Case of the day

Severe Traumatic Brain Injury

65yrs/M,Unhelmeted, Unconscious after he had lost control of his Scooty brought to the emergency department via ambulance NEUROSURGEON EXPLAINED POOR PROGNOSIS TO RELATIVES. Chief Complaints RTA with Head injury History HTN Vitals BP - 190/100,PR - 45,RR - 22,Spo2 - 100% on Ventilator Physical Examination GCS - E1M2Vet,Pupils - 4mm B/l Fixed pupils, Negative corneal reflex,Large LCW approx 10×0.4Cm on Right parietal region Investigations ABG - Ph -6.9,Pco2 - 60,Po2 - 120,Na -125,K -6 Rest report awaited Diagnosis DIAGNOSIS? Management PLAN?

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Left frontal contusion,left fronto temporoparietal SDH,sulcal blood, blood in the sylvian fissures left > rt,nloid in the suprasellar cisterns, duskatayion of rt lateral ventricle,midline shift to rt and brain e dema.

Imp SAH with frontal contusion,left frontotemporo parietal SDH,hydrocephalus ( dialatation of rt lateral ventricle post horn) uncal and sub falcine herniation ,mid line shift to rt withbrain edema. Suggest supportive management. Neurological documentation .
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Traumatic SAH lt tempoparietal region Total midline shift to rt Diffuse Cerebral oedema Hyponatremia Pt is uncontrolled hypertensive GCS is poor and critical rather presentation suggest pt is no more If alive Rx inj NS Inj manitol Inj dexamethasone Inj Ceftriaxozone Inj lasix Gradual lowering of bp keeping vitals intact and monitoring

Thanx dr Praveen Yograj sir
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With bilateral fixed pupils , negative corneal reflex , is indicative of the nature of severe head injury, diffuse cerebral oedema and axonal injury, multiple left frontal haemorrhagic contusions, left temporo- parietal SDH , , SAH , compression of left lateral ventricle and gross midline shift to right with uncal and subfalcine herniation. Not possible to revive in such condition Can be a candidate for organ transplantation

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Thank you doctor
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There is hemorrhagic contusion predominantly in left frontal region also extending on parietal region, there is subdural hematoma in left frontoparietotemporal region There is midline shift and compression of opposite side Patient is having poor neurological status If this is a fresh injury and not much time is lost - then left fronto parietal decompression craniectomy may be worthwhile. Following are factors which favour surgical intervention in consultation with neurosurgeon 1) Maximum brunt of injury is in left frontal region, left occipital and good part of left parietal lobe appears intact, entire of right brain is intact 2) Major part of injury appears to be concussion and midline shift causing compression on opposite side - both are reversible factor 3) Though pupils are not reacting, patient is not actually brain dead because he has M2 motor response, which indicate generalized extensor response, indicating decorticate status In this case time is precious. Early decompression craniectomy may be able to salvage life - there is slim Ray of hope. High risk consent and possibility of poor outcome need to be explained. Even few hours if delay - the golden hour may be lost.

R T A.. WITH SEVERE. HEAD. INJURY.... AND ..SEVERE. H T N... ON... 100%. VENTILATOR... FIXED. PUPILS DIFFUSE. CEREBRAL. EDEMA .. NICELY. DISCUSSED. IN DETAILS.... THANKS. DR

Lt Frontotemporal contusion with SDH and mass effect. Craniectomy and decompression. Will require Ventillatory support Outcome Guarded prognosis

mostly brain death Wait n watch

Nat Sulph arnica Montana

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