On exams some images are field test items [not scored]. In this group that should be the lower middle pt because he would likely arrive dead: he has a massive SAH that surrounds all of T cortical surfaces/even extends a long the fall in the midline. He would likely arrive dead also labeled as DOA. So you can’t save him. The pat in the upper middle has a knife blade into the brain: traumatic penetration by knife [transfer 1st] Esp if no other injury; T upper left is T lowest acuity so it is transferred last Of this mass casualty simulation. T EDH is arterial hemorrhage [lens-shape-lower Left…T issue is how is T pt…if hemodynamically normal with reactive pupils [incubate/mild hypervent after RSI [all get RSI but T SAH…he is dead]. An EDH might need a burrhole if the pt decompensates. The remaining cases: The SDH that has midline extension/a collapsed Lt ventricle has to improve w/measures to lower ICP or also likely dead…if N Surg is not far by transfer treat/send simultaneously. The hypertensive bleed needs mild hypervent/transfer ASAP too & cd survive. Decades prior if there was intraventricular blood the pt outcome was low survival…this was a pt with a right avm [av malformation that ruptured w/assoc’d HTN. T danger is T BP…do not lower T bp because with chronic hypertension cerebral perfusion is reset to a higher range; best to gently do RSI/transfer and don’t lower T bp…this patient actually survived so did all but the massive SAH…that’s because he has a convexity block…meaning the arachnoid granulations [AGs] are all blocked…No CSF can exit via the AGs…he would likely die prior to arrival…probably died at home in bed asleep…that is his best scenario…sorry sir…interestingly this is the pattern of pts who die during intercourse. In the midline the blood is fuzzy because it is a thin film that follows the sulci/gyri closely…it often looks like a zipper…”called the zipper sign/proves its a SAH along both sides o the falx. I labeled them also by acuity…by ambulance size in T image below
The third image will take time to read but describes how I would triage/manage these 6 patients as a mass casualty event … I did this to show you how I use limbic activation…because this would be a crazy shift…crazy you always remember! Super-emotional events cause new connections to long term memory in both of the two areas known as the hippocampus.