Podcasts about brain trauma foundation

Dr. Halinder Mangat, Director of Research at the Brain Trauma Foundation, has developed evidence-based guidelines for treating severe traumatic brain injuries, which have been shown to improve outcomes significantly. The Foundation is conducting research in collaboration with the US Defense Department and Veterans Administration, including a clinical trial on the use of lumbar drainage to reduce intracranial pressure from a brain injury. While the brain was once thought incapable of healing, research shows early intervention from injuries can result in the regeneration of cells and formation of new neural circuits.  Halinder explains, "The initial focus of the Brain Trauma Foundation's mission was treatment. The Brain Trauma Foundation in 1997 became the first surgical organization and first professional body to produce evidence-based guidelines for the treatment of severe head injury. That means looking at the comprehensive literature body, finding out what robust research is, and compiling it all. Some studies may have contradictory results. We compile it all in a very objective, systematic way to then frame recommendations as to the best practice, and these fall under the umbrella of evidence-based medicine. In 1997, the first edition was published. Over the years, multiple studies have shown that this set of guidelines has improved good outcomes or decreased poor outcomes by 50%, which is the most remarkable intervention, perhaps short of vaccines or antibiotics. But in the surgical field, it is probably the most impactful intervention."   "So the first impact of the injury causes X amount of damage, and then following that, there is a cascade of it like dominoes falling. The whole focus has been to prevent downstream dominoes from falling by early intervention. And after the first injury when a few dominoes, for example, have fallen, the goal of the guidelines has been to as early and as intensively as possible to minimize downstream dominos falling, which means secondary injury, which in itself has its own legacy of influencing outcome. Over a period of time, there's been a lot of trials to try neuroprotective drugs, which would, in the first instance, mitigate the secondary injury."  #BrainTraumaFoundation #BTF #Neurology #Neurologist #TraumaticBrainInjury #TBI #BrainTrauma braintrauma.org Download the transcript here

Dr. Halinder Mangat, Director of Research at the Brain Trauma Foundation, has developed evidence-based guidelines for treating severe traumatic brain injuries, which have been shown to improve outcomes significantly. The Foundation is conducting research in collaboration with the US Defense Department and Veterans Administration, including a clinical trial on the use of lumbar drainage to reduce intracranial pressure from a brain injury. While the brain was once thought incapable of healing, research shows early intervention from injuries can result in the regeneration of cells and formation of new neural circuits.  Halinder explains, "The initial focus of the Brain Trauma Foundation's mission was treatment. The Brain Trauma Foundation in 1997 became the first surgical organization and first professional body to produce evidence-based guidelines for the treatment of severe head injury. That means looking at the comprehensive literature body, finding out what robust research is, and compiling it all. Some studies may have contradictory results. We compile it all in a very objective, systematic way to then frame recommendations as to the best practice, and these fall under the umbrella of evidence-based medicine. In 1997, the first edition was published. Over the years, multiple studies have shown that this set of guidelines has improved good outcomes or decreased poor outcomes by 50%, which is the most remarkable intervention, perhaps short of vaccines or antibiotics. But in the surgical field, it is probably the most impactful intervention."   "So the first impact of the injury causes X amount of damage, and then following that, there is a cascade of it like dominoes falling. The whole focus has been to prevent downstream dominoes from falling by early intervention. And after the first injury when a few dominoes, for example, have fallen, the goal of the guidelines has been to as early and as intensively as possible to minimize downstream dominos falling, which means secondary injury, which in itself has its own legacy of influencing outcome. Over a period of time, there's been a lot of trials to try neuroprotective drugs, which would, in the first instance, mitigate the secondary injury."  #BrainTraumaFoundation #BTF #Neurology #Neurologist #TraumaticBrainInjury #TBI #BrainTrauma braintrauma.org Listen to the podcast here

Despite validated models, predicting outcomes after traumatic brain injury remains challenging, requiring prognostic humility and a model of shared decision making with surrogate decision makers to establish care goals. In this episode, Lyell Jones, MD, FAAN, speaks with Jamie E. Podell, MD, an author of the article “Traumatic Brain Injury and Traumatic Spinal Cord Injury,” in the Continuum June 2024 Neurocritical Care issue. Dr. Jones is the editor-in-chief of Continuum: Lifelong Learning in Neurology® and is a professor of neurology at Mayo Clinic in Rochester, Minnesota. Dr. Podell is an assistant professor in the department of neurology, program in trauma at the University of Maryland School of Medicine in Baltimore, Maryland. Additional Resources Read the article: Traumatic Brain Injury and Traumatic Spinal Cord Injury Subscribe to Continuum: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @LyellJ Guest: @jepodell Transcript Full transcript available here Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum, the premier, topic-based neurology clinical review and CME journal from the American Academy of Neurology. Thank you for joining us on Continuum Audio, a companion podcast to the journal. Continuum Audio features conversations with the guest editors and authors of Continuum, who are the leading experts in their fields. Subscribers to the Continuum journal can read the full article or listen to verbatim recordings of the article by visiting the link in the show notes. Subscribers also have access to exclusive audio content not featured on the podcast. As an ad-free journal entirely supported by subscriptions, if you're not already a subscriber, we encourage you to become one. For more information on subscribing, please visit the link in the show notes. AAN members, stay tuned after the episode to hear how you can get CME for listening.   Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum: Lifelong Learning in Neurology. Today, I'm interviewing Dr Jamie Podell, who has recently authored an article on traumatic brain injury and traumatic spinal cord injury in the latest issue of Continuum on neurocritical care. Dr Podell, welcome. Thank you for joining us today. Why don't you introduce yourself to our audience and tell us a little bit about yourself?   Dr Podell: Thanks, Dr Jones. It's great to be here. As you mentioned, I'm Dr Podell. I'm neurocritical care faculty at University of Maryland Shock Trauma. I have a primary interest in traumatic brain injury, both from a research and clinical perspective. I previously have more of a cognitive neuroscience background, but I think it kind of ties into how I think about TBI and outcomes from traumatic brain injury. But what I really like doing is managing acutely ill patients in the ICU, and I think TBI really affords those kinds of interventions, and it's a really rewarding kind of setting to take care of patients. Dr Jones: Yeah, and I really can't wait to talk to you about your article here, which is fantastic. For our listeners who might be new to Continuum, Continuum is a journal dedicated to helping clinicians deliver the best possible neurologic care to their patients, just like Dr Podell was talking about. We do that with high quality and current clinical reviews, and Dr Podell's article - it's a massive topic - traumatic brain injury and traumatic spinal cord injury. And, you know, as we start off here, Dr Podell, we have the attention now of a massive audience of neurologists. If you had one most important practice change that you would like to see in the care of these patients who have trauma, what would that practice change be? And, I think, maybe, we'll give you two answers, because you cover TBI and you cover spinal cord injury. What would be the most important practice changes you'd like to see?   Dr Podell: So, this isn't that specific, but I think it's really important. I think we need more neurologists, and specifically neurointensivists, managing these patients. I think there's a lot of variability across institutions and how acute severe TBI and spinal cord injury patients are managed. They're often in surgical ICUs, and neurology may be involved in consultation but not in the day-to-day management. But I think what we're seeing is that, you know, there's a lot of multisystem organ dysfunction that happens in these patients, and that has a really strong interplay with neurologic recovery and brain function. And I think, you know, neurointensivists are very well equipped to think about the whole body and how we can kind of manipulate and really aggressively support the body to help heal the brain with special attention to, kind of, the nuance of any individual patient's brain injury. Because TBI is extremely heterogeneous and there's not just a cookie-cutter script for how these patients can be managed, I think, you know, people like neurologists, neurointensivists who have a lot of attention to the nuance - that's really helpful in their management.   Dr Jones: I'm so glad you said that, and not just because I'm a neurologist who's a fan of neurologists, but I do think there are some corners of neuroscience care where neurologists could be a little more present - and trauma definitely seems like one of those, doesn't it?   Dr Podell: Yeah, I think it's tough, because some patients with severe TBI and spinal cord injury can have a lot of multisystemic trauma with, you know, pulmonary contusions, intraabdominal pathology - you need to go to the OR for their other injuries, and so I think it really makes sense to have kind of a collaborative multidisciplinary approach to these patients, but I think neurologists should play a very big role in that approach, however that's done (there are lots of different ways that it's done). But I think having a primary neurology-trained neurointensivist – I know I'm biased, but I think that's where I'd like to see the field moving.   Dr Jones: And, obviously, neurocritical care is an intuitive place for neurological trauma care to start, and even with the sequelae of downstream things, I think neurologists could be more engaged. I wonder if neurology hasn't historically been as involved because it's sort of gravitated to surgical specialists. And I think part of it is, you know, trauma is not usually a diagnostic mystery, right? The neurologist can't pretend to be Sherlock Holmes and try to figure out what's going on when it was pretty clear what the event was, right?   Dr Podell: Right. Yeah, I agree with both of those points. I think, for one, I think postacute care is also a big area where neurologists can be involved more - and patients kind of fall through the cracks. A lot of times, these patients will just follow up with a neurosurgeon and get a repeat head CT and it'll look stable. We started implementing post-TBI neural recovery clinics, which I think other places are starting to do as well, and I think that's kind of a good model for getting neurologists involved - but also, rehab specialists are involved in that. But in terms of, yeah, the diagnostic mysteries and stuff, I think there still can be some, though, with TBI. Yes, obviously, the initial primary insult is obvious, but the secondary pathology that can happen in patients is really nuanced, and it is so variable, and, sometimes, it does take that detective eye to see, “Oh, this patient has one cerebrovascular injury, their risk of stroke to this territory? How are we going to manage it? and thinking about all the kind of sources of secondary decline that are possible. I think it takes that neurology detective sometimes to think about, too.   Dr Jones: Yeah. We never stop pretending to be detectives, right?   Dr Podell: Yeah.   Dr Jones: And on a related note, you know, in your article, you mentioned some of the novel serum and electrophysiologic and imaging biomarkers that are being used to care for these patients. How are you using those in your practice, Dr Podell?   Dr Podell: That's a good question. I think, unfortunately, as with a lot of clinical care, the clinical care does kind of lag behind the research and what we know what we can learn about these patients and their outcomes through retrospective studies. So, to be completely honest, you know, even the serum studies that I mentioned in the article (like GFAP, UCH-L1) - those kind of things, that's not clinically available at our institution. We don't use those. I think a lot of the imaging biomarkers that we see, some of them are coming from more advanced imaging – like, we're talking about FMRI - that requires a lot of post processing (so, again, we're not necessarily using that clinically). But what I would say is that we use imaging to kind of try to predict what complications patients might be at risk of and to try to predict their clinical course. And I think it comes down to trying to break down the heterogeneity of these patients and to try to kind of lump them into different bins of, “What's this patient at risk for?”, “What's their trajectory going to be like?”, “When can I start peeling back how aggressive I am with this patient?”. And, so far, I don't think any of the markers that we have are really clear black-white prescriptive indicators of what to do (I don't think we're quite there yet). So, again, I think we just kind of use all of the data in combination to come up with a management plan for these patients. I think some of the markers, (like some of the electrophysiologic markers), looking at EEG for things like background can provide prognostic information, especially in patients who are comatose that you're wondering about if they're going to wake up (so a lot of this can inform family discussions). But, you know, we used to think that grade three diffuse axonal injury on MRI portended a very poor prognosis (and in the past, some surgeons and ICUs might use that to limit care in patients), but more and more, we're finding that even that is quite nuanced and we're detecting more and more diffuse axonal injury on images in patients who then wake up, or have already woken up and they have the MRI later, and you're like, “Hmm, they had DAI. It's a good thing you didn't get the MRI early and decide not to move forward with aggressive care”. But, I think, in a patient who's comatose and you don't have a good explanation, sometimes, looking for those additional biomarkers to explain what kind of injury pathology you have can just provide more information for families.   Dr Jones: Yeah, and that's a great point that comes up in a lot of our articles and interviews (that the biomarkers really do have to be in a clinical context). So, if I understand you correctly, really, no individual biomarker that has emerged as a precise predictor or prognosticator for outcomes - but you do talk a lot about recent advances in the care of these patients. What would you want to point out to our listeners that's come up recently in the care of trauma?   Dr Podell: Yeah. I think the evidence basis for severe TBI is limited because, again, there's so much heterogeneity and different things going on with different patients, but some of the evidence that has come out more recently involves, kind of, indications for surgical procedures and the timing of those procedures. Some of that is still kind of expert consensus-based. But, for example, doing a secondary decompression for elevated ICP with the DECRA and RESCUEicp trials. We do have better high-quality evidence that doing a secondary decompression for more refractory, elevated ICP can improve both mortality and functional outcomes in patients, so that has kind of become more standard of care. Additionally, I think timing for spinal cord injury, neurosurgical procedures - that's been a topic that's been studied in more evidence-based to perform earlier decompressive surgeries. And then, I think, you know, more and more is emerging just about the pathophysiology of secondary injury - and some of those things haven't necessarily translated to what to do about it - but we've learned about things like cortical spreading depolarizations being associated with worse outcomes in traumatic brain injury, and we've also identified that ketamine or memantine can both actually stop those cortical spreading depolarizations. But the overall impact of managing them is still unknown, and the way that we detect those, it requires an invasive electrocorticography monitor which not all centers have. So, I think, one of the important things as we move forward in TBI care is, as we get this better mechanistic understanding of some of the pathophysiology that's happening in these TBI patients, figuring out a way to be able to translate that across all clinical settings where you can actually do the monitoring invasively - that's also an issue we see. Even intracranial pressure monitoring is pretty standard of care, but not all centers do that, and we have to be able to apply practice recommendations to centers where there isn't necessarily access to the same things that we have at large academic trauma centers.    Dr Jones: Got it. Obviously, there's a lot of research in this area, a lot of clinical research, and I'm glad you mentioned the secondary injury - things that are happening at the tissue level are important for us to think about. As the care of patients with trauma has evolved (and I'm thinking now of patients with spinal cord injury), we still see patients who receive high-dose corticosteroids in the setting of acute spinal cord injury - and obviously, that's something that's evolved. Can you tell our listeners a little bit more about what they should be doing when they're seeing a patient with a traumatic spinal cord injury?   Dr Podell: Yes. So, the steroids story for spinal cord injury is kind of interesting. There were a series of trials called the NASCIS trials that looked at corticosteroids and spinal cord injury, and they were initially interpreted that high-dose steroids had a beneficial effect on spinal cord injury recovery - but then, kind of in relooking at the data and recognizing that these were kind of unplanned subgroup analyses that showed benefit, and then looking at kind of pooled reanalysis and meta-analysis of all the data out there, it was determined that there actually was no clear benefit from steroids and that there was a clear incidence of more complications from high-dose steroids. So, in general, corticosteroids are not recommended for spinal cord injury. Same for traumatic brain injury, too (even though some people will still give steroids for that) - there was a CRASH study that looked at corticosteroids in TBI and found worse outcomes in TBI (so there actually is high-level evidence not to use steroids in that case). That's not to say that there's not an inflammatory process that's going on that could be causing secondary injury - I think that's still, really, you know, an area of active research is to try to figure out what is the balance between potential adaptive mechanisms of inflammation that are happening versus more maladaptive sources of secondary injury from inflammation and how and when do we target that inflammation to improve outcomes. So, there's still, I think, more to come on that.   Dr Jones: And, you know, we are guided by evidence, obviously, but also, we learn from our experience as clinicians. You work in the neurocritical care unit. You take care of all patients with critical neurologic problems. When it comes to TBI and spinal cord injury, what kind of management tips or tricks have you learned that would be good for our audience to hear?   Dr Podell: I think the way that I would sum it up is that you should be very aggressive - supportive care early on, and then thoughtfully pull back and let the brain and spinal cord heal itself. And, you know, the patients come in with TBI (for example) very sympathetically aroused. They do need sedation, they need blood pressure support, they need mechanical ventilation - they need help kind of maintaining homeostasis. And other autonomic effects with spinal cord injury happen, too - you get neurogenic shock (you need very aggressive management of blood pressure, volume assessments), you know, in both cases in trauma patients, managing things like coagulopathy - but, you know, over time, usually, these things start to, kind of, heal themselves to some degree. And then, kind of thoughtfully figuring out when you can peel back on the different measures that you're doing to support them through their acute injuries. Different protocols have been developed, and the Brain Trauma Foundation has developed evidence-based guidelines that have improved (just having a protocol, we know, improves) trauma outcomes overall at centers - but I think those protocols are just guidelines, and you really have to pay attention to the individual patient in front of you. For TBI, for example, our guideline will say to aggressively manage fever within the first seven days with surface cooling. But in a patient that, for example, developed kind of a stroke or progressive cerebral edema even on day five (or something) you're looking at them, and on day seven, they're still having a lot of swelling in their brain, I'm not going to peel off the temperature management. So, there is nuance - you can't just kind follow a rule book in these patients.   Dr Jones: Got it. And I think that point about aggressive support early is a good takeaway for any listeners who might be engaged in the care of these patients. You know, I imagine working in that setting and taking care of patients who are in the midst of a devastating injury - I imagine that can be pretty challenging, but I imagine it could be pretty rewarding as well. What drew you to this particular area of interest, Dr Podell, and what do you find most exciting about it?   Dr Podell: A lot kind of converged for me in this area. I went into neurology thinking I would be a cognitive neurologist. I had more of a neuroimaging background and an interest in neural network pathology that certainly happens to patients with TBI (and patients with TBI often will have neuropsychiatric and neurocognitive problems after injury). But then, during residency, I found myself. My personality clicked in the ICU, and I just liked managing sick patients - I liked the pace of it, I also really liked it. It's kind of a team sport in the ICU with multiple people involved - the bedside nurses, respiratory therapists, neurosurgeons, trauma surgeons - all working together to figure out the best management plan for these patients, so you don't feel alone in managing them. And not all outcomes are good, obviously, but you can see people get better even during their course of their ICU stay - and that's really, really rewarding. And I think what we're seeing even in the literature following patients out longer and longer, the recovery trajectory for TBI is different than what we see in other neurologic injuries (like stroke, where the longer you go - up to ten, twenty years, even - people are still improving). I think the idea that you can keep hope alive for a lot of these patients and try to combat any kind of nihilism - obviously, there's a time and place for that after a really devastating injury, but I've seen a lot of patients who are really, really sick, needing therapeutic hypothermia, barbiturate coma, decompression, still then recovering and being able to come back into the ICU and talk to us.   Dr Jones: We might have some junior listeners who are thinking about behavioral neurology or neurocritical care, and it's probably - I don't know if it's reassuring, or maybe concerning, to them to know that they might swing completely to the other end of the spectrum of acuity, which is kind of what you did.   Dr Podell: Yeah, and what I'm trying to do now is, I'm very interested in autonomic dysfunction that happens in these patients. It's related a lot to multisystem organ dysfunction and, I think, may contribute to secondary injury, too, with changes in cerebral perfusion, especially in patients who have storming or even just the early autonomic dysregulation that happens early on. I think it's induced by neural network dysfunction from the brain injury, kind of similar to the way that there are other phenotypes that would be induced by neural network dysfunction (like coma).  So, we're trying to look at MRIs of acute TBI patients and trying to identify what structural imaging pathology then gives rise to these different kinds of clinical phenotypes - trying to bring it back to this neuroscience focus.   Dr Jones: Well, that gives us and our listeners something to look forward to, Dr Podell. And again, I just want to thank you for joining us, and thank you for such a great discussion on the care of patients with TBI, and spinal cord disorders and thank you for such a wonderful article.   Dr Podell: Thank you very much. It is my pleasure.   Dr Jones: Again, we've been speaking with Dr Jamie Podell, author of an article on traumatic brain injury and traumatic spinal cord injury in Continuum's latest issue on neurocritical care. Please check it out. And thank you to our listeners for joining today.   Dr Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, please consider subscribing to the journal. There's a link in the episode notes. We'd also appreciate you following the podcast and rating or reviewing it. AAN members, go to the link in the episode notes and complete the evaluation to get CME for this article. Thank you for listening to Continuum Audio.  

Annually, about 2 and a half million people sustain a traumatic brain injury, which can lead to disability and even death. It is the leading cause of death and disability in children and adults ages 1 to 44, according to the Brain Trauma Foundation. This year, UW-Eau Claire was awarded a grant to expand access […]

Annually, about 2 and a half million people sustain a traumatic brain injury, which can lead to disability and even death. It is the leading cause of death and disability in children and adults ages 1 to 44, according to the Brain Trauma Foundation. This year, UW-Eau Claire was awarded a grant to expand access […]

Mark Weedon takes us through the increasingly utilised concept of an optimal cerebral perfusion pressure (CPPopt) for each unique patient.  This podcast was recorded at the Brain Symposium which took place in March 2023. For more talks and content like this, visit neuroresus.com. 

Dos guías importantes sobre el manejo de pacientes con trauma a la cabeza fueron actualizadas en el 2023. Las "Guías de cuidado prehospitalario de la lesión traumática cerebral" del Brain Trauma Foundation y la guía "Trauma a la cabeza: Evaluación y manejo inicial" del National Institute for Health and Care Excellence (NICE). En su mayoría, la nueva guía del Brain Trauma Foundation consistió en una re-evaluación de la evidencia actual sobre el tema en cuestión. De igual forma, el sitio web de NICE tiene la sumatoria de todas las recomendaciones vigentes, incluyendo las más recientes. Es importante señalar que este artículo no discute todos los componentes de las guías nuevas, sino los cambios más relevantes y/o significativos. Para más información, consulte ambos documentos de referencia. Lesión cerebral traumática Las guías NICE definen el traumatismo cerebral o lesión cerebral traumática se define como una alteración en la función cerebral, u otra evidencia de patología cerebral, causado por una fuerza externa. Cuando hablamos de trauma a la cabeza, nos estamos refiriendo comúnmente a lesiones que causan un aumento en la presión intracranial. La causa más común del aumento en la presión intracranial es el sangrado, pero puede ser también edema (especialmente en la lesión axonal difusa). El aumento en la presión intracranial causa una disminución en la perfusión cerebral. Entonces, cuando hablamos de trauma a la cabeza, lo que estamos hablando realmente es de un aumento en la presión intracranial que disminuye la perfusión cerebral. En este otro episodio del ECCpodcast explico el tema de manejo del paciente con trauma a la cabeza y la fórmula: Presión de perfusión cerebral = Presión arterial media - Presión intracranial Si no ha tenido la oportunidad de oír ese otro episodio, por favor escúchelo primero antes de estudiar este ya que en este simplemente voy a reiterar los puntos más importantes de las guías nuevas. Resucitación inicial Existen lesiones catastróficas al sistema nervioso central, que no son compatibles con la vida, que provocan herniación cerebral y/o muerte cerebral inmediatamente (antes de que lleguen los primeros respondieres),  que exceden la posibilidad de alguna esperanza para el paciente... y por eso no hay nada que podamos discutir aquí que sea de utilidad en su manejo. La clave del manejo del paciente que tiene una lesión cerebral aparenta estar en el reconocimiento temprano de que la lesión está ocurriendo, para tratar de detener el aumento, y reducir la presión intracranial, antes de que ocurra el síndrome de herniación y la muerte cerebral. Por lo tanto, el punto de "Discapacidad" en el XABCDE del PHTLS (Prehospital Trauma Life Support), o la H de Head Trauma en el acrónimo MARCH, lo que busca es reconocer signos de trauma a la cabeza para que se puedan instituir manejos que eviten el aumento en la presión intracranial (lo que llamamos lesión secundaria). Debido a la fisiopatología del trauma a la cabeza (descrita en el podcast anterior), el paciente que tiene un aumento en la presión intracranial tratable, va a morir primero por problemas de su vía aérea, respiración y circulación posiblemente antes de que muera de la lesión a la cabeza. En adición, el mal manejo de la vía aérea, respiración y circulación redunda en un aumento en la presión intracranial y/o menor presión de perfusión cerebral debido a la hiposa, hipercarbia e hipotensión. Por estas razones, el mejor manejo del paciente con trauma a la cabeza consiste en el abordaje que presenta el PHTLS, con énfasis particular en los primeros cuatro componentes: X - Corregir sangrados exanguinantes A - Abrir la vía aérea B - Ventilación adecuada C - Mantener la circulación D - Reconocer la discapacidad E - Exposición para identificar otras lesiones y proteger del medioambiente (environment) También puede considerarse el otro acrónimo MARCH: M - Masiva hemorragia (massive bleeding) A - Abrir la vía aérea B - Ventilación adecuada C - Mantener la circulación H - Prevención de hipotermia y trauma a la cabeza (head) Se enseña en secuencia pero se realiza simultáneo. Si un estudiante me pregunta "qué hago primero", probablemente le diría que siga la secuencia XABCDE (o MARCH). Tiene mucho sentido el detener el sangrado masivo primero porque hay una gran oportunidad de hacer lo mejor por el paciente si detenemos un sangrado masivo de provocar un estado de shock hipovolémico. Es mejor detener el sangrado antes de que el paciente haya perdido suficiente cantidad de sangre para tener pobre perfusión cerebral por la hipovolemia. Pero luego de esto existen otras circunstancias que pueden complicar el manejo si se sigue un único orden siempre. Por ejemplo, el manejo definitivo de la vía aérea puede provocar episodios de hipotensión debido al uso de medicamentos para la inducción, estimulación vagal por la laringoscopía, y reducción en el retorno venoso por el aumento en la presión intratoráxica al llevar a cabo ventilaciones con presión positiva con un dispositivo de ventilación manual. No sería inapropiado brincar la vía aérea para manejar la pobre perfusión primero antes de intubar al paciente que lo necesita. Un equipo de trabajo que puede asignar a una o dos personas a atender la circulación mientras una o dos personas atienden la vía aérea y ventilación pudiera demostrar el mejor manejo posible de este tipo de paciente, aún teniendo en cuenta que el manejo apropiado de cada una de estas dos condiciones puede tomar algo de tiempo (corregir la pobre perfusión y/o mantener una ventilación efectiva). Cada uno de estos ejemplos, por separado, pudiera ser una buena razón para realizar las mínimas intervenciones necesarias en la escena y comenzar el transporte. Cuando se junta la necesidad de realizar todas, a la misma vez, en un paciente que lo necesita justo ahora (piense en una obstrucción a la vía aérea por sangrado y lesiones faciales y/o de cuello, en combinación con un sangrado sistémico y trauma a la cabeza), estamos discutiendo un tipo de paciente severamente lesionado. Nota a los instructores: cuando están dando un caso a un alumno, y quieren forzar que se siga un orden específico, no quieran traer complicaciones que puedan abrir la posibilidad de tener que realizar múltiples tareas simultáneamente. Ahora bien, cuando quieran evaluar el paciente verdaderamente politraumatizado, estén preparados para ver diferentes abordajes (buenos y malos) y luego discutir por qué uno, o más de uno, pudiera ser efectivo o perjudicial. Un abordaje por etapas En un paciente que eventualmente necesita ser intubado, una primera etapa puede consistir en mantener la vía abierta manualmente mientras se realizan otras intervenciones de circulación. No significa que no se manejó apropiadamente la vía aérea. Significa que se realizaron las intervenciones (una o muchas) necesarias para poder continuar con el abordaje de las amenazas a la vida, para entonces volver a retomar el tema de la vía aérea y pre-oxigenar al paciente mientras se preparan otros aspectos del transporte, y finalmente llevar a cabo la intubación tan pronto el paciente está lo mejor preparado desde el punto de vista de preoxigenación y perfusión. Cuando un grupo de proveedores se dividen la tareas, pueden ser más eficientes y adelantar estas etapas concomitantemente. El líder debe estar pendiente que un grupo no se adelante antes de tiempo (valga la redundancia y el ejemplo repetido: intubar al paciente antes de que el resto del equipo esté listo). Esto es un verdadero trabajo en equipo. Aunque es posible que el personal del servicio de emergencias médicas tenga pocos recursos en la escena, no siempre es así. En muchas ocasiones es posible contar con más rescatistas y paramédicos en la escena. No estoy abogando por retrasar el transporte, sino en evitar causar daño cuando el paciente necesita acción inmediata o si no va a morir ahora, en la escena y antes del transporte. CPP = MAP - ICP El insulto primario es la lesión que inicialmente provocó el aumento en la presión intracranial. Si bien no podemos hacer más nada por el insulto primario luego de que este ocurre, sí podemos prevenir lo que llamamos la lesión secundaria. La lesión secundaria es todo lo que agrava el insulto primario. El aumento en la presión intracranial tiene el efecto de reducir la perfusión cerebral. Todo lo que reduzca aún más la lesión intracranial produce una lesión secundaria. La fórmula CPP = MAP - ICP provee el marco de referencia para entender el problema de la lesión primaria y de la lesión secundaria. Todo lo que reduzca el MAP o aumente el ICP va a producir menos presión de perfusión cerebral. Presión arterial Por lo antes expresado, sabemos que el paciente con trauma a la cabeza necesita mantener la presión arterial porque esto es lo que está protegiendo la perfusión cerebral. Cuando hay una lesión al sistema central nervioso, un solo episodio de hipotensión puede ser detrimental. Es importante poder determinar de forma temprana el deterioro gradual de la presión arterial porque puede ser un indicador de otros sangrados concomitantes en el resto del cuerpo. Cuando se puede llevar a cabo un monitoreo invasivo de la presión intracranial, es posible determinar la presión arterial necesaria para mantener perfusión cerebral... y esta puede ser más alta que lo que las guías recomiendan como presión arterial mínima. Esto no quiere decir que todos los pacientes necesita valores más altos, y tampoco estos valores significan que esta es la presión ideal... sino la mínima. Las guías del Brain Trauma Foundation hacen referencia a valores específicos de presión según la edad: 28 días o menos >70 mmHg 1–12 meses >  84 mmHg 1–5 años > 90 mmHg 6 años o más > 100 mmHg Adultos 110 mmHg en adelante Sin embargo, el documento hace referencia a que no existe data específica acerca de cuáles son los valores óptimos, por lo que el valor ideal pudiera ser superior. Lo que sí especifica es que valores inferiores están asociados a peores resultados. En el contexto de trauma, hay dos escenarios que pueden resultar en hipotensión: sangrado concomitante en otras partes del cuerpo y procedimientos como la intubación endotraqueal. Equipo pediátrico Los equipos de respuesta a emergencia tienen que tener equipo de monitoreo de signos vitales pediátricos, incluyendo el mango para tomar la presión y sensores de oxímetría de pulso. Sin embargo, las guías sugieren la alternativa, en escenarios de bajos recursos, de documentar el estado mental, la calidad de los pulsos periféricos y el llenado capilar como marcadores sustitutos a la presión arterial. Resucitación con fluidos Es importante tratar la hipotensión rápidamente, ya sea con sangre, solución salina e inclusive vasopresores en casos extremos. La solución de salina hipertónica puede ser útil para reducir la presión intracranial. Aunque su uso como expansor intravascular es controversial, la alta concentración de soluto produce un gradiente osmolar que ayuda a reducir el edema. Sin embargo, no está recomendado de forma profiláctica. Ventilación La alteración en el aumento en la presión intracranial produce disminución en el nivel de consciencia y depresión respiratoria, lo que puede provocar la obstrucción de la vía aérea e hipoventilación. La hipoventilación produce hipercarbia, o aumento en el nivel de CO2 en la sangre, y esto a su vez, produce vasodilatación cerebral... que a su vez puede aumentar el sangrado. Por lo tanto, los problemas con la ventilación agravan la lesión cerebral traumática. Todo paciente que tenga alteración en el estado de consciencia necesita monitoreo de la ventilación. El método de monitorear la ventilación no es la oximetría de pulso sino el CO2 exhalado. El EtCO2 debe estar entre 35-40 mmHg. Escala de Coma de Glasgow No todos los traumas a la cabeza son clínicamente significativos. La frase "clínicamente significativo" quiere decir que tiene un efecto en el paciente. Por ejemplo, un jugador de baloncesto puede chocar con otro jugador y caer al piso, golpeando la cancha con la cabeza. El jugador rápidamente se pone de pie y continúa corriendo para recuperar el balón.  Aunque tuvo una leve abrasión en el frente de la cabeza, nunca tuvo ningún otro signo o síntoma adicional asociado. Esta historia hipotética puede ser un ejemplo de una lesión que no es clínicamente significativa. No significa que no haya tenido un golpe, sino que no hay nada que preocuparse. Todo trauma a la cabeza que sea clínicamente significativo produce una alteración en el estado de consciencia y/o un déficit neurológico focal. Por lo tanto, es sumamente importante evaluar correctamente el nivel de consciencia. Evalúe y trate la circulación, vía aérea y ventilación antes de evaluar la Escala de Coma de Glasgow porque la pobre perfusión y la hipoxia pueden producir una alteración en el nivel de consciencia que podemos mejorar si mejoramos la perfusión y oxigenación y no necesariamente estar asociado a una lesión cerebral traumática. La evaluación periódica de la Escala de Coma de Glasgow permite detectar tempranamente una lesión a la cabeza que sea clínicamente significativa y permite determinar signos de que continúa aumentando la presión intracranial si el nivel de consciencia sigue progresivamente disminuyendo. Se debe documentar la Escala de Coma de Glasgow cada 30 minutos, y cuando haya un cambio en el estado mental (ya sea mejoría o deterioro). También se debe documentar la Escala de Coma de Glasgow en el camino al hospital, o transferencia interhospitalaria. La Escala de Coma de Glasgow tiene tres componentes: respuesta visual, verbal y motora. De las tres, la más importante es la motora. Por lo tanto, es importante describir los tres componentes por separado. No es lo mismo que un paciente pierda 2 puntos en la respuesta visual a que pierda dos puntos en la respuesta motora. Si es posible, es útil documentar la Escala de Coma de Glasgow antes de administrar un medicamento que afecte el nivel de consciencia (sedación o parálisis, por ejemplo). Documente la presencia de cualquier medicamento que pueda alterar el nivel de consciencia cuando esté documentando la Escala de Coma de Glasgow porque puede ayudar a entender por qué hubo una disminución en el nivel de consciencia. Finalmente, la Escala de Coma de Glasgow es tan útil como se sepa medir correctamente. En ocasiones pudiera ser más útil medir solamente el componente motor como método alterno. También es importante medir a los pediátricos usando la versión pediátrica. [caption id="attachment_1891" align="aligncenter" width="532"] Imagen cortesía de Wikipedia Commons.[/caption] Déficit neurológico focal Lo que los ojos no ven y la mente no conoce, no existe.“ - David Herbert Lawrence. Cuando buscamos la presencia o ausencia de un déficit neurológico focal, buscamos lo siguiente: Debilidad Disminución en la sensación Pérdida de balance Problemas para caminar Dificultad en entender, hablar, leer o escribir Cambios visuales Nistagmo Reflejos anormales Amnesia desde la lesión Ácido tranexámico La guía NICE recomienda la administración de 2 gramos de ácido tranexámico IV a pacientes de 16 años o más, con un trauma a la cabeza de menos de 2 horas, que tengan un GCS igual a, o menor de, 12. Para pacientes de menos de 16 años, la dosis es 15 mg/kg a 30 mg/kg (hasta un máximo de 2 g). Sin embargo, la guía del Brain Trauma Foundation no recomienda el uso de forma rutinaria, sin embargo deja abierta la decisión al sistema de salud, citando que hace falta más evidencia para recomendar su uso generalizado en el paciente con trauma a la cabeza. El único estudio que demostró beneficio fue CRASH-3 pero fue solamente en pacientes con trauma craneocefálico leve a moderado. No hubo diferencia significativa en el paciente con trauma severo. En otros estudios, no hubo diferencia. Pacientes intoxicados Aunque NO es una recomendación nueva, es importante recordar que los pacientes que tienen intoxicaciones pueden tener lesiones concomitantes a la cabeza, y los pacientes con lesiones a la cabeza pueden tener lesiones que alteran su nivel de consciencia y parecen como si estuvieran intoxicados. Nunca asumir que la alteración en el estado mental se debe al alcohol si hubo un mecanismo de trauma a la cabeza. Tomografía computarizada (CT) de la cabeza Las Guías NICE detallan los criterios para realizar una tomografía axial computadorizada. Para pacientes de 16 años o más, se debe hacer un CT de la cabeza dentro de la primera hora de haber identificado cualquiera de estos criterios: Escala de Coma de Glasgow de 12 o menos en la evaluación inicial en el departamento de emergencias Escala de Coma de Glasgow de menos de 15 luego de 2 horas de la lesión al ser evaluado en el departamento de emergencias Sospecha de fractura abierta o deprimida Cualquier signo de fractura de base de cráneo (hemotímpano), ojos de mapache o de panda (equimosis periorbital), salida de líquido cerebroespinal del oído o nariz, signos de Battle) Convulsión pos-traumática Déficit neurológico focal Más de 1 episodio de vómito Las guías NICE establecen que para pacientes menores de 16 años, se debe hacer una tomografía computarizad para trauma a la cabeza dentro de la primera hora de haber identificado cualquiera de los siguientes criterios: Escala de Coma de Glasgow menor de 14 al llegar al departamento de emergencias, o menos de 15 en bebés de menos de 1 año. Escala de Coma de Glasgow menor de 15 luego de 2 horas de la lesión Sospecha de fractura de cráneo abierta o deprimida, o tensión en las fontanelas Cualquier signo de fractura de base de cráneo (hemotímpano), ojos de mapache o de panda (equimosis periorbital), salida de líquido cerebroespinal del oído o nariz, signos de Battle) Convulsión pos-traumática Déficit neurológico focal Sospecha de lesión no-accidental En bebés de menos de 1 año, una abrasión, edema o laceración de más de 5 cm en la cabeza Las guías NICE tienen unas recomendación especial para los pacientes que usan anticoagulantes (antagonistas de vitamina K, anticoagulantes orales de acción directa, heparina y heparina de bajo peso molecular), o terapia antiplaquetaria (excepto monoterapia con aspirina). En estos pacientes, se recomienda una tomografía de cráneo: Dentro de las primeras 8 horas de la lesión ó Dentro de la primera hora si llevan más de 8 horas luego de la lesión. Desde el 2007, las guías NICE aclaran que no se debe usar la radiografía simple de cráneo para diagnosticar una lesión cerebral traumática importante. No obstante, hacen el señalamiento que los pacientes pediátricos pudieran necesitar radiografías simples en búsqueda de otras lesiones por abuso. Transporte al hospital apropiado La principal diferencia entre el manejo intrahospitalario y el manejo prehospitalario del manejo de trauma a la cabeza es que el paciente va a recibir el cuidado definitivo dentro del hospital. Pero, esto es cierto solamente si el paciente se encuentra en un hospital que tenga la capacidad de neurocirugía para llevar a cabo el manejo definitivo. Si el paciente no se encuentra en la facilidad apropiada, para todos los efectos, el manejo sigue siendo el mismo como si estuviera fuera del hospital. Las guías recomiendan que los pacientes con trauma a la cabeza moderado a severo sean transportados directamente a un centro de trauma que tenga capacidad de neuroimágenes, cuidado de neurocirugía y la habilidad de monitorear y tratar la presión intracranial. Pero hace una sugerencia que debe tomarse con mucho cuidado: "Aunque el transporte directo a un centro de trauma es preferible para la mayoría de los pacientes, en el evento de que este transporte no sea posible, se puede realizar la estabilización en un centro no-traumatológico dentro de un sistema de trauma establecido, con transferencia subsiguiente a un centro de trauma." Es muy fácil malinterpretar a conveniencia este tipo de recomendación si no se entiende claramente a qué se refiere. "Estabilizar" - El primer y mejor ejemplo que me viene a la mente es la vía aérea. En el dado caso que el manejo del paciente requiera una vía aérea avanzada que no haya podido ser lograda en la escena, pudiera ser necesario detenerse en una facilidad con capacidad de cuidado inferior con el fin de patentizar la vía aérea, si esa facilidad tiene expertos en el manejo de vías aéreas avanzadas (y potencialmente difíciles). Esto tampoco quiere decir que los pacientes con trauma a la cabeza deben ser transportados primero a un hospital local para ser intubados. "Sistema de trauma establecido" - Un sistema de cuidado implica que ambas facilidades están coordinadas y comparten criterios y recursos para el manejo en la periferia de pacientes potencialmente gravemente lesionados. Si no existe esa estrecha colaboración, cómo sabemos que en su determinado sistema, eso funciona bien. El hecho de que funcione en un sistema no significa que va a funcionar en todos. Por lo tanto, debemos aceptar que en los lugares donde se ha demostrado que se puede lograr dicha coordinación, es posible llevarlo a cabo de esta manera. Pero, no necesariamente esto aplica a todos los lugares. El escenario más común donde se pierde la oportunidad de ayudar al paciente es cuando el sistema de emergencias médicas transporta el paciente a alguna (o cualquier) facilidad local, a veces por criterio de cercanía física y/o de ubicación geográfica y usan como excusa el hecho de que no pueden gastar recursos desviando una unidad largas distancias. O inclusive otros han sugerido que los hospitales son los que deben coordinar y costear la transferencia por lo tanto ellos solamente transportan al hospital local. Actitudes, mentalidades, opiniones y directrices operacionales como esas son las que hacen que los pacientes esperen horas antes de llegar a la facilidad adecuada. Los servicios de emergencias médicas deben tener protocolos claramente establecidos de a dónde es permitido transportar este tipo de paciente. Se debe intubar a los pacientes con trauma a la cabeza con una Escala de Coma de Glasgow de 8 o menos que requieran transferencia interhospitalaria. Igualmente, otros pacientes que pueden necesitar intubación endotraqueal previo al transporte pueden ser aquellos que tengan: Deterioro significativo de la consciencia (aunque no hayan llegado todavía a 8) Fractura inestable de huesos de la cara Sangrados excesivo en la boca Convulsiones La estimulación sensorial puede aumentar la presión intracranial. Por lo tanto, los pacientes que están intubados deben estar adecuadamente sedados y paralizados. Diferencia en mortalidad La mortalidad del paciente de trauma a la cabeza es 22% más alto en las zonas rurales que en las zonas urbanas debido a tiempos de transporte más prolongados y menos acceso a cuidado prehospitalario. Referencias https://www.tandfonline.com/doi/full/10.1080/10903127.2023.2187905?af=R https://www.nice.org.uk/guidance/ng232  https://pubmed.ncbi.nlm.nih.gov/31623894/  

Private Medical physicians Dr. Jordan Shlain and Dr. Kellen Glinder are joined by Dr. Jamshid Ghajar, the board certified neurosurgeon known for founding the Brain Trauma Foundation and NeuroSync and its EyeSync AR/VR technology, which is revolutionizing the way we measure attention, learning, and performance. The doctors discuss prediction timing, concussion misinformation, and a future where we do away with labels like ADHD or concussion and instead focus on the areas of attention that need improvement. Send us your thoughts and questions for Dr. Ghajar at askpm@privatemedical.org. We hope to answer your queries on a future episode. We hope this episode inspires you to think differently about your health and the healthcare system. Please subscribe to our feed and our bimonthly medical dispatch. 

Today's guest, Ala von Auerperg, was born Princess Annie-Laurie von Auersperg, Ala Isham is the daughter of Martha “Sunny” Crawford and Prince Alfred von Auersperg of Austria. Ala grew up between Kitzbühel, Austria, New York City, and Newport, RI where a legacy of style led her to create Ala von Auersperg in 2015, a collection of elegant silhouettes and vibrant proprietary prints created from her own artwork depicting scenes of nature and from her travels. Ala's passion for creating clothes that enhance a woman's confidence also underpins her philanthropic work. In 1985, she co-founded the National Center for Victims of Crime, an organization that provides victims of crime with rights, protection, and services to help them rebuild their lives. In 1986, she founded the Brain Trauma Foundation, which she created in homage to her late mother, and supports ongoing research on traumatic brain injuries. Together with her conservation efforts, Ala is committed to empowering women through beauty and instilling confidence and strength. Ala's brand has grown rapidly over the last few years as her beautiful and unique artwork provides the patterns for her pieces. You can shop her pieces online and at her stores in Charleston, South Carolina, Palm Beach, Florida, and New York City. --- Support this podcast: https://anchor.fm/howdshedothat/support

Ala Isham, Founder and Creative Director of Ala von Auersperg, co-founder of the National Center for Victims of Crime, and founder of the Brain Trauma Foundation, shared the true story behind her title with us on Sunday, December 19th, 2021.Ala had been working with the designer Antonio Gual for years, creating such pieces for herself, when in 2015 he suggested applying her original nature- and travel-inspired artworks onto them. From there, Ala Von Auersperg — the brand — was born, with her daughter Sunny Kneissl joining the team as their in-house stylist. Since day one, they've focused on making women feel wonderful in the feminine flow of the fabric, the transparency that reveals but also partially conceals the body, and the soft touch of textiles on the skin.Their goal is to help all women realize that they can be glamorous, no matter their size or age. AvA is about enjoying life as you are and being the best version of yourself because when a woman looks her best she feels better about herself. We all have roles to play and we're going to do them more effectively when we're at our best —and, frankly, there is too much fun to be had to be focused exclusively on what you're wearing.This passion for creating clothes that boost a woman's confidence also underpins Ala's philanthropic work, specifically her work with women who have experienced violence, because the thing that those crimes take away from women is their self-esteem. The National Center for Victims of Crime, which Ala co-founded in 1985, works to remedy this loss, while the Brain Trauma Foundation (originally the Sunny Von Bülow Coma and Head Trauma Research Institute), which she founded in 1986, supports ongoing research on traumatic brain injuries. Together with Ala's conservation efforts, these causes advance my ultimate aim as a daughter, mother, and grandmother: to leave the world a better place.SUE SAYS"Growing up in what Ala described as a privileged upbringing, she is grateful for the opportunities and experiences she had. At the same time, there were events in her life that truly tested her resilience. What she discovered about herself was that she could always move forward and never give up on life...there was always too much to be thankful for."Support this podcast at — https://redcircle.com/women-to-watch-r/donationsAdvertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy

As a child caught in the middle of angry, battling parents, Debra suffered extreme trauma. As she grew up, she developed an unhealthy obsession with success, and achievement. At age 42, her constant drive and need to push herself to the limits, would result in a near fatal accident. This episode has it all, as Debra suggests that we slow down, breathe, and stop running away!Links from DebraDebra's site: https://www.sunderlandcoaching.com/Brain Trauma Foundation: https://www.braintrauma.org/LinkedIn: https://www.linkedin.com/in/debrasunderland/Includes a quick Intro from your hosts Luke and Kyle, and a message from our sponsors.The Original Handlebar Jack Ultraportable Bicycle Repair Stand. Use code 'WTFMU' and some of the proceeds will go to www.foodonfoot.org, an organization helping the unhoused and low-income families in your neighborhood. Support the show (https://www.buymeacoffee.com/Wtfmupodcast)

It's another 'after thoughts' section to help us digest the amazing episode we just listened to. Debra's Story was one of the most powerful yet, and even brought your hosts, Luke and Kyle, to tears! Running so fast to get away from our feelings just isn't the answer. Helpful links from Debra:Debra's site: https://www.sunderlandcoaching.com/LinkedIn: https://www.linkedin.com/in/debrasunderland/Brain Trauma Foundation: https://www.braintrauma.org/Support the show (https://www.buymeacoffee.com/Wtfmupodcast)

This episode covers all things TBI.  It’s a perfect review for the non-neurosurgeon. References: ACS TQIP Best Practices in the Management of TBI (https://www.facs.org/-/media/files/quality-programs/trauma/tqip/tbi_guidelines.ashx) Brain Trauma Foundation guidelines (https://braintrauma.org/guidelines/guidelines-for-the-management-of-severe-tbi-4th-ed#/)

Dr. Steven Flanagan is the Chair, Department of Rehabilitation Medicine and Howard A. Rusk Professor of Rehabilitation Medicine at Rusk Rehabilitation. He is highly recognized, nationally and internationally, as one of the leading experts in the area of brain injury rehabilitation. He serves on numerous medical advisory boards, including the Brain Trauma Foundation and is a peer reviewer for several scientific journals. He currently is chairperson of the Medical Education Committee and sits on the Board of Governors of the American Academy of Physical Medicine and Rehabilitation Medicine. The author of numerous chapters and peer-reviewed publications, he has received awards from several organizations and been continually listed as one of America’s Top Doctors by Castle Connolly.

Dr. Steven Flanagan is the Chair, Department of Rehabilitation Medicine and Howard A. Rusk Professor of Rehabilitation Medicine at Rusk Rehabilitation. He is highly recognized, nationally and internationally, as one of the leading experts in the area of brain injury rehabilitation. He serves on numerous medical advisory boards, including the Brain Trauma Foundation and is a peer reviewer for several scientific journals. He currently is chairperson of the Medical Education Committee and sits on the Board of Governors of the American Academy of Physical Medicine and Rehabilitation Medicine. The author of numerous chapters and peer-reviewed publications, he has received awards from several organizations and been continually listed as one of America’s Top Doctors by Castle Connolly. In this interview, he discusses: the kinds of patients treated for TBI at Rusk, if a TBI sustained during early adulthood or mid-adulthood can pose a risk for dementia and other neurodegenerative diseases associated with aging, the role of brain reserve in developing an understanding of the interplay between TBI and neurodegenerative diseases associated with aging, treatment of chronic cognitive impairment in TBI, TBI and sleep disorders, inclusion of family members in the care giver team, the use of technological innovations in rehabilitation, and research on TBI being conducted at Rusk, along with any system enhancements underway or being planned.

This episode is part two of a panel discussion on TBI with Dr. Steven Flanagan and Dr. Erika Trovato. Dr. Steven Flanagan is Director of the Rusk Rehabilitation Institute. He is highly recognized, nationally and internationally, as one of the leading experts in the area of brain injury rehabilitation. He serves on numerous medical advisory boards, including the Brain Trauma Foundation and is a peer reviewer for several scientific journals. He currently is chairperson of the Medical Education Committee and sits on the Board of Governors of the American Academy of Physical Medicine and Rehabilitation Medicine. The author of numerous chapters and peer-reviewed publications, he has received awards from several organizations and been continually listed as one of America’s Top Doctors by Castle Connolly. Dr. Erika Trovato recently completed her fellowship in Traumatic Brain Injury Rehabilitation at Rusk. She obtained her medical degree from New York College of Osteopathic Medicine and completed her residency in Physical Medicine and Rehabilitation at Rusk Rehabilitation before beginning her fellowship. Her current research interest involves sleep dysfunction after traumatic brain injury. She has accepted a TBI attending physician position at Burke Rehabilitation in White Plains, NY and will begin working there in October 2017.  In this interview, the two discuss: how to deal with situations when a patient’s resilience and positive willingness to want to participate actively in all aspects of rehabilitation are not present; long-term motor dysfunction and movement disorders in the kinds of research being conducted; progress being made in the incorporation of advances in technology to patient care; availability of prognostic tools to predict and define outcomes after a TBI; ways in which the rehabilitation of TBI patients could benefit from the development of more innovations of a non-technology nature; breaking bad news to patients and their family members about reduced chances for significant recovery; and kinds of interventions effective in dealing with fatigue.

This episode is part of a panel discussion on TBI with Dr. Steven Flanagan and Dr. Erika Trovato. Dr. Steven Flanagan is Director of the Rusk Rehabilitation Institute. He is highly recognized, nationally and internationally, as one of the leading experts in the area of brain injury rehabilitation. He serves on numerous medical advisory boards, including the Brain Trauma Foundation and is a peer reviewer for several scientific journals. He currently is chairperson of the Medical Education Committee and sits on the Board of Governors of the American Academy of Physical Medicine and Rehabilitation Medicine. The author of numerous chapters and peer-reviewed publications, he has received awards from several organizations and been continually listed as one of America’s Top Doctors by Castle Connolly. Dr. Erika Trovato recently completed her fellowship in Traumatic Brain Injury Rehabilitation at Rusk. She obtained her medical degree from New York College of Osteopathic Medicine and completed her residency in Physical Medicine and Rehabilitation at Rusk Rehabilitation before beginning her fellowship. Her current research interest involves sleep dysfunction after traumatic brain injury. She has accepted a TBI attending physician position at Burke Rehabilitation in White Plains, NY and will begin working there in October 2017.  In this interview, the two discuss: the TBI Model System at Rusk; activities undertaken in the Rusk Fellowship Program; advice for incoming Rusk Fellows; when a patient is ill, how decisions are made regarding which different kinds of therapy should commence and when;​ and use of family caregivers to assist in the pain assessment of TBI patients.  

El trauma a la cabeza, o lesión cerebral traumática, ocurre cuando el sistema nervioso central se afecta debido a un trauma cerrado o abierto. Las lesiones a la piel, aunque sean en la cabeza, no implican lesión al sistema nervioso central. Muchas veces decimos "trauma a la cabeza" cuando en realidad deberíamos ser más específicos... lesión cerebral traumática, o trauma craneoencefálico. Para entender la solución, hay que entender el problema primero. El problema del trauma craneoencefálico es que la presión intracranial aumenta y el cerebro deja de recibir flujo de sangre (disminuye la perfusión cerebral). El curso de Prehospital Trauma Life Support (PHTLS) enseña el manejo y resucitación de este paciente. Presión intracranial El cráneo es una bóveda cerrada. No se expande cuando la presión interna aumenta. Cualquier lesión que provoque un efecto de masa dentro del cráneo va a provocar comenzar a hacer presión a las estructuras internas, que incluyen el cerebro, el líquido cerebroespinal y los vasos sanguíneos. El aumento en la presión intracranial va a provocar una disminución en el espacio que tienen los vasos sanguíneos para fluir sangre... es decir, disminuye la perfusión cerebral. A esto se le conoce como la doctrina Monroe-Kellie. Presión de perfusión cerebral = (presión arterial) - (presión intracranial) Si usted entiende esta fórmula, entiende el concepto básico del trauma a la cabeza. En palabras simples, la presión de perfusión cerebral es la presión que tiene que tener la tubería para que haya flujo de sangre al cerebro. Este número siempre tiene que ser positivo. Si la presión de perfusión cerebral baja a cero, perdimos al paciente porque no hay perfusión cerebral. La presión de perfusión cerebral se basa solamente en dos factores: presión arterial y la presión intracranial. La presión arterial es la fuerza del flujo hacia el cerebro. La presión intracranial se opone al flujo. Para que el resultado sea un valor positivo, la presión arterial tiene que ser un valor mayor, y la presión intracranial tiene que ser un valor pequeño. Si la presión intracranial aumenta, matemáticamente hablando, la presión de perfusión cerebral va a disminuir. El único mecanismo que tiene el cuerpo para evitar que esto ocurra es el aumentar la presión arterial. Cuando esto ocurra, el flujo hacia el cerebro debe mejorar. El problema es que si hay una lesión cerebral con un sangrado activo, entonces el restablecimiento del flujo cerebral implica que el sangrado va a continuar. Si el sangrado continua, sigue aumentando la presión intracranial. El aumento en la presión intracranial va a provocar mayor aumento en la presión sanguínea, tal y como está descrito arriba. Esto va a ocurrir hasta que el cuerpo no pueda compensar más. Herniación cerebral El único escape, como parte de la progresión natural de la enfermedad, a una presión intracranial insostenible, es la herniación cerebral. La herniación cerebral ocurre cuando el tallo cerebral intenta salir por el foramen magno hacia el cordón espinal. Este proceso provoca daño en las estructuras cerebrales. El tallo cerebral y el cerebelo son las dos partes más cercanas al foramen magno y tendrán serios daños si el cerebro se hernia. Dos de las funciones más importantes que se afectan son el sistema de activación reticular y el centro de control de la respiración. Esto significa que el paciente gradualmente pierde la consciencia y deja de respirar en la medida en que el cerebro se va presionando hacia el punto de herniación. https://youtu.be/bA1OOQ4gkdc Hipoventilación provoca vasodilatación Los niveles de CO2 alteran la circulación cerebral. Si el CO2 aumenta, la vasculatura cerebral se dilata. Viceversa, si el CO2 disminuye, la circulación cerebral se contrae. Si el paciente deja de respirar efectivamente (no se deshace del CO2 que tiene acumulado), el nivel de CO2 aumenta dentro del cuerpo. El aumento en CO2 provoca vasodilatación, y esto a su vez provoca un mayor aumento en la presión intracranial. Mayor aumento en la presión intracranial provoca mayor herniación, que a su vez provoca más presión sobre el centro de control de la respiración, que a su vez provoca menor capacidad de ventilar, que a su vez provoca mayor vasodilatación, que a su vez provoca mayor sangrado, que a su vez provoca mayor presión intracranial, que a su vez... provoca un ciclo sin fin que termina en la muerte cerebral. ¿Cómo se vería el paciente? En base a esto, podemos predecir la presentación del paciente que se está herniando. Alteración en nivel de consciencia (inconsciente probablemente) Hipertensión Patrón respiratorio alterado Bradicardia Ya hemos explicado por qué se afecta la consciencia (debido al efecto de la presión sobre el sistema de activación reticular). También hemos explicado por qué ocurre la hipertensión, como mecanismo de defensa para mantener la presión de perfusión cerebral. La bradicardida ocurre porque los baroreceptores en la aorta y la carótida sienten el aumento en la presión sanguínea y estimulan el corazón a latir más lento como medida compensatoria. Patrón respiratorio alterado de Cheyne-Stokes El fallo del centro de control de la respiración se manifiesta en la forma de patrones de respiración alterados. Uno de los patrones posibles en este caso se llama Cheyne-Stokes. El patrón de Cheyne-Stokes es un patrón de dificultad respiratoria que va progresivamente aumentando hasta que se va en apnea, y se repite de forma indefinida. https://youtu.be/eAx4fxy7WbA https://youtu.be/VkuxP7iChYY Triada de Cushing El neurocirujano Harvey Cushing describió en el 1901 su famosa triada de signos que sugieren una herniación inminente. Su descripción fue: Hipertensión Bradicardia Respiraciones irregulares ¿Lesiones visibles? La lesión cerebral traumática puede no necesariamente ser aparente a simple vista. Los traumas abiertos a la cabeza producen sangre visible y esta puede ser la alerta al personal para que evalúe la probabilidad de que haya lesión al cerebro. Algunos traumas cerrados pueden producir signos visibles. Por ejemplo, las fracturas de la base de cráneo pueden producir hematomas alrededor de la base del cráneo que pueden ser observables desde afuera en el área retroauricular (signo de Battle) y como periocular (signo de mapache). https://youtu.be/yRg6IbwuytE https://youtu.be/MjYXoWHWQWk No todas las lesiones cerebrales traumáticas producen fractura en la base del cráneo. Por lo tanto, estos signos solo ocurren en la población que sí haya tenido este tipo de trauma. El paciente con aumento en la presión intracranial va a tener múltiples amenazas a la vida identificables en el tradicional A-B-C de trauma, por lo tanto, la evaluación del paciente no varía. La alteración en el estado de consciencia va a provocar que no pueda proteger su propia vía aérea. Si el paciente tiene un estado mental severamente deteriorado, es probable que se decida proteger la vía aérea. Fundamentos del tratamiento CPP = MAP - ICP Esa es la fórmula mágica para entender el problema y entender el tratamiento. Veamos cada componente por separado. ICP - Presión intracranial elevada El tratamiento definitivo es reducir el aumento en la presión intracranial. Una de las formas para hacer esto es drenar el sangrado dentro del quirófano. Si el paciente no está en un hospital con capacidad de neurocirugía, ¿qué pasa que no está en movimiento hacia allá? Si el paciente está aún fuera del hospital, es importante que se inicie el transporte de inmediato. Probablemente está solamente en las manos del neurocirujano el control definitivo del sangrado y de la presión intracranial. Pero lo que sí está en el control del proveedor a nivel PHTLS y ATLS el evitar que aumente más. El mannitol o la salina hipertónica (NaCl 3%) puede ser una opción para ayudar a drenar el edema asociado al trauma que contribuye al aumento en la presión intracranial. De más está decir que no se debe permitir nada que aumente la presión intracranial. Por ejemplo, un aumento en el hematoma intracranial seguramente aumentará la presión intracranial. Por ende, es sumamente importante que llegue a la facilidad adecuada para que puedan identificar la fuente del sangrado y controlarlo. Otra causa común de aumento en presión intracranial es las convulsiones asociadas al mismo aumento en la presión intracranial. Las benzodiazepinas pueden ayudar a aumentar el umbral de inicio de las convulsiones y disminuir la probabilidad de que ocurran. Durante la intubación endotraqueal, las fasciculaciones por usar succinilcolina, o la laringoscopía en un paciente que no está completamente inconsciente y relajado, puede aumentar la presión intracranial. Este paciente no debe ir a cualquier hospital. Debe ir a un centro de trauma con capacidad de intervención neuroquirúrgica. Desafortunadamente a veces estas facilidades pueden quedar algo distantes por lo que se hace ideal el transporte aeromédico. Los pacientes con trauma a la cabeza deben ser aerotransportados lo más cerca posible a la altura del nivel del mar. La altura puede aumentar la presión intracranial. Presión sanguínea La presión sanguínea está protegiendo el paciente. Si perdemos la presión sanguínea, perdemos el cerebro. Por lo tanto, es importante evitar cualquier evento que disminuya la presión sanguínea. Tenga mucho cuidado a la hora de seleccionar agentes de inducción para manejar la vía aérea que puedan causar hipotensión. Controle cualquier sangrado activo. Lesión primaria y ¿secundaria? La lesión primaria es el trauma ocurrido al momento. Por ejemplo, es el sangrado epidural que está creando efecto de masa y aumento en la presión intracranial. La lesión secundaria es todo aquello que agrave la lesión primaria. Es decir, todo lo que disminuya la presión sanguínea o aumente la presión intracranial. Evaluación primaria: ¿Qué puede complicar el paciente? La evaluación del paciente comienza con el ABC (vía aérea, respiración y circulación). El manejo inicial del paciente con trauma a la cabeza requiere que se controle cualquier amenaza al ABC ya que estas son causas proximales de muerte. Vía aérea La profunda alteración en el estado de consciencia de este paciente progresivamente provocará una pérdida del control autónomo de la vía aérea. Como dijimos anteriormente, el aumento en el CO2 va a provocar vasodilatación. El no manejar la vía aérea a tiempo va a ser causa del deterioro agudo de este paciente. Ahora bien, los detalles son importantes. Aunque el manejo de este paciente pueda requerir la eventual intubación endotraqueal, es importante evitar que el intento por intubar el paciente no provoque complicaciones. Algunas de las complicaciones asociadas a la intubación endotraqueal son: Hipoxia Hipercarbia Hipotensión La intubación en secuencia rápida (la administración simultánea de un agente de inducción + un bloqueador neuromuscular despolarizante o no-despolarizante para inducir inconsciencia flácida) es probablemente tanto la forma correcta como la forma en que se puede causar los efectos antes mencionados si no se realiza correctamente. Ventilaciones La pérdida del control de la respiración provocará un pobre intercambio de gases. La pérdida de la respiración provocará más disminución en el O2 y un aumento en el CO2. La falla en corregir esto va a provocar mayor aumento en la presión intracranial y por ende la muerte del paciente. La ventilación, ya sea manual o mecánica, debe mantener el CO2 entre 35-40 mmHg. La disminución por debajo de 35 mmHg indica hiperventilación. La hiperventilación provoca vasoconstricción cerebral. La vasoconstricción que se provoca al hiperventilar al paciente es bueno por un lado pero muy malo por otro. En teoría, la vasoconstricción puede ayudar a disminuir el sangrado, y por ende, disminuir el aumento en la presión intracranial. El problema es que la vasoconstricción provoca isquemia especialmente en áreas que no están directamente afectadas. La vasoconstricción puede provocar un aumento en el daño en las partes no directamente afectadas. Por lo tanto, inicialmente no se recomienda la hiperventilación controlada. Sin embargo, si el paciente muestra signos de herniación, la hiperventilación puede ser una medida transitoria para arrestar la progresión del aumento en la presión intracranial. Usted sabe que está llevando a cabo una hiperventilación controlada si obtiene niveles de EtCO2 entre 30 y 35 mmHg. Circulación Es importante recordar que la perfusión cerebral se está manteniendo gracias al aumento en la presión sanguínea. Si se pierde la presión sanguínea, automáticamente se pierde la perfusión cerebral en la simple ecuación descrita arriba. Las guías más recientes de la Brain Trauma Foundation recomiendan un mínimo de presión sistólica de 110 mmHg en pacientes entre 15 y 49 años de edad (o más de 70), al menos 100 mmHg para pacientes entre 50 y 69 años de edad. Esta es una nueva recomendación diferente a lo que antes se recomendaba de mínimo 90 mmHg. Por lo tanto es importante controlar todo sangrado de forma rápida. Un paciente con trauma a la cabeza y signos de shock está sangrando por otro lugar que no es la cabeza (hasta que se demuestre lo contrario). Aunque un sangrado del cuero cabelludo puede ser, en algunos casos, significativo, los sangrados intracraniales no producen shock hipovolémico. Por ende es importante buscar otros posibles sangrados activos tales como el torso, pélvis, y/o múltiples huesos largos. Métodos de monitoreo El monitoreo invasivo de la presión intracranial probablemente es una de las formas más fáciles de monitoreo continuo, para el proveedor que puede hacerlo. https://youtu.be/q7nJEMyqWwo La alteración en el estado de consciencia es el signo más temprano de aumento en la presión intracranial. Es por esta razón que el PHTLS recomienda el monitoreo continuo del nivel de consciencia (inicialmente con la escala AVDI y/o con la Escala de Coma de Glasgow) para detectar los signos iniciales de deterioro. Una disminución de menos de 2 puntos o más en la Escala de Coma de Glasgow sugiere un aumento significativo en la presión intracranial. Una disminución de 2 puntos o más, partiendo de una puntuación inicial de 8 o menos, sugiere inicios de herniación. Conclusión La fórmula de CPP = MAP - ICP y la Doctrina Monroe-Kellie explican la fisiopatología del trauma craneoencefálico. La evaluación inicial y resucitación que enseña el PHTLS presenta el mejor abordaje inicial para este tipo de paciente críticamente lesionado. Referencias Brain Trauma Foundation PHTLS

April 20, 2016 Podcast: 351: Secrets Of The Fittest Old People, Ben's Top Healthy Baby Tips, How To Get Rid Of Injuries Fast & More! Have a podcast question for Ben? Click the tab on the right (or go to ), use the Contact button on the , call 1-877-209-9439, or use the “” form at the bottom of this page. ----------------------------------------------------- News Flashes: You can receive these News Flashes (and more) every single day, if you follow Ben on , , and . ----------------------------------------------------- Special Announcements: This podcast is brought to you by: - - use code bengreenfield for 15% off anything, including the chaga elixir Ben throws into his coffee most mornings. - - get $5 off any order from Harrys at and use promo code "BEN". - - Get 10% off the brand new emulsified MCT oil at . - - You take a 5 minute cold shower (no temperature rules, but as cold as your shower can truly go, scout's honor...) each morning for 21 days from April 1st - 21st. Then you post a (clothed or towel clad, no nudies!) photo on any social media outlet you have (Twitter, Facebook, Instagram, etc.) as evidence. You *must* tag @BenGreenfield and you must use the following hashtag: #ColdShowerChallenge. The best part? All proceeds go towards , an organization that conducts innovative clinical research and develops evidence-based guidelines that improve the outcomes for millions of people who suffer from traumatic brain injuries every year. During this challenge you will learn everything you need to know about cold thermogenesis and cold showers, and even get access to a private Facebook community with all participants (including me), donate money to Brain Trauma Foundation, revitalize your life, body, brain and waistline to be ready for spring, and bask in the many cognitive and performance-enhancing benefits of cold thermogenesis! So...you in? -, and get ready for some epic stories on his morning, daily and evening routine! - - 50% discount on instant access to a box shipped to your front doorstep and full of the latest cutting-edge biohacking gear, nutrients, smart drugs and more, handpicked and curated by Ben. Only three left. Did you miss the weekend podcast episode with Aron Synder?. It was a must-listen - titled "Backpacking, Wilderness Survival, Combat Conditioning, Hunting Fitness & More With Aron Snyder". May 11, 2016: Ben is speaking at the brand new Natural Grocers in Spokane, WA on "Little Known, Easy-To-Find Foods That Burn Fat". May 21-22, 2016: Ben is speaking at the Biohacker's Summit in London. The venue will be one of the most charming venues of London, BAFTA 195 Piccadilly, and features an Upgraded Dinner with wild forager Sami Tallberg and a great opportunity to bring together some fantastic UK based biohackers in the realms of digital health, wearables, supplements, biohacking, lifehacking, quantified self and much more. You'll discover digital health & wellness providers, nutrition & supplement companies, wearables & mobile applications and smart home appliances from infrared saunas to smart sensors. "Supercharged" will also premier at the London Biohackers Summit! Imagine, a mind quick as lightning, a body charged with energy. No, it’s not a fictional superhero. It’s you. SuperCharged. Ticket Includes a live Q&A panel with the stars of the movie: Ben Greenfied, Jack Kruse and Ruben Salinas. Panel moderated by the director Sarah Turner and producer Harry Massey. All conference tickets include the movie. A ticket for only the movie & panel is available at a price of £29, but you get an instant 10% off by clicking . May 26-29, 2016: Ben is speaking at in Austin, Texas. This is the The Who’s Who gathering of the Paleo movement, with world-class speakers including New York Times bestselling authors, leading physicians, scientists, health entrepreneurs, professional athletes, fitness professionals, activists, bloggers, biohackers, and more. And you DON’T need to be Paleo to be able to get a ton of benefit and fun out of this one! Also, one day prior, on May 26 is Health Entrepreneurs f(x) - a full day of deep discussion on marketing, business development, and entrepreneurship for health and wellness people, featuring Mark Sisson, Robb Wolf, Melissa Hartwig, Sarah Ballantyne, Mike Bledsoe, Abel James, and a bunch of other speakers in small group coaching sessions. July 8-10, 2016: Join SEALFit and Ben Greenfield for a SEALFit 20X event at Ben Greenfield's home in Spokane, WA - combined with Obstacle Course training with Ben Greenfield and Hunter McIntyre. August 11-13, 2016: Ben is speaking at the Ancestral Health Symposium (AHS) in Boulder, Colorado. AHS is a historic three-day event created to unite the ancestral health movement and to foster collaboration among scientists, health professionals, and laypersons who study and communicate about health from an evolutionary perspective to develop solutions to our health challenges. Nov 17-18, 2016: Ben is speaking at the in Helsinki, Finland. Discover the latest in wearables, internet of things, digital health, and mobile apps to increase performance, be healthier, stay fit, and get more done. Learn about taking food, preparation, cooking, and eating to the next level with the latest science and kitchen chemistry. Even delve into implanted chips, gene therapy, bionic arms, biometric shirts, robotic assistants, and virtual reality. Two days with an amazing crowd and a closing party with upgraded DJs to talk about. -Dec 3-10, 2016: Runga in Costa Rica: 8 days, epic food, twice daily yoga, salt water pool and manual therapy and spa services galore, experts from around the world teaching running clinics, kettlebell seminars, lecturing on nutrition, etc. Also daily adventures ranging from zip lining to white water, along with a full digital detox. Code "BEN" gets you a free gift with your RUNGA registration valued at $75! Grab this that comes with a tech shirt, a beanie and a water bottle. And of course, this week's top iTunes review - gets some BG Fitness swag straight from Ben - ! ----------------------------------------------------- Listener Q&A: As compiled, deciphered, edited and sometimes read by , the NEW Podcast Sidekick. How To Stay Fit When You're Sitting Dougie says: He's seen you write a lot about sitting and sedentary behavior. He has to sit in the same position for the 60 mins/day every day when he drives. He can't decrease his sedentary sitting time. Do you have any ideas for house to combat this? In my response, I recommend: - Ben's Top Healthy Baby Tips James says: His wife just had their first child. What are some of things you did with your boys to make sure they were flourishing and healthy? In my response, I recommend: - How To Get Rid Of Injuries Fast Neale says: He’s been having issues with RSI in his shoulder and his hip. He's wondering if you can give him any suggestions for how to get these things sorted out? Anything food/supplement related? He's currently doing LCHF diet, for the past year and its going well. He wanted to get consistently running again, can you help him out? In my response, I recommend: - What To Eat Before, During And After Workouts Rachel says: Her question is, what should she be eating pre and post workouts? She's heard a lot of conflicting information on protein, fat and carbs and when you should be eating them. She'd love to get your insight. In my response, I recommend: -  

April 13, 2016 Podcast: 350: Why You Should "Cheat" On Meals, When You Shouldn't Get A Blood Test, Which Massage Oil Is Healthiest & More! Have a podcast question for Ben? Click the tab on the right (or go to ), use the Contact button on the , call 1-877-209-9439, or use the “” form at the bottom of this page. ----------------------------------------------------- News Flashes: So… You can receive these News Flashes (and more) every single day, if you follow Ben on , , and . ----------------------------------------------------- Special Announcements: Two quick corrections: - earthing sandals discount is 10%, not 30%. Our apologies! - superfoods meal replacement discount is "BEN15". This podcast is brought to you by: - - use code BEN10 for 10% discount on these minimalist outdoor sandals that sync up with the earth’s circadian rhythm (24 hour cycle) by exposing your biology to planet's natural frequencies via carbon lacing and carbon plugs built into the sandal. - - get $5 off any order from Harrys at  and use promo code "BEN". - - get 20% off the best tasting green juice powder on the face of the planet with discount code "BEN". - - You take a 5 minute cold shower (no temperature rules, but as cold as your shower can truly go, scout's honor...) each morning for 21 days from April 1st - 21st. Then you post a (clothed or towel clad, no nudies!) photo on any social media outlet you have (Twitter, Facebook, Instagram, etc.) as evidence. You *must* tag @BenGreenfield and you must use the following hashtag: #ColdShowerChallenge. The best part? All proceeds go towards , an organization that conducts innovative clinical research and develops evidence-based guidelines that improve the outcomes for millions of people who suffer from traumatic brain injuries every year. During this challenge you will learn everything you need to know about cold thermogenesis and cold showers, and even get access to a private Facebook community with all participants (including me), donate money to Brain Trauma Foundation, revitalize your life, body, brain and waistline to be ready for spring, and bask in the many cognitive and performance-enhancing benefits of cold thermogenesis! So...you in? -, and get ready for some epic stories on his morning, daily and evening routine! - - 50% discount on instant access to a box shipped to your front doorstep and full of the latest cutting-edge biohacking gear, nutrients, smart drugs and more, handpicked and curated by Ben. Only three left. Did you miss the weekend podcast episode on Transcendental Meditation. It was a must-listen - titled "TM - Cult, Quackery or Science".  May 11, 2016: Ben is speaking at the brand new Natural Grocers in Spokane, WA on "Little Known, Easy-To-Find Foods That Burn Fat". May 21-22, 2016: Ben is speaking at the Biohacker's Summit in London. The venue will be one of the most charming venues of London, Tabacco Dock, and features an Upgraded Dinner with wild forager Sami Tallberg and a great opportunity to bring together some fantastic UK based biohackers in the realms of digital health, wearables, supplements, biohacking, lifehacking, quantified self and much more. You'll discover digital health & wellness providers, nutrition & supplement companies, wearables & mobile applications and smart home appliances from infrared saunas to smart sensors. . May 26-29, 2016: Ben is speaking at in Austin, Texas. This is the The Who’s Who gathering of the Paleo movement, with world-class speakers including New York Times bestselling authors, leading physicians, scientists, health entrepreneurs, professional athletes, fitness professionals, activists, bloggers, biohackers, and more. And you DON’T need to be Paleo to be able to get a ton of benefit and fun out of this one! Also, one day prior, on May 26 is Health Entrepreneurs f(x) - a full day of deep discussion on marketing, business development, and entrepreneurship for health and wellness people, featuring Mark Sisson, Robb Wolf, Melissa Hartwig, Sarah Ballantyne, Mike Bledsoe, Abel James, and a bunch of other speakers in small group coaching sessions. July 8-10, 2016: Join SEALFit and Ben Greenfield for a SEALFit 20X event at Ben Greenfield's home in Spokane, WA - combined with Obstacle Course training with Ben Greenfield and Hunter McIntyre. August 11-13, 2016: Ben is speaking at the Ancestral Health Symposium (AHS) in Boulder, Colorado. AHS is a historic three-day event created to unite the ancestral health movement and to foster collaboration among scientists, health professionals, and laypersons who study and communicate about health from an evolutionary perspective to develop solutions to our health challenges. Nov 17-18, 2016: Ben is speaking at the in Helsinki, Finland. Discover the latest in wearables, internet of things, digital health, and mobile apps to increase performance, be healthier, stay fit, and get more done. Learn about taking food, preparation, cooking, and eating to the next level with the latest science and kitchen chemistry. Even delve into implanted chips, gene therapy, bionic arms, biometric shirts, robotic assistants, and virtual reality. Two days with an amazing crowd and a closing party with upgraded DJs to talk about. -Dec 3-10, 2016: Runga in Costa Rica: 8 days, epic food, twice daily yoga, salt water pool and manual therapy and spa services galore, experts from around the world teaching running clinics, kettlebell seminars, lecturing on nutrition, etc. Also daily adventures ranging from zip lining to white water, along with a full digital detox. Code "BEN" gets you a free gift with your RUNGA registration valued at $75! Grab this that comes with a tech shirt, a beanie and a water bottle. And of course, this week's top iTunes review - gets some BG Fitness swag straight from Ben - ! ----------------------------------------------------- Listener Q&A: As compiled, deciphered, edited and sometimes read by , the NEW Podcast Sidekick. When You Shouldn't Get A Blood Test Phil says: His wife is 54 and has a long list of health issues, many of which developed later in life. From food allergies and asthma to aching knees to swollen fingers in the morning, which she describes as Mickey Mouse hands. All of her doctors just want to treat her symptoms but he wants to treat the causes. Would you recommend a functional wellness test like and if so, which one would you choose? Or would you recommend something else? In my response, I recommend: - - - - - Which Massage Oil Is Healthiest? Sherry says: She loves the show, she’s been listening for the past 6 months and she hooked. She’s going to a bunch of the conferences you're speaking at. She’s a personal trainer, group instructor and massage therapist. She’s wondering what the absorption level is of massage oil into your body. What are the pros and cons of of absorbing all that oil into the skin if she’s massaging 6 hours per day? In my response, I recommend: - Ben's Bug Out Bag Ryan says: He’s from Mobile, Alabama, and he’s got a fun question. He’s one of those Waco conspiracy theorist type - people who believes the sustainability of our financial system won’t remain much longer. He was hoping you could put together a list of top 10 items, foods, remedies that he can keep and start storming that will help them optimize or maintain health during times of hardship. In my response, I recommend: - - - - - - - - - - How Women Can Fix Metabolic Damage From Overtraining Jennifer says: She’s from Oceanside, California. She has a question about increasing thyroid function once damage had been done from a low carb diet. She’s was playing around with nutrition and trying to get leaner and depleted her thyroid function fairly significantly. She has a doctor of nutrition and nutrition coach helping her but in the interim, if you have any advice on how to use carbs to help reset her metabolism and get her back on track and what types of carbs to use, she’d appreciate it. She’s feeling really slow and not so good...it's not a fun feeling. She knows she can fix it in a month of two with help but if there’s anything we can provide in the interim she’d appreciate it. She thanks you for your excellent advice, and products and other things, she benefits so much from it. She’s a physician herself and she often passes along information to her patients, other physicians and friends. In my response, I recommend: -

March 30, 2016 Podcast: 349: Why Athletes Get Sick, How To Biohack Survival, How Often Do You Need To Workout & More! Have a podcast question for Ben? Click the tab on the right (or go to ), use the Contact button on the , call 1-877-209-9439, or use the “” form at the bottom of this page. ----------------------------------------------------- News Flashes: You can receive these News Flashes (and more) every single day, if you follow Ben on , , and . ----------------------------------------------------- Special Announcements: This podcast is brought to you by: - - get a free trial of their amazing protein powder with 18g of clean real whole food plant based protein and only 150 calories when you go to - - get nootropic infused coffee at and use 10% discount code BEN. No time for breakfast? Try this loaded smoothie for a quick on the go breakfast that will keep you running all morning long. 1 1/2 cups of brewed Kimera Koffee 1 scoop of raw organic protein powder 1 tablespoon of organic almond butter 1 small piece of raw organic cocoa butter 1 dash of cinnamon, cayenne, turmeric Blend all ingredients in a blender until smooth; pour over ice or take in a thermos for a filling morning pick me up. - - Get 10% off ANYTHING, from functional foods to supplements and beyond, at - - You take a 5 minute cold shower (no temperature rules, but as cold as your shower can truly go, scout's honor...) each morning for 21 days from April 1st - 21st. Then you post a (clothed or towel clad, no nudies!) photo on any social media outlet you have (Twitter, Facebook, Instagram, etc.) as evidence. You *must* tag @BenGreenfield and you must use the following hashtag: #ColdShowerChallenge. The best part? All proceeds go towards , an organization that conducts innovative clinical research and develops evidence-based guidelines that improve the outcomes for millions of people who suffer from traumatic brain injuries every year. During this challenge you will learn everything you need to know about cold thermogenesis and cold showers, and even get access to a private Facebook community with all participants (including me), donate money to Brain Trauma Foundation, revitalize your life, body, brain and waistline to be ready for spring, and bask in the many cognitive and performance-enhancing benefits of cold thermogenesis! So...you in?  -, and get ready for some epic stories on his morning, daily and evening routine! - - 50% discount on instant access to a box shipped to your front doorstep and full of the latest cutting-edge biohacking gear, nutrients, smart drugs and more, handpicked and curated by Ben. Only 4 left. Did you miss the weekend podcast episode with Laird Hamilton and Gabby Reece? It was a must-listen - titled "Anti-Aging, Homeschooling, Underwater Workouts, Pooping & More." May 21-22, 2016: Ben is speaking at the Biohacker's Summit in London. The venue will be one of the most charming venues of London, Tabacco Dock, and features an Upgraded Dinner with wild forager Sami Tallberg and a great opportunity to bring together some fantastic UK based biohackers in the realms of digital health, wearables, supplements, biohacking, lifehacking, quantified self and much more. You'll discover digital health & wellness providers, nutrition & supplement companies, wearables & mobile applications and smart home appliances from infrared saunas to smart sensors. . May 27-29, 2016: Ben is speaking at in Austin, Texas. This is the The Who’s Who gathering of the Paleo movement, with world-class speakers including New York Times bestselling authors, leading physicians, scientists, health entrepreneurs, professional athletes, fitness professionals, activists, bloggers, biohackers, and more. And you DON’T need to be Paleo to be able to get a ton of benefit and fun out of this one! Also, one day prior, on May 26 is Health Entrepreneurs f(x) - a full day of deep discussion on marketing, business development, and entrepreneurship for health and wellness people, featuring Mark Sisson, Robb Wolf, Melissa Hartwig, Sarah Ballantyne, Mike Bledsoe, Abel James, and a bunch of other speakers in small group coaching sessions. Nov 17-18, 2016: Ben is speaking at the in Helsinki, Finland. Discover the latest in wearables, internet of things, digital health, and mobile apps to increase performance, be healthier, stay fit, and get more done. Learn about taking food, preparation, cooking, and eating to the next level with the latest science and kitchen chemistry. Even delve into implanted chips, gene therapy, bionic arms, biometric shirts, robotic assistants, and virtual reality. Two days with an amazing crowd and a closing party with upgraded DJs to talk about. -Dec 3-10, 2016: Runga in Costa Rica: 8 days, epic food, twice daily yoga, salt water pool and manual therapy and spa services galore, experts from around the world teaching running clinics, kettlebell seminars, lecturing on nutrition, etc. Also daily adventures ranging from zip lining to white water, along with a full digital detox. Code "BEN" gets you a free gift with your RUNGA registration valued at $75!  Grab this that comes with a tech shirt, a beanie and a water bottle. And of course, this week's top iTunes review - gets some BG Fitness swag straight from Ben - ! ----------------------------------------------------- Listener Q&A: As compiled, deciphered, edited and sometimes read by , the NEW Podcast Sidekick. How To Biohack Survival Sebastian says: He's from the Great White North and has an interest in bush craft and survival. He's wondering if you have any biohacks for survival, say you have nothing on your back but a backpack, what would some biohacks be? Ie. Creating a fire and using the charcoal to clean your system afterwards? It would be cool to hear what you have to say about this and would be great if you got a survivalist on the podcast in future! In my response, I recommend: - - - - -Spit fishing - -Mention upcoming podcast with Aron Snyder How To Box Breathe Mark says: He's been experimenting with box breathing at work during stressful meetings etc and when he's doing Heart Math. Can you elaborate on the protocols for box breathing, when and how often can you use it etc? In my response, I recommend: - How Often Do You Need To Workout? Kyle says: He's a huge fan of the show and loves listening to it. He wants your opinion Ben on daily workouts. He's seen people who do 300 burpees/day, barbell squats every day, 30 min jump rope sessions every day. What's your opinion on doing these kinds of workouts? Are they really that good for you? In my response, I recommend: - Can You Eat A Kombucha Scoby? Rick says: He loves the podcast, his question is about SCOBY's. He's wondering if you can blend them or chop them up and put them in a salad? In my response, I recommend: -     

Guest: Jam Ghajar, MD, PhD Host: Mark Nolan Hill, MD Advances in diagnostics for traumatic brain injuries will soon allow us to evaluate these injuries immediately after they occur. With many of our troops suffering these injuries, the United States military is making a push to accelerate development of a new assessment device. Jamshid Ghajar, MD, PhD, president of the Brain Trauma Foundation, the organization working in partnership with the Defense Department, outlines this collaborative effort. Will this forthcoming diagnostic tool also be applicable in civilian circumstances? Are there certain sets of symptoms that would preclude its use?

Host: Mark Nolan Hill, MD Guest: Jam Ghajar, MD, PhD Traumatic brain injuries are a major cause for concern for our troops returning home from military conflicts abroad. The development of a new eye-tracking device, initiated and funded, in part, by the United States Department of Defense, will soon provide an immediate assessment of traumatic brain injuries. How might this device change the entire evaluation process for these injuries? When will this device be ready for use? Host Dr. Mark Nolan Hill gets the details from Jamshid Ghajar, MD, PhD, president of the Brain Trauma Foundation, the organization working in partnership with the Defense Department to develop this device.