[Music] um so i'll also go over some uh recommendations at this point um which i think will help you guys moving forward with how to think about these issues and when you talk about trauma you want to talk about the brain trauma foundation guidelines which i think get revised every few years and and really uh create a good consensus agreement on what to do in certain situations in terms of icp monitoring there isn't good level one evidence however there's uh level 2b evidence which suggests that they should get some kind of icp monitor to reduce in-hospital mortality previously they had had more specific recommendations of placing an icp monitor including an abnormal ct with a low gces or normal ct with a very low gcs and hypotension at our institution what we do is uh is basically follow this abnormal ct and low gcs requirement and the reason is we're looking for a diffuse brain injury or signs of diffuse brain injury that might evolve over time and that you can really only get by examining the patient and also monitoring their icp um so uh man some of you may have already placed an external ventricular drain at this point um so i'll just be reviewing how to do that real quick you paste the place the position supine with the head of the bed up it's typically called the fowler's position um and uh you uh have their head in a neutral position and then you mark coker's point which is in this right frontal area make incision do your twist drill your dural opening pass your catheter and then you tunnel it under the scalp which you can see sort of here um attach your catheter to your manometer kind of uh one of the methods that i use if you take your finger and you know the measurements of your hand then you can find coker's point just by putting your hand on the patient so if you put your index finger at the nasion you put your thumb aim to their their ear then right at that junction a couple centimeters away in front of the coronal suture you'll find you'll find coker's point and you got to make sure that when you're passing your catheter and really it starts at the drill you want to be aiming perpendicular to the bone and if you need other landmarks to guide you you can aim towards the contralateral medial canthus and the tragus laterally so you can use those two points to help you but if you if you aim contra perpendicular bone it won't fail you and this is an example of an avd that i recently placed in you know aimed in the the right lateral ventricle toward the foramen of monroe which is where you want hey everyone ryan rad here from neurosurgerytraining.org if you like that video subscribe and donate to keep our content available for medical students across the world