it's not that much betterbecause that's hyperemia. that's too much blood up there. there's not enough room, so youdon't want a super high blood pressure.

a map of 60 is good. a map of 110, ugh, that'skind of not good, right? so really, ideally,between 60 and 70. between 60 and 80 is kind of ok. greater than 70 is reallywhere the literature is pointing nowadays. we talked about this earlier. hypotension is really bad, badmorbidity, bad for mortality. hypotension.

hypoxia. truly devastating. and they don'thappen in your rig. they're devastating waylater on down the line when that person goes either home orto a skilled nursing facility. so any changecausing an increase in the volume in the skullwill cause an increase in icp, unless there is acorresponding change in another volume in the skull.

so what's that doctrine? something kellie. it's monro-kellie. yeah, very important. you have three thingsthat exist in here. you have brain. what do you thinkanother one is? blood. csf, ok?

brain, blood and csf. so if you have too much blood upthere, something's got to give. otherwise, you're goingto have the lights go out. if you have too much csf,that's hydrocephalus. something's got to give,otherwise the lights go out. can you ever get more brains? i wish. but no, i can't. but so what arethey talking about?

like if you have an increasein brain volume, what does that mean? swelling, right, becauseof a lesion, or a bleed, or something else like that. so increased icp, thetext book definition would be sustainedelevation above 20, ok? sustained elevationis the key word there. compensatory mechanisms, whatdoes our body automatically do? it shunts csf down, down,away, out of the brain.

and it will increasehow fast we reabsorb it. all these things are automatic. this is a slow process. it's going to have happenover days, hours to days. so this is not goingto be a quick fix. the quick fix is your bodyturning the lights out, drastically reducingblood volume up there. and then you go unconscious. or getting a neurosurgeon todrill a hole in your head,

and then you have a nice strawto suck all the extra csf out. cushing's triad, wetalked about that a lot, but it was in here again. so remember, it'shypertension, bradycardia, and often respiratorydepression. but a lot of times, you'll don'tsee respiratory depression, because with a badbrain injury, why don't we seerespiratory depression? because they're tubed.

and we're controllingtheir airway, so we lose that criteria. so watch for thatwidening pulse pressure. and the blood pressuregoes up, and the heart rate goes down, ok? herniation, we didtalk about this. a portion of the braincan be displaced here, there, or anywhere, rememberingthat your numbers don't always go up.

if you have a brainstem issue, and you have swelling in the brainstem, you can have a normal icp and have the brain herniatedownward and become brain dead with a normal icp,until you're brain dead. and then it becomes zero. i'm not going to go heavyinto uncal herniation, verses herniation downward outof the foramen magnum. it's just brain herniationis what brain herniation is, either above orbelow the tentorium.

another type-- wetalked about that. ok, so here's a nice picture. it's a good picture. can you see there? what have we got? this is good stuff, right? this is why do what we do. where do you see the open skull? put my finger up, or down?

to the left. left. that's bad, right? so that looks like morethan just scalp to me. that looks like skull as well. is that all we got going on? a burn? yeah, he's got somestuff going on here, and some dirt and some stuff.

we want to wipe that off, right? that's gross. that's snot. could be a motorcycleaccident with no helmet. now, that's brains. have you ever seen brains? brains are extremelyunimpressive. they look like overcookedpasta, they really do. so do you want to wipe that off?

oh, my god. don't touch it, ok? don't touch it. don't wipe it away. more will take its place, ok? let the neurosurgeon comeand wipe it away, ok? your brain is undera lot of pressure. what happens when weopen the cranial vault? [makes whooshing sound] it wantsto expand out like that chip

can. and all the snakes kind ofcome flying out of it, right? like that funny party joke,that's what happens, ok? do not disturb it at all, ok? you would not blockthis gentleman. you would drug him, ifhe's not already out. you would not putanything in his head, if you can help it, ok? or make it very loose.

i know, protocolsand whatnot, ok? but we would put a sterile,dry something over that, and then leave italone completely. we are not going to try towash that, make it pretty, nothing, untilthe neurosurgeon-- he is going where? to the or, if he makes it. what is the question up on top? what's the answer?

it's actually low. so your patientswith facial fractures often don't have icp problems. [makes funny noise] ok? so it can be a goodand a bad thing. so he's not at riskfor a super high icp. he'll probably wind up with abolt, at least, if not an evd. but what is he reallyat high risk for? we definitely have csf leakage.

we definitely have allkinds of bad stuff there. ok, so that's obviously anindication for an icp monitor, if he makes it,he's going to get a bolt, which literallyis a big giant screw. they sit there and drillat the head of the bed. have you seen themput one of these in? they sit there with a handdrill and drill into the skull. and i've seen it shootback and hit the ceiling, they can be undersuch high pressure.

but they are maximally garbed. it splashes on their goggles. then you have to give thema new mask and whatnot. but you can really,really, really drastically, very drastically,improve someone's exam by putting in an evd as a straw. the bolt is just to monitor. so the straw, orthe ventriculostomy, or external ventricular drain--those all mean the same thing--

those go into that ventriclewe were talking about. it's a straw. the bolt which-- ithink they're-- no, he didn't have one. i think i have a picturelater on of a bolt. that is literally a bigfiber optic catheter put through ascrew in the brain. and it sits in theparenchyma, the tissue. it does not go into any fluid.

it does not do anything. it just watches, ok? it's like an ekg monitor. it just watches. it doesn't do anything atall, versus your defibrillator is going to do something. ok, so a positive ct isanother reason to icp monitor. is that a happy thing? is that a smileyface, a positive ct?

positive cts are bad. we want negative cts. we want negative forbleed, negative for lesion, negative for everything. any of these reasons,we might put more in. we might put in abolt or an evd, ok? shift, shift, shift, big time. so how do we do it? noninvasive is watching exams.

so i put this here, like,the cereal or serial? so no, it's notcaptain crunch, right? it's over, and over, and over,and over, and over, again. invasive methods, that's goingto be your bolt or your evd. so your ivc,intraventricular cannula, it's more frequently calleda ventriculostomy or an evd. and that's your bolt. and you're boltingthe parenchyma. really, it's a screw.

it looks like what youwould have in your toolbox. obviously, infectioncan be a problem. you can have a bleed, ifsomebody puts it in wrong. air leakage, so apneumocephaly is a bad thing. how do you fix a pneumocephaly? any idea? so that's air in the brain. nope, because youcan't, sometimes. most times you can't,because they're still sick.

so this therapy that we do iskind of like inhaled albuterol for treating a high potassium. it's to apply high flow oxygen. and that graduallyhelps it reabsorb. the short realanswer is nothing. you have to let itresolve over time. so what does it do? it's very commonafter surgeries, especially emergent surgeries.

not so common in evdand bolt placement. i've actually never seen that. but after surgery, theyget these sometimes, especially if they've removeda space-occupying lesion. and before it fillsup with fluid, you can get some airin there and whatnot. but you just wait. and they haveexcruciating headaches. it's really, reallybad headaches.

but we would do maximal highflow oxygen for two hours, off for two hours,on for two hours, off for two hoursaround the clock. what's anothercomplication here? overdrainage of csf. so this is always our fault. we drain too muchcsf from them, ok? either we suctionedthem so we caused them to cough likecrazy, and forgot

to clamp the catheterbefore we did that. so they go [coughs loudly]. and the csf is shooting out oftheir head into the catheter. or we place theburetrol too low. or we weren'twatching it carefully, and we raised theirhead without raising the level of the buretrol. so over-drainage isalways our fault, ok? soon as i say always,something else

is going to come up that is not. but really, it'salways our fault. if the catheteroccludes, obviously. if you're doingan inappropriate-- i don't know, really, what theymean by inappropriate therapy. so complicationof icp monitoring, all i can think of inappropriatedrug coverage, because they do need to be on aprophylactic antibiotic. they don't need vancomycin, butthey need, like, some zosyn,

not zosyn. ancef, not zosyn. that's pneumonia. problems, so it can benefit,so it's good and bad. you can put in anelective evd, to see if someone's normal pressurehydrocephalus gets better. and then they'll be acandidate for a shunt. and then they'll go offand live their lives, ok? and that's good.

so you see somebodywith a gate like this. did you ever see this,walking in the mall? you ever see that? what is that? they need a shunt. they have normal pressurehydrocephalus, or parkinson's. so watch that. you can watch for thatin your family members and get them to a neurologistright away for a diagnosis, ok?

so what else? this big sad face. problems, we can providean additional assessment when we're suspectingbrain death. so if someone's braindead, again, there's multiple other thingsnowadays that we can do. we do not put in an evdfor diagnostic criteria. however, a lot of times,they already have one in. so when you have a flat icpwaveform and a reading of zero,

sorry. it's like a flat ekg. that's true. you know, it's like aflat art line that's true. if you have an icp of120-- which i've seen-- and it's also flat,that's just as bad, ok? cost, risk of infection,and hemorrhage, those are all bad things. here we go.

here's a picture of a nice,sick patient with a bolt. and this is a horrible dressing. never use this typeof dressing, ever. it should never look like this. this is terrible. huge risk ofinfection right here. this is not evenclose to sterile. that's paper tape. it's covering everything.

oh, my goodness. you can't assess the site. so here's a picture of whatnot to do, dressing-wise. but that's exactlywhat it looks like. and this is terrible placement. this is kind of a pictureof what not to do, but it was all i could find. but looping it around. and it weighs, like, a pound.

this is a long catheterthat plugs into itself. this is a fiber optic catheter. it does not drain anything. you have to clip it totheir cervical collar. you have to clip it onsomething that's going-- or if they're wearingan etat or an-- oh, my god-- comfit-- sorry--you've got the comfit on, clip it to that. if you're transportingthem, they'll

have some sort--you have a bolt in, you absolutelyhave an et tube in, so you'll have somethingto secure it to. but what happens isyou turn them over, that thing slides off. and then the fiber opticcatheter is now out. the bolt will stay there, butthat catheter will go whoops, and it's out. so that's really bad.

there are three slides onhere on the skill drill. so there are 1,000different models of this. i'm not going over these slides,because this may or may not be what you have to work with. at froedtert we use one. at community memorial, whichis a froedtert hospital, we use a different one. at aurora, we getpatients in from aurora, and they have different ones in.

and i've seen a fourthtype at the wheaton system, as well, when i'vedone stuff over there. so don't worry aboutthe specific things. the most important thing is toremember you need to zero this, just like an arterialinvasive line. and make sure you haveyour waveform correct. ok, aseptic technique isbeyond critically important. never touch this thing. don't mess with it.

don't ever change the bag,ever, ever, ever, in transit. we wait to change the bag untilthe last possible minute, when it's over 2/3 full, at 3/4full, because we can never be as clean as we need to be. you just reallyneed to be careful. and you are absolutely going tobe inducing bacteria directly into their brain andalmost giving them a death sentence, sostrict aseptic technique. this is not one of thosetimes where we're just like,

oh, i'll just hurry upand slap it on and not worry about letting it dry. leave it alone. but if you have tomess with it, it needs to be strict aseptic, ok? leveling and zero,we talked about. no hyperextension or flexion. no rotation of the neck. when you have abad icp issue, you

want to promote venous drainage. neutral head alignmentis where it's at, ok? raise their head, ifyou can bend them. if they're on spinalprecautions, every bed, every cart now-- i know, youguys, it doesn't in the rig. but try to, as much as possible,get them-- tilt the board that they're on then,with some towels or blankets underneath it. and gravity helps a huge amount.

does the collar need tobe strangulating them? you're obstructingvenous outflow. if they're out of it,loosen the collar. don't take it off. i'm not saying that. we can't clear them. but loosen it a little bit, ok? promote venous drainageany way that you can. no trendelenburg.

trendelenburg, honestly,is gone out a vogue. it goes in and out ofvogue every five minutes. so no, we're not goingto do that, right? all right, precautionsfor the icp monitoring. high icp alarm, hm. this is an important one,avoid getting the filter wet. so that fancy pants--they don't have a good shot in hereof the buretrol. here's where itkind of sort of is.

this is the measuring zero line. but in all thechambers, they have a store-- it'scalled a buretrol. its a long storage chamber. if you laid that flat, there'sa little filter on top. i don't know whythey haven't come up with something to fix this. but if it getswet, it is useless. and it will not drainthrough anymore.

i'm not a mechanical person. i don't know why that is. but then the wholesystem has to be changed. so is that good? no, that's really bad, ok? that's not a bag change,that's the whole evd system. you have to change it at theconnection point at the brain. that's really bad, ok? big chance of bacteria.

so you want to open thatsystem, like, never, ok? only a little bitof csf at one time. so if you're going to suctionthem, if they're coughing, clamp the drain, so that theycan't spurt out a ton of csf. first-line management,we talk about making patient comfortable. effective handling of theabcs of trauma management is total common sense. you guys know all of that.

second-linemanagement, we're going to induce cerebralvasoconstriciton. we have to be very, very,very, very careful, ok? so very briefly, themannitol discussion. administration of an osmoticdiuretic, that's mannitol. anybody ever given it? how do we give mannitol? and it comes in bottlesof 50 milliliters. that's 12 and 1/2 grams.

that's like standardeverywhere, right? so are you going to givesomebody 50 milliliters? they're really crumpingdown in front of you? you might give four, six,eight bottles of that. i mean, you've got tofollow doctor's orders i received a patientlike three weeks ago from an outside hospitalwho had a mannitol drip. we do not. this is not mannitol drips.

that's way out of vogue. never drip it. if you're going togive it, they need it, and you should have theimprint of the syringe on the heel of your handfrom pushing so hard. how does it work? you're giving itbecause, very likely, you've now got a fixedand blown pupil, right? so you've got pressure onthe optic nerve up there, ok?

let's give them 50 of mannitol. let's give them fourbottles of mannitol. what is an osmotic diuretic? it's a big, fatmolecule that we're introducing into thevessel, the vascular space. and water follows what gradient? uphill or downhill? downhill. water flows downhill, right?

so we have now madethe vascular space-- we've put this huge, giganticmolecule into the vascular space. and there's highpressure up here, and low pressure in the blood. so the water wantsto go from the brain tissue, the free water,the extra water that's around there, and itgoes out of the tissue into-- i'm [makes whoosh noise]bringing this down

to a level that's easy totalk, you know what i mean? anybody got their phdin pharmacokinetics yet? because i'm takingsome liberties here. and i know i'mtaking them, but i'm doing it on purpose,as my disclaimer. and then all that free watergoes into the vascular space. and then what? it goes through thekidneys, and then it-- pee it out?

you pee it out, right? it's an osmotic diuretic. it's fantastic, ok? so it will draw thatwater out of the brain into the vasculature. and then you will pee it out. so now you haveaffected monro-kellie. you have reduced the amountof brain, kind of, sort of, in there.

so your icp goes down. so what happens, you givethem four bottles of mannitol, they're going to pee outtwo, three, four, five, six, liters of fluid, ok? it's going to work,if you get it, and the body's ableto respond to it. so what happens toyour blood pressure when you pee outa gallon of fluid? so what do you do fora low blood pressure?

so does the fluid stop here? so what happens to your icp? so what might youhave to give again? mannitol. and what happens to the fluid? so yes, we do that inmedicine sometimes. but you really wantto keep that icp down. so don't be afraidto slam mannitol. incidentally, if you have anice ij introducer up here

and a 14 gauge inthe ac, where do you want to give the mannitol? why do you want to give acentral rather than peripheral, if it's a good peripheral, ok? why do you want to give mannitolperipherally, rather than centrally? because the cathetersize is this small. that's a lot of volume, andyou'll get it to them faster. so if someone's dead,obviously, you're

not pushing mannitol anyway. so bear with me on thetrain that i'm going here. but it's a lot easier pushmannitol through a peripheral. never through a pic line. if that's all you've got,you've got to use it. or a central line,if you have to. but if you havethe choice, if you have a good peripheraland a subclavian or an ij, you don't want to bedisturbing this, right?

if you've got headstuff going on either. so ok, sorry. hyperventilation,briefly to talk about. hyperventilation will work,but it is absolutely dangerous. hyperventilation is something,when i started in the ni in 2002, we usedto hyperventilate as a first-line therapy. that was only 12years ago, right? so we would hyperventilate.

initially, when youhave icp going up, you bag them really fast. why do we do that? what's the patho there? why do we bag them very fast? let's go and kindof run through it. so when i hyperventilate,what's happening to a number on my abg? something's happenedto my carbon dioxide.

so i talked about spinalcord injury, who was not effectively, wasn'tbreathing deep. and his carbondioxide went what? up. hypercarbia is bad. hypocarbia is bad too. so you're blowing it off. so your co2, you'reblowing it all off. your co2 is goingto go down, right?

pco2 of 30, 25, 22, ok? it will go down. what happens, it isa direct effect when you have your pco2 go down,when you have hypocarbia to a certain extent,the direct effect is cerebral vasoconstriction. so you are alteringmonro-kellie, right? you are now reducingthe amount of blood. we talked about mannitolwill alter monro-kellie

by reducing the amountof brain, right? hyperventilation will reducethe amount of blood, right? so that's good, right? our icp will go down. is that right? that's correct. icp will go down. what is the badflip side to having reduced blood in the brain?

drastically reduced, acutelyreduced blood flow to the brain is what? that's the definitionof a stroke. the reason we do not do it,and it needs to be-- we're not talking mildhyperventilation, but that acute where we'rebagging them like crazy. you will fix your number. it will get better, butthey will suffer a stroke. that's why we don't do itfirst-line anymore, ok?

so do it if you haveto, but don't do it if you don't have to. try to use otherthings, all right? because we are havingall these patients-- that's why we--evidence proves it. and again, that's notmild hyperventilation. and if it's lifeor death, you do what you've got to do, right? so also, the flip sideof hyperventilation,

the minute you stop doing it,you get rebound vasodilation. so it rebounds. and your number canactually be worse. spinal cord injuries, i knowwe talked about this to death. but we've gotrapid deceleration. can be a result ofrapid acceleration, these flexion-extensioninjuries. so remember, in a head-on crash,where does your head go first? hyperflexion.

and then it goes hyperextension. people get that mixed up. so everybody, hyperflexyour neck, and hyperextend. hyperflex, hyperextend. usually, this is theresult of an entry in the cervical region. that makes sense. it can result in ligamentalinjuries and possibly a spinal cord injury.

we are a species of lollipops. we have-- well, notme, but some people are-- little stick bodiesand big, giant heads. jeez, how do we survive? we've got strong necks. vertical compression isyour axial load injury. how do you do this to yourself? almost exclusively? what are a lot ofpeople doing outside?

diving, and not checkingthe depth, right? so you go in and, boom. but yes, it canhappen the other way. so especially in acertain type of patient, axial loading canoccur the other way, you're just a littlebit lower down. you think about thosecalcaneal fractures, but you also get thelumber injuries as well. but usually, it'sa diving injury.

talking about falls,this kind of makes sense. we just talked aboutthat, and the jumping, and burning building,and things like that. all right, rotationwith flexion, this can occur not usuallyexcessively common. stable or unstable fracturesdeserves a chat about. stable is not are theystable or unstable. stable has to do with thevertebral body stability and whether or not itwill result in impingement

upon the cord through theprocess of normal healing, or through the process ofnormal physiologic loading as we're walkingaround afterwards, ok? so if i break a bonein my back, and it's a simple linear fracture,then i might be just fine. and that's how ijust walk around with a brace for sixweeks or eight weeks. and then i'm fine and dandy. but if i have, say, alittle piece that broke off,

that's free floating. that will move, right? and remember, that csf thatthat's in, the spinal cord is in, has the balloon around,the dura, that can be broken, that can go internally, thatcan impinge upon the cord either as i'mlaying in bed there with the normal flow of fluids,or as i'm getting up and down, doing pt, and walking around. in that case, they would go in,probably surgically, and fix.

primary, we talk about primaryand secondary injuries. primary is whatbrought you to them. can't do anything about that. we really have a huge effecton the secondary injury. so this is whatthat's talking about, blunt trauma,displacing ligaments, not so much, but bone fragments. and these can cause injuryto the cord later on. those patients go tosurgery almost all the time.

hypoperfusion, ischemia, so wetalked about not enough blood you can infarctyour spinal cord, just like you canhave an infarction of the heart or the brain. a bruise is usuallyblunt trauma. and sometimes, the swelling cancause, hopefully, transient, but it can be permanentdamage, depending on how much swelling there wasin what area and for how long. laceration has to do with,exclusively, pretty much,

penetrating trauma. so the knife blade, thegun, a bullet, whatever. secondary, we talkedabout this a lot. i won't beat thisto death for you. secondary, some ofthem are unavoidable. but you can minimize furtherinjury through stabilization. and has anyone heard thatdata out there about them not caring anymore aboutlong-boarding people? we're not talkingabout that, ok?

involves completespinal cord injuries. i've never experienced aspinal cord injury, ok? however, i've caredfor many of them over the years indifferent phases of care, as well, acute, ed, long-termrehab, spinal cord injury centers, things like that. complete spinal cord injuriesare easier for the patients, because there's no guessingand it is what it is. incompletes are hard for them.

and i could tell you thesame is true for care giving. the caregiver,it's easier to care for a complete injurythan an incomplete, because it's not predictable. it's not routine. and it could changeyears afterwards on a day-to-day or aminute-to-minute basis. anterior cord syndrome,these are extremely brief. they don't really evenneed to be pertinent,

because you're not going tobe doing diagnostic criteria within pretty much anything. and most of us walking aroundas anybody but a neurosurgeon, this includes most ofphysicians as well, really aren't ableto remember what this particular setof symptoms goes with that particular diagnosis. saying that, the one verybig, easy to remember one is central cord syndrome.

this is your walking quad, ok? so you're walking quad, hasanybody ever seen one of these? this is very rare. i've never caredfor one, ever, ok? it is really, really, really,really, a lot of times, not a penetrating or a blunt. sometimes from contusion,so maybe from blunt, or biochemical problems,infarctions, things like that. it depends on where theblood supply was interrupted.

but this is greater lossof movement up here, and your lowerextremities are ok. extremely rare. anybody ever seen one? anterior cord syndrome,again, your symptoms are going to be basedon what blood supply was interrupted, so itkind of makes sense. damaging the frontof the cord can be a result of thosebony fragments that

are moving around. this is why they reallywant to go in and clean those things up. so front of the cord, flexion. this makes sense, right? posterior injury, extension. extension injuries,back of the cord. that all makes sense, right? brown-sequard, again, ihave never seen or talked

to anyone who has caredfor one of these patients. have you guys? brown-sequard isstunningly rare. it is an acute hemi-transectionof the cord, ok? so almost exclusivelyfrom a knife. i believe i have anice picture here. so that very well could result--i don't know-- but result in a hemi-transectionof the cord, ok? or a bullet projectile nicks it.

so you lose the front andthe back of half the cord. so everything is way,way, way messed up. bad stuff. you lose sensationand touch on one side, and movement and proprioceptionon the other side of the body. really rare. like i said, i'venever seen one. i've not ever heard of--usually, you talk to people. oh, that's a good story.

can i have that? can i use that? i have yet to ever run into,so keep your eyes peeled. tell mark and blake about it. when you're assessing,assessment before, assessment after. we've talked this to death. i won't kill youover with it again. again, watching airway, soaggressive airway management

is really important, ok? you're going to assess over,and over, and over again. you're not just goingto look, but you're going to feel, feelingfor bony crepitus, step off, so deformities. and what is the patienthaving, as far as sensation and mobility? can they feel? and can they move?

those are not the same things. different parts of thecord, different nerves. watching uppers andlowers to death. spinal and neurogenic shock, ihave a nice table here for you. you will not ever remember this. these are frequentlytalked about as if they're the same thing,and they're totally different. but you have thisnow, if you like it. neurogenic is a higher injuryand a shorter duration.

and it will go away. versus spinal shock, who knows? so when you've gotyour neurogenic shock, you're going to pickup your patient, he's going to be hypotensive. he's going to be bradycardia. you won't really noticeabout the ability to sweat or whatnot. because he's lost hissympathetic nervous system.

no clamping down. no nothing. so that's the quicker one. spinal shock, if youthink about spinal shock, has more to dowith reflexes, ok? iv opiates, we talked aboutthe one drug, the solu-medrol. the other thing that'sreally important to note is that vasoactivemedications, this may be the only shockpatient that you will ever

start a vasopressor on, ok? they talk about atropine here. much more common thanatropine is dopamine. why do we use dopamine? only in spinal shock patients,neurogenic shock patients we've got adistribution problem. what is dopamine good for? it does everything. and it's cheap.

and it's old. and it's pre-mixedtoo, by the way, right? so that's really nice. dopamine, what effectdoes it have on the heart? it's a positivechronotrope, right? so it will speed up. you will not have asprofound bradycardia, ok? positive chronotrope. and what does itdo peripherally?

how might it helpour blood pressure? yes, cardiac output is heartrate times stroke volume. so if you increasethe heart rate, that might make yourblood pressure better. but remember,distributive shock, you've got all the blood there,it's just all pooled down. what do we want from dopamine? the squeeze, theperipheral vasoconstriction getting the blood back up,giving them a blood pressure.

so a person in shock, younever give them a drip, right? never give them epior norepi or dopamine, except a distributive shock,like your neurogenic shock patients. complications, we'vekilled all this. you know that, ifthey are still, they're going to get dvts,which will become a pe, if they start moving again. so keep them active.

keep them anticoagulated iswhat you really need to do. pressure ulcers are a bad thing. this is reallykind of silly stuff to be in here,because you're not going to be reallyconcerned about giving them their pepcid in the rig. but give them theirgastric prophylactic agent, like pepcid, or protonix,or something like that. huge, huge, huge thing canbe a problem in a prolonged

transport, remember? you're laying them flat, orthey might be mildly elevated. that foley may not bedraining as good as it should. we talked about that to death. so autonomic dysreflexia,you've got to really watch that. very quickly talk about stroke. i know i've talked aboutstroke a lot earlier on. so they divy this out. if it's a short-term,if your symptoms are

gone within 24 hours, it'sa tia, a transient ischemic attack. if your systems are stillthere after 24 hours, it's a cva or a stroke, ok? what they did in yourbook here is they-- i put the word ischemic nextto, because these are all ischemic strokes. i'm not sure why theylabeled it like this. but ischemic is not enoughblood supply, right?

there's ischemic strokesand hemorrhagic strokes. not enough blood,or a blood vessel rupturing, whichone's more common? ischemic. so about 85% are ischemic, maybeeven a tidge higher than that, but then you do havethe hemorrhagic, which is your aneurysmswe talked about. so thrombotic strokes,does this make sense? if a plaque orsomething kind of breaks

off and then eitheraccumulates there and gets-- that would be an embolic,if it breaks off. but you've got thisatherosclerotic plaque. and it's harder, andharder, and harder. and then it just builds outward. and then you don'tget blood flow. so you've got your embolic,when it breaks off and then gets lodged somewhere smaller. your focal strokes.

there's lacunar strokes. i don't know if anybody'sever talked about this. people say, oh, they'rejust old and demented. that's when you have tonsof tiny little strokes. and you never know it. and they don't findit until autopsy. not the same thingas alzheimer's, but those are lacunar strokes. global ischemic strokes, that'sjust if you have no blood

pressure, you're not goingto perfuse your brain. so probably, by that point,you're dead of something else. edema will occur in a fewof these, not usually. but our treatments for themcan cause cerebral edema. secondary hemorrhage is calledhemorrhagic transformation. and that will happenseveral days post. again, you should notsee that in transit, either from facilityto facility, or from the field onward.

this is why they do serialexams, over and over again, to watch. and if they do, it'sgoing to be very quick, like a sudden bleed. it's almost like dic, but notas devastating systemically, but it's here. they can have seizures. the characteristic signhere is the sudden onset of focal neurologic signs.

so that's your fast, yourface, arms, speech and time. time, time, time,get them there. so do they have a facial droop? do they have speech problems? and then do theyhave an arm drift? or you can do your la or yourcincinnati pre-hospital screen. symptom onset, not thetime you got to them, but the time that theywere last seen normal. that's the number onething, because you've

got that golden timewindow of three hours. watching out, becausethey are at risk, just like any otherneural problem. if they don'tprotect their airway, they're at risk for aspiration. and upper airwayobstruction, all these are from reducedmental status, ok? oh, it was the la. yay.

ok, so this is a littlebit more complicated. cincinnati is out there. also, use what your own medicalcontrol has you use, ok? tpa, fibrinolytics may be used. they are great. and the use criteria keepsgetting broader, and broader, and broader every five years. it's wonderful. if you're now 85years old, it's not

an automatic rejecting of a no. i mean, it's on the inclusionand exclusion criteria, but they'll assess it,because it works great. it works great. prior to-- yeah, wetalked about that. exclusion criteria. intracerebral hemorrhage,so bleeding into-- we talked about epidural,subdural, all those. intracerebral is anywhere else.

and i believe i'vegot a couple of-- it can be the result ofhypertension, blood vessel induced rupture. i've got a couple ofslides to show you on it. this makes sense. this is repetition. wow. i didn't realize how longi was talking to you guys. holy moly.

4:50. i'm so sorry. take it out on my eval. symptoms of an ich can startoff as a local problem, and then proceed to globally. remembering that one big one isbad, and a lot of little ones can be just as bad. so those anticoagulated patientsor those multiple trauma patients can havethese going on, ok?

so here is-- yeah,i did, good for me-- a bunch of little ones. can you see all thepunctate hemorrhages here? and then a great, big,gigantic one here, ok? so you are going tohave mass effect. you're going to have swelling,which is mass effect. this is to the top of the brain. they're harder to see alittle bit lower down. we talked about subarachnoidhemorrhage exhaustively.

i won't do that again. an avm, statistically, whendoes someone blow their avm? what age range, i mean? early 20s. so be very suspicious. early 20s to mid-20x iswhen those usually blow. you don't know they havethem, because they're healthy. everything's fine. and then, all a sudden, boom!

i've got a hugecerebral hemorrhage. is not usually from an aneurysm. it's from their avm blowing. so that's when you'rearteries and veins are all conglomerated, grown togetherin really bad, bad ways. like a back woods family,really bad, bad ways. no offense, ifanybody's back woods. i didn't mean it like that. they describe itbetter, tangled masses

of arterial andvenous blood vessels. and there are no interveningcapillary beds, ok? it's just oxygenated,deoxygenated in all the wrong spots. and they haveweaknesses in the walls. and technically, they blowin the early to mid 20s. we talked about this a lot. underline that photophobia,because that's hugely present very quickly andprolonged throughout,

until that blood iscompletely reabsorbed. if icp goes up, they mightbecome comatose or die. holy moly, i'vegot five minutes. well, this makes sense. what do you manage it with? you maintaincardiopulmonary function. so you're going to support theirblood pressure and whatnot. you're going to try toprevent a rise in icp. all this kind of makes sense.

so watching out forcerebral vasospasm. i talked to you guys a lotabout the cerebral vasospasm and what we do. take them down toir, and they fix it. we bulk up their salt. we do triple h therapy, althoughthat's kind of fallen out of favor. we give them highblood pressures to keep thoseblood vessels open.

so this is where we wouldinduce a map of 120 to 140, a map of 120 to 140. overactivity, seizureis overactivity. or it could be the result ofan electrolyte disturbance, or drugs that they're taking,or anything, or a plain old head injury. you've had somebodyfall off the horse, you're going to have a seizure. a direct blow to the head,all that kind of business.

we might need to give them,one, an anti-epileptic load. they might need to stay onanti-epileptic medications for a period oftime, or they might need to stay on them forever. number one thing you really wantto have around is iv benzos. they're having a seizure. the dilantin is not goingto work for a long time. the ativan will break theseizure activity right away, you've got tobreak the activity,

before you can then treatand get the airway in and everything else, somaintaining an airway. we don't try to stop them. we don't hold them down. turn them on theirside, if you can. don't put anythingin their mouth, ever. not anything that looks likeit was made to go in the mouth, like the stick with thesponge on the end of it. why do they makethings like that?

don't put it in their mouth. don't restrain them. try to get an iv in whenthey're doing all this. it might not be possible. im works for certaindrugs as well. check to make sure they'renot having a seizure and that's why. anticonvulsant load, yes. but you've got to breakthe activity before you

can give them the dilantinor [inaudible], ok? transportconsiderations-- great. we're at the lastthree slides here-- major early risks, wetalked about this a lot, hypoxia and hypotension. won't kill it anymore. abcs. severe closed head injury--remember, open head injuries, even though they're scarier andlook a lot more attention-wise,

they're going to havelower icps, usually, because there's roomto grow out, ok? anybody flight in here? i've done some stuff withflight, when i was in army. and i've done abunch of ride-alongs with milwaukee flight for life. and i have not reallyseen this, actually. with special stuff for them,they just fly as per norm. but it's possible.

special protection for thepatients, i don't know. i've transported patientswith evds, only riding along. i'm not a flight nurse. i'm not acting like i am. but that's a possibility. what you really wantto watch is altitude, because air pressure changesthe higher that you go. so i think that is on here. it is on the next one.

if you need to drop youraltitude to equalize pressure for them. again, no. i do not know of anybody thatroutinely adjusts cuff size in the et tube or in the foley. again, we're not flying atfixed wing height here, ok? so it's a little-- but idon't want to say never. this is per order. i don't like that word must,because some docs will want it

at 10. some will want it at 15. but this is a measurement. and again, you can'treally tell on this. you have to actually seewhat device you're actually working with. but your normal settingis 20 cm of water is high you put itin a normal brain. they're not a normal brain.

so they get them upin a noisy helicopter, and it might be even worse. if they show changes or anyevidence of deceleration, is another one. deceleration, that'sindicating hernias. and get the aircraft down. if it's fixed wing, whatare you going to do? but get them down. get them somewhere.

give them mannitol, ok? was that all right? did you take away one ortwo things, hopefully? oh, yes. did anything not make sense? thank you, verymuch, for your time. [applause]