Head, Facial and Neck Trauma

Head, Facial and Neck TraumaChapter 22 and 23Eric Tessin, CCEMT-P, EMS ICOutlineIntroductionAnatomy & PhysiologyPathophysiologyAssessment and ManagementIntroductionCommon major trauma4 million people experience head trauma annuallySevere head injury is most common frequent cause of trauma deathAt-risk population:Males 15 24 Infants, Young children, ElderlyIntroductionInjury Prevention ProgramsMotorcycle safetyBicycle SafetyHelmet and head injury awarenessSportsFootballRollerbladingContact SportsIntroductionTIME IS CRITICALIntracranial hemorrhageProgressing edemaIncreased ICPCerebral hypoxiaPermanent damageSeverity is difficult to recognizeSubtle signsImprove differential diagnosisAnatomy & PhysiologyHeadScalpStrong flexible mass of skin and muscleHair provides insulationHighly vascular

HeadSkull comprised of Facial bonesCraniumUnyielding to increased intracranial pressureBonesFrontal- EthmoidParietal- SphenoidOccipital- Temporal

Meninges

Protective MechanismDura MaterBlood flow to surface of the brainArachnoidSuspends brain in cranialcavityPia MaterCovers brain and spinal cord

The Meninges and Skull

BrainOccupies 80% of cranium3 Major StructuresCerebrumCerebellumBrain StemReceives 15% of cardiac outputConsumes 20% of bodys oxygen

CerebrumFunctionCenter of conscious thought, personality, speech and motor controlVisual, auditory, and tactile perceptionStructuresCentral SulcusTentorium

Lobes

FrontalPersonality

ParietalMotor and sensoryMemory and emotion

LobesOccipitalSight

TemporalLong-term memoryHearingSpeechTasteSmell

15CerebellumLocated under tentoriumFunctionFine tunes motor controlAllows smooth movementBalanceMaintenance of muscle toneBrain StemCentral processing center

Communication junction amongCerebrum- Cranial NervesSpinal Cord- Cerebellum

StructuresMidbrainPonsMedulla OblongataMidbrain

HypothalamusVomiting ReflexHungerThirst

ThalamusSwitching CenterAscending Reticular Activating System (A-RAS)PonsCommunication interchange

Bulb-shaped structure

Medulla OblongataRespiratory CenterDepth, rate, rhythmCardiac CenterRate and strengthVasomotor CenterMaintains BPDistribution of blood

Cerebral Perfusion PressurePressure within cranium (ICP)Pressure usually less than 10 mmHgMean Arterial Pressure (MAP)Must be at least 50 mmHg to ensure adequate perfusionMAP = DBP + 1/3 Pulse PressureCerebral Perfusion Pressure (CPP)Pressure moving blood through the craniumCPP = MAP - ICPCalculating MAPBP = 120/90DBP = 90

Pulse Pressure =120 90 = 30

MAP 90 + 1/3(30) = 100 CPPMAP = 90 & ICP = 10

CPP = MAP ICP

CPP = 100 10 = 90 Cerebral Perfusion PressureAutoregulationChanges in ICP result in compensationIncreased ICP = Increased BP

Expanding mass inside cranial vaultDisplaces CSFIf pressure increases, brain tissue is displacedMechanism of InjuryBlunt InjuryMVAAssaultsFallsPenetrating InjuryGunshot Wounds StabbingExplosions

Scalp InjuryContusionsLacerationsAvulsionsSignificant Hemorrhage

ALWAYS reconsider MOI for severe underlying problems.Cranial InjuryTrauma must be extreme to fractureLinearDepressedOpenImpaled objectBasal SkullUnprotectedSpaces weakened structureEasier to fracture

Basal Skull Fracture SignsBattles SignsRetroauricular ecchymosisAssociated with fracture of auditory canal and lower area of skullRaccoon EyesBilateral periorbital ecchymosisAssociated with orbital fractures

Basilar Skull FractureMay tear duraPermit CSF to drain through an external passagewayMay mediate rise of ICPEvaluate for halo sign

Brain InjuryClassificationDirectPrimary injury caused by forces of traumaIndirectSecondary injury cased by factors resulting from the primary injuryDirect Brain Injury TypesCoupInjury at site of impact

ContrecoupInjury on opposite side from impact

Direct Brain Injury CategoriesFocalOccur at a specific location in brainDifferentialsCerebral contusionIntracranial hemorrhageIntracerebral hemorrhageDiffuseConcussionModerateDiffuseConcussionModerate diffuse axonal injurySevere diffuse axonal injuryFocal Brain InjuryCerebral ContusionBlunt trauma to local brain tissueCapillary bleeding into brain tissueCommon with blunt head traumaConfusionNeurologic deficitResults fromCoup-contrecoup injuryEpidural HematomaBleeding between duramater and skullInvolves arteries Rapid bleeding and reduction of oxygenHerniates brain

Subdural HematomaBleeding within meningesBeneath dura mater and within subarachnoid spaceSlow bleedingSigns progress over several days

Intracerebral HemorrhageRuptured blood vessel within the brainPresentation similar to stroke symptomsSigns and symptoms worsen over timeDiffuse Brain InjuryTypesConcussionModerate diffuse axonal injurySevere diffuse axonal injuryConcussionNerve dysfunction without anatomic damageTransient episode of Confusion, disorientation, event amnesiaSuspect if patient has a momentary loss of consciousnessManagementFrequent reassessment of mentationABCs

Moderate Diffuse Axonal InjurySame mechanism as concussionUnconsciousnessIf cerebral cortex and RAS involvedSigns and SymptomsUnconsciousness or persistent confusionLoss of concentration, disorientationRetrograde and antegrade amnesiaVisual and sensory disturbancesMood and personality changesSevere Diffuse Axonal InjuryBrainstem InjurySignificant mechanical disruption of axonsHigh mortality rateSigns & SymptomsProlonged unconsciousnessCushings reflexDecorticate or decerebrate posturingIntracranial PerfusionCranial Volume Fixed80% = Cerebrum, cerebellum, and brainstem12% = Blood vessels and blood8% = CSFIncrease in size of one component diminishes size of anotherInability to adjust = increased ICPCompensating for PressureCompress venous blood vesselsReduction in free CSFPushed into spinal cordICPBPDecompensating for PressureIncrease in ICPRise in systemic BP to perfuse brainFurther increase of ICP

ICPBPRole of Carbon DioxideIncrease of C02 in CSFCerebral vasodilationEncourage blood flowReduce hypercarbiaReduce hypoxiaContributes to increase in ICPCauses classic HTN and hyperventilationReduce levels of C02 in CSFCerebral vasoconstriction anoxiaFactors Affecting ICPVasculature ConstrictionCerebral EdemaSystolic Blood PressureLow BP = Poor cerebral perfusionHigh BP = Increased ICPCarbon DioxideReduced respiratory efficiency

Brain InjuryAltered Mental StatusCushings ReflexIncreased BPBradycardiaErratic Respirations

VomitingWithout nauseaProjectileBody temp changesChanges in pupilsDecorticate posturingObtain a blood glucose level on all patients with AMS. Brain InjuryPathophysiology of ChangesFront Lobe InjuryOccipital Lobe InjuryRetrograde AmnesiaUnable to recall events before injuryAntegrade AmnesiaUnable to recall events after traumaRepetitive questioningHemiplegia, weakness, or seizuresUpper Brainstem CompressionIncreasing blood pressureReflex bradycardiaVagus nerve stimulationCheyne-Stokes respirationsPupils become small and reactiveDecorticate posturingMiddle Brainstem CompressionWidening pulse pressureIncreasing bradycardiaCNS hyperventilationDeep and rapidBilateral pupil sluggishness or inactivityDecerebrate posturingLower Brainstem InjuryPupils dilated and unreactiveAtaxic respirationsErratic with no patternIrregular and erratic pulse rateECG changesHypotensionLoss of response to painful stimuliRecognition of HerniationCushings ReflexIncreasing blood pressureDecreasing pulse rateRespirations that become erraticLowering level of consciousnessSingular or bilaterally dilated fixed pupilsDecerebrate or decorticate posturingBrain Injury Eye SignsIndicates pressure on oculomotor nerveSluggish dilated fixedReduced peripheral blood flow

Reduced Pupillary ResponsivenessDepressant drugs or cerebral hypoxiaFixed and DilatedExtreme hypoxia

Pediatric Head TraumaSkull can distort due to anterior and posterior fontanellesBulgingSlows progression of increasing ICP

Intracranial hemorrhage contributes to hypovolemiaDecreased blood volume in pediatrics

Facial InjuriesSoft-Tissue InjuryHighly vascular tissueRarely life threatening and rarely involve the airwayDeep injuries can result in blood being swallowed and endangering the airwaySoft-tissue swelling reduces airflowConsider basilar skull fracture or spinal injury Facial FracturesMandibularDeformity along jaw and loss of teethPossible airway compromiseMaxillary and NasalLe Fort I, II and III CriteriaOrbitReduction of eye movementLimitation of jaw movement

Nasal InjuryRarely life threateningSwelling and hemorrhage interfere with breathingEpistaxisMost common problem

AVOID NASOTRACHEAL INTUBATIONEar InjuryExternal EarPinna frequently injured due to traumaPoor blood supply Poor healingInternal EarWell protected from traumaInjured due to rapid pressure changesDiving, blast, or explosionsTemporary or permanent hearing lossTinnitus may occur Eye InjuryPenetrating TraumaCan result in long-term damageDO NOT REMOVE ANY FOREIGN OBJECT

Corneal Abrasions and LacerationsEye InjuryHyphemaBlunt trauma to the anterior chamber of the eyeBlood in front of iris or pupilEye InjurySub-conjunctival HemorrhageLess serious conditionMay occur after strong sneeze, severe vomiting or direct trauma

Eye InjuryAcute Retinal Artery OcclusionNontraumatic originPainless loss of vision in one eyeOcclusion of retinal artery

Retinal DetachmentTraumatic originComplaint of dark curtain in the field of viewNeck InjuryBlood Vessel TraumaBlunt TraumaSerious hematomaLacerationSerious exsanguinationEntraining of air embolism (occlusive dressing)Airway TraumaTracheal rupture or dissection from larynxAirway swelling and compromisNeck InjuryVertebral FractureParesthesia, anesthesia, paresis, or paralysis beneath the level of injuryNeurogenic shock

Subcutaneous EmphysemaTension pneumothoraxTraumatic asphyxia

AssessmentScene Size-upInitial Assessment Rapid Trauma AssessmentHead, face, neckGCSVital SignsFocused History and Physical ExamDetailed AssessmentOngoing AssessmentManagementAIRWAY

BREATHING

CIRCULATION!

HypoxiaHyperoxygenate prior to intubation

Hyperventilate with BVM at a rate of 20 immediately following intubationIf not a herniation concern, return to normal ventilationsIf herniation is probable, maintain hyperventilationHypovolemiaReduces cerebral perfusion and hypoxiaEarly management with 2 large bore IVs and isotonic fluidsPrevents slower compensatory mechanismMaintain SBP 90 100 mmHg in an adultMaintain SBP 80 mmHg in a childMaintain SBP 75 mmHg in a young childMaintain SBP 65 mmHg in an infantSpecial Injury CareScalp AvulsionCover the open wound with bulky dressingPad under the fold of the scalpIrrigate with NS to remove gross contaminationPinna InjuryPlace in close anatomic position as possibleDress and cover with sterile dressingSpecial Injury CareEye InjuryCover injured and uninjured eyeCorneal AbrasionInvert eyelid and examine eye for foreign bodyRemove with NS moistened gauzeAvulsed or Impaled EyeCover and protect from injurySpecial Injury CareDislodged TeethRinse in NSWrap in NS-soaked gauzeImpaled ObjectsSecure with bulky dressingStabilize object to prevent movementIndirect pressure around woundTransport ConsiderationsLimit external stimulationCan increase ICPCan induce seizuresBe cautious about air transportSeizuresEmotional SupportHave friend or family provide constant reassuranceProvide constant reorientation to environment if required.Keeps patient calmReduces anxietyQuestions?