Missouri EMS Central Region

September 2012 WebinarCase Review

Jeffrey Coughenour, MD, FACS

Assistant Professor of SurgeryMedical Director, Missouri EMS Central Region

Patient 1Admission brain CT

Patient 1Repeat brain CT, 24 hours after admission

Primary Brain Injury

• Direct result of the disruptive forces that are transmitted during impact– Various mechanism of injury– Result: Several types of mass lesions, axonal shear, skull

fracture, etc.

• Best therapy—prevention

Secondary Brain Injury

• Events after the primary insult that exacerbate injury and worsen outcome

• Leading cause of in-hospital death following TBI

• Injured brain swelling reduced cerebral blood flow and reduced threshold for cerebral ischemia more damage worsened functional outcome

Secondary Brain Injury

• Paramount to therapy is…

Avoidance of hypotension and hypoxemia

• Intensivist-based management to manage elevated ICP and optimize cerebral blood flow

Evaluation

• D “Disability” portion of primary survey• Glasgow Coma Scale score most reproducible

measurement of injury– Mild (GCS 14-15): 80%– Moderate (GCS 9-13): 10%– Severe (GCS 3-8): 10%

• Report initial GCS, repeat with clinical change• Motor component most predictive of recovery

Evaluation—GCS

Patient 2Admission chest radiograph

Patient 2Left chest

Patient 2Posterior view

Patient 2Bilateral sacral fractures

Patient 2Extravasation from posterior pelvis

Patient 3Admission chest radiograph

Patient 3Brainstem hemorrhage

Patient 3Ischemia/reperfusion injury of the small bowel

Patient 3Left lower lobar extravasation