[MUSIC] [MUSIC] [MUSIC] [MUSIC] [MUSIC] [NO_AUDIO] The aims of the following part of the course are to provide a clear definition of a traumatic brain injury, to present the epidemiology and the optimum forms of diagnostic investigation and treatment and then to provide a brief summary once again at the end. [NO_AUDIO] Traumatic brain injuries are designated in very different ways in the literature. The terms used range from concussion through contusion and compression to descriptions of the accident mechanism. Uniform terms should be used as far as possible so as to be able to discuss comparable diagnoses. On the one hand, it is important to ascertain whether an open or closed traumatic brain injury is involved. Classification should be undertaken according to the Glasgow Coma Scale and, under this, a Glasgow Coma ranking of 13 to 15 points is classified as a mild traumatic brain injury, one between 9 and 12 as a moderate one and below 9 as being severe. [NO_AUDIO] As great importance is attached to the neurological assessment of the patient on the basis of the Glasgow Coma Scale, I would like to explain the method of awarding a Score in such a way that you will never forget it again. The Glasgow Coma is an absolute standard and has to be mastered by every doctor. There are a total of 15 points covering neurological performance. These are divided into a maximum of 4 for eye movement, a maximum of 5 for verbal reaction and a maximum of 6 points for motor reaction. Division is undertaken in a very simple way. Spontaneous opening of the eyes is awarded 4 points, eyes upon request 3 points, in response to pain 2 points and without any reaction being gained 1 point. Orientated conversation is awarded 5 points, confusion 4, muddled words 3, groaning 2 and no reaction one point. If the patient follows instructions, he receives 6 points for motor reaction, if he defends himself in a focused manner in cases of pain, 5 points, unfocused 4, if flexion synergisms follow, he receives 3 points, in the case of extension synergisms 2 and if no motor reaction is obtained, the patient receives 1 point. This approximates quite roughly to the way the brain gradually switches off from the cerebral cortex to the brain stem. This means that overall the Glasgow Coma can be between 3 and 15 points. [NO_AUDIO] Traumatic brain injury is an injury which occurs relatively frequently. Up to 1.4 million cases of injury, for example, are reported per year for the United States. 75% of these refer to what is termed “mild traumatic brain injury”. Between 15 and 20% of patients are left with residual symptoms. [NO_AUDIO] The division between mild, moderate and severe traumatic brain injury is shown here. The majority of cases are mild traumatic brain injuries. [NO_AUDIO] It is important to note in this context that approx. 10% of patients with a mild traumatic brain injury display pathological findings in a cranial CT scan. Approx. 1% requires surgical intervention and 15% suffer from persisting complaints lasting longer than one year following the injury. [NO_AUDIO] A diagnostic investigation following a traumatic brain injury should contain a neurological examination by means of the GCS as well as an assessment of the pupillary reaction and a thorough search for symptoms of paraplegia. [NO_AUDIO] In terms of an imaging diagnostic investigation following a traumatic brain injury, it is important to know that conventional x-ray imaging is now hardly used any more. The reason for this is to be found in the fact that potential intracranial haemorrhages cannot be seen in an x-ray image. In contrast to this, these haemorrhages can be detected in a cranial CT image. This is why a CCT currently forms the Gold Standard for any diagnostic investigation for traumatic brain injury. In some rare cases, it may be necessary to conduct a magnetic resonance imaging examination. [NO_AUDIO] [NOISE] >> Keep pressing. >> But it doesn't hurt anymore. [TALKING] >> Yes, I know. [GERÄUSCH] Are you OK? Somebody or other must be here somewhere. Oh, here they are. Here, look. Hello. >> Mhm. >> Stop. Hallo? >> Hallo. Can I help? Grüß Gott. >> Hullo, Excuse me. >> What has happened? >> She has been hit >> Okay. >> by a tram. >> Mhm. >> But not too badly. >> Oh yes, it was. She took the full impact. >> Mhm, okay. >> And then she lost consciousness for a short time as well. >> Unconscious, I see. And you have suffered an injury here as well? >> Yes. >> It's not so bad. >> I see. >> I told you >> not to cross on red. >> Mm. >> What is your name? >> Miriam Schmidt. >> Mhm, okay. >> My name is Schmidt >> as well. >> M. >> I’m Sister Martina >> Mhm. >> and to begin with we’ll call on some reinforcements. Shall we go and see the doctor? >> But we still need the wine. >Yes, I know. We can do that later. You were unconscious for a short period of time. >> Why are we here? >> Dr. Neumaier, >>Here we now are in the Rechts der Isar Hospital. The doctor is just on his way. >> here is a 20-year old patient, Mrs. Miriam Schmidt. >> Hello, Mrs Schmidt. >> Hello. >> Good day. What has happened? >> Hello. >> Grüß Sie. my name is Dr Neumaier. >> She has been hit by a tram. >I see. And she was on the ground for a short time and then she also lost consciousness for a short period. >> Mhm. >> Then I was about to pick her up and then she was suddenly gone for a short time. >> It's not so bad, though. >> Yes. On your head, >> [NOISE] >> up there, you have a laceration, and >> Precisely. She was hit >> [NOISE] >> fairly hard >> I see. >and then lost consciousness for a short period of time. I wanted to help her get up. Just a short period of time. >> Okay. Can you remember what happened in the accident, Mrs Schmidt? >> No, I just know I wanted to buy some wine. >> I see. When is your birthday? >> My birthday was yesterday. >> Okay. >> Exactly. >> Do you know where you are, now, here? [NOISE] >> In a hospital? >> Yes. In which one? >> Where are we here? >> Rechts der Isar. I’ve already told you. >> In the Rechts der Isar Hospital. >> Ts. >> Can I shine this light into your eyes? >> I already told you that before. >> Well, perhaps it is still important. Previously, >> Yes? >> on the street she just she had to vomit as well. >> Hmm, that’s good. Therefore, vomited and hit directly once? Can you see my finger >> [NOISE] >> once? >> Mhm. Yes. >> Once or double? >> Once. >> If I move it upwards, downwards, to the side - still just once? >> Yes. >> Can you move everything freely; arms, legs? >> Yes. >> Can you feel everything OK? [NOISE] >> Mhm. >> Aha. >> Yes. >> Everything as it should be? >> Yes. >> Can you move everything? >> Yes. >> Does anything feel unusual? >> But we still need the wine. >> Yes, I'll take care of it later. >> Don't worry. I’ll take care of it. >> Okay. Good. We now need to take a blood test >> Mhm. >> for severe traumatic brain injury, together with a CCT scan and conduct a FAST test. >> Mhm. [NOISE] >> Can you lie down, please? Please take your jacket off first. Is that OK? >> I see. >> Wait a moment. We’ll help you. >> Can you go and buy the wine, >> Yes, >> please? >> I’ll go and buy the wine. >> Please do. You know we need the >> [NOISE] >> Yes. >> wine. >> Yes, I know. I’ll buy it afterwards. >> Okay. >> That's not so important now. >> In any event, not the Chianti my parents buy, please? >> Yes, okay. >>Okay. >> I won’t buy any Chianti. We don’t have to drink Barolo every time. [NO_AUDIO] The indication for the initial CCT scan is derived from the GCS. If the latter is at 13 or fewer points, then a computerised tomogram needs to be conducted. If the GCS is between 13 and 15 points, then the indication is given based on the supplementary individual risk for intracranial haemorrhages. [NO_AUDIO] This risk is particularly high if a convulsion, motor deficit, sensory deficit or repeated vomiting by the patient occurs at the same time. [NO_AUDIO] Furthermore, the risk of intracranial haemorrhaging increases if a fracture of the scull is palpable, liquorrhea is being discharged through the nose or ear, a monocular haematoma or raccoon eyes are evident as well as impaired vision or hearing following trauma. It is important to ask the patient about any potential disturbance in their coagulation system. Studies have shown that the risk of suffering intracranial haemorrhaging is significantly increased if anticoagulant medication is taken at the same time. [NO_AUDIO] These studies have also shown that advanced age can likewise be a significant risk factor. [NO_AUDIO} In summary, it must therefore be stated that currently the only sure way of excluding any potential post-traumatic intracranial haemorrhaging in the course of a diagnostic investigation is by conducting an initial CT scan. [NO_AUDIO] This slide shows in diagrammatic form the pathophysiological consequences of intracranial haemorrhaging following a traumatic brain injury. It can be clearly seen how the nerve cells are compressed by the increasing intracranial masses of blood and thereby are incapable of maintaining their original neurological function any more. The special features of the anatomy of the cranium reveal indications within this of some compensation mechanisms countering the increasing intracranial pressure. [NO_AUDIO] This is also the reason why neurological capabilities deteriorate in an initially relatively unspecific manner with increasing pressure over a long period of time. If these innate compensation systems are overcome, then clinical deterioration occurs relatively quickly. [NO_AUDIO] [NO_AUDIO] [NOISE] >> OK, so now let's take a more precise look at that finger. Can you still move your thumb? >> Mhm. >> Yes? Can you feel everything OK? >> Mhm. >> Yes? Looks like just a deep scratch. Have you been vaccinated against tetanus? >> Mhm. >> When was the last time you were vaccinated? >> Mmm. I think it was in 2005. >> Aha. In that case, we need to give you a booster. We need a tetanus booster vaccination, Sister. >> OK. Will do. Mhm. >> Okay. A plaster on this. And then we’ll need an ultrasound. >> Okay. >> And now I would like to take a blood test quickly >> Mhm. >> so that we have the values to make sure we have not overseen anything untoward. >> I would have really thought that it would be more important to worry about the head to begin with. >> Yes. We’ll do that right away. It will take some time before the CT scan is ready. [NOISE] >>In this, we will measure the S100 level which will also tell us about the brain trauma and whether the brain has been damaged. [NOISE] So, This will prick briefly >> Mm. [NOISE] >> Now we can take some blood. [NO_AUDIO] [NOISE] Everything OK for you as well? >> Mhm. >> Mhm. >> Hmm. Is the ultrasound all set up now? >> Yes. Then let's place a dressing on here now. >> Mhm. >> Can I have another look at your abdomen? >> Mhm. >> Now we’ll take an ultrasonic image quickly to make sure that no abdominal haemorrhaging is occurring. [NO_AUDIO] [NOISE] Yes, thank you. [NO_AUDIO] Aha. OK. That looks good to begin with. Heart is OK. [NO_AUDIO] Here is the aorta. >> I would have really thought it would be important to worry about the head at this point. [NOISE] >> We will do in a moment. [NOISE] OK, now we need to check the left kidney. [NOISE] [NO_AUDIO] Is that OK? >>Mhm. >> But we are here because of a head injury. [NO_AUDIO] >> There is the spleen up there. Yes, it can be seen well. Good. Breathe in deeply and hold. [NO_AUDIO] There it is. [NO_AUDIO] OK. I cannot see any bad case of haemorrhaging in the abdomen at present. >> [LAUGH] >> But we now need to conduct the CCT. [NO_AUDIO] >> Have we already booked for it? >> The CT has been booked. >> OK. Then off we go to the CT area. >> Okay. >> Let’s make a start. >> Yes. At last. [NO_AUDIO] [NOISE] [NOISE] >> Just stay lying very quietly. I’ll be right back, OK? Just a moment. [NO_AUDIO] [NOISE] The CT is finished. >> Mhm. Is she still OK? >> She is still doing well. >> Yes, because she is experiencing a minor haemorrhage here. >> Okay. >> Look here. [NO_AUDIO] You can see it better over there. [NOISE] And actually here in the front left. There. Can you see it? >> Mhm. >> Precisely where she was hit by the tram; that is where the laceration is. [NO_AUDIO] [NOISE] >> Okay. Nothing wrong with the cervical spine and everything is OK behind there as well. [NOISE] She has to be admitted to the observation ward, so we need a bed for observation >> Mhm. >> on a monitor. >I’ll phone right away. >> Mhm. Is her husband still outside? >> Hopefully he is far away, but >> [LAUGH] >> I’ll fetch him back in. [LAUGH] >> He can come in and I’ll have a quick word with her. >> Yes. [NOISE] [NO_AUDIO] >> The image on the left shows a clinical example with typical raccoon eyes. On the right side is a computerised tomogram image in which subdural haematoma and incipient displacement of the midline can be recognised. [NO_AUDIO] In order to provide relief for this intracranial pressure, an osteoclastic relief trepanation has to be carried out. In the left image, the typical drill holes on a skull are marked, while on the right there is an intraoperative depiction of a subdural haemorrhage following relief. [NO_AUDIO] The image on the left side shows the bone lid which has been removed and on the right side a corresponding computerised tomogram image can be seen. It can be seen on this that the brain now has considerably more room to swell into. These computerised tomogram images show the combination injury of a subdural and intra-parenchymal haemorrhage. [NO_AUDIO] The displacement of the midline caused by the rise in intracranial pressure can likewise be clearly recognised. [NO_AUDIO] The intraoperative image corresponding to this shows the cerebral cortex after relief. [NO_AUDIO] The postoperative computerised tomogram images show that the displacement of the midline has been removed again by the relief from pressure. [NO_AUDIO] These operations are conducted in collaboration with the Department for Neurosurgery. In contrast to this, a mild traumatic brain injury is a problem typically dealt with by trauma surgery as the majority of the patients concerned are emergency admissions. The reduction in the GCS in such cases is caused significantly more frequently by concomitant intoxication than by intracranial haemorrhaging. [NO_AUDIO] Extensive scientific investigations have therefore recently aimed to identify additional diagnostic investigations to supplement computerised tomograms. In this connection, this slide shows what happens when a traumatic brain injury occurs. The blood-brain barrier opens for a short time and this means proteins typical of the brain can then be identified in the peripheral circulation. [NO_AUDIO] One protein specific to the brain is S-100B which is shown here in the axonal cells by way of example. When the blood-brain barrier opens, then the S-100B becomes recognisable for a short time in the peripheral circulation. The outcome of these scientific investigations is that reference can be made to the measurement of S-100B in the peripheral circulation of patients following traumatic brain injury as an exclusion parameter so as to be able to dispense with a computerised tomogram having to be conducted. [NO_AUDIO] This Level C recommendation lays down that an initial computerised tomogram can be dispensed with for patients following traumatic brain injury and with a concentration of S-100B <0.1µg/l being present at the same time. [NO_AUDIO] The indication can be derived from this for imaging for traumatic brain injury based on a risk-stratifying scheme based on validated risk factors. If the patient is at high risk, then a CCT must be undertaken immediately. After a moderate risk has been established, a period of waiting can elapse before the S-100B needs to be measured. If the concentration of this protein is below the marginal threshold, then a CCT does not need to be conducted. [NO_AUDIO] [NOISE] >Hello, Mrs Schmidt. Here we are. Everything still OK? >> Yes, mhm. >How do you feel now? >> Good. >> Yes? [NO_AUDIO] [NOISE] The thing is, however, that we found a small haemorrhage in your brain [NOISE] and precisely there in the upper left region where you were hit by the tram. >> Okay. Is that bad? >> [NOISE] It does not look so bad at the moment, but it could get worse. That is why we have asked for you to be monitored and we’ll then do another check-up in six hours. >> Okay. >> Yes? [NO_AUDIO] >> Can you die from this? >> Well, if it gets worse and there is subsequent bleeding, then it may be necessary to operate. But given the way it looks at present, everything should turn out fine. >Okay. [NO_AUDIO] Okay. Can you give me any medicine for it? >> We can administer pain-killers if required, [NO_AUDIO] but otherwise just a little fluid and nothing else at all is to be taken. >> Okay. [NO_AUDIO] >> We still need to apply stitches to the wound. We’ll do that straight away. >> Mhm. >> And the important thing for you is: If anything happens, if you feel worse, if you cannot move your arm any more or you have a headache: report this right away. >> Okay. [NO_AUDIO] >> Is my husband still here? >> The sister is just fetching him in and then we’ll all go to the observation ward and after that we’ll see what the next one or two hours bring. >> OK. Thank you. Until afterwards, then. [NO_AUDIO] [NOISE] [NOISE] [NO_AUDIO] This algorithm shows the procedure currently used in our Emergency Admissions Department. If the patient presents with a traumatic brain injury, then a blood sample is taken as the first step. The Glasgow Coma Score is then established. If this is below 13 points, then a computerised tomogram is undergone immediately. If the Glasgow Coma Score is between 13 and 15, then the previous history is compiled in order to ascertain whether a corresponding risk is present. Depending on the classification of risk, then arrangements are either made immediately for a computerised tomogram to be undergone or the further procedure is to be followed. If the interval between accident and admission is under four hours, then the blood sample can be taken. If the patient is at moderate risk and has a GCS below 15 points, then a CCT should be conducted. The appropriate further procedure to be followed is then derived from the findings obtained. [NO_AUDIO] In summary, it can be stated that a traumatic brain injury represents an appreciable problem which frequently occurs. A mild traumatic brain injury tends rather to represent the greater diagnostic challenge for the doctor providing treatment in terms of sifting out any patient who is suffering from haemorrhaging from among the large mass of mild traumatic brain injury patients. Severe traumatic brain injuries frequently require a neurosurgical operation. The exclusion of intracranial haemorrhages is currently only undertaken by means of cranial computerised tomogram. It is possible that in future an additional diagnostic technique will become established. [NO_AUDIO] [MUSIC] [MUSIC] [MUSIC] [MUSIC] [MUSIC]
