Pre-hospital Care

You got house call
patuent at home
Case: trauma / medical

Pre-hospital care

From the time you received the call, went to the house and till going back to the hospital

Question : describe pre-hospital care

Scope & Run OR Stay & Play

What do you do when you arrive at the scene

1) Scene size up
- Make sure the environment is safe for you to go in
- hazard present or that can happen
2) Initial assessment : primary survey
3) General impression
4) Priority despatch - respiration, pulse, mental
5) Targetted and short history
6) Physical examination : secondary survey
7) Initial management
8) Transport process
- from the house to the ambulance, how you do it
- either patient come with ambulance or patient come to the hospital with their own vehicle
- challenges : if patient is obese / bed-ridden : how
- if stucked in jam, how?
- inform ETA ( estimated time of arrival)
- let the receiving hand know
9) Ongoing assessment and management

Reading CT Scan Brain Part 2

Hydrocephalus
- dilatation of ventricle

Chronic hydrocephalus with normal pressure
- patient came with blindness but no headache

Acute hydrocephalus

5 things

1) Frontal horn of lateral ventricle became rounded

2) third ventricle became rounded

3) Temporal horn became big and visible

4) CSF sip out - went to the brain parenchyma
- periventricular hyperlucency

5) No sulci visible in top slice
- brain became tight
- sylvian fissure obliterated

Ventriculomegaly
- dilated ventricle without increased ICP

Hydrocephalus
- dilated ventricle with increased ICP

Normal pressure hydrocephalus
patient presented with incontinence, difficulty in micturition, dementia and difficulty in walking

Communicating hydrocephalus
- all ventricle dilated

Contrast CT Scan - not indicated in trauma

1) because it is neurotoxic - blood brain barrier already damage, CT scan with contrast will cause more harm to the brain
2) Blood already hyperdense, contrast also hyperdense

Tumour

Why tumour enhancing with contrast
- contrast indicate breach in enhancement of blood brain barrier
- it is not only because of the vascularity

describe whether the tumour is intraaxial or extraaxial

Intra-axial
arising from the brain

Extra-axial
from outside the brain , arise from the dura

example
glioma - intraaxial
meningioma -extraaxial

Ischaemic infarct

ischaemic, infarct, oedema, inflammed, more water, look like black

oedema
- finger like projection
- going along the white matter
- travel along neuron
- more prominent in white than grey matter

Territorial- area that is supplied by the blood vessel
MCA
PCA
ACA

Cystic lesion

Arachnoid cyst

- congenital
- temporal lobe not formed and space taken by CSF

Hydatid cyst

not an abscess
no ring enhancement

Abscess
- ring enhancement lesion because of the vascularity (capsule)
- inside ( central) is hypodense because of the abscess

Subdural empyema
- central : hypodense
- edges along the dura enhance because of vascularity

Encephalomalacia
- scarring of the brain parenchyma
- pulling effect
- no midline shift or mass effect

Reading CT Scan of Brain

Presentation by Mr Arshad 27 July 2011>

CT Scan speaks the language of DENSITY

the brighter or whiter - more dense

why gray matter is more dense compared with the white matter
- gray matter composed of cell bodies, more dense because of the vascularity (blood supply)

- white matter composed of neurones, less dense, looks grey

3 normal calcification in the CT brain
1. bilateral choroid plexus
2. pineal region

they made a pyramid

sometimes the calcification can be seen in area of basal ganglia or thalamus

Mass effect & Midline shift

If there is tumour or lesion compressing the brain, there'll be mass effect
- sulci effaced
- sylvian fissure effaced etc

how to know the midline shift
- measure from septum pellucidum

A scan can have mass effect without midline shift
but cannot have midline shift without mass effect

CT brain with contrast
how to know?
the contrast will be in the veins, arteries and slyvian fissure

Extradural Haemorrhage

Why EDH has lens shape (convex)
- because there is no subdural space for the blood to go, so it expands
- stripping of dura
- associated with fracture

Why EDH not hyperdense
1. patient is anaemic
2. fresh blood, blood still not coagulate
3. patient has coagulopathy, blood didn't clot

Subdural Haemorrhage

Why concave shape
- blood collected along the space

Acute SDH
- within 2 weeks of haemorrhage
- blood still clot

Subacute SDH
- after 2 weeks of haemorrhage
- blood started to liqufied

Subdural haemorrhage usually causing midline shift and produce oedema

Chronic SDH

Vascular layer of the brain situated within subarachnoid space (between pia and arachnoid)

Haemorrhage due to aneurysm usually in basal cistern (weak blood vessel)

Subarachnoid haemorrhage
-usually traumatic
-at sulci

blood in CSF
-can be also in the ventricle

Introduction

Starting from today I will write note on my blog for future reference

The notes are from multiple sources : books, journals, power point presentation, teaching, seminar or from the experts

Hope I can be a better doctor with this notes