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Head, Facial and Neck Trauma
Chapter 22 and 23 Head, Facial and Neck Trauma
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Outline Introduction Anatomy & Physiology Pathophysiology
Assessment and Management
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Introduction Common major trauma
4 million people experience head trauma annually Severe head injury is most common frequent cause of trauma death At-risk population: Males 15 – 24 Infants, Young children, Elderly
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Introduction Injury Prevention Programs Motorcycle safety
Bicycle Safety Helmet and head injury awareness Sports Football Rollerblading Contact Sports
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Introduction TIME IS CRITICAL Severity is difficult to recognize
Intracranial hemorrhage Progressing edema Increased ICP Cerebral hypoxia Permanent damage Severity is difficult to recognize Subtle signs Improve differential diagnosis
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Anatomy & Physiology
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Head Scalp Strong flexible mass of skin and muscle
Hair provides insulation Highly vascular
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Head Skull comprised of Facial bones Cranium Bones
Unyielding to increased intracranial pressure Bones Frontal - Ethmoid Parietal - Sphenoid Occipital - Temporal
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Meninges Protective Mechanism Dura Mater Arachnoid Pia Mater
Blood flow to surface of the brain Arachnoid Suspends brain in cranial cavity Pia Mater Covers brain and spinal cord
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The Meninges and Skull
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Brain Occupies 80% of cranium 3 Major Structures
Cerebrum Cerebellum Brain Stem Receives 15% of cardiac output Consumes 20% of body’s oxygen
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Cerebrum Function Structures
Center of conscious thought, personality, speech and motor control Visual, auditory, and tactile perception Structures Central Sulcus Tentorium
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Lobes Frontal Parietal Personality Motor and sensory
Memory and emotion
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Lobes Occipital Temporal Sight Long-term memory Hearing Speech Taste
Smell
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Cerebellum Located under tentorium Function “Fine tunes” motor control
Allows smooth movement Balance Maintenance of muscle tone
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Brain Stem Central processing center Communication junction among
Cerebrum - Cranial Nerves Spinal Cord - Cerebellum Structures Midbrain Pons Medulla Oblongata
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Midbrain Hypothalamus Thalamus Vomiting Reflex Hunger Thirst
Switching Center Ascending Reticular Activating System (A-RAS)
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Pons Communication interchange Bulb-shaped structure
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Medulla Oblongata Respiratory Center Cardiac Center Vasomotor Center
Depth, rate, rhythm Cardiac Center Rate and strength Vasomotor Center Maintains BP Distribution of blood
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Cerebral Perfusion Pressure
Pressure within cranium (ICP) Pressure usually less than 10 mmHg Mean Arterial Pressure (MAP) Must be at least 50 mmHg to ensure adequate perfusion MAP = DBP + 1/3 Pulse Pressure Cerebral Perfusion Pressure (CPP) Pressure moving blood through the cranium CPP = MAP - ICP
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Calculating MAP CPP BP = 120/90 DBP = 90 Pulse Pressure = 120 – 90 = 30 MAP /3(30) = 100 MAP = 90 & ICP = 10 CPP = MAP – ICP CPP = 100 – 10 = 90
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Cerebral Perfusion Pressure
Autoregulation Changes in ICP result in compensation Increased ICP = Increased BP Expanding mass inside cranial vault Displaces CSF If pressure increases, brain tissue is displaced
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Mechanism of Injury Blunt Injury Penetrating Injury MVA Assaults Falls
Gunshot Wounds Stabbing Explosions
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ALWAYS reconsider MOI for severe underlying problems.
Scalp Injury Contusions Lacerations Avulsions Significant Hemorrhage ALWAYS reconsider MOI for severe underlying problems.
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Cranial Injury Trauma must be extreme to fracture Basal Skull Linear
Depressed Open Impaled object Basal Skull Unprotected Spaces weakened structure Easier to fracture
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Basal Skull Fracture Signs
Battle’s Signs Retroauricular ecchymosis Associated with fracture of auditory canal and lower area of skull Raccoon Eyes Bilateral periorbital ecchymosis Associated with orbital fractures
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Basilar Skull Fracture
May tear dura Permit CSF to drain through an external passageway May mediate rise of ICP Evaluate for “halo” sign
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Brain Injury Classification Direct Indirect
Primary injury caused by forces of trauma Indirect Secondary injury cased by factors resulting from the primary injury
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Direct Brain Injury Types
Coup Injury at site of impact Contrecoup Injury on opposite side from impact
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Direct Brain Injury Categories
Focal Occur at a specific location in brain Differentials Cerebral contusion Intracranial hemorrhage Intracerebral hemorrhage Diffuse Concussion Moderate Diffuse Concussion Moderate diffuse axonal injury Severe diffuse axonal injury
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Focal Brain Injury Cerebral Contusion
Blunt trauma to local brain tissue Capillary bleeding into brain tissue Common with blunt head trauma Confusion Neurologic deficit Results from Coup-contrecoup injury
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Epidural Hematoma Bleeding between dura mater and skull
Involves arteries Rapid bleeding and reduction of oxygen Herniates brain
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Subdural Hematoma Bleeding within meninges Slow bleeding
Beneath dura mater and within subarachnoid space Slow bleeding Signs progress over several days
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Intracerebral Hemorrhage
Ruptured blood vessel within the brain Presentation similar to stroke symptoms Signs and symptoms worsen over time
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Diffuse Brain Injury Types Concussion Moderate diffuse axonal injury
Severe diffuse axonal injury
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Concussion Nerve dysfunction without anatomic damage
Transient episode of Confusion, disorientation, event amnesia Suspect if patient has a momentary loss of consciousness Management Frequent reassessment of mentation ABCs
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Moderate Diffuse Axonal Injury
Same mechanism as concussion Unconsciousness If cerebral cortex and RAS involved Signs and Symptoms Unconsciousness or persistent confusion Loss of concentration, disorientation Retrograde and antegrade amnesia Visual and sensory disturbances Mood and personality changes
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Severe Diffuse Axonal Injury
Brainstem Injury Significant mechanical disruption of axons High mortality rate Signs & Symptoms Prolonged unconsciousness Cushing’s reflex Decorticate or decerebrate posturing
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Intracranial Perfusion
Cranial Volume Fixed 80% = Cerebrum, cerebellum, and brainstem 12% = Blood vessels and blood 8% = CSF Increase in size of one component diminishes size of another Inability to adjust = increased ICP
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Compensating for Pressure
Compress venous blood vessels Reduction in free CSF Pushed into spinal cord ICP BP
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Decompensating for Pressure
Increase in ICP Rise in systemic BP to perfuse brain Further increase of ICP ICP BP
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Role of Carbon Dioxide Increase of C02 in CSF
Cerebral vasodilation Encourage blood flow Reduce hypercarbia Reduce hypoxia Contributes to increase in ICP Causes classic HTN and hyperventilation Reduce levels of C02 in CSF Cerebral vasoconstriction anoxia
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Factors Affecting ICP Vasculature Constriction Cerebral Edema
Systolic Blood Pressure Low BP = Poor cerebral perfusion High BP = Increased ICP Carbon Dioxide Reduced respiratory efficiency
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Obtain a blood glucose level on all patients with AMS.
Brain Injury Altered Mental Status Cushing’s Reflex Increased BP Bradycardia Erratic Respirations Vomiting Without nausea Projectile Body temp changes Changes in pupils Decorticate posturing Obtain a blood glucose level on all patients with AMS.
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Brain Injury Pathophysiology of Changes Front Lobe Injury
Occipital Lobe Injury Retrograde Amnesia Unable to recall events before injury Antegrade Amnesia Unable to recall events after trauma Repetitive questioning Hemiplegia, weakness, or seizures
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Upper Brainstem Compression
Increasing blood pressure Reflex bradycardia Vagus nerve stimulation Cheyne-Stokes respirations Pupils become small and reactive Decorticate posturing
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Middle Brainstem Compression
Widening pulse pressure Increasing bradycardia CNS hyperventilation Deep and rapid Bilateral pupil sluggishness or inactivity Decerebrate posturing
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Lower Brainstem Injury
Pupils dilated and unreactive Ataxic respirations Erratic with no pattern Irregular and erratic pulse rate ECG changes Hypotension Loss of response to painful stimuli
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Recognition of Herniation
Cushing’s Reflex Increasing blood pressure Decreasing pulse rate Respirations that become erratic Lowering level of consciousness Singular or bilaterally dilated fixed pupils Decerebrate or decorticate posturing
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Brain Injury Eye Signs Indicates pressure on oculomotor nerve
Sluggish dilated fixed Reduced peripheral blood flow Reduced Pupillary Responsiveness Depressant drugs or cerebral hypoxia Fixed and Dilated Extreme hypoxia
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Pediatric Head Trauma Skull can distort due to anterior and posterior fontanelles Bulging Slows progression of increasing ICP Intracranial hemorrhage contributes to hypovolemia Decreased blood volume in pediatrics
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Facial Injuries
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Soft-Tissue Injury Highly vascular tissue
Rarely life threatening and rarely involve the airway Deep injuries can result in blood being swallowed and endangering the airway Soft-tissue swelling reduces airflow Consider basilar skull fracture or spinal injury
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Facial Fractures Mandibular Maxillary and Nasal Orbit
Deformity along jaw and loss of teeth Possible airway compromise Maxillary and Nasal Le Fort I, II and III Criteria Orbit Reduction of eye movement Limitation of jaw movement
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Nasal Injury Rarely life threatening
Swelling and hemorrhage interfere with breathing Epistaxis Most common problem AVOID NASOTRACHEAL INTUBATION
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Ear Injury External Ear Internal Ear
Pinna frequently injured due to trauma Poor blood supply Poor healing Internal Ear Well protected from trauma Injured due to rapid pressure changes Diving, blast, or explosions Temporary or permanent hearing loss Tinnitus may occur
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Eye Injury Penetrating Trauma Corneal Abrasions and Lacerations
Can result in long-term damage DO NOT REMOVE ANY FOREIGN OBJECT Corneal Abrasions and Lacerations
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Eye Injury Hyphema Blunt trauma to the anterior chamber of the eye
Blood in front of iris or pupil
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Eye Injury Sub-conjunctival Hemorrhage Less serious condition
May occur after strong sneeze, severe vomiting or direct trauma
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Eye Injury Acute Retinal Artery Occlusion Retinal Detachment
Nontraumatic origin Painless loss of vision in one eye Occlusion of retinal artery Retinal Detachment Traumatic origin Complaint of dark curtain in the field of view
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Neck Injury Blood Vessel Trauma Airway Trauma Blunt Trauma Laceration
Serious hematoma Laceration Serious exsanguination Entraining of air embolism (occlusive dressing) Airway Trauma Tracheal rupture or dissection from larynx Airway swelling and compromis
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Neck Injury Vertebral Fracture Subcutaneous Emphysema
Paresthesia, anesthesia, paresis, or paralysis beneath the level of injury Neurogenic shock Subcutaneous Emphysema Tension pneumothorax Traumatic asphyxia
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Assessment Scene Size-up Initial Assessment Rapid Trauma Assessment
Head, face, neck GCS Vital Signs Focused History and Physical Exam Detailed Assessment Ongoing Assessment
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AIRWAY BREATHING CIRCULATION!
Management AIRWAY BREATHING CIRCULATION!
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Hypoxia Hyperoxygenate prior to intubation
Hyperventilate with BVM at a rate of 20 immediately following intubation If not a herniation concern, return to normal ventilations If herniation is probable, maintain hyperventilation
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Hypovolemia Reduces cerebral perfusion and hypoxia
Early management with 2 large bore IVs and isotonic fluids Prevents slower compensatory mechanism Maintain SBP 90 – 100 mmHg in an adult Maintain SBP 80 mmHg in a child Maintain SBP 75 mmHg in a young child Maintain SBP 65 mmHg in an infant
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Special Injury Care Scalp Avulsion Pinna Injury
Cover the open wound with bulky dressing Pad under the fold of the scalp Irrigate with NS to remove gross contamination Pinna Injury Place in close anatomic position as possible Dress and cover with sterile dressing
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Special Injury Care Eye Injury Corneal Abrasion Avulsed or Impaled Eye
Cover injured and uninjured eye Corneal Abrasion Invert eyelid and examine eye for foreign body Remove with NS – moistened gauze Avulsed or Impaled Eye Cover and protect from injury
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Special Injury Care Dislodged Teeth Impaled Objects Rinse in NS
Wrap in NS-soaked gauze Impaled Objects Secure with bulky dressing Stabilize object to prevent movement Indirect pressure around wound
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Transport Considerations
Limit external stimulation Can increase ICP Can induce seizures Be cautious about air transport Seizures
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Emotional Support Have friend or family provide constant reassurance
Provide constant reorientation to environment if required. Keeps patient calm Reduces anxiety
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Questions?
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