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Patient 1

Missouri EMS Central Region September 2012 Webinar Case Review Jeffrey Coughenour, MD, FACS Assistant Professor of Surgery Medical Director, Missouri EMS Central Region. Patient 1. Admission brain CT. Patient 1. Repeat brain CT, 24 hours after admission. Primary Brain Injury.

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Patient 1

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  1. Missouri EMS Central RegionSeptember 2012 WebinarCase ReviewJeffrey Coughenour, MD, FACSAssistant Professor of SurgeryMedical Director, Missouri EMS Central Region

  2. Patient 1 Admission brain CT

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

  4. Primary Brain Injury • Direct result of the disruptive forces that are transmitted during impact • Various mechanism of injury • Result: Several types of mass lesions, axonal shear, skull fracture, etc. • Best therapy—prevention

  5. Secondary Brain Injury • Events after the primary insult that exacerbate injury and worsen outcome • Leading cause of in-hospital death following TBI • Injured brain  swelling  reduced cerebral blood flow and reduced threshold for cerebral ischemia  more damage  worsened functional outcome

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

  7. Evaluation • D “Disability” portion of primary survey • Glasgow Coma Scale score most reproducible measurement of injury • Mild (GCS 14-15): 80% • Moderate (GCS 9-13): 10% • Severe (GCS 3-8): 10% • Report initial GCS, repeat with clinical change • Motor component most predictive of recovery

  8. Evaluation—GCS

  9. Patient 2 Admission chest radiograph

  10. Patient 2 Left chest

  11. Patient 2 Posterior view

  12. Patient 2 Bilateral sacral fractures

  13. Patient 2 Extravasation from posterior pelvis

  14. Patient 3 Admission chest radiograph

  15. Patient 3 Brainstem hemorrhage

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

  17. Patient 3 Left lower lobar extravasation

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