Pestana’s Surgery Review, Ep. 1 – Trauma

Hello, I'm Dr. Carlos Pestana. I'm going to be reviewing with you the surgical topics for USML instead too. Let me start by telling you how we're going to do this. First of all, this is not going to be a comprehensive review of all of the surgical topics. It is impossible to do that in a limited time. So we're going to cover only selected material, selected because we expect it has a highest possibility of being on the exam. Now this exam, as you know, is a clinical exam. It emphasizes clinical material and to the greatest possible extent. All of the people who write questions for it are asked to do it in the form of a clinical vignette. So the first selection criteria to decide what we're going to cover is actually that one. I'm going to cover primarily topics that lend themselves to the vignette format, a little clinical description of a patient, and then we take it from there. And in fact, we have structured this whole review around approximately 500 such clinical vignettes. Now the clinical vignette's cover material that's either very commonly found in the surgical practice or that follows a definition of what's called high impact disease. High impact disease means something that even if it isn't terribly common, it's something that makes a big difference for the patient if the right diagnosis and management is made. So those clinical entities that if misdiagnosed or mishandled would lead to the death of the patient or would impose severe problems on the patient, those are excellent examination topics. So we're going to cover primarily those. Now in each of the vignettes, the first thing we're going to have to recognize is the diagnosis. If we don't know what we're dealing with, obviously we cannot go any further. But actually in the examination questions, there are not very many questions that ask only for the diagnosis. There are some. There is a form out of question called an extended matching set in which you have the beginning a list of diagnosis, perhaps eight or ten or twelve. And then after that a list of little vignettes, these are very short vignettes, one, two, three lines each and then you have to match each of the vignettes to the diagnosis at the beginning. But for most of the exam, you're going to be asked to produce more than a diagnosis. Because many of exam questions actually call for the management of the patient, for the treatment. Now the question could be phrased, you know this is a clinic of scenario, how would you treat the patient? And of course in doing that you have to come up with both the diagnosis and the treatment. But the question could be phrased in an even more comprehensive way by not asking you for the treatment or asking you for the management. And management is a somewhat vague word. It could include treatment if you are ready to treat the patient with the information at hand. But it might be that the next step in management has to be another diagnostic test. And so as we go through the vignettes, we'll try to identify in each one of them what is the diagnosis, what if any other additional tests do we need and then finally what the management would be. Let me point out on the latter when it comes to the treatment and perhaps even for the diagnosis as well, that there are many examples in surgery where the same condition could be handled in different ways by different practitioners. Now that is a reality of surgical practice and that can be reflected on the exam. So many times as we go through some of these vignettes I may point out to you this could be diagnosed with these or these other tests or it could be managed in these or these other way. And in doing that, I don't want you to panic and think well what if I am given two of these things, both of which you said they are correct, how can I pick one of the two? I'm a real sugar that you will not be given both. It is a very important design feature of the exam that every question can have only one unequivocally correct answer. And so in pointing out in some of the vignettes that there are different ways of managing, I'm simply alerting you to the various correct answers only one of which could appear on the question. And we point out incidentally as we go forth, you know, forth that the text that you can use as we go through these vignettes is the text where we have in fact the collection of vignettes. In your material there is also a narrative description of the surgical topics. It follows the exact same pattern, the same headings and titles and some titles. The narrative part was given to you because that's more convenient for just reading. So in the evening, when you're reading by the fireplace, it flows better to read a narrative thing. But for the review here, we're going to use the vignettes. Well, we're going to begin now and we are then on the first block of vignettes which deal with trauma. The first subheading is the initial survey, the famous A, B, C's that stand for airway breathing and circulation. And the very first group has to do with the airway. Now, vignette number one says a patient involved in a car accident is fully conscious and his voice is normal. Now, obviously you're not going to have an examination question that says only that and then ask you what are you going to do for this patient. But embedded in a longer vignette, if you read the words, the patient is fully conscious and his voice is normal. That means that patients airways fine. That patient doesn't need an airway. So that vignette might say that the patient also is short of breath or is blood pressure is down or whatever. Those may be the things that need to be addressed. But let me repeat again, if we read in a trauma patient that the patient is fully conscious and his voice is normal, airway is not the issue. But let's move on because we have to be alert to the possibility of that very same information followed by a qualifier that then gives us a different situation. Let me read vignettes two and three. A patient with multiple stavoons arrives in the ER fully conscious and he has a normal voice but he also has an expanding hematoma in the neck. In vignette number three, a patient with multiple stavoons arrives in the ER fully conscious and he has a normal voice but he also has subcutaneous air that is to say emphysema in the tissues and the neck and upper chest. Now both of these patients, as we speak, they have a good airway. They are awake, they are speaking with a normal tone of voice. But the expanding hematoma in the neck or the air building up in the neck tissues means the patient is going to lose that airway in the very near future. Obviously, it would be then better to put an airway now rather than waiting until it's panicky because the patient is blue in the face and is not breathing anymore. So both of these patients need an airway. Now let me go a little bit into how that airway would be placed. It's a little different for the two. Let me begin with the first one. The one that has a expanding hematoma. He is fully awake, fully conscious. So this patient is going to need a brief quick anesthetic induction. This is typically done with false oxymetry to make sure that he's oxygenating while this is done. And then the most common way would be oral tracheal intubation. But it's not the only way. It could be nasotracheal. And so the correct answer could say rapid anesthetic induction with false oxymetry and intubation. And that could be oral tracheal. That could be nasotracheal. And the second one of these two, the one that has a tissue with air. That one is a little different. And in fact, we're going to talk more about that one later. But that one signifies that there is a tracheal bronchial injury. And that one will need the kind of intubation where we see the inside of a tracheal bronchial treat. The intubation will have to be done over a fiber optic bronchoscope. I'm not going to delve into that one because we have it in yet coming up later that has to do in fact with tracheal bronchial injuries. So we'll cover it then. Now let me move on then to the next one. The end of a four, a patient involved in a severe car accident has multiple injuries and is on the right. conscious is breathing spontaneously but is breathing sounds girically noisy. Now we have two very important clues in this Vignette. The very first one is when we read that this accident victim is unconscious. That alone is an indication for getting an airway. In fact, if you look at all the patients, all the trauma patients that is, that are driving an emergency room that get to be intubated, the most common reason why they are intubated is that they are unconscious. A trauma victim who is in coma, who is unconscious, cannot maintain, cannot protect an airway. But in addition to that, if you didn't get the clue at the beginning, when you then breathe that is breathing spontaneously but is breathing sounds girly and noisy, that second little detail there alerts you again to the fact that he is not breathing easily. So here again we need an airway. Now obviously if the patient is unconscious, you no longer need that rapid induction of an anesthetic. The patient is already anesthetized. So all you need here is to place the airway. The most common thing would probably be auto-trivial intubation but it could be nasal traculum, it could be in some other way. Now as we move down we are going to get into a little more complicated situation. Pneum number 5. An unconscious patient is brought in by paramedics with spontaneous but noisy and labored breathing. They relate that at the accident side the patient was conscious but was complaining of neck pain and was unable to move with lower extremities. He lost consciousness during the ambulance ride and effort to secure an esotrachial airway were unsuccessful. So here you are presented with a classical dilemma. You know from living yet that the patient has spinal cord injury and therefore you should not be moving his neck. The vignette also gives you two good reasons why he needs to be intubated. He is unconscious, his breathing is noisy and labored. Well in this particular dilemma the airway comes first. Obviously we'll have to be placed in a way that doesn't move the neck, that doesn't compound and make wears a spinal cord injury. But there is no doubt that the airway has to come first. So don't pick the answer where you first take chestaches, I mean x-rays of the neck or seeke scans of the head because the patient without an airway will be dead in 5 or 10 minutes. So now we have to look for an answer where we put the airway in but do it in a way that doesn't hyper extend the neck, doesn't move the neck. Probably the best answer might be nasal tracheal over a fiber optic broncoscope. And that way the person doing this can see where the tube is going. It could be oral tracheal also with a use of a broncoscope and it could be without a broncoscope. There are anesthesiologists that have become very adept at blindly placing the tube and by listening to it, by you know in some other way determined that he's gone into the airway. The point, I think the important point on this vignette is given the coexistence of spinal cord injury and the need for an airway, the need for the airway still comes first. Final answer was done without moving the neck on the society. Now as we move on we get into other complicated situations. Vignette number 6. A patient involving a severe automobile crash is fully awake and alert but he has extensive facial fractures is bleeding grisly into his airway and his voice is masked by gurgling sounds. Here is another need for an airway. You got blood going down from his multiple injuries and the face, the patient needs an airway otherwise he may drown in his own blood. But now the usual avenue to get into the airway, putting a tube through the nose, putting a tube through the mouth is not available. Those areas are now smashed. Multiple fractures is probably not a nasal passage anymore and if you go through the mouth or you're going to see his blood all over the place. So these are indications then to secure an airway by going through the neck directly. Now let me first alert you to the answer that is not the correct answer. Do not pick the answer that asks for an emergency tracheostomy, don in the emergency room or don at the field. Emergency tracheostomy is a horror show. Emergency tracheostomy simply shouldn't be done. A tracheostomy is a procedure that needs to be done in the operating room with proper light, with proper health, in a patient who already has an airway. So that's not the answer. The answer probably the best one would be a cryocthyroidotomy. I mean I'll add to the existence of another possibility. One can place a little catheter pericoteniously into the trachea, not a big enough airway tube, just a little catheter and then place the patient on a machine that does high frequency ventilation. So that is another possibility. If the patient were to have a head injury where good ventilation is required then the little catheter would not be a good idea because you cannot truly ventilate the patient very well, even though the name of the procedure is high frequency ventilation. Any fact in ExpoNet exemplifies that. In year number seven, the patient involved in a high speed automobile crash, arising the ER on conscious with multiple facial fractures, breeze bleeding into his mouth and throat and girly irregular labor breathing. He needs an airway, we have no access to the nose or mouth, but the fact that his unconscious means he's got a head injury, he's going to need good ventilation, putting a little catheter in the trachea would not be a good idea. So the only correct answer here is going to be the cryocthyroidotomy. Well that finishes the airway. Let me recapitulate the essential points on the airway. The patient is awake and speaking with a normal tone of voice, we don't need an airway. That very same description, but expanding him at home in the neck or air in the tissues in the neck, it's going to be needed. If we're given the patient and has the airway need, plus the spinal cord injury, we still need the airway first. And if we're given the patient who's bleeding through the nose and mouth, multiple fractures in the face, the airway will have to be placed directly through a cryocthyroidotomy. All right, let's move on then to the B of the ABC, the B stands for breathing, the N number 8. An unconscious trauma patient has been rapidly intubated in the air. He has spontaneous breathing and bilateral breath sounds and his oxygen saturation by post-oxymetry is above 95. That patient is breathing for him. So these items of information that I've just read identify a patient who doesn't need help breathing. Three things. One, he is starting his own breathing motion. Number two, both lungs are participating. As evidence by the fact that he's got bilateral breath sounds and enough oxygen is being put into the blood. Now the examples of situations where breathing needs to be helped pretty much relate to chest trauma. So we're going to be reviewing those later on as we go to that chapter. So let's move on now to the C of the ABC, the C stands for circulation. And therefore we're now identifying the Neds where the patient is in shock. Therefore it doesn't have good enough perfusional tissues. The N number 9, let me alert you by the way to the fact that it's going to be a long discussion, following the N number 9. But let's begin with the Vignette because this sets the you know stage of what we need to discuss. A 22 year old gang member arrives in the ER with multiple gonciad wounds to the abdomen. His diaphoretic, pale, cold, shivering, anxious, and asking for a blanket and a drink of water. His blood pressure is 60 over 40, his pulse rate is 150 barely present. Well first of all we can identify that this patient is in shock. We have the two numerical measurements that are immediately obtained in a patient in shock. The blood pressure is way down. It's below 90 which is the you know the the level at which shock is set to exist and his pulse rate is very fast and very poor quality. So we have the low blood pressure, the fast poor quality pulse, but an addition to that, that classical presentation of a patient who is in shock, the individual who is diaphoretic and pale and cold and shivering and anxious and so on. So we know this is a patient in shock and we also know from Breed-Indivinear that this is in the trauma situation. This is not a patient who is sitting at home and went into shock from internal bleeding or something. This is a trauma situation. There are three conditions that may be responsible for shock in a trauma patient. Number one and by far the most common is bleeding. The patient is bleeding somewhere, the shock is hypervolumic, hemorrhagic shock. There are two other possibilities to consider in a trauma patient. A trauma patient could be in shock because of very carnal tamponad or because of tension pneumothorax. Now for either of the last two to be the reason for the patient being in shock, the trauma then has to have included the chest. So if the vignette is that penetrating trauma, gonchard wound or stab wound, it will have to say gonchard wounds to the chest and maybe other places, stab wounds to the chest and maybe other places, but the chest has to be included. Now if it is a long trauma patient then automatically the chest could be included. The patient is in a car accident and has multiple trauma. There is no way that we can exclude the chest as a possibility. So in the blonde trauma they don't have to specify he had blonde trauma and he hit his chest. Now in addition to the fact that the chest has to be involved, there is one physical find in that immediately alert you to the fact that what the patient has is either a pericardial tampon or tension pneumothorax. And this is that the patient will have big, distended veins in the neck and forehead. Of course that information could be given to you as a measurement of central venous pressure which will be very high above 20 or 25. So we have then to identify the patient that has either pericardial tampon or tension pneumothorax as a reasonable shock. A trauma victim in which the trauma has included the chest and who in addition to the description of shock were told it's got big, distended veins in the neck and forehead. I might point out that the patient who is bleeding, the patient who is in hemorrhagic hypervolimic shock has empty veins. You certainly wouldn't see them distantly. Now what about between pericardial tampon and one hand and tension pneumothorax on the other? But in pericardial tampon and add you have the trauma that included the chest, you have the patient in shock, you have big, distended veins but that patient is breathing fine. Pericardial tampon add doesn't interfere with breathing. Tension pneumothorax on the other hand interferes severely with both breathing and circulation for the patient whose reason for shock is a tension pneumothorax as a patient who is gasping for breath, who is flaring at the nostril, who clearly has a labor difficult breathing. And as you examine that patient or do we need to tell you the patient has been examined, it will be obvious eventually also that there are no breath sounds on one hemithorax but it is when it pericardial tamponetic and the dimetia stony is shifted to the other side. So with that background, let's go back and read this thing yet again because now when we read it and we read during a bank robbery, excuse me, we read a 22 year old organ member arrives in the yard with multiple gunshot wounds to the abdomen and he doesn't say he was shot in the chest. Then we already know his individual is in shock because he's bleeding. We even know where he's bleeding in the abdomen that's when he was shot. So this brings me now to another very long discussion what I were going to do with his patient, what's the management for this patient. And the reason there is going to be a long discussion here is that our understanding, our philosophy of the treatment of hypervolimic shock, hemorrhagic shock has undergone a very significant change in the last decade or so. We have known, or ever and ever, that hypervolimic shock is an emergency situation, requires immediate attention. We have known that if a patient is allowed to remain in shock for several hours, he gets very sick and may not be salvageable anymore. So the urgency in the treatment of shock is something we've understood for a long time. But typically when we talked about the treatment of hemorrhagic shock, our emphasis was always on feeling the vascular tree as quickly as we could. And we talked about a resuscitation phase, one or two liters of ranger's lactate or a similar balance electrolyte solution infused in the first 20 or 30 minutes to be followed by blood as quickly as it became available. And almost as a footnote, in this emphasis on the feeling of the vascular tree, almost as a footnote, we said yes, and we should also stop the source of bleeding. Well, now that sequence has now been changed. And we now realize that if the circumstances are right, the first order of business and the patient was in hemorrhagic shock is to stop the bleeding. It makes no sense to be pouring blood and fluids in one way at the same time they're pouring out through the injury that hasn't been dealt with. And so the current philosophy of the management of hemorrhagic shock is if at all possible, fair stop the bleeding, then feel the vascular tree. Now obviously there are some conditions I will have to be fulfilled for this new philosophy to be applicable. First of all, we have to be in a place where the bleeding can be stopped. So this philosophy applies to the patient who's in the emergency room or in the operating room in the hospital in a big trauma center or near the trauma center. The patient will get shot and the place where he was shot, it just five minutes away from the biggest hospital in town. And the patient who's near a place where the source of bleeding can be stopped. But there is a second requirement too. We must know right away where the bleeding is. And the patient who gets shot in the abdomen is a good example. We know he's bleeding in the abdomen. So if we go back to this particular being yet, we've already read twice. But this patient needs first. This patient was shot in the abdomen and we know he's in hypervolimic shock. Is he needs an emergency laparotomy to stop the bleeding and then we'll fill up his vascular tree. Now, anytime I review these with a live audience, the students always ask me, do you mean you're going to do the exploratory laparotomy without starting intravenous lines? No, that's not what I said. Actually, to put a patient to sleep to do an operation we need intravenous axis and we will get it. What I'm saying is the correct answer is not infused two liters of ringers like they'd follow with blood and then operate the patient. The correct answer is not filled of a sculler tree until the hemoglobin is at a certain level and then operate the patient. The correct answer is not transfused until he's hemodynamically stable, then operate the patient. The correct answer is operate the patient, stop the bleeding and then fill up the vascular tree. I have to realize in contrast to this one that if we're dealing, let's say with a multiple trauma patient from blunt trauma who is in shock. We know he's bleeding, but he may be bleeding in a number of different places. He may be bleeding in the abdomen, he may be bleeding in a pelvic fracture, femur fracture. If it's going to take some time to do studies to determine where he's bleeding, during that time we will be filling up his vascular tree because we don't know where to go to immediately stop the bleeding. It will also be obvious as we go through some of the other vineyards that if the patient is very far away from where the appropriate steps could be taken to stop the bleeding, we're still better off filling up the vascular tree. I should make another observation. They pointed out two conditions, really they are three. The third condition would be the injuries one that we know will need surgery anyway. Like a concert wound to the abdomen. We're going to see a little later when we see patients with blunt trauma. Sometimes in the blunt trauma patient we may already know where he's bleeding, but it may be the kind of injury that could be managed in a conservative way. And if that were to be a situation, obviously, we will give the fluids and give the blood and not jump in and operate. Okay? Let's go to the next being yet because we're going to see the same issue again, emphasized in different ways. Here's another yet number 10. During a bank robbery in Innocent by standard, he shot repeatedly in the abdomen. When the EMTs arrive, they find him to be in shock. A fully staffed trauma center is two miles away from the site of the shooting. The question here obviously is what should the EMTs do? Well, you know, not too long ago, the EMTs would have spent 20 or 30 minutes at the site starting IVs on both arms, running fingers like they quote, "stabilize" and the patient before they moved him. Today, the instructions that we would give to the EMTs is scoop and run. Scoop and run is the way we express this new philosophy. Get the patient run to the hospital and, you know, we will operate, stop the bleeding and then fill up the vascular tree. Let's move up to being yet number 11. A 19-year-old male is shot in the right groin during a drug deal gone bad. He staggers to the hospital on his own and arrives in the ER with a blood pressure of 90/70 and a pulse rate of 105. He squirted him right red blood from the groin wound. Well, here is another example where we should stop the bleeding first, but this is one that doesn't need an operation to do it. The first thing to do in this patient is to put a finger where that bleeding vessel is and stop the bleeding with lock or pressure. Then we can fill up his vascular tree and get ready to do the operation that will repair the vessel that is injured. So perhaps a big question on this one will be really how to do that and the correct answer is not to blindly put a clamp in. That could injure other structures. The correct answer is not to put a tourniquet. The correct answer is direct pressure, either a glove finger or a sterile dressing direct pressure. All right, let's move on to being yet number 12. The car accident victim has arrived in the ER and the initial survey indicates that he is unconscious. This is not the topic here, but it reminds you he needs an airway, right? With spontaneous but noisy breathing and a blood pressure of 80 over 60 with a pulse rate of 95. His head and neck veins are not obviously distended. When the anesthesia team is intubating him and other team is placing a central line for CVP measurement and others are examining his chest and abdomen. Let's go through this. This is a trauma victim and he is in shock and we're told that his head and neck veins are not obviously distended. So we've been given every reason to believe this gentleman is bleeding somewhere. But this is a car accident victim. We don't know right now. He's bleeding his chest into his abdomen into a pelvic fracture into fractures in the legs. So the philosophy, let's go and stop the bleeding before we fill up the vascular tree is not applicable. We have to begin to fill up the vascular tree while we figure out where he's bleeding from. And so the point to this vignette is how do we do that? What is the route of access and what do we put into the veins? Now the route of access is one of those interesting things that changes with time. What used to be the correct time serve became the incorrect time serve and then became the correct time serve again. You know when I went to medical school and in the early years of my career we used peripheral veins to give fluid resuscitation to patients. And then there was a time when that was considered to be inappropriate and the emphasis was on a central line, a big catheter place either in a subclavian vein or in the internal jugular vein. But interestingly enough we've gone back to the peripheral veins and one of the reasons is the reality of what happens in an emergency room when there are a million people working around a patient. And this is a good example. The anesthesia team has already taken command of a head and neck to intubate the patient. There is another team nearby that is putting a central line for pressure measurements is not in yet. We cannot put the fluid in yet. Somebody else is examining the chest and what else is examining the abdomen. And yet lying out there are two arms and two legs that nobody is paying any attention to. They are the available sites. And so the preferred route is two big boards that be 16 gauge catheters in each of the arms. If that couldn't be done then cut down the ankles are acceptable as an alternative or a direct puncture of the femoral vein. So the route, let me repeat then, the preferred route for the fluid resuscitation is two 16 gauge IV lines in each, I mean in both arms one inch or if that is not possible then either cut down the ankles or punctures of the femoral vein. Now what do we put through those lines? We begin with one or two liters of a balanced electrolyte solution. I want to get into the big dilemma of what exact solution to use. Most people use ringer's lactate. If you happen to be concerned that lactate might not be converted to vicarbonate in the trauma setting with the patient in shock you can use acetating instead of lactate. This is not an issue that really has been settled. Most people agree that it should be a fluid that contains no sugar. So this is not D5 ringer's lactate. This would be ringer's lactate alone. The reason for that is you're going to infuse several liters in a short period of time. You're going to depend heavily on your urinary output as a guideline for the adequacy of therapy. And in those circumstances you don't want to create an osmotic dioresis that could invalidate the meaning of your urinary output. And let me emphasize again the amount we're talking about one or two liters in 20 or 30 minutes. We're not talking about a little you know vein in the back of the hand and a little thing going drip, drip, drip. This has to be a realistic rate of infusion followed by blood as soon as a blood becomes available. And eventually then monitored by the response of the patient. Among other numerical parameters the two most important ones would be our urinary output and central venous pressure. Let's move on to the next one. We need 13. A four-year-old child has been shot in the arm in a drive-by shooting. The sight of bleeding has been controlled by local pressure. But he is hypotensive and tachycardic. Two attempts at starting peripheral IVs have been unsuccessful. If one cannot get peripheral IVs in a child, this age or younger. The last resort for avenue of access would be intra-osios cannulation in the proximal tibia. The ringers lactated were using that for fluid resuscitation. The initial ballers would be approximately 20 ml per kilogram of body weight. All right. Let's move on to another one. We're keeping with examples of different circumstances and what we do in each of them. During a wilderness trek, a 22-year-old man is attacked by a bear and beaten repeatedly in the arms and legs. His trek companion manages to kill the animal and to stop the bleeding by applying direct pressure. When our paramedics arrive one hour later, they find the patient to be in a state of shock. Transportation to the nearest hospital will take at least two hours. Well, first of all, in his vignette, the bleeding has already been stopped. The direct pressure is taken care of that. His man is a long distance away from where he could receive adequate help. This is a situation where the EMT should spend the 10 or 20 minutes at the site, starting the IVs, getting the ringers lactated to flow to then move the patient. So I'm not implying that EMTs are never to start intravenous lines again. We don't want them to do it when the patient is five minutes away from the biggest hospital in town, but we want to do it. We want them to do it when in a situation like this, the patient can begin to be resuscitated before the long transportation takes place. All right, let's now move on to the end of the 15th. The 22-year-old gang member arrives in the yard with multiple gunshot wounds to the chest and abdomen. Let me emphasize again, now chest and abdomen. His diaphoretic, pale, cold, shivering, anxious, and asking for a blind in the drinker water. His blood pressure is 60 over 40. His pulse rate is 150 barely percent. We have here a person with a trauma victim that trauma includes the chest as well as the abdomen and he is in shock. So knowing that the chest is a component of the situation, we have to think could he possibly have very cardinal tamponat or tension pneumothorax rather than bleeding. Now if all you had on the exam was the vignette as I read it, then the answer is easy. He has to be bleeding. And let me tell you why. And this goes again to the design of the exam. If there is some essential item of information that you need to make the diagnosis and that essential item of information is not in the vignette, not in the stem of the question, then that cannot be the correct answer. In other words, if this patient had been meant to have a very cardinal tamponato tension pneumothorax, there would have been a line in the vignette saying he has big, distended veins or he has a high central venous pressure. In the absence of such information, we have to assume the patient doesn't have it. But on the other hand, this vignette opens up a very good potential line of inquiry. You might be given this vignette and then not ask what is the diagnosis or how would you manage the patient. The question might be what other item of information do you need in order to decide what's wrong with the patient? In the vatsic case and the answer obviously is I need to know if the veins are distended or I need a central venous pressure measurement, because otherwise you cannot determine that the patient has either a very cardinal tamponato or tension pneumothorax. All right, let's move to the next map. In January 16th. A 22-year-old gang member arrives in the yard with multiple gonzoid wounds to the chest and abdomen. His diaphragmatic, pale, cold, shivering, anxious and asking for a blanket and a drink of water. His pulse rate is 150, very impressive. He has big, distended veins in his neck and forehead. His breathing okay, has bilateral breath sounds and no tracheal deviation. We should have no problem recognizing this. As a trauma patient is in shock, the chest has been included, has been involved in the trauma. He's got big, distended veins, but his breathing is fine. His breath sounds are on both sides. He doesn't have deviation videos time. Obviously this is a very cardinal tamponato. How are we going to manage this patient? Let me first alert you to what not to ask for. Very cardinal tamponato, as described in this vignette, is a clinical diagnosis. You already know what's wrong with this patient. Furthermore, this patient is dying. His blood pressure is only 60 over 40. So don't send this patient to get a chest x-ray. That's not the answer. Don't ask for blood gases either. You have a clinical diagnosis and you are ready to treat the patient. The answer you're looking for is one that empties the pericardial sac. I can only give it to you that way. I can not be more precise because there are many different ways of opening an emptying the pericardial sac. It could be a pericardial window. It could be a pericardial synthesis. It could be a pericardial tube. In fact, the mediums are an auto-meat that might be done to control a heart injury is another way to open the pericardial. So look for an answer where you decompress the pericardial sac. Let me add one more thing though. It takes a little time to do one of those things. It takes a little time to do a pericardial window or to put a tube in the pericardial space. You might be asked, what do you do in the meantime? In the meantime, you would help the patient by giving him additional fluids and blood. One of the reasons I'm making this observation is that intuitively, you recoil from the idea of adding intravascular volume to a patient that has a big, distended veins. Because we all remember the message that pertains to the patient in congestive failure, that if you have big, distended veins and so on, that patient cannot handle any more fluid. But that's not a situation here. This patient's heart is not in failure. The reason for the big, distended veins is not that the ventricle cannot bump the existing blood. It's that the ventricle cannot feel with blood because higher up at the level of the atrium, the big veins, there is pressure that is preclude in the blood from getting into the ventricle. If we put more blood from above into the vascular tree, more blood will squeeze through and into the ventricle and the situation will be improved somewhat. I'm not implying that the main treatment or the only treatment is blood transfusion. But if you're asked, what could you do while getting ready to enter the pericardial site? The answer is you feel that vascular tree even more. Well, I open up an interesting issue here when I said there are different ways of opening the pericardial site and I think this is going to be illustrated in the next being yet. The end of the year 17. During a domestic dispute, the young woman is stabbed in the chest with a six inch long butcher knife. On arrival at the yard, she's found to have an entry wound just to the left of a sternal border at the fourth intercostal space. Her blood pressure is 80 over 50. Her pulse rate is 110 and she's cold, pale and perspiring heavily. She has big, distended neck and facial veins, but she's breathing normally and has bilateral breast. So we have again the picture of a patient in pericardial time for that. In fact, this one is easy because you have that entry wound exactly where you know that the heart is. But in this particular vignette, that's the only injury the patient has. Contrast that to the previous one. There was multiple wounds to the chest and abdomen. The previous one, it was clear that the patient was in pericardial time for that. That was a reason for the patient being in shock. But that was a patient who was going to need a lot of things done in addition to taking care of the pericardial time for that. So he was a good candidate for a quick solution to the pericardial time for that with a tube or a pericardial window. These are the lady on the other hand, the vignette were in now. The only injury she has is the one that has given rise to the pericardial time for that. We have every reason to believe it's a stab wound to the heart to the right ventricle problem. And she's going to have to have that stab wound to the heart repair. Well, when a medium sternotomy is done to open the chest to repair that wound that will open the pericardial side. So many trauma surgeons faced with this vignette would not bother to take the time to do a pericardial window and then do a medium sternotomy. They would start infusing fluids into the patient, rush the patient to the operating room and do the medium sternotomy that both decompresses the pericardial side and gives access to the repair of the injury. All right, let's move on now and we should have another one here that should be easy to recognize. This is now being yet number 18. A 22 year old gang member arrives in the ER with multiple gonciot wounds to the chest and abdomen. He has labored breathing and is cyanotic, diaphragmatic, cold and shivering. His pulse rate is 150 barely perceptible. He is in respiratory distress. As big, distended veins in his neck and forehead, his tracheus deviated to the left and the right side of his chest is hyper-resonant to per caution with no breath sounds. The elements are all there. A trauma victim in shock, the trauma included the chest. The patient has big, distended veins but in addition to that, the patient has respiratory distress. One side of the chest has no breath sounds. There is deviation of the trachea to the left. This is clearly a case of tension, pneumothorax, that third potential cause for shock and the trauma victim. Alright management, well let me alert you just like we did for the pericardial tampon ad. You have a clinical diagnosis, it's already evident then you have a dying patient, blood pressure 60 over 40. You don't need blood gases, you don't need chest X-rays, you don't need cat scans. The answer here is one where you immediately decompress the pleural space that is full of air under pressure. And the quickest way to do that is a needle, big bore needle, big bore catheter right through the second intercostal space into that pleural space to be followed then by a chest tube that is put on suction and underwater seal. So the answer here for this Vignette Lemur repeat again, first of all is a needle or a catheter to the pleural space, follow them by a chest tube. And follow that I might add by an exploratory laparotomy because if you go back to the beginning of a Vignette he was shot in the chest and abdomen but we will deal with abdominal penetrating injuries a little later. Alright. Vignette number 19, a 22 year old man is involved in a high speed head on automobile collision. He arrives in the ER in coma with fixed dilated pupils. He has multiple obvious fractures in both upper extremities and in the right lower leg. His blood pressure is 70 over 50 with a barely perceptible pulse rate of 140. So here again we have a trauma victim who happens to be in shock and the Vignette does not sense that he has a big, extended vein and then I can forehead so we have to make the assumption he is bleeding somewhere. The reason I put this Vignette here is that we have a clue here as to where he might be bleeding and the clue happens to be the wrong one that we need to avoid because we are told at the very outset that he is in coma with fixed dilated pupils. Namely we have been told he has closed head injury and then we are told he is in shock. And the question then might be where is he bleeding and the potential answers are going to include acute epidural hematoma, acute subdual hematoma, acute intraceuripral hematoma, acute bleeding into the subaragnosed space, none of which are the correct answer. The point that I am illustrating on his Vignette is there is sent in off room inside the head to bleed sufficient volume to go into hypervolimic shock. I am not saying that a patient cannot die from intraoclinia bleeding. They do all the time but when a patient dies from intraoclinia bleeding that patient dies because the clot has squashed the brain. But there isn't enough room in the cranial cavity for a liter and a half of blood which is what it takes to go into hypervolimic shock and the functioning brain. So this particular patient is bleeding someplace other than the cranial cavity. Where we are going to see later as we review other Vignettes. Let me alert you to this. This is a good example. You will give you those four options all of which are bleeding into the head and none of which are correct. All right. See we have been talking about shock and we have done it in the trauma setting. Let's take a little detour here and talk about shock in the non trauma setting. Now we said when we began reviewing shock in the trauma victim. That the trauma victim could be in shock for three different reasons. Bleeding which was the most common but also potentially pericardial tamponad, potentially in orthotics. In the case of a patient who goes into shock but not as a consequence of trauma, there are also three potential types of shock the patient could have. And two, excuse me, the three potential problems that the patient may have including and bleeding. And this could be spontaneous bleeding, a peptic ulcer, a rupture, or something like that. And the other two are either a myocardial problem that is to say cardiogenic shock. It would not be pericardial tamponad because that requires trauma but it could be something wrong with the ventricle like a massive myocardial infarction. And the third possibility would be vasomotor shock, the loss of peripheral vascular tone. Let's go through the examples. The enumer 20. A 72 year old man who lives alone calls 911 saying that he has severe chest pain. He cannot give a coherent history with a big top body EMTs. And on arrival at the ER, his skull and diaphoretic and his blood pressure is 80 over 65. He has an irregular fecal pose at a rate of 130. His neck and forehead veins are de-stended and he's short of breath. Remember, this is not a trauma victim. So now the de-stended veins and the shortness of breath are not telling us either a pericardial tamponad retention and motor rate. But they are telling us that this gentleman probably has had a massive myocardial infarction. That's a way it began, right? Chest pain. And because of a massive myocardial infarction is gone into cardiogenic shock. How do we identify a cardiogenic shock because it's got those big, de-stended veins? And then we can forehead. We could have been told also that he had a high central venous pressure. So let me say it again in the trauma setting, the big, de-stended veins mean either pericardial tamponad retention and motor rate, but in the non-trauma setting, the big, de-stended veins and the patient wasn't short, mean the shock is cardiogenic shock. Incidentally, the other two that we've been talking about in the trauma center setting are also cardiogenic shock, but extrinsic cardiogenic shock. Pericardial tamponad retention and motor rates are examples of extrinsic cardiogenic shock. This vineyard here is an example of intrinsic cardiogenic shock. We would treat this patient the way we treat the patient as having myocardial infarction. This vine, this one incidentally could not handle any more fluid into the veins. Now, vignettes, 21, 22 and 23 are examples of a somotor shock. A 70-year-old girl is stung many times by a swarm of bees. On arrival to the ER, she has a blood pressure of 75/20 and her pulse rate is 150, but she looks worn and flush rather than pale and cold, her CVP is low. In January 22, 20 minutes after receiving a penicillin injection, a man breaks into hives and develops wheezing. On arrival at the ER, his blood pressure is 75/20 and his pulse rate is 150, but he looks worn and flush rather than pale and cold, his CVP is low. In January 23, an inginal hernia repair patient has a spinal anesthetic place. His level of sensory block is much higher than anticipated and shortly thereafter his blood pressure becomes 75/20, but he looks worn and flush rather than pale and cold, his CVP is low. All three of these are examples of the sudden loss of the refralbascular tone, either as part of anaphylactic shock in the first two or as part of very high spinal anesthetic, you could have been from a spinal transaction on the third of the examples. What identifies these three as vasomotor shocking addition to the circumstances is the fact that each of those, the patient looks worn and flush rather than pale and cold. And we would treat all three of these by vasomotors, by given the patient's vasoconstrictors by restoring that vascular tone that has been lost. This is vasomotor shock, it needs that kind of therapy. Volume replacement would not hurt these patients. Let me recapitulate this brief detour of shocking the non-trauma setting. If we have a patient who's gone into shock and his veins are distended, we should identify that the patient is in cardiovascular or genetic shock. If the patient was gone into shock but looks worn and flush rather than pale and cold, that identifies the vasomotor shock. And with that, we move now to the next subheading. It's a review of. trauma, essentially from head to toe, and we begin with head trauma. Let me say though, before we go into the specific vignette, that as we go through the various trauma vignettes, some of them are going to be penetrating trauma, some of them are going to be blunt trauma. The penetrating trauma as a rule is easier to diagnose and easier to manage because the location of the entry wound, the location of the weapon, if it's still embedded in the patient, tells us where the injury is. Blond trauma on the other hand, the patient was being in a car accident, could have been injured in the head or the neck or the chest or the belly, or all of those places. Some more diagnostic tests are needed for the blonde trauma patient. And for the management is also as a rule, easier in the penetrating because as a rule, they're going to be exceptions. But as a rule, we end up having to repair the area where the penetration took place, whereas in blonde, we often can adopt a more conservative attitude and just let the patient heal from his injuries. All right, let's read the first vignette. An 18-year-old man arrives in the ER with an axe, fear me implanted into his head. Already clear from the size of the axe blade and the penetration, that he has sustained an intra cranial wound, he is awakened, alert and human-anamically stable, and incidentally this is possible. I know you think this is incompatible. How could somebody have an axe and the head and be talking to you? It can happen. Now, the point here, though, is there is an impale foreign body in the patient. This could have been the patient was in a car accident and there's a branch of a tree sticking out of his belly. All right? But this question is designed to test. Is what do we do with a foreign body that is still in the patient, sticking out of the patient? And the answer is it doesn't get to be removed until we're in the operating room with the patient and estetized and the whole surgical team ready to go. Because that penetrating instrument may in fact be tamponating the blood vessels that have been injured and if we were to remove that foreign body at the scene of the accident or eating in the emergency room, we may then have massive bleeding that would be difficult to control. So the answer here for this vignette, this gentleman with the axe still sticking out of his head will be taken to the operating room and estetized, draped and ones were ready to proceed to remove the foreign body. But I've been in number two in the course of the mugging and man is sitting over the head with the blunt instrument. He has a scalp laceration and skull x-rays show an underlying linear skull fracture. He's neurologically intact and gives no history having lost consciousness. The patient has a linear skull fracture and that's all there is. We don't need to do anything about it. But really what this vignette is driving at is in the presence of a linear skull fracture and the scalp laceration above it. How do we handle that scalp laceration? Well, in this particular situation, it can be clean and it can be closed in the emergency room because the linear skull fracture wasn't going to need any specific therapy anyway. Contrast that to the next one. Vignette number three and the course of the mugging and man is hit over the head with the blunt instrument. He has a scalp laceration and the skull x-rays show an underlying, a combination of the press skull fracture. It's neurologically intact and gives no history having lost consciousness. Now, if we have a combination of the press skull fracture, that's going to need to be dealt with in the operating room. So we don't clean and close up the scalp laceration in the ER in this case. In this case, we go to the operating room to do it there. Vignette number four is going to bring up a very important point. Pedestring is hit by a car. I'm brought to the ER. He has minor bruises and laceration, but he's otherwise quite well with a completely normal neurological exam. However, the ambulance crew reports that he was unconscious at the site. And although he woke up during the ambulance right and is now completely lucid, he does not remember how the accident happened. Here is the answer. Here's a rule. Every patient in the US, who has lost consciousness, secondary to head trauma, gets a CT scan of the head. Even though he's awake now, even though he's completely lucid, even though he's neurological exam is normal, the history that he lost consciousness is sufficient to trigger the need for the CT scan of the head. Remember, this is a trauma patient. I'm not suggesting anybody who faints has to get a CT scan of the head. But anybody who in the trauma situation has lost consciousness needs a CT scan of the head. Now, that CT scan is negative. The patient could be sent home. The family is instructed to wake him up frequently during the next 24 hours or so. But the CT scan is an important item here. All right. We have another set ofignettes now that identify a particular diagnosis. The number five. A pedestrian is hit by a car. He is rising the ER in common. He has echinomes around both eyes. This is a sign that is also known as raccoon eyes. The number six, a pedestrian is hit by a car. He has clear fluid dripping out of his nose. The number seven, pedestrian is hit by a car. He has clear fluid dripping from the ER. The number eight, a pedestrian is hit by a car. He has echinomes behind the ER. All four of these identify. The fact that the patient has a base of the skull fracture. We know it either from the hematoma and those strategic locations, both eyes or behind the ER. Or a cerebral spinal fluid. That's leaking from the nose or leaking from the ER. So if you were to find these on an extended matching set, the diagnosis obviously is base of the skull fracture. The question that all revolve around management. The management is actually not that much different from the management of anybody else who had head trauma and is in common. They all need an airway. They all need a CT scan. The CT scan is primarily looking for the potential hematomas inside the head that may need to be evacuated. Although they will also identify the base of the skull fracture. It's interesting that as far as the base of the skull fracture is concerned, in many instances no specific treatment is needed. Many times that's the ER spinal fluid leak will stop on its own. At one time there was a feeling that all of these patients should be on antibiotics, but that really hasn't been proven to be of benefit. So the management is really the same of anyone who is in common from trauma to the head. Perhaps there is one additional angle though. If there is a base of the skull fracture, obviously this was not trivial trauma. This was big trauma. All of them is a person who is hit by a car. This is a big violent trauma to the head. The head is connected to the rest of the body by the neck. The head injury of his magnitude in this setting could very well also have a neck injury. Pushing is unconscious or is not talking. It's not easy to determine whether he's got a neurological deficit or not. So perhaps the most important additional facet here is that we have to also look at the neck. At one time that would have meant the patient needs cervical spine x-rays. That still might be a good answer if it's the one offered on the next time. So cervical spanic rays have to be a P and lateral. They have to include an odd-on-toid views. Because these, all four of these, are patients in common, they're all going to get a CT scan of the head. And maybe just as easy to extend that CT scan to include the neck as well. So the answer may very well be CT scan of the head that also includes the neck. All right. But now I'm going to move on to some of the syndromes that we see when there is head trauma and specific types of intra cranial bleeding. These I might add make very good examination questions, so please pay attention here. We're now in Vignette Number 9. The 14-year-old boy is hit over the right side of the head with a baseball bat. He loses consciousness for a few minutes, but he recovers promptly and continues to play. One hour later he's found unconscious in the locker room, his right pupil is fixed and violated, and they are signs of contralateral hemiparosis. This is a classic. This is in fact an acute epidural hematoma. Let's see what identifies it as such. There is a sequence here of five things. The patient was hit over the head. The patient lost consciousness. The patient woke up in and the patient lost consciousness for the second time. And finally, the finding of a dilated pupil on one side, contralateral hemiparosis on the other. The sequence of five things following a trauma, identifying, in fact, two potential conditions, acute epidural hematoma or acute sub-dural hematoma. But in acute subdural hematoma, the trauma is usually much bigger, trauma, and the patient is much sicker. So when we read here the relatively trivial trauma being hit with a baseball bat as opposed to crashing an occurra 100 miles an hour leads to these five things. And we also read that between the first time the patient was unconscious and the second time the patient is unconscious, the patient was completely normal in every respect. In fact, he went back to play. That identifies the acute epidural hematoma. In fact, you might be even asked on what side, because 90% of the time it's the same side with the big dilated pupil is. So this is in fact the right acute epidural hematoma. Whatever you ask for management, well, it begins with a CT scan of the head. This is a patient who's unconscious and we know that the patient like that needs a CT scan. And when we do that, we should see a lens shaped, that is to say a bi-convict hematoma. That's the shape of a hematoma in the acute epidural. And we should also see deviation of the midline structures to the opposite side, because that is already manifested clinically by the fact that one pupil is dilated, not the other, and that there is hemiparesis on the opposite side and not on the other. And then after that, these patients need a emergency craniotomy, evacuation of the clot, and the prognosis is excellent. And this is one of the reasons that makes this a very good examination question. Remember what we said an hour or two ago? Examination questions deal with either very common surgical problems or high impact disease. This is high impact. This is a good example, where proper diagnosis and management ends up with a completely normal patient whose life was saved. But if a diagnosis is missed, if a management is not made appropriate, the patient will die. And that brings me to an interesting point before we go to the next few vignettes. This is a little detour, but it's important to understand the vignettes that follow. And someone sustains head trauma, and there is damage to the central nervous system. There are essentially three ways that damage is inflicted. One is by the original trauma. So if that initial trauma is gigantic, that alone already damages the brain. The second thing is the hematomas that may develop later on and push them in line with structures. And it is for that second mechanism for which surgery provides the adherence, because we operate on the patient, we remove the hematoma, and that source of damage to the CNS is no longer there. Obviously, there's nothing we can do about the initial damage done by the initial blow. We cannot take that away. And then the third thing is the swelling that frequently follows the head trauma, the swelling of the brain and the increased intercranal pressure. And for that, we do mostly medical measures, although we could also, in real severe cases, open up the head and give it room for expansion. But those are the three elements. And you realize then, when we go back to the vignette, we just read that this little kid that was hit with a baseball bat did not sustain significant damage from the original blow. It wasn't big enough. The only damage it was sustaining was the one from the hematoma pushing structures off the midline. And therefore, when the surgery is done and that is removed, the prognosis is excellent. In contrast with that, the screen now being yet number 10. A 32-year-old male is involved in a head-on, high-speed automobile collision. He is unconscious at the site. He is consciousness briefly during the ambulance ride and arrives at the ER in deep coma with the fixed dilated right pupil and control at the hemiparesis. We have again the sequence of the five events. The trauma to the head, patient becomes unconscious, patient wakes up, patient becomes unconscious again and then the big pupil on one side, the hemiparesis on the other. And we can sense when we read this vignette, much bigger trauma, much sicker patient. This was a head-on, high-speed automobile collision. Yes, the patient did wake up a little bit during the ambulance ride, but barely. This is more likely they are for it to be an acute sub-dueral hematoma rather than an acute epidural. If we were asked for the diagnosis, I would be our best bet. We were asked for the management, it again begins with a CT scan. In this case, a CT scan should show rather than the lens shape hematoma, a bi-concave, semilunar crescent shape hematoma. This is the shape of the acute sub-dueral. It should also show pushing the midline structures to the side because we read already that was a big dilated pupil on one side, hemiparesis on the other. And the neurosurgeons will operate a patient like this. So if you ask what's an ex-stepping manager, it will be craniotomy and decompression. We have to take out that hematoma that's pushing the midline structures. But the prognosis obviously is not as good. In fact, the prognosis is quite grim because that original trauma has already done a lot of damage to the brain and we cannot take that away by operating on the patient. On our being at number 11, a man involving a high-speed head-on automobile collision is in common. He has never had any lateralizing signs. Let me stop here for a second. Lateralizing signs is shorthand. So we don't have to say big dilated pupil on one side but not on the other. Hemiparesis on the opposite side but not on the other. In other words, the shorthand that says clinically we know that the midline structures are being pushed to the side before referred to as lateralizing signs. So he's never had any lateralizing signs. And CT scan shows a small crescent shape hematoma but there is no deviation of the midline structure. If you're asked for the diagnosis, the diagnosis is clear. This man has an acute sub-dueral hematoma because that's what a crescent shape hematoma identifies. But if you're asked for the management, there is no point in operating the patient. There is no deviation of the midline structure. There isn't a big hematoma that needs to be removed. It is there but it's small, not pushing structures. The man has already sustained the damage from the original block and now what he's facing is the third mechanism of injury. The swelling of the brain has likely to occur and now the management then is center of pong controlling, minimizing that increased intercronic pressure. So this patient is going to need hyperventilation. This patient is going to need avoidance of fluid overload. Perhaps money at all. There are some things that lower or control the intercronic pressure. With that pushing them to the extreme that he loses the profusing pressure. Let me remind you that the objective is not a single number of what happens to intracranial pressure. The objective is let's keep profusion of the brain. If we dehydrate him to the point that he becomes hypotensive, then he's not getting profusion to the brain. An incident I might add, since now the objective is going to be control of intracranial pressure, probably intracranial pressure monitoring would be a good idea. And I think we're going to see the same thing here in the next Vignette. Vignette number health. The pressure involved in a head-on high-speed automobile collision, arising the air in deep coma with bilateral fixed pupils. City scan of the head shows diffuse blurring of the great white mass interface and multiple small pontech hemorrhages. There is no single large hematoma or displacement of the headline structures. Now this patient has sustained severe damage, severe head trauma. But what that radiological diagnosis is, that diffuse blurring of a great white mass interface and multiple small pontech hemorrhages are classical for what's called diffuse axonal injury. This patient has had the damage from the original blow and is going to sustain the additional damage as intracranial pressure rises, but he has no indication for an operation. There is no one single big hematoma pushing the headline structure. So here again, the treatment centers upon intracranial pressure. We need the monitor for the intracranial pressure. We need the hyperventilation, the money, the fluorosamide, avoidant fluid overlog, but don't push the patient all the way to be hyperboiled. Alright, now we need number 13. It's an entirely different situation, but one that again makes an excellent examination question. Let me read it and then we'll analyze it. The 27-year-old man becomes senile over a period of three or four weeks. He used to be active and manage all of his financial affairs. Now he stares at the wall, barely talks and sleeps most of the day. His daughter recalls that he fell from a horse about a week before the mental changes began. This is a chronic subdual hematoma. Let me explain this to you. This is a situation that we see only in two types of patients. Either they're very old or they are alcoholic. Now both of these either by virtue of old age or the damage from alcoholic intake. The brain shrinks somewhat. The brain is now smaller than it used to be. The bone head though doesn't shrink along with the brain. So now we have a relatively smaller brain in a cranial cavity that's now too big for it. In fact, when we explain these two medical students who often use the analogy, the patient has a size seven brain and a size eight skull. Now don't look for that in the US Emily. The US Emily doesn't have a sense of humor and it will not be phrased in that way. But it helps us understand that with very minimal trauma, this brain can easily rattle inside the head. Tear off one of the venus sinuses and then very slowly bleed from the venus sinus until the big hematoma has developed. That is now pushing on the brain and interfering with brain function. And we see all the elements here. This is an old patient. He sustained that little trauma. He fell from the horse. But he took several days for the symptoms to be obvious. This is an excellent example of a high impracticist. It could be easily missed. And one could easily say, "Well, the man is old. He got Alzheimer's. He's got senility." Let me remind you that neither Alzheimer's nor senility developed over a three or four week period. When you see that short time span, think of a chronic subduer of hematoma. Look for the answer where you do a CT scan. The CT scan will show the hematoma. The neurosurgeons will decompress. The back weight of hematoma in this gentleman will be back to reading the financial pages of the New York Times the next week. All right. I want to repeat every year that I read a little while ago because it deserves repetition. We're now talking about head injuries. In January 14th. The 45-year-old man is involved in a high-speed automobile collision. He arrives at the ER in Koma with a fixed dilated pupil. Excuse me, fixed dilated pupil is both of them. He has multiple other injuries including fractures of the extremities. His blood pressure is 70 over 50 with a fee-goal pulse at a rate of 130. And then the question will be, what kind of intracranial bleeding is responsible for the low blood pressure and the high pulse rate? You know the answer? None. Right? This may in fact have you drug anial bleeding and that may be the reason for the fixed pupils and the factories in Koma, but it doesn't explain the fact that he's in shock. We have to look for the source of the blood loss elsewhere.