Well, first and foremost, remember, this is a multi trauma patient so we need to complete our trauma primary survey
which means that we need to assess and stabilize his airway, breathing and circulation before we move on to D for disability.
So only once we've completed our ABC assessment should we be performing a neurologic exam and remember,
if it’s altered, we wanna make sure we check his glucose as well.
Maybe he became hypoglycemic and that’s why he fell off the roof in the first place.
Now, our patient’s vital signs are not stable.
He's in respiratory distress and he's got evidence of shock, so he’s hypoxia and his hypoperfusion can actually affect his mental status,
so it’s really important that we stabilize him and then reassess his neurologic state
because we might not be getting an accurate assessment of his neurologic picture if he’s unstable from other injuries.
When we do perform our neurologic primary survey, we're always gonna calculate the GCS as we discussed.
We're gonna do a pupillary exam cuz that’s gonna give us a sense of whether there are any lateralizing or focal signs
and we're gonna check a four extremity motor exam,
so it is not enough to just know that he withdraws to pain in one extremity,
we wanna make sure that he’s moving everything cuz that can give us clues as to whether there is a brain or spinal cord injury.
This is the essential exam.
It gives us a sense of the level of consciousness; it gives us a sense of neurologic focality.
You definitely can and should do a more detailed exam once the patient is stabilized
but this is gonna be your upfront assessment to get an immediate sense of where your patient is from a neurologic standpoint.
Back to our patient, we have listened to his lungs, we found the chest x-ray, there is no evidence of pulmonary injury.
He does have an unstable pelvis on exam so we've applied a pelvic binder and given him a liter of fluid.
His mental status is the same despite the fact that his vital signs have stabilized.
His pupils are equal and he's moving all of his extremities symmetrically
so he doesn’t have any sign of neurologic focality but he does have a significantly depressed GCS.
So now the question is, what do you wanna do to further evaluate this?
Very simply this guy needs immediate neuroimaging.
So imaging is mandatory for any patient with a GCS of less than 13 and even if the GCS is greater than 13,
you should really think about imaging the brain if the patient has significant evidence of head or face trauma,
if they’ve got a serious mechanism, remember this guy fell from a third story building
so this is potentially a very serious mechanism of injury.
If their level of consciousness is sort of waxing and waning over time,
if they have signs of basilar skull fracture, focal deficits or seizure activity,
you definitely should plan to image patient’s who fall into those categories.
When you do neuroimaging in multi trauma, noncontrast head CT is always gonna be the initial test of choice
and it’s a great study because it shows all of the critical findings that you're worried about in the trauma setting.
It will show you hemorrhage, it will show you mass effect and it will show you fracture.
Furthermore, it’s readily available in most emergency department settings and can be performed very quickly.
So when we looked at head CTs, it’s important to kind of understand what we're looking at.
So CT imaging is based on tissue density.
Acute blood on a CT scan will appear as bright white. Fluid on a CT scan will appear black,
so your ventricles for example, which are filled with cerebrospinal fluid are always gonna appear black.
The brain itself is gonna be varying shades of gray.
They're slightly different tones of gray for the gray matter versus the white matter but in general your brain is gonna be gray.
And subacute blood, so blood that has been setting around in the brain for awhile as it breaks down
will also become gray and that’s important to realize
because it can become isodense with the brain and make it more difficult to see on CT scan.
And then, lastly, your bones will gonna be white.
Now there are special bone windows on CT which we're not gonna cover here that can be used to better elucidate fractures.
In this particular CT scan you might notice that there's a big white stripe right down the middle of the brain
and this patient actually has an interhemispheric hemorrhage.
So this is an example of acute blood in the brain and you can see how bright white it is
and what a striking contrast it has to the surrounding gray soft tissue of the brain.
So there are specific patterns of intracranial injury that we need to be aware of
because they all have their own individual treatment approaches
so we wanna make sure that we make a correct diagnosis so we can plan treatment accordingly.
So the things that we're gonna be worried about on our CT scan are epidural hematoma,
subdural hematoma, subarachnoid hemorrhage, intraparenchymal hemorrhage, and cerebral edema
or elevated intracranial pressure and we're gonna talk about each one of these.
Now, again, it’s very important to know what type of intracranial injury your patient has
because management of different injury types is totally different,
so diagnostic imaging is absolutely mandatory because it’s gonna dictate your future care of the patient.