Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Head and Facial Conditions Chapter 10

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy of Head and Face Bones of skull –Cranium Protects the brain –Facial Provide the structure of the face Form the sinuses, orbits of the eyes, nasal cavity, and the mouth Scalp –Protective function –Extensive blood supply

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy of Head and Face (cont.)

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy of Head and Face (cont.) Brain –Major regions Cerebral hemispheres Diencephalon Brainstem Cerebellum

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy of Head and Face (cont.) Meninges Protective tissue that encloses brain and spinal cord Dura mater; arachnoid mater; pia mater

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy of Head and Face (cont.)

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy of Head and Face (cont.) Eyes –Conjunctiva –Lacrimal glands –Tunics: sclera; choroid; retina –Cornea

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy of Head and Face (cont.) Nose –Composed of bone and hyaline cartilage –Nasal septum

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy of Head and Face (cont.) Ear –Major areas Outer ear (auricle and external auditory canal) Middle ear (tympanic membrane) Inner ear (labyrinth)

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy of Head and Face (cont.)

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy of Head and Face (cont.) Nerves –Cranial nerves Motor functions, sensory functions, or both Numbered and named in accordance with their functions Blood vessels –Common carotid –Vertebral

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Prevention of Head and Facial Injuries Protective equipment –Helmets –Face guards –Mouth guards –Eye wear –Ear wear –Throat protectors

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Scalp Injuries Highly vascularized; bleeds freely Laceration –Control bleeding –Prevent contamination –Assess for skull fracture (fx) –Management: If no fx, cleanse, cover, and refer Abrasions and contusions –Cleanse; ice and pressure –24 hours: no improvement – refer

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Cranial Injury Mechanisms Injury dependent on: –Material properties of skull –Thickness of skull –Magnitude and direction of force –Size of impact area Bone deforms and bends inward –Inner border – tensile strain –Outer border – compressed

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Cranial Injury Mechanisms (cont.) Brain acceleration –Shear, tensile, and compression strains within brain –Contrecoup injury

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Cranial Injury Mechanisms (cont.) Focal injury –Localized damage –Epidural, subdural, or intracerebral hematomas Diffuse injury –Widespread disruption –Concussion Accurate assessment of head injury is essential Conscious, ambulatory individual should not be considered to have only a minor injury

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Skull Fracture Types –Linear –Comminuted –Depressed –Basilar

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Skull Fracture (cont.) Potential for varying signs and symptoms (S&S) –Visible deformity–do not be misled by a “goose egg”; a fracture may be under the site –Deep laceration or severe bruise to scalp –Palpable depression or crepitus –Unequal pupils –Raccoon eyes or Battle’s sign

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Skull Fracture (cont.) –Bleeding or CSF from nose and/or ear –Loss of smell –Loss of sight or major vision disturbances –Unconsciousness 2 minutes after direct trauma to the head Management: activation of EMS (refer to Application Strategy 10.1)

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Focal Cerebral Conditions Epidural hematoma –Direct blow to side of head –Meningeal artery tear –Rapid “high-pressure” hematoma

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Focal Cerebral Conditions (cont.) Epidural hematoma (cont.) –S&S LOC Lucid interval Gradual deterioration  Head pain, dizziness, nausea, dilation of one pupil, sleepiness Possible:  Deteriorating consciousness, neck rigidity, depression of pulse and respiration, convulsions

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Focal Cerebral Conditions (cont.) Epidural hematoma (cont.) –Life threatening … death –Management: activate EMS; ABCs, vitals, shock –Requires surgical decompression

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Focal Cerebral Conditions (cont.) Subdural hematoma –Acceleration forces –Involves bleeding of the veins –S&S slower to develop Acute – hours post-injury Chronic – later time frame

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Focal Cerebral Conditions (cont.) Subdural hematoma (cont.) –Simple Blood in subdural space—no injury to cerebrum –Complicated Cerebral swelling –S&S Headache, nausea, dizziness, sleepiness simple – usually no LOC complicated – unconscious, pupil dilation on one side –Management: activate EMS; ABCs, vitals, shock

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Focal Cerebral Conditions (cont.)

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Focal Cerebral Conditions (cont.) Cerebral contusion –Focal injury, without mass-occupying lesion –Acceleration-deceleration

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Focal Cerebral Conditions (cont.) Cerebral contusion (cont.) –S&S (can vary greatly) Develop over hours and days Normal function or neurologic deterioration Danger sign:  Neurological exam—normal  But presence of headaches, dizziness, and nausea –Management: activate EMS; ABCs, vitals, shock

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Diffuse Cerebral Conditions Concussion –common features incorporate clinical, pathological, & biomechanical injury constructs caused by direct blow to head, face, neck, or elsewhere with an impulsive force transmitted to head; typically result in rapid onset of short-lived impairment of neurologic function that resolves spontaneously. neuropathologic changes may occur, but acute clinical symptoms typically reflect a functional disturbance rather than a structural injury. may or may not involve an LOC …may lead to a gradient of clinical symptoms associated with grossly normal structural neuroimaging studies. resolution of the clinical and cognitive symptoms usually follows a sequential course

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Diffuse Cerebral Conditions (cont.) Classification of concussion –Numerous!!! …potentially problematic! –Zurich panel 2008 diagnosis of a concussion will involve the assessment of a range of clinical signs and symptoms in four categories: physical, emotional, cognitive, and sleep

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins CognitivePhysicalEmotionalSleep Feeling like in a “fog”HeadacheIrritability Drowsiness Feeling slowed downNausea or vomitingSadnessSleeping more than usual Difficulty concentrating Balance problemsMore emotionalSleep less than usual Difficulty remembering Visual problemsNervousnessTrouble falling asleep Forgetful of recent information Fatigued Confused about recent events Photophobia Answers questions slowly Sensitivity to noise Repeats questionsDazed or stunned

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Diffuse Cerebral Conditions (cont.) –On-field management Remove from activity; examine immediately – standard emergency assessment & management Detailed clinical assessment of signs and symptoms using SCAT 2 or similar tool Presence of any signs/ symptoms – initiate appropriate management

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Diffuse Cerebral Conditions (cont.) Return to activity after a concussion follows a sequential process: 1.No activity, complete rest; once asymptomatic, proceed to step 2 2.Light aerobic exercise such as walking or stationary cycling; no resistance training 3.Sport-specific exercise (e.g., skating in hockey, running in soccer); 4.Noncontact training drills; Progression to more complex training drills; may start progressive resistance training 5.Full-contact practice -- after medical clearance 6.RTP – normal game play (Refer to Table 10.4)

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Diffuse Cerebral Conditions (cont.) Posttraumatic headache –Result of vasospasm; doesn’t usually occur with impact, but develops shortly afterward –S&S Localized area of blindness that may follow the appearance of brilliantly colored shimmering lights Posttraumatic migraines –Management Immediate referral to a physician

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Diffuse Cerebral Conditions (cont.) Postconcussion syndrome –Can occur following a mild or serious concussion –S&S Decreased attention span Persistent headaches Blurred vision Vertigo Memory loss Irritability Inability to concentrate on even simplest task Exercise may lead to headache, dizziness, and premature fatigue –Management No definitive treatment other than treat headache symptoms No activity

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Diffuse Cerebral Conditions (cont.) Second impact syndrome –A second head injury before the symptoms associated with a previous one have totally resolved –Does not necessarily require a blow to the head

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Diffuse Cerebral Conditions (cont.) Second impact syndrome (cont.) –S&S May not lose consciousness; stunned look; may leave field under own power Rapid deterioration of condition  LOC, dilated pupils, loss of eye movement, respiratory failure –Brainstem failure in 2-5 minutes –Management Activate EMS –Prevent it from happening!!!

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment of Cranial Conditions ALWAYS ASSUME A CERVICAL INJURY IS PRESENT!!!!!!!!!!!!!

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment of Cranial Conditions (cont.) Vitals –Pulse Small weak pulse Short, rapid weak pulse Slow bounding pulse Accelerated pulse

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment of Cranial Conditions (cont.) –Respiration Slow breathing (bradypnea) Cheyne-Stokes breathing Ataxic (Biot’s) breathing Apneustic breathing –Blood pressure Increase in the systolic blood pressure or a decrease in the diastolic blood pressure indicates rising intracranial pressure –Pulse pressure >50 mm Hg indicates increased intracranial bleeding

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment of Cranial Conditions (cont.) pulseslow bounding pulse  intracranial pressure accelerated pulsepressure on base of brain respirationbradypnea  intracranial pressure Cheyne-Stokes breathingbrain damage Ataxic (Biot’s) breathingbrain damage, typically at the medullary level apneustic breathingindicates trauma to the pons blood pressure  systolic BP or  diastolic BP  intracranial pressure  BP (rare in head injury) possible cervical injury or serious blood loss from an injury elsewhere in the body pulse pressure pulse pressure  50 mm Hg  intracranial bleeding

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment of Cranial Conditions (cont.) History and mental status testing –Orientation –Concentration –Memory –Behavior –Symptoms –Loss of consciousness

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment of Cranial Conditions (cont.) Observation and inspection –Leakage of cerebrospinal fluid –Signs of trauma (deformity, body posturing, raccoon eyes, and Battle’s sign) –Skin color –Loss of emotional control (irritability, aggressiveness, or uncontrolled crying) –Graded symptom checklist Palpation –Bony and soft tissue structures for point tenderness, crepitus, depressions, elevations, swelling, blood, or changes in skin temperature

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment of Cranial Conditions (cont.) Neurologic examination –Cranial nerve assessment –Pupil abnormalities Pupil size Response to light Eye movement Nystagmus Blurred or double vision –Babinski’s reflex –Strength –Neuropsychological assessments

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment of Cranial Conditions (cont.) –Coordination and balance Finger to nose test Gait

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment of Cranial Conditions (cont.) Romberg test

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment of Cranial Conditions (cont.) One-legged stork stand

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment of Cranial Conditions (cont.) Balance error scoring system (BESS)

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment of Cranial Conditions (cont.) External provocative test –40-yard sprint –5 sit-ups –5 push-ups –5 knee bends

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment of Cranial Conditions (cont.) Determination of findings –Re-assess every 5-7 minutes –Immediate management and follow-up care

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Facial Conditions Facial soft tissue conditions –Contusions, abrasions, and lacerations are managed the same as elsewhere on the body –Complicated injuries—immediate physician referral

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Facial Conditions (cont.) Temporomandibular joint conditions –S&S Inability to open and/or close mouth (dislocation and meniscus displacement) Malocclusion Joint crepitus with opening and closing Pain with opening and biting Deviation of the mandible on opening (toward side of injury)

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Facial Conditions (cont.) Fractures –Zygomatic S&S: cheek appears flat or depressed, double vision, numbness in affected cheek Management: ice, immediate referral – Mandibular Common: mandibular angle and condyles S&S: malocclusion, changes in speech, oral bleeding, + tongue blade Management: ice, immediate referral

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Facial Conditions (cont.) Fractures –Maxillary LeFort fx (upper jaw) S&S: appearance of longer face, nasal bleeding, malocclusion, nasal deformity, ecchymosis Management: ice, immediate referral Facial “red flags” (refer to Box 10.2)

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Nasal Conditions Epistaxis –Anterior – bleeding from anterior septum Posterior – bleeding from lateral wall –Management: ice, mild pressure, slight forward head tilt; nasal plug; 5 minutes – physician referral Deviated septum –S&S Consistent difference in airflow between the 2 sides of the nose when one nostril is blocked Confirm using otoscope –Management: physician referral

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Nasal Conditions (cont.) Fractures –Most common: lateral displacement –Range of severity varies –S&S Asymmetry – especially with lateral force Epistaxis Crepitus –Management: control bleeding; refer Nasal “red flags” (refer to Box 10.3)

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Oral and Dental Conditions Periodontal disease –S&S of gingivitis Tender, swollen, or bleeding gums Change in the gums' color from pink to dusky red Plaque and bacteria that cover the teeth not readily visible

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Oral and Dental Conditions (cont.) –S&S of periodontitis Swollen or recessed gums Unpleasant taste in the mouth Bad breath Tooth pain Drainage or pus around one or more teeth –Management: referral to dentist

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Oral and Dental Conditions (cont.) Dental caries (tooth decay) –Primarily caused by plaque...dissolves the tooth enamel…allows bacteria to infect the center of the tooth –S&S Pain during chewing Sensitivity to hot/cold foods and beverages If tooth abscess is present:  Throbbing pain  Sharp or shooting pain –Management: refer to dentist

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Oral and Dental Conditions (cont.) Mouth lacerations –Minor lacerations are the same as in other lacerations –Lip and tongue lacerations: require special suturing Loose teeth –Displaced outward or lateral: attempt to place back in normal position –Intruded: immediate referral to dentist

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Oral and Dental Conditions (cont.) Fractured tooth –Enamel: no symptoms –Dentin: pain and increased sensitivity to heat and cold –Pulp or root: severe pain and sensitivity –Management: refer to dentist

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Oral and Dental Conditions (cont.) Dislocated tooth –Time is of the essence; refer –Hold tooth by crown –Do not rub the tooth or remove any dirt; milk or saline Oral and dental “red flags” (refer to Box 10.4)

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Ear Conditions Cauliflower ear (auricular hematoma) –Repeated trauma pulls cartilage away from perichondrium – hematoma forms –Untreated – forms a fibrosis –Management: ice; possible aspiration by physician –Key is prevention! Impacted cerumen (wax) –Possible hearing loss or muffled hearing –Management: irrigate canal with warm water

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Ear Conditions (cont.) Otitis externa (swimmer’s ear) –Bacterial infection to lining of external auditory canal –S&S: pain, itching –Management: ear drops, custom ear plugs Otitis media –Middle ear infection due to bacteria or virus –S&S: earache, hearing difficulty, possible serous otitis –Management: physician referral

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Ear Conditions (cont.) Tympanic membrane rupture –Caused by: Infection Direct trauma Changes in pressure Loud, sudden noises Foreign objects in the ear

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Ear Conditions (cont.) –S&S Very painful Tinnitus Pus-filled or bloody drainage from the ear Sudden decrease in ear pain followed by drainage Hearing loss –Management: physician referral Ear “red flags” (refer to Box 10.5)

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Eye Conditions Preorbital ecchymosis (black eye) –Assessment –Management: ice, referral to ophthalmologist Foreign bodies –S&S: intense pain, tearing –Management Not embedded: removal, inspection Embedded: do not touch, activate EMS

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Eye Conditions (cont.) Sty –Infection of sebaceous gland of eyelash –Starts as a red nodule; progresses into a painful pustule –Management: moist heat compress

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Eye Conditions (cont.) Conjunctivitis (pink eye) –S&S: itching, burning, watering, red appearance –Management: infectious; refer to physician Corneal abrasion –S&S: pain, tearing, photophobia, irritated with blinking and eye movement, feeling of “something in the eye” –Management: drops and eye patch

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Eye Conditions (cont.) Corneal laceration –S&S: severe pain, decreased visual acuity –Management: cover with no pressure, activate EMS, transport supine or upright

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Subconjunctival hemorrhage –Rupture of small capillaries; sclera appears red, blotchy, inflamed –Requires no treatment Hyphema –Caused by blunt trauma –Hemorrhage into anterior chamber –Management: activation of EMS Eye Conditions (cont.)

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Eye Conditions (cont.) Detached retina –Can occur with or without trauma –S&S: floaters and light flashes –Management: patch both eyes; refer to ophthalmologist

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Eye Conditions (cont.) Orbital “blowout” fracture –Impact from a blunt object, usually larger than the eye orbit –S&S: Diplopia Numbness below eye Lack of eye movement Recessed downward displacement of globe –Management: ice; immediate referral to physician Eye “red flags” (refer to Box 10.6)