Good morning, everybody. Welcome back to the third day of the 2020 AANS from Cranial to Spine overview of neurosurgical topics for the advanced practitioner. And it is our first time to be virtual. And I will have to say that you all have come in larger numbers than we ever have had in the past. It's over 370 APPs on for this virtual course this year. So congratulations to everybody. Thank you. And we have a few things to go over, just some housekeeping. Of course, the moderator Q&A. Put your questions there, please. I might not see them if they're in the as well as the other moderators. We also have polling questions for this course. And today, we will have polling questions for the first trauma section, but not the next two. So just an FYI. Don't forget the APP virtual challenge. This is the badges that you can earn by going to the exhibitor, by interacting within these sessions. And the more badges you get, you get higher on the leaderboard. And there will be a lottery for those that have not gotten so high on the leaderboard. So you haven't lost out completely. So some of the items that you might win today or at the end of the course is the complimentary registration for next year's APP course. SNAP, which I've talked about this in the beginning. It is a new webinar series for new to neuro people as well as advanced. We have created a bundle of webinar activities that your physician or group can buy for the group or they can buy for an individual. And you'll have access to everything you kind of need to know when you're getting started. So we all know it takes a lot of time and effort for people to, you know, PAs to teach other PAs or PAs teach MPs and MPs teach PAs. We're all in the mix of it and it's very time consuming and you feel like you can't get it all in in one day. So this provides you an opportunity to log on at your leisure. You get CME along with it and look at some maybe some areas that you don't normally see on an everyday basis. Again, go to the vendors, tell them thank you for adding to this wonderful seminar that we're having this week and making it all possible. So our first trauma lecture today will be Michael Johnson and he's back to return with us this time. He did the suture course last year and it was amazing. Everyone loved it. So thank you for returning back with us today, Michael. In the last seven years, he's worked as a PA in neurosurgery department at George Washington Medical Faculty Associates. He's split between inpatient outpatient neuro IR and his clinical interests include trauma, stroke, quality improvement, billing and coding. He also teaches with the PA program and takes on PA students. He's a native Las Vegas. He previously worked in the fire department. I don't think that many of us can say that one. Currently, he lives in Washington D.C. with his wife, three sons and two dogs. So your stick figures are pretty cute on the back of those that little car, Michael. So those badges, don't forget they are office space flair in this world. So gain as much as you can. And please do chat in the box. We love seeing all the comments of what you do in your neck of the woods and where you are. And we love to see the variety and ways people are treating patients and getting new ideas every day. So thank you for joining us again. And we'll start off with our first lecture. Thanks, Michael. Thank you. All right. Thank you, Alice, for that welcome. Welcome everybody this morning to welcome to our lecture on acute management of traumatic brain injury. And this is kind of a protocol update. I'm happy to be here. I'm happy to be back. And I'm happy to have all you guys with us this morning. Like Alice was saying, we really like the interaction. And I think the interaction this year is even more exciting than it has been in the past. People are more prone to put stuff in the chat box. I'm not going to be monitoring the chat box quite as much. Alice is going to monitor it for me and kind of synthesize questions as we go. And we'll stop periodically to answer those questions. But please feel free. I think really one of the coolest things about bringing all of us advanced practice providers together is the sharing of information, is understanding what other people do, how other people are doing it, and getting different perspectives. So please, looking forward to that participation. Disclosures, I have none. I don't get any commercial support from anybody else. I have nothing to disclose. Further, I always like to say that if I do use a brand name during this lecture that's incidental, I don't have any allegiance to any particular brand. So we're going to jump right in. What do we want to get out of this course? And I hope at the end of this, you have a little enhanced understanding of the initial evaluation of traumatic brain injury. And another thing I think that factors into that is we all come from different places. And there's some people that work in the clinic, and there's some people that only work in the ER, and there's some, excuse me, OR, and there's some people that only see consults. So we have to have a little bit for everybody. So I hope there's some people who this is going to be old hat to, but I want everybody to hopefully get a little increased understanding of the initial stuff that has to go on. Increased awareness of the guidelines themselves that guide all those initial actions and that help us make the decision, not just initially, but in the management of these patients. There's a lot that goes into these guidelines, and I want to kind of brush up on what goes into making them. And again, the awareness of some newly released stuff, and there's some kind of paradigm shifting new stuff that just came out just this month. So it may not even be stuff that you've had a chance to digest with your trauma team or your attending physician at this point. We're talking in the last couple of weeks. So we'll go through some of that stuff. So why does this all matter? Because it's a big deal, and it costs us a lot in terms of people and money that, you know, the most recent data from CDC is from 14. And there's a lot of people going to the emergency room with traumatic brain injuries, about 3 million. And a lot of these are among children. So, you know, we have to work on prevention. And the deaths, there are about 57,000 deaths in 2014 from traumatic brain injury. This is tremendously important. The cost for society, the care of these people is huge. And it's $76 billion. And again, that's not just the care of these people, which sometimes is extensive that they need home therapy and vents and stuff like that. But a lot of, you know, the epidemiology of these injuries is often young, healthy, otherwise healthy, very productive people who were working and who were paying taxes, and who are now not contributing society and now, you know, have a cost to society. So it's a huge burden to take care of these patients. And that acquired brain trauma is really the second most prevalent disability in our country. So the awareness on how to manage these people to make their outcomes a little better is supremely important. So it really can't be understated what a big deal traumatic brain injury is for these countries. And this is not just, you know, severe traumatic brain injury, the cool stuff. This is the concussion stuff. This is the young athletes, there's a huge public campaign to understand more about it. And, you know, we don't know a lot yet. And there's a ton of research that needs to go into learning about these and how to most appropriately manage these patients to decrease that burden. And it's, it's very important. I mean, there's a Will Smith movie about it that tells you how important concussion management is. So it's important in our sports with our kids at our schools, all of that. Why do we need guidelines? Guidelines are tools, and they are kind of developed by these reputable organizations like the Brain Trauma Foundation. And they are really deeply researched. And the whole goal is to improve the quality of care in these patients. And one of the really important things is to decrease discrepancy, so that we know when outcomes are being being met and how they're measured, and to make sure this evidence is followed. And this is great in our country. But I think especially in developing countries and areas where resources are a little bit more limited for research, it's really important to have these, these protocols just to make sure that everyone is doing the best they can and using the best research. And it's all formulated in one place. At the end of the day, these guidelines are tools, right? They don't necessarily substitute for good judgment, or clinical gestalt from, from, from us and our surgeon partners. And you can go outside the guidelines, but you have better have a good reason, you better be able to document why that you're going outside of the guidelines. And, and, and, and, and, and, but again, these are just tools to help us make these better decisions. There's a lot of sources for these, for these guidelines. I think the most, certainly the most important one is the Brain Trauma Foundation. And I certainly hope most of us in neurosurgery have at least heard of the Brain Trauma Foundation and read up on some of their guidelines because it really is the basis for, for what we do. It's the most highly researched and certainly the most evidentiary of the guidelines and, and that we, that we use to manage these patients. But there are some others. The American College of Surgeons has several quality improvement projects. And one of them is with the brain trauma group, and they have produced some really great guidelines that will go through as well. There was a consensus conference that was convened in the last couple of years that goes through some of the stuff that may not have the evidence, but they managed to create some consensus statements on how to manage it. Your AANS and CNS, your professional organizations are great sources for up-to-date information. I think CNS even has an app you can have on your phone, which is super helpful. Your Greenberg book actually does a really great job in synthesizing evidence and each chapter has references to guidelines. So that stuff is all integrated and really easy to use in your, in your right in your pocket Greenberg. And you're, you ought to know your hospital's protocols, and hopefully most of them are based on these other guidelines for management, but you really better know because if you operate outside your hospital guidelines, you're leaving yourself in a tough position with hospital administration and your trauma department. They're developed there, and they're there for a reason. So really ought to know what your guidelines are and what your hospital expects of you as a brain surgery team. So getting back into a little bit of what the Brain Trauma Foundation is, it is a nonprofit organization and they were kind of founded in 1980s and their whole goal is to further TBI research. And they develop these guidelines and they maintain the guidelines and they work on implementation and they really do kind of full service. They have some really great research on concussion and they have some pediatric protocols and they're most important to I think us is their severe TBI and their coma protocols. They get most of their funding from the Department of Defense and then they partner and spread out the research with a bunch of research organizations. They do a lot with Oregon and Stanford and Cornell and NCAA. I mean, they really are really involved in every facet of research and development. They're very, very important in their development of protocols and implementing their protocols. They do updates regularly, so they want to make sure that they're staying on top of their game and the greatest research that's out there. The most recent concussion guidelines, the step two guidelines, again, just came out this year. So when I was researching this lecture, I was like, well, what am I going to talk about? The severe TBI hadn't been updated, but then all this other stuff started being kind of more front and center. So there's these new concussion steps. The severe pediatric TBI just came out last year. Not much has changed in the surgical management guidelines of severe TBI that came out in 2006. And here's something we're really going to talk about today is the adult severe TBI protocols, the, excuse me, the guidelines. It's the fourth edition. The fourth edition came out in 2016 and they really take their time with these. So in between the third and the fourth was seven years, and they reviewed 94 new studies and tons of publications. You can see right there, 189 publications, all the different classes of evidence that they've reviewed. And it took them seven years to come up with the fourth. And they decided at the fourth guidelines that that was the last time they were going to do a full update that they decided they were going to transition into this living guideline kind of format where they would just have updates to the guideline and they would continue to watch the literature. And I think they knew that some of the major TBA trials, the DECRA trial was just getting ready to release some new long-term data. So they knew they had to stay on top of it. So they have just released a update last month. So based on some of the research that has just kind of been synthesized from the DECRA trial that we'll get into a little bit later. So Brain Trauma Foundation is something you should know. Their website is extremely user-friendly. I encourage you to be very familiar with who they are and what they do to kind of have an understanding of how we're supposed to operate. Now, TQUIP is a, like I said, it's a joint operation between the American College of Surgeons and their trauma department. And they work with other groups, other interested groups. So they have a imaging, they have an ortho, they have a transfusion, they have a geriatrics, they have all these different TQUIP guidelines on management. And they make these recommendations. And while Brain Trauma Foundation is really meticulous and highly researched and very evidentiary, TQUIP, I find very user-friendly. It's almost like brain surgery for non-brain surgeons. It's how I think really we're able to communicate with our partners in the trauma department. And it's very user-friendly in terms of the operation. It's spreadsheets and algorithms, and this is what we do and why we're doing it. And it still uses this highly evidentiary data, but I think it's synthesized in a way it's very user-friendly. Certainly for me, I think it's very easy to work with. And I think our colleagues in trauma appreciate it as well. So again, I encourage you to look into the TQUIP guidelines. We'll talk about some of them in one of our cases that's coming up. They're probably due for an update. The last update from them was in 2015. So I would think I don't have any inside information, but I think they're probably due for an update for their guidelines. Something that I think is really interesting that came out again last year is the Seattle International Severe Trauma Brain Injury Consensus Conference. And who these folks are, are 42 experts on management of traumatic brain injury. So it's a combination of neurosurgeons, critical care neurosurgeons, neurointensivists, rehab physicians, researchers. And so they got 42 people essentially together. And what they did is they decided that not every problem can be solved by evidence right now. Because one thing, the longer you get into brain trauma is we don't really know a lot. And there's a lot of research yet to be done. And even when we've got really great studies, and we do, we have two really great studies on some of this stuff, we still have a long way to go. So they got together and they created consensus-based recommendations based on consensus, because there wasn't evidence to support them. And there's a really cool poster, you can click on that and see this. You can, I think you can get it and print it out and hang it on the wall of your ICU about how to manage these. And it's a really great reference, right? And so we have to understand that consensus is not the strongest evidence. It's class three evidence. So it's not the best evidence, but it's what we have now. And it works really well. And they've basically come up with 18 interventions that are fundamental and 10 things we probably shouldn't do. Probably shouldn't give steroids, probably shouldn't give Lasix. So it's all on that really cool poster that we have a link to on the bottom. I highly recommend you look at that and take some of this home and discuss it with your team. It's very helpful information. All right, so we're going to go to a polling question. Again, one of the things I really like about these conferences is getting to know people and getting to know the people who are participating in this. And I went several times as a participant, and it's just great to meet so many different people who do different things, that there are people here in our audience that only do outpatient. So they don't go to the OR. So some of this is new to them, but they're the ones that are gonna be managing these patients when we're done with them at the hospital. So it's important to know that everyone has a stake. You're right, everyone has a stake in what we're doing here and that the knowledge has to be shared so that we can really understand kind of treating the whole patient. So some of us work inpatient, some of us work outpatient, OR, ICU. I am definitely in the some combination they're in and the results are trickling in that about half of us are some combination. 27% are inpatient, 16% are outpatient only. So there's a fair number of people that aren't in the hospital, in the OR, see in the consults. Some people are in the ICU doing this high-end management of ICPs every day. So it's really neat to see of the people who have responded, that it's really a wide variety of folks in this. I really enjoy seeing this. So I'm certainly some combination, I do a bit of everything. So that's interesting to see. Moving on. So for those of us who are inpatient or some combination, do you see consults? Do you carry the pager? So my case studies are going forward are, do you see consults? So this is another polling question. It's gonna be set up like you get a page from trauma department on the consult. So while I waiting for these results to pop up, I really love this. This is really neat. This is certainly more interactive than being in a big ballroom and people kind of meekly raising their hands as to what we do. All right. All right. So of the folks that see, excuse me, that work out in some inpatient, a lot of people see consults. So this will be pertinent to a lot of folks. So we're gonna see some consults. Everybody's favorite pager goes off. Case one, right? You have your pager on, trying to you're in line at Starbucks and you get a urgent page from the ER and they're freaking out. This guy's got a big head bleed. So get your attention. And so what they've described is a 52 year old guy, no known history. He didn't look good. And he walked into the ER and he said, oh, my head hurts and I don't feel good. And then he vomited in his bed and he passed out. So they, because he had a headache, they ran him off to CT scanner, no known trauma. And they see, whoa, that's not great. So as you're walking to go see the patient, you stop by the radiology desk, you see this, you're thinking, oh dear. So we're gonna see this and get into gear. This is clearly a very large epidural hematoma. So we're gonna get our priorities straight here, right? We're gonna move quickly because we've already kind of developed in our plan and our mind. This person, if he's alive, is going to the operator. So we're gonna move quickly. We're gonna do our very, very best to get an exam. We're gonna get the best exam we get because he's probably about to get intubated. And probably before you get too much further, you're gonna let your attending know, because again, you're already thinking from a disposition point of view, this person is going to the operating room. So you wanna get your attending involved early so they can start getting the OR open in case they're on the golf course or something like that. So Glasgow Coma Scale, this should be very routine for everyone, but it can't really be understated in trauma and head injury, how important being proficient at the Glasgow Coma Scale is. It really is one of the most powerful tools as it relates to objective information that we have because so much of our decision-making is based on the Glasgow Coma Scale. And it's this thing that we can do initially and anybody can do it and it can be repeated regularly. And it's kind of how we watch this person. So it's based on the response of their eyes, the response of their voice, and the response of their upper extremities really and what they're able to do. So this patient, we gave him central stimuli and he kind of opened his eyes and he withdraws in his uppers. And he's not really making any words, but he's kind of moaning and making some sounds. So we're gonna give him two for his eyes, three for his motor, two for his verbal, for a GCS of seven. So, and this is again, repeatable. We can watch this. We can do it every half an hour. And we can say, we can surmise that he was talking when he came in and walking, that his GCS was very close to 15 when he came in and he's had a very precipitous drop. So this person is very ill and it can be repeated regularly to watch his progress. So to have the GCS, you're really down like the back of your hand, have it on the back of your badge. In our trauma bay, it's up on the wall in big so that we're all on the same page of how this gets evaluated. All right, another polling question. What do we wanna do with our poor Uber driver? There are plenty of options that we can do. Go to the OR, I think I might've spilled the beans on that one. So we're already thinking that he needs to go to the operating room. We could place an ICP monitor. We could give him some hyperosmotic of your choice, depending on what kind of access we have and how he's doing otherwise. And, or you could say, yeah, he's getting too sick. Not feeling it. We can decide we don't wanna treat him. So waiting for the results to filter in and let's see what everybody... All right, I think I spilled the beans. I think that wasn't quite fair. So OR emergently is I think the ultimate goal, but I don't think the other questions, the other B and C are incorrect. I think D is probably incorrect. I think you should probably treat this person. Hyperosmotic is, I think it would be a decent temporizing measure if you are, certainly if he's blown a pupil, you've got signs of herniation. That is absolutely a reasonable choice. If you are waiting to go to the operating room, ICP monitor, I think is also a very reasonable choice, but I don't think it's gonna change the management that this person needs to go to the operating room rather immediately, really as quick as you can. But hyperosmotic and ICP monitors are very reasonable choices. Moving on. All right, so going back to our 2006 guidelines for the surgical management, this person is a slam dunk. He needs to go to the operating room. That acute epidural hematoma, GCS less than nine, he's gotta go to the OR. So pretty straightforward. I didn't even bother measuring out that thing. It's probably more than 30 CCs, but he's a guy with an acute epidural who's doing bad. So he probably ought to go to the OR and be in staying in with these trauma, well-established guidelines on management of surgical epidural hematoma. All right. Oh my goodness, what do we do? So for those who don't get to spend much time in the operating room, we turned a big flap on this gentleman. And we did a craniotomy to evacuate this epidural. And I have a, I don't think I created an official polling question, but if you wanna type it into your box, Alice is gonna kind of keep a track for us. What are you guys, what's everybody doing with your bones on a someone like this, who's got a really huge hematoma and is doing bad and a younger, youngish person. So replacing the bone, put it back on, close. Are you taking the bone off? You're gonna leave it off for a little while, put it in the freezer. Are you gonna take it off, put it in the abdomen, which we do from time to time, because DC is kind of the transient place. Or are you just gonna take the bone off and put it in the trash and plan to make this person an aftermarket peak implant when you're ready to put it back on? We have a question while we wait for them through. Is there any push for tertiary centers to do bedside decompression for large EDA epidurals and subdurals prior to transfer to definitive peer center? I don't know the answer to that question. I've certainly heard that in the, some of the research that I've done, but I've not seen any guidelines and I don't clearly know the answer. That's a very good question and I can certainly research and follow it up. We'll be coming back for some Q&A after these two sessions. So I will look up that answer before we go forward. So the question is, is there any data support before sending out a patient to a tertiary doing a trepanation or basically a decompression of these? So I will look it up and I'll have some more answers later, but I don't know. What are people- We have all freezer, a couple of abdomen. Some say, I like this comment. Here we go, Erica. You'll get two different answers. One does abdomen, the other trashes it and the other one does peak. Yeah, so I agree that there's a lot of variation of this and there's no really great research to support one or the other. There's a lot of surgeon opinion on this. I worked with a military trained surgeon who spent a lot of time overseas and he puts a lot of these in the trash just because that's kind of what he's come to do and he's very comfortable putting peaks back on and there are some problems. Oftentimes it's hospital. There's some kind of, I watched another trauma lecture where there was discussion of the hospital mishandled it, mislabeled it. There was concern that it got swabbed wrong. We've had one that wasn't packaged correctly and then we get the patient back in and we open up the thing and we find it wasn't packaged. So this is entirely surgeon dependent based on experience but I think you're gonna find some combination for this person, a freezer or trash. We'll do an abdomen occasionally but our craniacs cranies are getting so big that it's hard to put that big a bone flap in the trash or excuse me, in the abdomen. So there was a comment on that. Why would you use the abdomen versus the freezer? And then some people have raised the concern that the freezer might have a higher increase in infection rate. Correct. I think that is, they're all reasonable. So you use the abdomen. That was kind of the way it was done to preserve the bone especially if DC is a transient town. So say somebody is visiting from Tennessee and we need to take their bone off and we put it in their abdomen. We can send them home to Tennessee and when their swelling goes down they can in theory get it put back on. You don't see that quite as much anymore. Freezers, I will agree that there may be a higher increase risk of infection just because it's, just because there is that risk that we're swabbing all these. So we're gonna get, it's kind of selection bias that if you're swabbing more things you're gonna get more infections that maybe these peaks and have the same risk but we're certainly seeing more positive cultures if we're swabbing these coming in and out of the freezer. I don't think there is any data to support one or the other. The only data I have heard is that younger people with autologous bone have a slightly higher risk of resorption, but I don't think there is any definitive data to support one or the other. Reasonable. All right. Good discussion. Thank you, Alice, for helping moderate that. All right, so we decompressed him, he got better, so on and so forth. So pretty straightforward, right? There are, and I said earlier, we don't know much. We have a pretty good idea about this, right? The lesionals, traumatic brain injuries, we should probably take out the lesion, right? So there are some things we do know but we get into non-lesional and we start to realize that we don't know as much as we would like. So we're gonna get into another case here and trauma service calls, they have a major activation, whatever that's called, in your facility. And they call us before the patient's here because they have a person they think is sick. It's a 28-year-old male, non-belted passenger, high-speed motor vehicle accident. This person was detected with a great degree of separation between the patient and the vehicle. There's discussion of maybe a seizure on scene by EMS, but these scenes are so chaotic that it's really hard to say. So as soon as he gets there, you watch this person come in and their GCS was six on the initial prior to intubation. Again, that's great information. Going kind of back to this real quick is when you're called for something like this, it is incredibly important that you get there as quickly as you can. If they take the time to call you and say, come in, we got a person we think has had a head injury, you know, a lot of times we roll our eyes because, you know, call us when you get the CT scan. But something like this, where you think it may be something the first exam really matters. And if you don't get to perform the first exam, at least get to watch the first exam, you get a better idea and you convey that information. Secondly, being there early is important to your trauma department. They're evaluated by all these metrics from the College of Surgeons on how fast their specialists are responding. So when you show up, it's basically a gold star for the trauma department. And maybe I'm biased, but getting a chance to talk to the EMS that brought this person in offers you a tremendous amount of information. And you're basically now getting firsthand information when you might have not, you know, you might have had the EMS sign out to the charge nurse or the trauma nurse and the trauma nurse to sign up to the resident, the resident sign up for attending. And by the time you get the information, the person had a six minute tonic clonic, but you actually talked to the EMS and they say, no, not really. Maybe the family saw something, but if you can get the information right from the source, you're really doing your patient a good service. So we get there and the guy's sick and he's intubated and you get a CT scan and there's no lesion, but the guy's looking really bad and you've got these little hyper densities throughout the three room and that little bit there on the right one, a little bit of hyper intensity and kind of back to the corpus plosum. So what you're starting to think in your mind is this person's very sick. You know, it's not lesional, but this looks to be a diffuse axonal injury. So again, back to the GCS scale and we wanna know everything about this person and we wanna be able to convey the information in this very succinct, very clear way. So he's not opening his eyes at all, no matter what you do to him, but he does withdraw and he's intubated. Intubated gets you a V1 pretty automatically. So this person's GCS is 6T is how we would indicate that to modify, to acknowledge the fact that the patient is intubated. So it's a sick dude, this is a DII with a GCS of six. So what does this look like? So we're gonna open another polling question and see what our folks would think we need to do. Do we take this person to the OR electomy? Do we do a big decompressive craniectomy? Do we place a bedside ICP monitor? Do we fire right away to hyperosmotics? Or do we say, nah, he's too sick, sorry. Nothing we can do, nothing we can do. So starting to open up here. So let's see what people would do with our poor 28 year old. If he'd have just worn a seatbelt, right? We wouldn't be having this conversation. I think we're at 94% OR emergently. Are we? All right. We are. We are, interesting. We have 3% at placing ICP monitor and 2% is hyperosmotic. That's very interesting. So this is, so we would, so that is very interesting that we wanna go right to the OR. So- There's some very eager neurosurgeons and APTs. I love it. I love it. So the question would be is, what are you hoping to accomplish with a decompressive craniectomy? And I guess what would be your side? Would you do a big bifrontal? Would you do left side, right side, decompressive hemicraniectomy? So I think the data supports is putting an ICP monitor in this person and using that as a basis for maybe some more gathering more information. So ICP monitor is placed. And I think in this case- I think, wait, wait, wait, Michael. I'm sorry. I think the polling's not working quite right. Is everybody in the chat box is saying they're not gonna do that. Yeah, good. So maybe we're in the wrong poll. I don't think it's updated. All right. So everyone in the chat box is saying that they're gonna put a bolt in. Good. And they're saying that the polling works. So anyway. Oh, yeah, look, I got 100% now. Good, good, good. All right. So I was having to backtrack. I don't think that person needs to go to the OR. So I think absolutely placing a ICP monitor is the correct thing to do depending on what you do with your local protocols. And this is kind of where your hospital protocols would come into place as far as what they want you to do as far as intracranial pressure monitoring. And I think a lot of the most recent guidelines support the use of EVD because it's got some benefit as to being able to drain out some CSF as a temporizing measure to lower ICP. So you put in an EVD and you find out his intracranial pressure is 16, so we're good. I don't think at this point you need to go to write to the operating room, but clearly this person is sick and needs to go to the ICU so they can manage him. And we all know this is a young person with traumatic non-lesional blood in his head. This is probably going to get worse before it gets better. So he's gonna need something. So we send this person to the ICU and we print out our SIBCC flyer on the wall, and we're gonna have to know that we're gonna aggressively manage this person's ICUs over the next couple of days. Good, I'm glad that was not everybody wanted to take that place to the person in the OR. I was a little nervous. Yeah, careful. Yeah. Yeah, making it- All right, so this is, I think, a great spot to talk about the TQIP information. And so the TQIP was, again, this kind of basis of communicating what we want when we send this person upstairs to manage these patients with severe traumatic brain injury. And this is some really good best practice. And some of this is kind of a jumping off point to management and certainly it would get changed if we had to do different things. But we can say with really specific certainty, we want the CPP, the cerebral perfusion pressure above 60. We want platelets, we want a good hemoglobin. And some interesting talk is I've heard about hemoglobin of seven being the kind of transfusion protocol that most people, I think, would like it a little higher. But the data doesn't necessarily support that. So this is where the data says it's transfused below seven. I think you'll find people that will tolerate numbers in seven and even eights and nines. But if you get too close to the actual seven number, that should be your transfusion, your cutoff. But these are all really just the basis of management. And if someone is having, if their pressures are going up, one of the things we can certainly do is change this sodium, right? Give them, move your sodium goals from 140 to 150 if you're gonna be giving hypertonics. And then you also wanna start measuring serum osms and stuff like that. If you wanna temporize and breathe them down a little bit and run the PaCO2 down closer to 30, I think that's a reasonable thing as a temporary measure. But this is really kind of how we can communicate with our trauma colleagues and our ICU colleagues. This is kind of a good jumping off point. And this is this kind of very straightforward user-friendly thing that I was talking about earlier about the TQIP, that it's just, here it is. This is what we want and we can modify it from there. But these are very important things. One of the things on top that I had questions about is the ICP of 20 to 25. And I don't think they want you to keep the ICPs between 20 and 25, but the threshold, I think the evidence is moving away from 20 being the hard alarm cutoff to a more gradual cutoff between 20 and 25. I certainly wouldn't let it ride over 25, but you need to start thinking about doing stuff before it gets over 25, that maybe 20 is not exactly the right number. So we're gonna manage this person with this as our basis with these treatment parameters and adapt as we can. So here is a part of the SIBICC consensus that how we're gonna manage them and how to use these tiers. Again, this is really great information. And this is, today's not a class on how to use it, on the management, which I think may be a really cool class in the future of active management of intracranial pressure in a traumatic brain injury. I think that would be a great class. This isn't it, but this is certainly should spur some discussion with you and your intensivists and your attendings on how we do this. And are we following kind of these practices? Again, this is just the tool, it's class three evidence, but it's certainly some really great information. So we know this, we're pretty sure this guy has DAI and we've got him in the ICU and we've just had to really work to keep his ICPs, but we've, for the most part, been able to do it. And by day four, he is stable enough for MRI. And what's the point of an MRI? It seems like a lot of work. An MRI is really excellent. It can offer a lot of prognostic information. So A, it confirms the diagnosis of diffuse axonal injury, which is really not sensitive in CT, but again, and it also provides us some prognostic information. So say you get an MRI on a person who's you've been working to keep their ICPs down and their brainstem is shot. So they've been basically, you've been working around their auto-regulation and their brainstem is shot. Then you can take that information and have a discussion with the family about what the end game is. But this person has an MRI that again, he's been on the suite. It's got these little hypotenuations here throughout the cortex. And this sure looks like DAI. There's a little bit of edema in the brainstem, but not a ton. So it looks like there's a little hemorrhage there that maybe wasn't evidence on CT, but overall, not a terrible MRI, not a devastating MRI. It doesn't have a bunch of big infarcts, just got a bunch of hemorrhages. So maybe this person will perk up and do okay. So we stabilized this patient and they had this long ICU stay. We're able to get the EBD out. He went to the floor, he got PTOT. And eventually he went to SAR, which is at three weeks out, being able to go to rehab and not needing long-term care or an LTAC is a win. So, I mean, I don't think his outcome needs to be judged to six months and probably even a year, but this sounds like a pretty good case to me that he was able to get to a rehab. So managing his ICP was certainly the right thing to do for this person who will hopefully do some recovery. This is a patient I treated, I helped to treat earlier this year. So I haven't heard how he did. So moving on, case 2.5. So you have the pager, this should sound quite familiar. So you get a call for a 28 year old, it's the same thing, except he's a little sicker, right? This person, this time his GCS is four and you are making sure you get that information that he didn't get some Ativan for a possible seizure by EMS. And so this person is looking pretty sick, but it's the same deal, right? And you've gone through his GCS and you confirmed he's really all he's doing is extensure posturing. So this is a bad way, this is a sick, sick, sick person that we know we're gonna be managing. So back to management options, same person, GCS has gone down, here is another polling question that we need to open. So what are we gonna do with this person who's just a bit sicker than the last person? So are we gonna go straight to the OR for a decompression? Are we going to put the ICP monitor in? Are we gonna go with the hyperosmotic or are we gonna say GCS four? Probably not, probably not. So as the results come in to see what we should do for this person, again, CT was the same, right? It's non-lesional, there's no big subdural, there's no big epidural, there's no big interstitial contusion that we could evacuate. So he's just got a diffuse brain injury, this diffuse axonal injury again. So as the results come in, it kind of looks like people are pretty much on the same ballpark of this ICP monitor is probably the jumping off point. Some people wanna take him to the operating room, some people wanna haul right off and give the hyperosmotic. I think in this case, I think the ICP monitor again is gonna guide our initial treatment of what we're gonna do. And then we can talk about ICP or ORs or osmotics after that. But I think I would certainly in a patient less than GCS less than eight, your trauma department and your hospital protocols probably tell you to put in an endocrine pressure monitor, especially if there's blood in the head. So what do we do? EBD is placed. ICP 47 for our office colleagues. This is bad. This is a very, very, very high endocrine pressure. And what do we wanna do for this person? Do we take him? We say, okay, OR, we're gonna do a barge difrontal decompressed craniectomy. I think, am I missing the polling question, Alice? No, we have a question to your last one before we get started on this one. Seizure on case two, would you give them time to prove they're not post-dictal before you placing a monitor? That's a very reasonable question. I probably would not. I would say if we're saying it's a possible seizure with someone with blood in their head, I think putting the ICP monitor in when they look this sick, I think probably putting the ICP monitor in. And maybe they wake up from a seizure, but you've got somebody who was ejected from a car with blood in their head with a bad GCS. I think you're better off placing a monitor and letting them wake up. It's just kind of like a patient who's drunk. I think you have to be cautious and manage the patient in front of you. Certainly, could they be post-dictal if they had a seizure? That's a very reasonable thing to consider. But I think putting in an ICP monitor and if they wake up, say, well, okay, good. That wasn't it. But I think spending time waiting to see or how long do you wait? I think it's probably not the right thing to do. It would be certainly my clinical gestalt on that. So we have a few more questions before we get started again. Can you briefly summarize when it is safe to remove an EBD for diffuse axonal injury? Also, do you initialize antibiotic prophylaxis at a certain point when managing the EBD? Certainly. So again, this is not necessarily a class on the management. There is, I'm gonna back up a few slides. I think it's on. So if you go to the big poster, if you follow off my link off of earlier in thing when I was in that slide, they link to a big post, I'm too far ahead. There's a link to some information on how, when it's safe on how to do that. It's kind of surgeon dependent, but there's some information on the SIBCC consensus statement on, I think if they call it a heat map on when it's safe to reduce, excuse me, remove the ICP monitor. What my practice is, and again, this is a disclaimer, is if they had no ICP issues for 24 to 48 hours and they've gotten through any medical stuff that they need, say they need their femur fixed, that they need to be trach and pegged, we might leave the ICP monitor in through any further anesthesia things. But if generally, if they've gone 24 to 48 hours and they're several days out, five, six days out, I think that's certainly safe to remove. But I would look at the SI, the Seattle consensus heat map on removing ICP monitor. And then the other- There's another question. Do you not do hyper osmotics in addition to the ICP monitor? I would put in the, without lateralizing sign, without somebody blowing the pupil, I would probably give the ICP monitor first. So you know what you're treating. So it's like the first person whose ICPs were only 17. So you can, you need- I personally feel that again, unless they've blown a pupil or they've got signs that they're herniating, that I think putting the ICP monitor in is gonna give you a more complete look. Again, Surgeon Bennett, and this is not necessarily a class in that, but I think having the ICP monitor should guide, could guide therapy. But again, if they blow a pupil and you think they're herniating, certainly it's not the wrong thing to do. The comments, I work mostly in the office and the OR, but no ICU. Can you give me a little quick rundown on ICP monitoring? Certainly. We monitor ICP to decide who needs to be decompressed. The ICP is, should be below 20. And there's a old physical understanding of our skull as a box. And the Monroe Kelly doctrine says that if the pressure increases, the mass have to go somewhere else. And what you'll end up with is herniation. Down pressure from above, pushing the brain down through the foramen magnum or across the uncus. And that will cause brain damage and death. So we want to manage the intracranial pressure to keep it in a safe range, which is thought to be below 20 to 25 to prevent herniation and brain damage. The pressure gets too high. It obstructs the cerebral blood flow. So you'll get less blood flow to your brain and a lot of bad things will happen. So we really have to be diligent about managing intracranial pressure in these patients. And that can be done through surgery. That can be done through medical management. That can be done through simple things like putting the patient's head of the bed up, making sure their head is straight. So they're not taking their regular venous return, making sure the EBD is working properly. So everyone who sees ICU patients and sees neurosurgery patient at ICU should have their quick five things they check every time they get a call for increased IIC intracranial pressures. But it's something that we have to really watch closely. And it's really all we have when we're managing these comatose patients because they don't oftentimes have much of an exam to follow. So we're following their intracranial pressures. How long do you wait to provide prognosis for DAI patients? It depends. And there's some stuff that we're going to talk about on this case about prognosis and what to do with these very sick patients who are sick when they come in. The questions are rolling in. Sorry, Michael. Oh, no. Okay. How long is putting an EBD versus an ICP monitor appears to be used interchangeably? EBD is the standard of care in my hospital. And I think Brain Trauma Foundation supports its use, but BOLT is, or Lycox or whatever, again, I'm getting into names, any kind of intracranial pressure monitor. Whatever your attending physician and your hospital expects you to place. Yeah. Case two, with the patient's ventricles being so small, would you try to place an EBD or just place a BOLT monitor? Our protocols are to, I think, three passes for an EBD and then place a BOLT. Do you use Manitol on these patients as well or is this just in the OR? No, we'll use Manitol on these patients, absolutely. If they have adequate blood pressure and they're appropriately resuscitated, you can't give Manitol to under-resuscitated patients. That's one of the important things. What are the five things to always check when getting the call about increasing intracranial pressure? I think that's just what you mentioned. Perfect. So first thing I'm going to say is the position, right? Our patients who are traumatic brain injury should be, they should be in reverse Trendelenburg. So their head should be above their butt to some degree, whatever it is in your facility, 25, 30, 40 degrees. And that's just basically gravity. Let gravity do some work for you. So there's one thing. Is there, they're undoubtedly in a C-collar. Is the C-collar placed appropriately? And is their head essentially looking midline? You can convene your jugular venous return. That is enough to increase your intracranial pressure. So position is super important. Is the EBD functioning properly? Is it draining? Is it reading? Is it open to drain or is it continue? Is it just draining pressure? So you have to always check your EBD. Is there anything clamped? Are they clamped on there? Did they clamp to move the patient to set them up in bed and forgot to unclamp? Those are all things certainly to look at. Are they in pain? Pain can certainly run it up. So if they've got some sedation that should be running, should they be on, can they get their fentanyl or can their propofol be turned up? Are they sedated and are they calm? Cause that will certainly run up your intracranial pressure. And I think another one is to get an exam because you can't, you know, you can't not do an exam if you're called and miss a blown pupil and just say, ah, you know, head wasn't high enough. They're fine. So always get an exam. So everyone should kind of develop the first things that they do when they get called. That's a really common call for someone carrying the neurosurgery pager on our service. Okay, one more comment before we move on to your polling question. All right. Regarding an MRI, EVD versus bolt. The pros of an EVD versus a bolt. I think it's an interesting question. I think it's hard to get an MRI with a bolt. I think it may be another good reason to get it to have an EVD. That's a technical question I don't have the answer. I think they're the, I'm not positive whether the bolts, we place so many EVDs and we don't place a lot of bolts anymore, but I don't know. And a lot of that stuff happens overnight when I'm not here. So I think it is that bolts are probably harder to get with MRIs, but I don't know for sure. That was kind of the comment, so. Absolutely. It's harder to get any BD with a bolt. And what's your blood pressure goal? Blood pressure goal, I'd like the blood pressure, if we go back, right in here. So I think blood pressure should be on here. We want the systolic really above 100. What that's going to do is support our cerebral perfusion pressure. So SBP is, or cerebral perfusion pressure is MAP minus ICP. So we want to keep the MAP nice and high and the ICP nice and low so that we get this cerebral perfusion pressure 60-ish, above 60. Okay, I think we're good to go now. All right, let's rock. So we are starting to get up against some time. Where are we? All right, so this was our polling question. So it looks like, do I have... 60% ICP monitor, 18% OR emergently, 17% hyperosmotic. All right, so this is where some new information has just kind of come out. So ICP monitor, I'm going to be an ICP monitor person and think that we need the information. If he looks like he's herniating, then hyperosmotic is certainly not the wrong thing to do. And so we've got an ICP now of 47. And now we've got some more management questions. Do I have an official, I don't think I have an actual polling question for this. So if you just want to put into the chat box what people are thinking for this person, we can kind of get a consensus. I don't think I created an official polling question for this. So do we want to take this guy right to the OR and do a big bifrontal decompressive craniectomy? Are we going to kind of see if we can see it? Maybe it's a little worse on the right side and decide to do a lateralizing frontotemporal. Are we going to take this person to the ICU and try to manage their ICPs medically? Or are we going to tell the family there's nothing we can do? So there's a lot going on here. So young guy, sick, DCS4, ICP is closing in on 50. So there's a lot of things to think about of what we want to do. And Alice, what are we getting for answers? We're getting medical management. Medical management. That's hard. That's a tough one. But I think the data and the new data supports medical management for this person. So here's the hot off the press stuff that I mentioned that there's some new management for severe traumatic brain injury, decompressive craniectomy recommendations. And the two trials, the RESQ-ICP and the DECRA trial, have produced some outcome data in the last couple of years. And that has been synthesized and gone over. And what they've basically done is broken people into, and if you have a chance, follow, I think there's a link in here, but follow the link and look at this data. And it's really pretty amazing what they've done. And they're really pretty cool pictures too. They've dichotomized the outcomes, right? So they have good outcomes, okay outcomes based on kind of one year and six month and one year follow-up of how these patients are doing. And they've dichotomized it into basically bad and acceptable outcomes and made new recommendations on management based on, you know, are they dead or vegetative or close to vegetative or are they acceptable, which would mean fully functioning, almost fully functioning, so on and so forth. But again, if you want to look at this data, it's worth reading because it's fairly impressive. So what do they do? So the fourth edition, they have these recommendations where they said the bifrontal decompression is not recommended with diffuse injury. So they've removed that. They basically put that back in into play and they have restated the fact that a big hemicraniectomy is better than a small hemicraniectomy, but I think for most of us, that's probably fairly self-explanatory that we wouldn't do. In terms of decompression, we really want a larger decompression. So that was restated, but they removed that guideline about not recommending the bifrontal decompressive craniectomy. And they added some new recommendations and this is really, this goes right into this case that we were just discussing. So it's important when you look about, look at these new recommendations to kind of understand the context and that primary decompressive craniectomy is for, is lesional, right? It's for the epidural, subdural, the intracerebral hemorrhages. So we pretty well know those people need to go to the OR, but the interesting stuff comes in secondary and secondary decompressive craniectomy for late refractory, and that really is pretty much past 72 hours, is recommended to improve outcomes. But this is really something I've had my trouble wrapping my head around. Secondary decompressive craniectomy for early refractory ICP is not recommended to improve outcomes. So that's, that's our patient, right? He's got early increased intracranial pressure. We don't know if it's refractory yet, we haven't tried much. So I think we're going to have to manage, see if we can manage this person medically, but doing it for early high ICP is not. Again, they've kind of changed some of the wording in the frontal temporal decompressive craniectomy showing that it improves outcomes. And the fourth there on the bottom, secondary decompressive craniectomy for either early or late is suggested to reduce ICP, but it's relationship to the outcome. So yeah, if you do it early, if we did it on our friend case two and a half, certainly we'd probably get his ICPs down, but we're really not sure if he's going to make him any better. So the people who had that surgery are still falling into the dead or vegetative or poor outcome dichotomy of, of outcomes for these patients. So the research doesn't support really taking these people right to the operating room, certainly within the first three days. And the, the kind of analysis from the committee who developed this new recommendations really kind of said some profound stuff. And I think really laid the groundwork for further discussion. And I'm sure there's going to be a lot of letters in the editor, in the journals about this in the next few weeks and months, but they noted that, that the old recommendations saying, you know, when and when, when to not decompress people didn't really change people. The docs still did kind of what they thought was right, that they, they went outside the guidelines. And even when they weren't necessarily supposed to for guidelines, they still did the decompression because it's hard to withhold a possible life-saving therapy. Even when we, we know we have evidence to tell a family, yeah, he's probably going to die, or he's going to probably not have a good outcome. So it's hard to do that. It's just like when, when you have a big MCA stroke and you see all that dead brain on their dominant side, and do you offer the decompressive craniotomy for a completed MCA stroke, even though you know, the odds of them doing well are bad, you know, these are really difficult decisions. They also noted that patients with evidence of good brain function who declined because their ICPs go down during the course of their, their hospitalization, those people are the best candidates for secondary decompression. So our first case, case 2.0, if his ICPs would have crept up, he would have certainly been someone who would have maybe benefited from a, from a secondary decompression, because he came in with a six GCS and normal ICPs, and he got worse while he was in the hospital. So he's the one that's most likely to benefit from decompression. And something that's kind of central to the debate is, is for us trying to predict who has, who's going to have a good outcome. And that's really hard. And there's a old study that I heard reference to that they basically brought in a surgeon and had them look at a case and say, how do you think the first person's going to do? And they made their statement on how they thought, and they followed the patient. And it turns out we're not very good at it. So we're trying to predict who's having a good outcome, which is hard enough, which we're not, we know we're not that good at. And then understanding what is an acceptable outcome is even harder, because what is acceptable to me and my family is, is maybe different to another family. There's cultural, there's religious nuance to this, and it's, it's hard, it's complex. So there, there has to be more research. And even though we've got these two really good trials that have given us a tremendous amount of data so far, there's still a lot that needs to go into our understanding. And there's a lot that we need to digest as clinicians, so that we can go to these families who are having absolutely the worst day of their lives, and provide them with the best information that we can to help them make a decision that is reasonable for the patient, for the family, for, for society to, to figure out what is, is the right thing to do. And it's, it's hard. So I encourage you, if you haven't had the opportunity to discuss this with your attendings, say, what are we going to do here? What do you expect me to say when you tell me to go tell the patient's family there's nothing we can do, even though they're alive right now? You know, this is, this is hard. So please take some time to digest it, go through and read the articles, or that most recent update, because it's, it's, it's impressive. So we're going to move on a little bit. Are there any last bit of questions, Alice, filtering in from the severe TBI? Yeah, I was trying to hold them since you, we had gone so long before. Are there any differences in peds? Are they, they're much more resilient than adults. Do you change any of your treatment options? Certainly. I don't treat pediatric patients. I mean, I'll take, we'll take teenagers if they come to us. So my experience is not great with pediatrics. I recommend checking in with the Traumatic Brain Injury. They just came out with some new guidelines in 2019 about traumatic brain injury and pediatrics and their severe TBI protocols. And I don't have that information. I'm sorry. I don't, I don't treat pain. So that's, I'm not, I wouldn't be false advertising if I gave my opinion. Okay. All right. You can move on. All right. So we're kind of done with the cool stuff. You know, the surgeries and cranies and blood and everything like that. But we're going to get into the, where we're really going to make a difference in probably the most people's, right? We'll do a bunch of cranies in a year, but we're really going to see a lot of head injuries in our outpatient clinic and being able to help manage these folks most appropriately is incredibly important. So we gave the pager to the inpatient team and now we're over at the outpatient clinic and we're doing some follow-ups and we have a 20 year old female college student and she's a softball player. She plays third base. And 10 days ago, she got hit in the head by a grounder and she didn't have any loss of consciousness. There was no seizure. All she really reported was that she felt foggy. You know, her coach kind of noticed that she was a little bit confused and the trainer brought her into the emergency department. She did not meet the criteria for scanning and she was diagnosed with a concussion. If you see patients in the ED or your clinic with these, I really highly recommend looking up the CDC website. They've got a really, really great section on it called heads up to head injuries for athletes. It's got, it's a tremendous resource. So there's resources for us as clinicians, for parents, for patients and trainers and coaches. So if you don't know about that and you find yourself having to manage these patients, I really recommend you look into that. So anyhow, this patient was an excellent diagnosis of concussion. They didn't meet the criteria for a CT, but as we do with all our concussion patients, we make sure they have follow-up. Supremely important. So this patient is here for follow-up and they're here 10 days out for routine care and all they're really reporting is still some kind of lingering headaches, which is not uncommon. We often tell people that, you know, concussion symptoms are self-limiting and most resolve in 10 to 14 days. So for someone to come in, a healthy person to come in and say, I'm still having intermittent headaches, that's, this is quite reasonable. And we really want to continue basically supportive care. The Brain Trauma Foundation just came out with the, some new guidelines for classifying subtypes of concussions. So the first guideline, step one was basically, yep, concussions are a problem. There's not much research. We should do more research. And if you think we don't know anything about severe TBI, we really have a long way to go on concussion management. There's really not a ton of evidence-based management for concussion. There's a lot of research that needs to be done and the Brain Trauma Foundation just brought out this and tries to let us know that it's really important to fully assess symptoms to classify the different subtypes. And it helps us not only classify, but it helps us not miss something. So that if we have someone who's having the cognitive issues or the oculomotor or the vestibular, that we are making sure that we're still catching them as mild, or excuse me, as confessions, and we're treating them as such, and that we're ensuring appropriate therapy and follow-up for whatever their symptoms are. We're still in symptom management at this point, but we need to start thinking if they're having vestibular symptoms, if they're dizzy or stuff like that, that we're getting them to the correct therapy that they need, because that's really one of the things we do know is early therapy decreases the overall duration of symptoms. So this person is subtype 1, they're having headache characteristics. We can still probably say symptom management with Tylenol and keep them in the concussion protocol from their school, and the NCEA has forwarded that they probably still need to be in the concussion protocol if they still have symptoms. But again, going back to the brain trauma stuff, if we are able to classify these folks, we can get them on the right track as far as their recovery, and the recommendation at the end of this is we need more research, which is absolutely correct. There is not great evidence-based management options for concussions. I'm sure a lot of you know, as you struggle, there's some algorithms that are put up by different folks, but there's really the research is ongoing. So if you're seeing these patients, please make sure that you're up to date on all this stuff and how to manage these folks. So what did we learn today? I hope we learned something. There's a lot of sources for information. Some are great, some are good, some are not so good. So please familiarize yourself with the Brain Trauma Foundation, the TQIP, if that's your particular speed, which it is kind of mine, kind of a user-friendly guy. Read through the SI, the Seattle Consensus stuff, which is very fascinating, and see if your doc wants to print out that poster. The BTF stuff is really evidence-based and some is less so, and I think it's clear that there is further research that is active and ongoing that will help us understand the management and treatment of traumatic brain injury to really make, increase, improve outcomes and help these people. It's like we looked at in the first slide, traumatic brain injury is a huge problem and it's a huge burden on our society. So we didn't even get into prevention, so I think prevention is unbelievable, but hopefully your trauma department has some prevention stuff there. But take some information back, discuss it with your attendings. I hope you guys enjoyed learning up on these new protocols today, and I will see you guys for some Q&A later this afternoon, I guess. This might be a loaded question, but we have one to go. Would you send concussion patients to neurology rather than neurosurgery? That's a very easy thing. Yes, absolutely. It's very, I see a lot of them in my clinic. I just do, we are neurosurgical, PA clinic, we run a PA clinic, and so we are easy to get into, and I think that's the most important thing for traumatic brain injury patients is access. And sometimes neurologists, they don't want to see it, so they're not accessible. So if you're programmed as a TBI clinic, I think is the most appropriate. Neurology is certainly most appropriate. Neurosurgery is probably less so, but I'm going to see the patient. I'm going to see the patient. I'm going to check on the patient and make sure that they're doing well, because it really, it boils down to access. Can they get seen? And I think it's the most important thing is they can. So something I want to do from QI point of view is making sure that we're identifying these patients in the ER and they are getting routed appropriately to somebody. If the patient was having more significant symptoms, certainly I'll push hard to get them into neurology, but if it's just 10 days out and still need some Tylenol, I feel pretty comfortable managing that. And if they continue to have symptoms beyond a month or two, then they're going to go to neurology to an expert in TBI. Well, thank you, Michael. I think they loved it. It's been my privilege. And we hope to have you back next year. I'm sure that we'll just continue to a larger session since it went so well. I hope we meet in person. Where are we going next year, Alice? Do we know yet? It might be right here and it might be right here and somewhere. I hope we're somewhere. Thank you, guys. I'll see you in a couple hours for Q&A. Thank you so much for your time. Everybody, we'll be moving to cranial trauma next with Dr. LaRue. See you there.

traumatic brain injury

TBI management

conference presentation

surgical management guidelines

decompressive craniectomy

ICP monitoring

hyperosmotic therapy

Brain Trauma Foundation

TQUIP guidelines

concussion management

access to care