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- 1. Trauma Craneoencefálico Nicolás Hernández Herrera Nicolás Hernández Herrera R2cg R2cg Junio 11, 2013 Junio 11, 2013 ©ACS
- 2. Objetivos Describir la fisiología intracraneal básica. Reconocer la importancia de limitar el daño cerebral secundario. Estabilizar y realizar los arreglos para los cuidados definitivos.
- 3. Preguntas clave ¿Cuáles son las características especiales de la anatomía y fisiología cerebrales y cómo afectan éstas las formas de lesión cerebral? ¿Cuál es el manejo óptimo del paciente con lesión cerebral? ¿Cómo hago el diagnóstico de muerte cerebral?
- 4. ¿Efectos anatómicos y fisiológicos? Cráneo rígido, no expandible, lleno con tejido cerebral, LCR y sangre. Autorregulación del flujo sanguíneo cerebral La lesión cerebral causa una disrupción de la compensación autorregulatoria Efecto de masa de la hemorragia intracraneal Programa Avanzado de Apoyo Vital en Trauma para Médicos ATLS. 7º Ed.
- 5. Doctrina Monro-Kellie Volumen venoso Vol. ven. 75 mL Vol. Art. Vol. Art. Cerebro Cerebro Volumen Cerebro arterial Masa Masa LCF LCR LCR Programa Avanzado de Apoyo Vital en Trauma para Médicos ATLS. 7º Ed. 75 mL
- 6. Volumen – Curva de Presión 60555045403530252015105- Herniación PIC (mm Hg) Punto de Descompensación Compensación Volumen de la Masa Programa Avanzado de Apoyo Vital en Trauma para Médicos ATLS. 7º Ed.
- 7. Presión Intracraneana (PIC) 10 mm Hg = Normal > 20 mm Hg = Anormal > 40 mm Hg = Severa Muchos procesos patológicos afectan el resultado ↑ Sostenido de la PIC da lugar a una ↓ de la función cerebral, afectando el resultado Programa Avanzado de Apoyo Vital en Trauma para Médicos ATLS. 7º Ed.
- 8. Presión de Perfusión Cerebral* PAM – PIC = PPC Normal 90 10 80 Respuesta de Cushing 100 20 80 Hipotensión 50 20 30 * PPC ≠ Flujo sanguíneo cerebral Programa Avanzado de Apoyo Vital en Trauma para Médicos ATLS. 7º Ed.
- 9. Autorregulación Si la autoregulación se mantiene intacta, el FSC se mantiene a una PA media de 50 a 160 mm Hg. Lesión cerebral moderada o severa: La autorregulación muchas veces se deteriora El cerebro es más vulnerable a episodios de hipotensión → lesión cerebral secundaria Programa Avanzado de Apoyo Vital en Trauma para Médicos ATLS. 7º Ed.
- 10. Metas en el tratamiento 1. 2. 3. 4. 5. Prevenir lesion cerebral secundaria Proveer oxigenación adecuada Mantener presion sanguinea ABCDE Identificar lesiones con efecto de masa Programa Avanzado de Apoyo Vital en Trauma para Médicos ATLS. 7º Ed.
- 11. Clasificación de las lesiones cerebrales Por su Mecanismo Contuso: Alta y baja velocidad Penetrante: HPAF y otras Programa Avanzado de Apoyo Vital en Trauma para Médicos ATLS. 7º Ed.
- 12. Clasificación de las lesiones cerebrales Por su morfología: Fracturas de cráneo Basilar Deprimida / no deprimida • Abierta / cerrada • Bóveda • Con / sin salida de LCR Con / sin parálisis de nervios craneales • Programa Avanzado de Apoyo Vital en Trauma para Médicos ATLS. 7º Ed.
- 13. Clasificación de las lesiones cerebrales Por su Mecanismo: Cerebro • Focal Subdural • Intracerebral • • Difusa Epidural (extradural) Concusión Contusiones múltiples • Hipóxica / lesión isquémica • Programa Avanzado de Apoyo Vital en Trauma para Médicos ATLS. 7º Ed.
- 14. Lesión Cerebral Difusa Concusión moderada → Daño isquémico severo TAC normal Lesión difusa Programa Avanzado de Apoyo Vital en Trauma para Médicos ATLS. 7º Ed.
- 15. Hematoma Epidural Se asocia a fractura del cráneo Clásica: Ruptura de la arteria meníngea media Lenticular / biconvexa Intervalo lúcido Puede ser rápidamente fatal Rápida evacuación es fundamental Programa Avanzado de Apoyo Vital en Trauma para Médicos ATLS. 7º Ed.
- 17. Hematoma subdural Ruptura venosa / laceración Cubre la superficie cerebral Morbilidad / mortalidad debido a la lesión cerebral subyacente Se recomienda una rápido drenaje quirúrgico, especialmente si la línea media está desviada > 5 mm Programa Avanzado de Apoyo Vital en Trauma para Médicos ATLS. 7º Ed. ©ACS
- 19. Contusión / Hematoma Lesión por golpe / contragolpe Más frecuente: Lóbulos temporal / frontal Cambios en la TAC usualmente progresivos La mayoría de los pacientes concientes: No cirugía Programa Avanzado de Apoyo Vital en Trauma para Médicos ATLS. 7º Ed.
- 20. Contusión / Hematoma Gran hematoma frontal con desviación ©ACS
- 21. Lesión Cerebral Leve Escala CG = 14-15 Rx según indicación Historia Excluir lesiones sistémicas Búsqueda alcohol / drogas según indicado Uso liberal de TAC de cráneo Examen neurológico Observar o alta basada en los hallazgos Programa Avanzado de Apoyo Vital en Trauma para Médicos ATLS. 7º Ed. ©ACS
- 22. AREA PUNTAJE OCULAR Espontánea Estímulo verbal Al dolor Ninguna 4 3 2 1 MOTORA Acata órdenes Localiza dolor Retiro a estímulo dolor Flexión anormal Extensión Flacidez 6 5 4 3 2 1 RESPUESTA VERBAL Orientada Conversación confusa Palabras inapropiadas Sonidos incomprensibles Ninguna 5 4 3 2 1 Escala de coma de Glasgow Programa Avanzado de Apoyo Vital en Trauma para Médicos ATLS. 7º Ed.
- 23. Lesión cerebral moderada Escala CG = 9-13 • Exámenes neurológicos frecuentes • Repetir TAC Evaluación inicial igual que para lesión leve TAC a todos Admitir y observar Deterioro: Manejo como lesión cerebral severa Programa Avanzado de Apoyo Vital en Trauma para Médicos ATLS. 7º Ed.
- 24. Lesión Cerebral Severa Escala CG = 3 a 8 Evaluar y resucitar Intubación para proteger la vía aérea Reevaluación frecuente Identificar lesiones asociadas Programa Avanzado de Apoyo Vital en Trauma para Médicos ATLS. 7º Ed.
- 25. Prioridades ABCDE Minimizar la lesión cerebral secundaria • Administrar O2 • Mantener la presión arterial (sistólica > 90 mm Hg) Programa Avanzado de Apoyo Vital en Trauma para Médicos ATLS. 7º Ed.
- 26. ¿Examen neurológico enfocado? Escala CG Pupilas Signos de lateralización Consulta neuroquirúrgica temprana Programa Avanzado de Apoyo Vital en Trauma para Médicos ATLS. 7º Ed.
- 27. Manejo Médico Líquidos intravenosos • • Euvolemia Isotónica Ventilación controlada • Meta: Paco2 a 35 mm Hg ©ACS
- 28. ¿Indicaciones para TAC? Todos los pacientes en los que se sospecha lesión cerebral ©ACS
- 29. Manejo Médico Manitol • Uso cuando hay signos de herniación tentorial • Dosis: bolo IV de 1.0 g / kg • Primero consultar con el neurocirujano Programa Avanzado de Apoyo Vital en Trauma para Médicos ATLS. 7º Ed.
- 30. Manejo Médico Otros medicamentos • Anticonvulsivantes • Sedación Programa Avanzado de Apoyo Vital en Trauma para Médicos ATLS. 7º Ed.
- 31. Manejo Quirúrgico Lesiones del cuero cabelludo Sitio posible de hemorragia importante Control del sangrado mediante presión directa Oclusión temporal ocasional Programa Avanzado de Apoyo Vital en Trauma para Médicos ATLS. 7º Ed.
- 32. Manejo Quirúrgico Lesión por masa intracraneal Puede poner en peligro la vida si se expande rápidamente Consulta neuroquirúrgica inmediata Hiperventilación / manitol Craneotomía para control de daños: Referencia a NeuroQx Programa Avanzado de Apoyo Vital en Trauma para Médicos ATLS. 7º Ed.
- 33. ¿Diagnóstico de muerte cerebral? Clínico Escala CG = 3 Sin respuesta pupilar Ausencia de reflejos del tallo cerebral Sin respiración expontánea Programa Avanzado de Apoyo Vital en Trauma para Médicos ATLS. 7º Ed.
- 34. ¿Diagnóstico de muerte cerebral? Estudios Auxiliares Sin actividad EEG Gammagrama cerebral sin flujo sanguíneo PIC > PAM x 3 horas Sin respuesta cardiaca a la atropina Recuerde, donación de órganos Programa Avanzado de Apoyo Vital en Trauma para Médicos ATLS. 7º Ed.
- 35. Resumen: ¿Qué debo hacer? Mantener PA media > 90 mm Hg Mantener Paco2 cerca a 35 mm Hg Uso de soluciones isotónicas para euvolemia Exámenes neurológicos frecuentes Uso liberal de TAC Consulta neuroquirúrgica temprana Programa Avanzado de Apoyo Vital en Trauma para Médicos ATLS. 7º Ed.
- 36. Resumen: ¿Qué es lo que NO debo hacer? Permitir que el paciente caiga en hipotensión Hiperventilación sobreagresiva Uso endovenoso de soluciones hipotónicas Programa Avanzado de Apoyo Vital en Trauma para Médicos ATLS. 7º Ed.
- 37. Resumen: ¿Qué es lo que NO debo hacer? Uso de paralizantes de larga acción Paralizar antes de relizar un examen completo Depender exclusivamente del examen clínico Programa Avanzado de Apoyo Vital en Trauma para Médicos ATLS. 7º Ed.
- 38. GRACIAS
- 39. BIBLIOGRAFÍA • ATLS 7º ed. Capitulo Traumatismo craneoencefalico
Notes de l'éditeur
- 6-1Title Slide The instructor should introduce the topic and relate to the students that base don their preparation for the course, a series of questions will be asked throughout the lecture, and their active participation and responses are expected. The first mouse click causes the “Committee on Trauma” to “type” in and the second click causes the photograph and lecture title to stripe down to the right. This individual sustained a basal skull fracture. The corresponding Battle’s sign is apparent. Note: Pressing the down arrow key on the computer keyboard or left-clicking on the mouse initiates the animation on the slide. For brevity in this dialogue, mouse clicking is referenced. However, either method may be used. (Photograph: Courtesy of Charles Aprahamian, MD, FACS)
- 6-2Objectives The instructor should review the objectives with the students as provided on the slide, while emphasizing the important aspects in the approach to the brain-injured patient. Each objective appears with a mouse click, the preceding item dimming as the next one appears.
- 6-3Key Questions The instructor indicates that these are the primary questions to be pursued during the presentation. Each question appears with a mouse click and then dims with the next mouse click. Note: To facilitate an interactive discussion, the instructor may wish to prepare additional, related questions to ask during the presentation.
- 6-4What are the unique features of brain anatomy and physiology, and how do they affect patters of brain injury? The instructor should reveal the responses on the slide after the students have discussed the anatomic and physiologic affects on brain-injury care. The instructor should make these salient points. Cerebral blood flow (CBF) is autoregulated closely by vasodilatation and vasoconstriction, which allows for constancy over a wide range of blood pressures. Carbon dioxide changes in the blood also affect cerebral vasodilatation and vasoconstriction. Brain injury disrupts this autoregulatory mechanism. Intracranial bleeding causes a mass effect within the brain. This is initially compensated for by venous constriction and absorption of cerebrospinal fluid. Because the skull does not expand and as compensatory mechanisms begin to fail, blood flow to the brain is reduced. Although there is not a direct linear relationship between cerebral blood flow and cerebral perfusion pressure, the Monro-Kellie Doctrine describes the uncompensated state that is reached when a mass reaches a specific size. (See next slide with graphic depiction of the Monro-Kellie Doctrine. Each bulleted item on the slide appears with a mouse click and then dims with the next mouse click.
- 6-5Monro-Kellie Doctrine (See description for slide 6-4 and related text in manual.) The instructor should briefly review this graphic depiction of a mass’s effect on the brain. Note: This slide is not animated.
- 6-6Volume-Pressure Curve The instructor should relate to the students that an exponential increase in intracranial pressure (ICP) associated with a small increase in the volume of the mass, results in increased pressures in the rigid skull and reduced cerebral blood flow. The x and y axes are not animated on this slide. However the line of compensation, point of decompensation, and point of herniation are animated. The first click of the mouse causes the line of compensation to stretch from left to right to the point of decompensation. The second mouse click results in the line curving up to the right to include the point of decompensation and herniation.
- 6-7Intracranial Pressure (ICP) Dr. Parks and Dr. Marion: Need narrative for this slide Each bulleted item on the slide appears with a mouse click and then dims with the next mouse click
- 6-8Cerebral Perfusion Pressure The instructor should relate to the students that intracranial pressure follows the Monro-Kellie Doctrine. The Cushing Response is compensation for increased ICP. If hypotension ensues for any reason, secondary brain injury occurs and the outcome is worsened significantly. This table graphically depicts these factors. The instructor also should relate to the students that cerebral perfusion pressure does not equate with cerebral blood flow. Note: This slide is not animated.
- 6-9Autoregulation The instructor may query the students about the autoregulatory mechanism of the brain. The instructor should emphasize that if autoregulation is impaired due to brain injury, the brain is significantly more vulnerable to secondary brain injury. Therefore, brain-injury treatment focuses on the prevention of secondary brain injury. Each bulleted item on the slide appears with a mouse click and then dims with the next mouse click
- 6-9Autoregulation The instructor may query the students about the autoregulatory mechanism of the brain. The instructor should emphasize that if autoregulation is impaired due to brain injury, the brain is significantly more vulnerable to secondary brain injury. Therefore, brain-injury treatment focuses on the prevention of secondary brain injury. Each bulleted item on the slide appears with a mouse click and then dims with the next mouse click
- 6-10Classification of Head Injury by Mechanism of Injury Two mechanisms of injury may cause brain injury, blunt and penetrating. Blunt trauma can be of high or low velocity, eg, motor vehicle crashes, falls, and blunt assault. Depicted here is a patient with Battle’s sign resulting from blunt trauma and basilar skull fracture. (Photo used with permission of Trauma.org. Adrian Caceres. Neurotrauma Images – neuro0014. Trauma.org, http://www.trauma.org/imagebank/imagebank.html.) Gunshot wounds are almost always lethal. Depicted here is a patient with a gunshot wound to the left frontoparietal region. (Photo used with permission of Trauma.org. Author unknown. Neurotrauma Images – neuro0004a. Trauma.org, http://www.trauma.org/imagebank/imagebank.html.) The first mouse click results in the first bulleted item with photograph to stretch from left to right across the screen. The second mouse click causes the same to occur with the second bulleted item.
- 6-11Classifications of Head Injury by Skull Morphology This slide is not animated. Drs. Marion and Parks: The text discusses linear and stellate, but not depressed / nondepressed. Will this inconsistency be confusing to the students? The instructor should relate to the students that linear fractures increase the incidence of intracranial hematoma by 400 times in an awake patient and 20 times in a comatose patient, the latter of which already has a higher incidence of intracranial hematoma. Open fractures are associated with an increase risk of meningitis. Basal fractures have an associated risk of CSF leak. Clinical symptoms (raccoon eyes, Battle’s sign, otorrhea, and rhinorrhea) should increase the index of suspicion in identifying basal skull fractures.
- 6-12Classifications of Head Injury by Brain Morphology Drs. Parks and Marion: Need narrative for this slide
- 6-13Diffuse Brain Injury The key point for the instructor to make here is that diffuse brain injury may range from a mild concussion to a severe, ischemic insult. The instructor might query the students about symptoms of a concussion. Typically, these include a transient loss of consciousness and retrograde or antegrade amnesia. Nausea, vomiting, and headache symptoms may worsen before lessening. Sequellae are common. The instructor may query the students about the cause of severe diffuse brain injury. This latter type of injury usually results from a combination of trauma and hypoxia, due to airway and breathing problems at the time of injury. A normal CT scan (mouse click to reveal normal CT scan) is common, but diffuse edema (click mouse to reveal diffuse injury) may exist. The instructor should emphasize that the CT should be repeated for any significant symptoms, eg, persistent or worsening headache, somnolence, and change in GCS score. Note: Need CT of diffuse injury
- 6-14Epidural (extradural) Hematoma The instructor may query the students about factors related to epidural hematomas. Once the students have provided their responses, the instructor reveals the items on the slide in summary of the discussion. Each mouse click reveals a bulleted item and dims the preceding item. The instructor should emphasize that with early evacuation of the hematoma, the patient can recover completely. The instructor also should note that sometimes the patient is unconscious and will not have a lucid interval. The corresponding CT scan of an epidural hematoma is on the next slide and is the same as that in the students’ manual.
- 6-15Epidural Hematoma The instructor should explain that on CT an epidural hematoma appears lenticular / biconvex due to the dura’s adherence to the skull.
- 6-16Subdural Hematoma The instructor may query the students about factors related to subdural hematomas. Once the students have provided their responses, the instructor reveals the items on the slide in summary of the discussion. Each mouse click reveals a bulleted item and dims the preceding item. The instructor should relate that bleeding from the surface of the brain and the amount of brain injury determine the patient’s mortality. Early evacuation is recommended, but outcome may be determined by the severity of the underlying brain injury.
- 6-17Subdural hematoma
- 6-18Contusion/Hematoma The instructor may query the students about factors related to cerebral contusions and hematomas. Once the students have provided their responses, the instructor reveals the items on the slide in summary of the discussion. Each mouse click reveals a bulleted item and dims the preceding item. Contusions are fairly common and occur in up to 30% of severe brain injuries. Coup injury is where the brain is impacted and contrecoup injury is where the brain bounces off the skull on the opposite side of the impact. Cerebral contusions and hematomas are frequently progressive injuries and contusions may coalesce into hematomas. For this reason, repeat CT scans are important to follow the patient’s progress.
- 6-19Large frontal contusion with shift
- 6-20Mild Brain Injury The instructor should relate to the students that determining the GCS score is a good way to stratify brain injury by mild, moderate, and severe. The instructor should relate to the students that approximately 805 of the patients seen in the emergency department with a head injury have a mild brain injury. The instructor may discuss each salient point as it appears on the screen. If patients are to be discharged, they must be alert and oriented enough to understand the written discharge instructions and should have a companion to stay with them for the next 24 hours. Each bulleted item on the slide appears with a mouse click and then dims with the next mouse click
- 6-20Mild Brain Injury The instructor should relate to the students that determining the GCS score is a good way to stratify brain injury by mild, moderate, and severe. The instructor should relate to the students that approximately 805 of the patients seen in the emergency department with a head injury have a mild brain injury. The instructor may discuss each salient point as it appears on the screen. If patients are to be discharged, they must be alert and oriented enough to understand the written discharge instructions and should have a companion to stay with them for the next 24 hours. Each bulleted item on the slide appears with a mouse click and then dims with the next mouse click
- 6-21Moderate Brain Injury The instructor reviews each salient point about moderate brain injury as it appears on the screen. Approximately 10% of brain-injured patients seen in the emergency department have a moderate brain injury. They are confused and somnolent, and may a have focal neurologic deficit. Between 10% and 20% of the patients with a moderate brain injury deteriorate neurologically and lapse into a coma. Each bulleted item on the slide appears with a mouse click and then dims with the next mouse click
- 6-22Severe Brain Injury The instructor reviews each salient point about moderate brain injury as it appears on the screen. Patients with severe brain injury cannot protect their airway and need to be intubated. Secondary brain injury is disastrous. Hypotension alone increases mortality from 27% to 60%. Hypoxia, in addition to hypotension, is associated with a mortality of 75. Therefore, it is imperative that the patient’s cardiopulmonary status be optimized. Associated injuries that might result in hypotension or hypoxia must be identified early. Therefore, evaluation for occult injuries is routine, eg, CT of the abdomen, FAST, DPL, or chest x-ray. The instructor should emphasize the need for a CT scan, frequent neurologic revaluations, and repeat CT scans to identify progressive injuries. Each bulleted item on the slide appears with a mouse click and then dims with the next mouse click
- 6-23Priorities The instructor uses this slide to reemphasize the need to secure and maintain a patent airway, administer oxygen, and prevent secondary brain injury. These management measures provide optimal management of the brain-injured patient. Each bulleted item on the slide appears with a mouse click and then dims with the next mouse click
- 6-25Medical Management The instructor should emphasize the need to maintain good circulating blood volume, adequate oxygenation, and controlled ventilation. The instructor also should emphasize the need to avoid hyperventilation and why. Each bulleted item on the slide appears with a mouse click and then dims with the next mouse click.
- 6-26Indications for CT Scan When this slide first appears on the screen, the instructor may ask the students what the indications are for obtaining a head CT scan. The students should respond, with direction from the instructor, “All patients with suspicion of a brain injury.” The instructor can then reveal the statement in the 3-dimensional box.
- 6-27Medical Management: Mannitol The instructor may use this slide to query the students about the use of Mannitol (indications, dose, etc). After a brief discussion the instructor may reveal the bulleted text items under Mannitol. The instructor should stress that a 20% Mannitol solution usually is used for IV boluses over a 5-minute period. Repeated doses of Mannitol should not be given to hypotensive patients because it is a potent diuretic and may cause hypovolemia. A brief discussion of other drugs can then ensue. Each bulleted item on the slide appears with a mouse click and then dims with the next mouse click.
- 6-28Medical Management: Other Drugs Phenytoin is commonly given to brain-injured patients to prevent seizures during the 1st week after injury. This should be determined by the neurosurgeon caring for the patient. Sedatives and paralytics are used to control the combative, agitated patient. They sometimes reduce ICP in these patients and allow performance of the CT scan. Care must be used to prevent hypotension, and the user must realize that the clinical symptoms change after the administration of these agents. Each bulleted item on the slide appears with a mouse click and then dims with the next mouse click.
- 6-29Surgical Management: Scalp Injuries The instructor briefly reviews the management of scalp lacerations, while emphasizing that the scalp can be a source of major blood loss, especially in children. Each bulleted item on the slide appears with a mouse click and then dims with the next mouse click.
- 6-30Surgical Management: Intracranial Mass Lesion The instructor may query the students about managing a patient with an expanding intracranial mass lesion in a remote or austere environment. The instructor can present a simple and brief case history. The students’ responses should include those on the slide. The instructor may then reveal the bulleted items on the slide, while emphasizing that patients with a severe brain injury and a rapidly expanding mass lesion should be transported rapidly to neurosurgical care. Transfer delays to stop the bleeding and stabilize the patient is appropriate. However, transfer delays for tests, eg, CT scans, must be avoided. An emergency craniotomy, performed by a nonneurosurgeon, is not recommended by the Committee on Trauma. In areas where neurosurgical care is not available, the Committee on Trauma recommends that the surgeons residing in the area should anticipate this need and obtain the proper training from a neurosurgeon before the situation arises. Each bulleted item on the slide appears with a mouse click and then dims with the next mouse click.
- 6-31How do I diagnose brain death? After asking this question of the students, the instructor asks for the clinical signs of brain death. The students elicit their responses and the instructor summarizes this component of the discussion by revealing the bulleted items under “Clinical” on the slide. The instructor then asks what ancillary studies might be performed to determine brain death. The students elicit their responses and the instructor then summarizes this component of the discussion by revealing the bulleted items under “Ancillary Studies” on the slide. The instructor may indicate that many people rely on the ancillary studies to diagnose brain death. The instructor should emphasize that certain reversible conditions can mimic brain death, eg, hypothermia and barbiturate coma. Physiologic parameters should be normalized. The instructor then reveals the last item on the slide, “Remember organ donation.” In trauma and nontrauma centers, doctors should be aware of the need for organ donation. Recognizing potential organ donors is important. The determination of brain death is appropriate in these situations. U.S. federal law requires that organ procurement agencies be notified of all patients with the diagnosis of or impending diagnosis of brain death.
- 6-33Summary: What should I do? The students should identify these main items of what to do for the brain-injured patient. After eliciting their responses, the instructor reveals each of the bulleted items in summary to the discussion, making any salient points not made by the students. Each bulleted item on the slide appears with a mouse click and then dims with the next mouse click.
- 6-34Summary: What should I not do? The students should identify these main items of what to do for the brain-injured patient. After eliciting their responses, the instructor reveals each of the bulleted items in summary to the discussion, making any salient points not made by the students. Each bulleted item on the slide appears with a mouse click and then dims with the next mouse click.