[Music] so she comes in she was actually just struck by a car so out of automobile versus pedestrian and she's moving purposefully but very agitated in the shock room heart rate 70 blood pressure is 180 over 98 people's uh right people now is actually much larger than the left and on your assessment so this is different from what they found in the sealed field her gcs is now six so it went from 13 to six she's only now just um withdrawing from pain so you want to uh or or or flexing from pain so you want to at this point do your abcs you want to get through your trauma evaluation you uh someone notes that she has an open tib fit fracture they also do a fast which is an ultrasound test of the abdomen to look for free fluid which is negative and then she gets that intubated all right so everyone wants to get a ct of the head and i think that's the correct answer for some reason um i've been asked this multiple times when i see when a patient comes in with a blown pupil and a poor exam that was previously okay some trauma surgeon or something goes and says shouldn't you just put a burr hole in or something like that and if you were in the middle of nowhere and you had no access to and you you weren't in a hospital you had no access to any imaging then i think that would be the right answer um and uh uh you know you're doing what you need to do to save the patient's life but in any urban setting especially any hospital setting get a ct of the head first there can always be false localization with a blown pupil um as a you can get with hernia some several herniation syndromes where you can have impingement on kernaghan's notch and a a contralateral third nerve palsy for example so you don't want to you if you can get imaging safely get it the airway secure we get our ct head and this is what this is what it shows so we have a large right-sided acute subdural hematoma with a lot of midline shift so what do you guys want to do about that now you're in the scanner and you got to decide what to do all right so let's take the patient's step to the or i think this is a no-brainer at this point and the reason why i put this case in is because we were just talking about placing evds for tragic brain injury however in this case uh to relieve the patient's cranial hypertension we're not talking about css flow diversion we're not talking about placing an evd to drain csf we need to get this huge uh mass lesion out of the out of the head right to make room so um there are uh in addition brain trauma foundation guidelines for this as well um which are mostly consensus and uh so a lot of you will hear that acute subdural greater than a centimeter with a greater than five millimeter midline shift should be evacuated as soon as possible or in a patient with a very poor gcs with uh slightly um less uh subdural thickness and midline shift with a rapidly decreasing mental status should also be taken and just briefly to go over that so you know you'll have your patient positioned usually supine with the head turned in this diagram they have them pinned um we don't pin for our trauma cranies ever because it's just a waste of time and also provides less flexibility for the scalp and you make your reverse question mark incision large craniotomy again in a in this situation in an acute with an acute clot you don't want a small cute craniotomy because what you're going to find is this huge gelatinous mess underneath so this is a case that i did um not too long ago huge clot that we're just kind of sweeping off here and then once we get it off you find this you know the surface of the brain here um your large dural opening and at this point is a good point to think about placing your ebd or you can close up and place it afterward if the brain is uh swelling you decide whether or not you put the bone back on leave the bone off these are all conversations for another time but in general once you get the subdural out and the brain looks okay and it's not swelling out you can put the bone back on usually leave an ebd and if you're going to place an ebd you can place it through a point called pains point which on the left side unfortunately goes straight through broca's area so you don't want to do that necessarily but what you can do is take that same point and go a little bit more medial um and place it through the the front the uh middle frontal gyrus or hey everyone ryan rad here from neurosurgery training.org if you like that video subscribe and donate to keep our content available for medical students across the world