My talk is Trauma and Burns. This is a summary of the talk that you have in your handout or in your package. And the main talk was written by Dr. Michael Dingledine from Rainbow. He's a trauma surgeon. I'm not a trauma surgeon. And I extracted some of his slides, and I will focus mainly on TBI. And disclosures, I don't have any. I'm not from New York, like Dr. Conway, obviously. And I have nothing to disclose. So things that you need to know. Can you hear me well? Things that you need to know for the exam. Well, everything that was presented needs to be, you know, you need to know. But things that are important in terms of TBI. One is how to calculate GCS. I know it sounds obvious. Everyone knows GCS. You know, but people use applications these days. Like, you know, when you do a line, and you use the ultrasound. So know how to calculate the GCS, and I'll show you the scale in the next slide. Know cerebral perfusion pressure. So what it is, is the gradient, you know, pressure gradient that will drive perfusion to the brain. And how to calculate it. This you need to know. This is mean arterial pressure minus ICP. And the units are in millimeters of mercury. Know the concept of cerebral blood flow. I do not think they will ask you, you need to know what are the components. But I don't think they will ask you to calculate cerebral blood flow. I have never seen a question like that. But you do need to know what are the factors that can, or that will affect cerebral blood flow, because that's part of how you're going to manage a patient with traumatic brain injury. So if the patient, what's the effect of oxygen in the cerebral vasculature? So if it's low, what happens? So vasodilation, right? And at the PCO2, PCO2 is high. You have vasodilation. It's more complex, but the idea is basically we have vasodilation. If the PCO2 is low, you have hypocapnea. You have vasoconstriction of the arterioles. So it's important that you review these three items in TBI. Know the physiopathology of cerebral edema, vasogenic edema versus cytotoxic edema. Vasogenic is extracellular edema. And it's accumulation of basically water in the extracellular space. And cytotoxic is intracellular edema in the neurons and the astrocytes. And that cytotoxic is related to failure of the sodium potassium ATPase. And there is decreased ATP, basically, energy substrate. There are two other types of cerebral edema that are common, but I don't think they're going to be that frequently on the exam. One is the interstitial edema. And the other one is osmotic edema that you can see in DKA, for example, or hyponatremia. So sorry, let me figure out this. OK, GCS briefly. So I put it here. I'm not going to read all the components. You guys know there is the motor, a verbal, and an eye function, basically, or response. Few things to note. There is no zero. So the worst is one for each item. So your worst GCS is going to be three. Your best GCS is going to be 15. Having 15 doesn't mean that you're smart. It means that you are awake. Right now, I don't know how many GCS of 15. But that's OK. And so if you don't know how, you do know the components, but you don't know how to calculate it because you use an application 99% of the time, just remember that the worst for each item is going to be one. So that's easy. And then for the motor, for example, the highest is six, for the verbal is five, and for the eye is four. And then you can kind of play a little bit with the data. Sometimes it's like they give you an exam and you have to calculate the GCS. And then the next question is, what would you do with a patient? You know, the previous video was like, well, if you didn't calculate it right, the next answer will be wrong as well. OK, TBI. So be very familiar with the 2019 TBI guidelines. I don't know if you are or not, and I don't know if you have experience with trauma or not. But a couple of things to walk you through this kind of complex, busy slide. So severe TBI is defined as GCS equal or less than eight. So everything that's in black here relates to the baseline management of any patient with severe TBI. And you can read the components, but basically, it's an LGCN sedation, maintain normal thermia, maintain a hemoglobin above seven, elevate head of bed, et cetera. Then you have four different pathways. I don't think they will ask you this one on purple. Is the brain oxygenation basically a pathway? I don't think they're going to ask you for that because not everyone uses this type of monitoring, only a few centers. And so anyway, so I wouldn't focus that much on that. Definitely the ICP pathway, the yellow one, and the CPP pathway. And then I'll go over the herniation pathway in a moment. So ICP pathway, if you have a patient with a severe traumatic brain injury, and the CPP is above 20, and you have to look at everything in the context, right? But severe TBI, CPP is increased, let's say 25, and is sustained, right? So there is an algorithm that will walk you through what you need to do. And if the patient has an EVD already in place, you will drain CSF. If the patient is awake or not well sedated, you will sedate, you will use hyperosmolar therapy, et cetera. Depending on the patient, you may decide, like if you're doing an arterial line on a patient, and you don't give him analgesia, the ICP will go up. So probably more than draining CSF, you have to give him analgesia. And so regarding osmolar therapy, either Manitoulin or 3%, the guidelines don't specify, you know, which one you have to use during management of ICP. The only thing is that Manitoulin is an osmotic diuretic, so you will have a lot of water losses, and so you have to be careful with that. And then in terms of CPP, CPP, remember the concept? So for adults, the goal CPP has to be between 50 and 80. In kids, it's a little variable, I would say, but on the guidelines, the recommendation is the CPP should be above 40. And in general, we keep it higher than that, you know, closer to 50, 45, 50. And if the CPP is low, so then there are some things that you could do to help, you know, improve the perfusion pressure. So you can replace the intravascular volume, and you can use vasopressors. In general, we use norepinephrine. And of course, you can give 3% sodium chloride as well. I want to go over the herniation pathway. So because many times they like to put those questions on what your intervention is going to be. If you have a case where they are giving you a kid who has a traumatic brain injury and blew a pupil, and they give you different options, including CT. And Dr. Zimmerman mentioned this earlier today. The first step is not to take the patient's CT. It's going to be there. They will put CT, and people will jump on CT. But when the patient is herniated in your face, like Dr. Zimmerman said, you start to hyperventilate the patient, put him 100% oxygen, and blow CO2. And at the same time, you are going to give him 3%, and you're going to say, I need to take this kid to CT stat, and you will call your neurosurgeon, et cetera. But do not answer CT, because it's going to be the wrong question, the wrong answer, sorry. Okay. If all your measures have failed in terms of managing ICP, then you move to the next step that is in the guidelines, second-tier therapy. And the second-tier therapies are focusing on refractory ICP. And you will CT the patient to be sure that there's nothing you need to do. You know, there's a hematoma that needs to be decompressed, et cetera. And if there is no new expanding lesion, then these are all the things that can be done. So, for example, the first-tier therapies recommend normothermia, right? It's not hypothermia. So, and that can be a question as well. For second-tier therapies, once all the other measures have failed, the recommendation is hypothermia, like it's showing you here, and it's 32 to 34 degrees. For example, hyperventilation, normally, not normally, but in the first-tier therapy, we try to keep PCO2s between 35 and 40. But if you're using, a patient has refractory ICP, you may hyperventilate him a little bit lower, but you will try not to do it for prolonged period of time, but you may use a lower CO2. And then the higher smaller therapy, it depends on the centers, because you can say, if you're from San Diego, for example, they tend to use a lot of 3%, and sometimes they use the, you know, they bring the sodiums up to the high 160s. Most of the centers use around, you know, 150, 155. So, per guidelines, not per your individual centers, but per guidelines, I mean, if you're using refractory, if you are managing refractory ICP, you will use higher, higher or smaller therapy, bringing the sodium, ideally not beyond 160. And, okay, any questions about this? Okay. Monitors. So, this graph, or similar, was in my exam. So, know about the monitors, and where do they go? So, main thing is there are two types of monitors. One is the intraventricular monitor, the EVD, that you guys are familiar with, and that the catheter goes, usually in the third ventricle, if the neurosurgeon is able to place it. And the other ones are the intraparenchymal or the subdural monitors, or the epidural monitors, that basically, the difference between one and EVD is that with these ones, you cannot drain CSF. So, with the EVD, obviously, you are able to drain CSF. That's one difference. The other difference is how you set up, and sometimes they ask you some things about how you set up the monitor. So, for the EVD, you level, you zero the monitor, the transducer, at the level of the triggers. So, the catheter is being placed by the neurosurgeon. Once the catheter is in place, the zero happened, the zero level happened after catheter placement. In these other monitors, that have a fiber optic, basically, catheter, the zero has to occur before the placement. So, what happens is, if you have a subdural bulb, for example, and it has not been zero prior to placement, you will not have a reliable ICP. The other thing that can happen is that it's called zero drift, which is drift basically of the pressure that some of these catheters, you cannot reset once they are placed. So, over several days, even if you zero the catheter prior to placement, then after several days, the zero may drift, and the numbers may not match the clinical picture of the patient. So, if you have a case with a patient that has, for example, a bolt, not an EVD, and the ICP measurement doesn't match the clinical picture of the patient, that patient needs to be taken to CT, for example, or don't rely just, or some intervention should happen according to the clinical picture of the patient. Like, if the patient looks bad and the ICP is reading well, well, trust the clinical picture of the patient. So, different CSF drainage, yes, no, and how you zero the catheters. I know Ed Conway has some slides about this, so I will skip Blitz, but just know this is an epidural subarachnohemorrhage, and I saw that he has some slides on this, so I will skip this one. Okay, so here is a summary of the TBI guidelines. Keep in mind, analgesia and sedation essential. Which sedation and analgesia, the recommendations from the guidelines are benzos and anacortic. Maintain intravascular volume, maintain good CVP, maintain good urine output. Range for our targets for mechanical ventilation, PAO2 90 to 100, PCO2 35 to 40, unless you are in the next step, second tier therapies, and when a patient has refractory ICP that you will use a lower PCO2. Temperature, first tier therapy, normothermia, second tier therapy, you can lower the temperature to 34, 32, 34. Maintain normal glycemia, maintain sodiums above 140, maintain hemoglobin above 7, correct coagulopathy if needed. Another important topic is anticonvulsants. So it is recommended to use in severe TBI anticonvulsants for the first few days, and ideally put a continuous EEG. And the anticonvulsants recommended are orfenitoin, fosfenitoin, or Keppra. This is not for long term. This is for the initial management. And the other topic that's important is nutrition. So do we feed these patients? Yes. Unless you are escalating pressures and the patient is derailing, you will not feed him. But otherwise, if the patient is not happy and has a period of stability and you're maintaining, you know, not epinephrine to maintain adequate CPP, it is OK to feed these patients. And the earlier, the better. We talk about all the other items. OK. Spinal cord injury. So in general, kids have a very flexible spine. And these are the factors that lead to spinal cord injury in kids. In general, they don't have fractures. They have stretching. They have ligamentous injury, or they have some displacement. But in general, they don't have fractures. So they may ask you how to clear a spine, a C-spine. And this is what most centers are using this day. I put another slide, the next one, that is similar to this that is from the AIP. But most of the trauma centers use this nexus criteria. And so if the patient, if you think a patient has a spinal cord injury. So deciding how you're going to manage the patient will depend on your exam, will depend on your exam. So should I obtain x-rays or not? Well, in general, yes, depends on the mechanism of injury and depends, you know, if the kid, you know, is awake and alert and doesn't have any tenderness, you may not. But the things to keep in mind are if there is any cervical spine tenderness. If the patient, an older kid, is intoxicated, that is altered mental status, and you cannot have a good exam. If there is any type of neurologic deficit. If there is a concurrent painful distracted injury, let's say the patient has a fracture or has an abdominal injury, a laceration, these patients are in pain, and it will be very difficult to figure out if they are in pain because of the spine or because of the other injuries. If the patient has significant facial or head trauma, any type of trauma, in little kids, torticolis, in the mechanism of injury, all these things will guide you to say, well, I do need, I cannot clear the spine clinically, so I need to get some imaging. What type of image? Well, the first step is plain films. And you can see if there are fractures of these locations. In general, CT can show you bone injuries, but in general, and especially in kids, we move to MRI if needed. So how do we clear? Do we have to go to neurosurgery all the time to clear the spine or to the trauma surgeon? Not always. Some ERs, they do it themselves, and it depends if you're in a trauma center or not. But basically, if the patient has, if you did x-rays and the x-rays are negative and the patient doesn't have any pain to palpation and has full range of motion and doesn't have any other neurologic deficits and doesn't have facial injuries, so then you can probably clear the spine clinically. If you are concerned, then you have to just make a consult, keep the patient on the C-collar. This is the Pediatric Cervical Spine Clearance Working Group algorithm, and this is from the AAP. In reality, it's similar to what I just showed you from Nexus. And what is telling you here is if the patient is awake, because a GCS of 14 or 15, then you have here the history, what type of injury, like is the physical exam, does the patient have torticollis or not, et cetera. And if all this is negative, then you can clear the spine clinically. Any questions about this? No? Okay. CWORA. So, CWORA stands for Spinal Cord Injury Without Radiologic Abnormality. And before people had MRIs pretty much in every center, it was something that people suspected but didn't have enough imaging because in the CT, you didn't see anything, and the X-ray didn't show anything either. So basically, what this stands for are clinical findings of spinal cord injury without abnormalities in the X-ray or the CT scan. So for the exam, what they may give you, the case of a kid, you know, have some neck tenderness or you are concerned a little bit about, you know, the exam, but the kid doesn't have severe deficits, and then they will show you an MRI. And you don't know what the MRI shows, but they say X-ray is negative, you did the CT, the CT is negative, and you did an MRI. Most likely, there's going to be some ligamentous injury, and it's going to be CWORA. So they like to ask about this. Okay, neurogenic shock and spinal shock. Neurogenic shock is basically a hemodynamic shock. It's characterized with hypotension and bradycardia. So patients with trauma, in general, they are hypotensive because they are bleeding most of the time. Spinal cord injury, especially in kids, it's not the first diagnosis, but depending on the mechanism of injury, and if the patient has hypotension and bradycardia, and you think the patient could have spinal cord injury, think about spinal shock. So how, why this happened? Well, there is loss of sympathetic stimulation, and then you have over-parasympathetic stimulation, and that's why you have bradycardia and hemodynamic changes. So the initial management is vasopressors and fluid. These patients with this bradycardia can develop severe arrhythmias and can be really hemodynamically very, very unstable. With initial resuscitation, the shock resolves within a few days. The spinal shock is something different. It's basically flaxseed paralysis, so it's motor and sensation. It's flaxseed paralysis, loss of bowel and bladder function. And these ones can coexist, but if there is a question about this, most likely it's going to be trauma patient presents with hypotension, bradycardia, and how would you manage this patient, which with pressure you use in general is norepinephrine, and norepinephrine and not phenylephrine because phenylephrine has only alpha effect, and in general, it's recommended to use something that will also increase a little bit the heart rate. Pressure source in spinal cord injury, things to remember is that they happen very, very, very early, so they can develop within hours in patients that cannot move, and it's important to remove the backboards and roll the patient and start taking precautions from the moment the patient is admitted and do the initial stabilization of these patients. Okay, so summary of spinal cord injury in kids, how to clear, you can clear if the patient is awake and asymptomatic, can clear without even any imaging. If you obtain image, you can obtain x-ray CT of MRI, but this will depend, what you're going to do will depend if the patient is awake and alert and the mechanism of the injury and what you find in the physical exam. Know about seawater, remember spinal shock, hypotension, bradycardia, and remember what I mentioned about pressure ulcers, and also remember nutrition in these patients is essential. Burns, okay, I think I'm, let me see, what time should I be done, by now? I'm over, 10 minutes ago, yeah, okay, 10 minutes ago, yeah, okay. I don't know, Teresa is waving, but I'm not sure, I should be, five, okay, let me just go over just a few things, because again, I will skip the carbon monoxide and all that, because Ed Conway has slides about that. They may not ask that many things about burns, but I think the things that may ask are, and some of these questions, in fact, were in my exam way, way back, is if you have, they won't ask you, you know, what's a superficial burn and you're red and a little painful and all that, no, what they want you to know is what do you do if the patient has, for example, develop compartment syndrome? And that usually happens, you know, in patients that have deep burns and they have full thickness and in general, you know, circumferential burns. So if you have a patient that's intubated and has chest or abdomen or severe burns in the lower extremities, you know, in, if the patient, for example, perfusion changes to the lower extremities, or for example, in the chest, you cannot ventilate the patient because what, so these type of burns, the tissue is, doesn't stretch out, so you can basically have compartment syndrome. And so the initial management is by surgery, you know, kind of to break the scar and in different places. It's not a fasciotomy. It's like they have to break it in different sides and to kind of allow the tissue to expand. I don't think that we'll ask anything else on that. And if they do, let me know. We talked earlier about resuscitation. So the Parkland formula in, I still think that that's what the formula that they would like you to know. And I hope we are right. How do you know your resuscitation is going correct? Okay, follow your urine output. These patients, you know, I sound like Raj, but really in this case, it's like, yeah, you need to have urine output at least 0.5, preferably one per kilo per hour. Okay, I will skip most of the next few slides. I just want just a couple of things about inhalation injury. If the patient has respiratory distress, any change in voice, any burns on the face, any stridor, the patient needs to be intubated. These patients develop, you know, like airway burns can present initially with minor symptoms and then progress rapidly. They have edema. They have, you know, eventually develop necrotizing bronchitis, severe bronchospasm. They have casts. You have to bronch them. So the thing, most of the questions are related to the initial management. The patient gets to your unit or to your emergency department and he has a little distress. The tats are okay and a little cannula, but he has a little stridor. Would you give resamecapinephrine or you will take care of the airway? And the answer is you take care of the airway. You could give resamecapinephrine to start with, but you have to intubate the patient. So, yeah, that's all from that one. Carbon monoxide, Ed mentioned. One thing I want to mention about carbon monoxide is, well, remember that you need to measure carboxyhemoglobin. You need co-oxymetry. But the other thing is, like, if a patient was in a, he has carbon monoxide intoxication, was a burn in the house, you have to think that maybe cyanide intoxication as well. So they go together and you cannot exclude it. So any patient who has severe carbon monoxide intoxication should be considered to have also cyanide intoxication. And it's important to remove the clothes, wash the skin, et cetera. And this patient should receive hydroxycobalamin. I think it's misspelled there. And that's a precursor of vitamin D that binds the cyanide and helps to remove the cyanide from the respiratory chain. That's the summary. And I think that's the end. That's all. Thank you.

Traumatic Brain Injury

Glasgow Coma Scale

Cerebral Perfusion Pressure

Spinal Cord Injuries

Parkland Formula

Compartment Syndrome

Hydroxycobalamin