Trauma: Introduction

by Carlo Raj, MD

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    00:01 Trauma is our topic.

    00:03 Let’s take a look at all the different manifestations of trauma and keep in mind that when there is trauma, there could be other neuropathologic issues that might be taking place simultaneously.

    00:15 Let’s take a look.

    00:17 Skull fractures.

    00:18 For whatever reason, you got into an accident then you flew out the windshield.

    00:23 You got hit by a baseball.

    00:24 Whatever it may be.

    00:26 Skull fractures, trauma.

    00:30 Specifically here though, let’s say that the brain itself, the tissue or the parenchyma becomes injured.

    00:37 There are specific clinical descriptions that we then give these.

    00:42 First, let’s talk about concussion.

    00:46 A boxer, not really Mike Tyson, he never really got hit too much, but maybe Muhammad Ali, a boxer.

    00:56 Payton Manning, quarterback, football.

    01:01 So these are sports in which it’s pretty high contact.

    01:04 The quarterback or boxer may get hit in the head quite often and may result in a concussion.

    01:11 So what does a concussion mean to you by definition? A clinical syndrome of altered mental status secondary to head injury, typically brought up by a change in momentum of the head, such as – Let’s say a linebacker coming at you and he dives right into you.

    01:30 And your head hits the ground, momentum of the head, resulting in a concussion.

    01:36 A boxer for obvious reasons.

    01:38 What happens? Instantaneous onset.

    01:42 The operative word here is transient neurologic dysfunction including loss of consciousness, temporary respiratory arrest and loss of reflexes.

    01:53 The operative word, transient.

    01:56 And obviously, in such severe contact sports, especially football, it has come under a lot of scrutiny because of the hits that take place to the head constantly.

    02:08 And all these concussions, concussions, concussions that the athlete or the patient may then incur may result in now-- We call this severe form of concussion, which may then result in finally traumatic spongiform encephalopathy, right.

    02:27 And in fact, there’s even a movie called Concussion in which Will Smith plays a role.

    02:32 You may want to take a look at it.

    02:34 Rather interesting, especially because you’re going to be a doctor and you are one in just a matter of time.

    02:40 Amnesia.

    02:41 Amnesia may be present.

    02:43 Now there are different types of amnesia.

    02:46 You can have the anterograde or the retrograde, now.

    02:49 Allow the name to speak to you.

    02:52 If there’s concussion, a temporary, transient loss of consciousness and all of sudden you can’t remember exactly as to what happened.

    03:00 When? How far back? Are we talking about what happened when you’re a baby and you maybe got, I don’t know, thrown into the snow.

    03:10 That’s actually a personal story, but anyhow, my point is those long-term memories do exist.

    03:17 So that’s retrograde.

    03:18 If you cannot remember those long-term memories from decades ago, that’s your retrograde type of amnesia.

    03:26 And a concussion though, those memories from way back when actually will still exist so you’re okay there.

    03:33 But the problem – Not the problem.

    03:34 But the issue is you might not exactly remember as to what caused the particular concussion.

    03:40 And this then refers to as being anterograde.

    03:42 And for that moment in time, there’s every possibility that you do not remember what happened a few moments prior.

    03:49 And might be a little bit difficult initially to create new memories, you know, for that moment in time.

    03:56 But really, this is all transient, isn’t it? But it doesn’t mean it’s not dangerous.

    04:00 There’s a last statement here, postconcussive neuropsychiatric syndromes.

    04:04 This is no joke.

    04:05 This is what I was talking to you about earlier.

    04:07 Make sure you know the definition of concussion.

    04:09 We’re doing trauma.

    04:10 Specifically, it’s the brain tissue, the parenchyma that becomes injured and by definition, it’s altered mental status or loss of consciousness.

    04:19 But it’s all transient.

    04:21 It might be an anterograde type of amnesia that’s taking place with an intact, long-term memory.

    04:27 But in the sequelae here, if the patient continues to have concussion after concussion after concussion, the patient may then develop what’s known as traumatic spongiform encephalopathy where literally, the brain looks like a sponge.

    04:40 But this is traumatic versus, earlier, we had talked about a condition or prion disease known as transmissible, spongiform encephalopathy.

    04:51 And of course, with traumatic, there’s even movies that are coming out in which it addresses it and the sequelae here is something that you very much need to take into consideration in such patients who have history of being involved in contact sports.

    05:09 Continuing our discussion of parenchyma injury, this now brings us to contusion.

    05:15 Is this clear? Our previous discussion was concussion.

    05:19 This is contusion.

    05:21 Now, what does that mean to you? There’s a direct parenchymal injury to the brain.

    05:24 What does that mean? Well baseball player or even, let’s say, soft ball, whatever it may be and the ball then hits the head.

    05:34 And when it does, there’s a direct impact, direct impact, to the parenchyma.

    05:39 There’s a contusion.

    05:40 Now, they are descriptions of what kind of impact is taking place.

    05:45 If the injury is at the point of contact, if the injury to the brain is at the point of contact directly, then we call this coup injury.

    05:56 So cerebral injury at the point of contact versus what’s the opposite of coup? Well, then you add in the French word contre-.

    06:06 So contrecoup injury means what? That means that the point of injury is the opposite of the point of contact.

    06:14 So you got hit maybe perhaps in the frontal lobe, and then directly on the opposite side, is where you would actually find the parenchymal contusion.

    06:23 This is then referred to as being contrecoup.

    06:26 So coup or contrecoup is referring to contusion.

    06:30 And it’s referring to the fact that the parenchyma itself has become injured.

    06:34 If it’s concussion, then you’re looking at it more or less as kind of like a syndrome.

    06:38 Upon injury to brain itself, the patient is going to lose consciousness, maybe suffer amnesia, but it’s all temporary.

    06:46 That’s concussion.

    06:48 This is contusion.

    06:52 And we have another type of parenchymal injury.

    06:54 This is called diffuse axonal injury.

    06:57 By the definition, what does that mean to you? The axon.

    07:00 So therefore the injury to the white matter due to, well, let me give you the patient.

    07:05 The patient is on a rollercoaster at the amusement part.

    07:09 And repeatedly, I’m not saying every single patient, but when you go in a rollercoaster, you are putting yourself at risk for sudden acceleration.

    07:19 My head whips back.

    07:22 Or deceleration, my head whips forward, right? Or an accident is my point.

    07:28 So when this occurs, this may result in a very, very serious matter called diffuse axonal injury.

    07:34 Literally, the axon gets twisted and it gets stretched and it gets damaged and as far as you’re concerned, this is irreversible injury.

    07:42 As far as you’re concerned right now, this is irreversible injury.

    07:47 Location: Corpus callosum.

    07:50 So where are you? Around the ventricles.

    07:53 Therefore we call this paraventricular white matter and hippocampus, or common areas where you might find diffuse axonal injury with such a history of your patient.

    08:03 Cerebral and cerebellar peduncles will be other places where this could be locations of injury.

    08:09 What happens to the axon? Swelling, inflammation, twisting, poor prognosis.

    08:16 So as much as the patient is having fun during the particular roller coaster ride or whatever type of ride or an accident that causes sudden acceleration, deceleration, the complications are rather poor or should I say rather grave with poor prognosis.

    08:37 Let’s talk about traumatic vascular injury.

    08:39 Types: Epidural, subdural.

    08:42 Subarachnoid, we actually have discussed extensively and intraparenchymal.

    08:47 What we will do and what I will do for you is make sure that we delineate the differences clearly between epidural and subdural.

    08:55 Before we move on, I need you to bring in some of your neuroanatomy here, please.

    09:00 And if it’s epidural, what kind of blood vessel? Remember, what's my topic? vascular injury.

    09:05 So, I’m going to keep using this example for you.

    09:08 A child gets hit by a ball, playing baseball or whatever it may be.

    09:13 And this then causes vascular injury and may then result in the blood vessel in the epidural space, becoming injured.

    09:21 And then resulting in what’s known as a hematoma, okay? And you should know that particular blood vessel there.

    09:27 It’s known as middle meningeal, right? Middle meningeal.

    09:31 And you have the subdural.

    09:33 In the dura mater or subdural, the blood vessel there would be what, please? Bridging veins.

    09:40 In the subarachnoid space, we’ve talked about the circle of Willis, berry aneurysm, if it ruptures, it may result in subarachnoid hemorrhage.

    09:47 In any point in time, you could have intraparenchymal type of issue.

    09:51 Clear? Our topic, traumatic vascular injury.

    About the Lecture

    The lecture Trauma: Introduction by Carlo Raj, MD is from the course Trauma. It contains the following chapters:

    • Trauma
    • Traumatic Vascular Injury: Types

    Included Quiz Questions

    1. Contrecoup injury
    2. Coup injury
    3. Intraparenchymal brain hemorrhage of frontal lobe
    4. Concussion injury
    5. Diffuse axonal injury
    1. Diffuse axonal injury
    2. Coup injury
    3. intraparenchymal hemorrhage
    4. Concussion injury
    5. Countre coup injury
    1. Traumatic spongiform encephalopathy
    2. Retrograde amnesia
    3. Prolonged loss of conciousness
    4. Contusion
    5. Intraparenchymal hemorrhage
    1. Concussion
    2. Coup injury
    3. Contre coup injury
    4. intraparenchymal hemorrhage
    5. Diffuse axonal injury
    1. Concussion injury
    2. Coup injury
    3. Countre coup injury
    4. Diffuse axonal injury
    5. Intraparenchymal hemorrhage

    Author of lecture Trauma: Introduction

     Carlo Raj, MD

    Carlo Raj, MD

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