brain herniation

BS Medical Tropes that Need to Die, 2/? : Making People Unconscious

For Part 1 of the BS Medical Tropes series, click here!

So I got an ask the other night about a character choosing not to kill people, but knocks them out with blows to the head instead. And it’s not an unreasonable thing for writers to think is legitimate. In fact, in fiction, there are dozens of ways to produce unconsciousness! A sharp hit to the head; a sedative drug injected right into the neck, bro!, or even Darkly Dreaming Dexter with his special horse paralytic.

Hell, on Person of Interest the main characters routinely produce unconscious enemy combatants by shooting them in the @$#RY)G!@#% knees

Here’s the thing: Every single one of those is complete bullshit.

Poppycock. Nincompoopery. Asscrap. And you’d realize that it’s a crock of crap if you thought about it this way for even half a minute:

Keep reading

Increased Intracranial Pressure

(>20 mm Hg) Due to a rigid and fixed skull, there is no room for any additional fluid, blood, or lesions. Additional matter without an expansion of volume, especially, creates increased pressure. Increased intracranial pressure is very serious and could lead to brain herniation and subsequent death.

Causes

  • Brain tumors
  • CNS infections
  • Cerebral edema
  • Intracranial bleeding
  • Excess CSF

Manifestations

  • Changes in level of consciousness (LOC) ***often the first indication***

Glasgow Coma Scale measures LOC via eye, motor, and verbal responses to stimulus from the environment. It scores from 3-15 w/ 8 being the “magic number” - think magic 8 ball. If you shake it up, or stimulate it, and a number < 8 appears a severe coma is present. 9-12 represents a moderate coma. 13-14 represents a mild coma.

  • Blurred vision
  • Coma
  • Decerebrate posture (extension of arms indicative of brain stem involvement)
  • Diplopia
  • Doll’s eye phenomena
  • Headache
  • Projectile vomiting
  • Behavior changes
  • Seizures
  • Cushing’s reflex (as manifested by Cushing’s triad):  increased BP w/ widening PP (peripheral resistance increased to shunt blood towards the oxygen-needy brain), decreased pulse rate (in a vagal-induced response to rising BP), decreased/irregular (Cheyne Stokes) respirations

Indicative of impending herniation - emergent medical response necessary.

Treatment of ICP

  • Keep HOB elevated at 30 degrees
  • Keep patient well hydrated
  • Frequent neuro-checks needed
  • Strict I&O
  • Anticonvulsants for seizure prevention (phenytoin)
  • Mannitol (osmotic diuretic used to reduce cerebral edema)
  • Loop diuretics
  • Avoid aspirin, narcotics, or meds that depress respirations (as they are already at risk for being low)
  • Hyperventilate patient (blow off CO2 [hypocapnia]) to decrease cerebral blood flow (cerebral vasoconstriction in response to low CO2 levels)
  • Decrease environmental stimuli
  • initiate seizure and safety precautions (padded side rails up, call light w/in reach)

i-dragonqueen  asked:

Hi Aunt Scripty! One of my characters is dying from a cerebrovascular accident. I know that in those, the victim can die during the recovery phase, but I'm not sure how that happens. How long would it take for her to die after the stroke (she has access to fantasy medicine but no open brain surgery)? What exactly would kill her? She's a fairly healthy woman in her mid-forties (though seriously out of shape). Thank you so much for the hard work you put in this blog! It's so helpful!

Hey there! Thanks for your question! 

So let’s clear something up: there are two kinds of strokes, and the term “stroke” and “cerebrovascular accident” (or CVA) are used almost interchangeably. 

First there are ischemic strokes, in which a character has a blood clot that suddenly cuts off flow to part of the brain, resulting in damage to the brain tissue past the clot. These can be absolutely devastating. 

Then there are hemorrhagic strokes, in which a blood vessel in the brain bursts. These can also be devastating. 

I’m going to assume the latter, actually, because I feel like it’s more likely to cause a secondary death than the former. 

So when a blood vessel bursts and causes a stroke, there are a few problems. First, the distal tissue isn’t getting the blood flow it needs, but the problem gets bigger, and I mean that literally. That’s because the bleed expands and puts pressure on the brain. 

The actual initial bleeding can be (mostly) stopped, but the pressure on the brain can cause severe brain damage, brain death, or death by apnea. Basically, the brain gets smooshed to the wrong parts of the skull, a process called herniation. When the brain herniates, it tears the neurons and damages the connections (or synapses). 

So even once the bleeding stops, that pressure can cause all kinds of dysfunctions that your character doesn’t want. Also, anything that causes a rise in pressure (like getting up or, miraculously enough, the stroke itself) is liable to cause a re-bleed, where the character whose bleeding had stopped, begins bleeding again, adding more pressure, and moving them towards death. 

Other ways to die during recovery: not being able to drink water, not being able to chew and swallow food, etc. But re-bleeding is what makes the most sense in this scenario. 

I know literally nothing about how the medical magic of your world works, but one explanation might be that they can stop the bleeding but that they can’t actually just make the blood on the brain vanish (this implies that they know what’s going on and have a “magic CT scan”, which, I don’t know what the state of medical knowledge or what have you is in your story, so I’m not sure I can help with that one.) 

Anyway, I hope this helps! 

xoxo, Aunt Scripty

[disclaimer]

[Come to Patreon, the land  where the inbox never closes!]

[Preorders for Maim Your Characters: How Injuries Work in Fiction are almost sold out!]

thatsyoraven  asked:

Have you ever considered being a doctor? If not, what drives you away from it and towards nursing?

Hi there,

I know you mean this question well, but this is a very dangerous question to ask a nurse. I say this emphatically, being a nurse does not mean that you failed to become a doctor. This question can be construed as insulting to a large, intelligent, capable profession.

Once upon a time, I wanted to be a doctor. I was in college, so I volunteered at a hospital. What I saw made me reconsider my plan. It was nurses at bedside, with patients, while stressed looking doctors carried around 3 pagers, saying “Oh f^&K” every time one beeped. No, thank you.

Healthcare is a team. Just last night at work, a patient’s pupil’s were blown and non-reactive, her systolic BP was wayyy up, her diastolic down and her heart rate was bradycardic. This is Cushing’s triad, a major medical emergency when the brain is herniating out of the skull. Let me tell you how quick stuff happens. My friend (primary nurse) called the ICU doc, and asked myself and another nurse for back up. The doctor asked for some meds and placeed a central line. One nurse was pushing meds, one nurse was drawing up meds, one nurse was running between the 2 and giving the doc the supplies he needed to get the line placed. 15 minutes later the line was in and a lot  of medication was given, the pupils reacted to light. We saved her life. That fact is not any less amazing because there is not an MD behind my name. It took the team, when we congratulated the doc, he said “I didn’t do anything, it was you.” 

Brain Herniation Syndromes

  • occur due to the skull being a fixed inflexible space, any rise in pressure is exerted on soft tissues –> compression and shift
  • cause of raised ICP e.g. haematoma, SAH, ischaemia, mass

Subfalcine 

  • can lead to compression of the anterior cerebral artery –> contralateral weakness (stroke)

Uncal 

  • CNIII palsy (ipsilateral dilated pupil, then ophthalmoplegia)
  • followed by contralateral hemiparesis = false localising sign

Tonsillar = coning

  • cerbellar tonsils down through foramen magnum
  • loss of consciousness, abnormal breathing (cheyne-stokes), upgoing plantars
  • Cushing’s Triad = hypertension, bradycardia, irregular breathing

In situ view of the incisura of the tentorium.

 Removal of the cerebrum allows for a better view of the tentorial opening, through which uncal herniation occurs. The incisura of the tentorium plays a similar role to the foramen magnum in cerebellar tonsillar herniation. (Although irrelevant to this discussion, this patient happens to have had a pituitary adenoma compressing the optic chiasm.)

vimeo

BRAIN HERNIATION

EXCELLENT EXPLANATION USING MRI

Anatomy for Emergency Medicine #9 Brain Herniation

atartsboudoir  asked:

The Mary Sue BS makes my brain herniate. Ray Palmer can have four PhDs and be a mega multi-billionaire by age 30-ish - oh, and a minister of some sort - but Felicity, if she is presented as being equally smart or smarter and capable of flying the suit (incidentally, she is the reason the fecking thing flies at all) she's a Mary Sue. Ditto for anyone declaring it's unrealistic that she could be CEO. She's more qualified than Oliver ever was lbr (but together they'd be a top notch team).

This is why it’s so important to curate your Tumblr dash, IMHO.  Because if you’re following people who are saying Felicity is a Mary Sue … you’re following the wrong people.  I don’t tend to go outside my dash, like going on the Olicity tag or checking the Arrow Facebook page.  Partly it’s because I have enough trouble keeping up with my dash, but also, why do I want to read the haters’ opinions?  Why should I let them into my bubble?  Short answer, I don’t.  So most of the crap that goes on, I only hear whispers of–and that’s how I like it.  :-)