Chapter 22 and 23

HEAD, FACIAL AND NECK TRAUMA

Eric Tessin, CCEMT-P, EMS IC

Outline

• Introduction • Anatomy & Physiology • Pathophysiology • Assessment and Management

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

Introduction

• Injury Prevention Programs – Motorcycle safety – Bicycle Safety – Helmet and head injury awareness – Sports • • • Football Rollerblading Contact Sports

Introduction

• • TIME IS CRITICAL – Intracranial hemorrhage – Progressing edema • • • Increased ICP Cerebral hypoxia Permanent damage Severity is difficult to recognize – Subtle signs – Improve differential diagnosis

Anatomy & Physiology

Head

• Scalp – Strong flexible mass of skin and muscle – Hair provides insulation – Highly vascular

Head

• Skull comprised of – Facial bones – Cranium • Unyielding to increased intracranial pressure – Bones • Frontal • Parietal • Occipital - Ethmoid - Sphenoid - Temporal

Meninges

• Protective Mechanism – Dura Mater • Blood flow to surface of the brain – Arachnoid • Suspends brain in cranial cavity – Pia Mater • Covers brain and spinal cord

The Meninges and Skull

Brain

• • • • Occupies 80% of cranium 3 Major Structures – Cerebrum – Cerebellum – Brain Stem Receives 15% of cardiac output Consumes 20% of body’s oxygen

Cerebrum

• • Function – Center of conscious thought, personality, speech and motor control – Visual, auditory, and tactile perception Structures – Central Sulcus – Tentorium

Lobes

• Frontal – Personality • Parietal – Motor and sensory – Memory and emotion

Lobes

• Occipital – Sight • Temporal – Long-term memory – Hearing – Speech – Taste – Smell

Cerebellum

• Located under tentorium • Function – “Fine tunes” motor control – Allows smooth movement – Balance – Maintenance of muscle tone

Brain Stem

• Central processing center • Communication junction among – Cerebrum - Cranial Nerves – Spinal Cord - Cerebellum • Structures – Midbrain – Pons – Medulla Oblongata

• Hypothalamus – Vomiting Reflex – – Hunger Thirst

Midbrain

• Thalamus – Switching Center – Ascending Reticular Activating System (A-RAS)

Pons

• Communication interchange • Bulb-shaped structure

Medulla Oblongata

• • • Respiratory Center – Depth, rate, rhythm Cardiac Center – Rate and strength Vasomotor Center – – Maintains BP Distribution of blood

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

MAP

BP = 120/90 DBP = 90 Pulse Pressure = 120 – 90 = 30 MAP 90 + 1/3(30) = 100

Calculating

CPP

MAP = 90 & ICP = 10 CPP = MAP – ICP CPP = 100 – 10 = 90

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

Mechanism of Injury

Blunt Injury Penetrating Injury

• MVA • Gunshot Wounds • Assaults • Stabbing • Falls • Explosions

Scalp Injury

• • • • Contusions Lacerations Avulsions Significant Hemorrhage

ALWAYS reconsider MOI for severe underlying problems.

Cranial Injury

• • Trauma must be extreme to fracture – Linear – Depressed – Open – Impaled object Basal Skull – Unprotected – Spaces weakened structure – Easier to fracture

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

Basilar Skull Fracture

• May tear dura • Permit CSF to drain through an external passageway • May mediate rise of ICP • Evaluate for “halo” sign

Brain Injury

• Classification – Direct • Primary injury caused by forces of trauma – Indirect • Secondary injury cased by factors resulting from the primary injury

Direct Brain Injury Types

• Coup – Injury at site of impact • Contrecoup – Injury on opposite side from impact

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

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

Epidural Hematoma

• Bleeding between dura mater and skull • Involves arteries • Rapid bleeding and reduction of oxygen • Herniates brain

Subdural Hematoma

• Bleeding within meninges – Beneath dura mater and within subarachnoid space • Slow bleeding • Signs progress over several days

Intracerebral Hemorrhage

• Ruptured blood vessel within the brain • Presentation similar to stroke symptoms • Signs and symptoms worsen over time

Diffuse Brain Injury

• Types – Concussion – Moderate diffuse axonal injury – Severe diffuse axonal injury

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

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

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

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

Compensating for Pressure

• Compress venous blood vessels • Reduction in free CSF – Pushed into spinal cord

ICP BP

Decompensating for Pressure

• Increase in ICP • Rise in systemic BP to perfuse brain • Further increase of ICP

ICP BP

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

Factors Affecting ICP

• Vasculature Constriction • Cerebral Edema • Systolic Blood Pressure – Low BP = Poor cerebral perfusion – High BP = Increased ICP • Carbon Dioxide • Reduced respiratory efficiency

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.

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

Upper Brainstem Compression

• Increasing blood pressure • Reflex bradycardia – Vagus nerve stimulation • Cheyne-Stokes respirations • Pupils become small and reactive • Decorticate posturing

Middle Brainstem Compression

• Widening pulse pressure • Increasing bradycardia • CNS hyperventilation – Deep and rapid • Bilateral pupil sluggishness or inactivity • Decerebrate posturing

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

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

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

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

Facial Injuries

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

Facial Fractures

• • • Mandibular – 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

Nasal Injury

• • • Rarely life threatening Swelling and hemorrhage interfere with breathing Epistaxis – Most common problem

AVOID NASOTRACHEAL INTUBATION

Ear Injury

• • External 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

Eye Injury

• Penetrating Trauma – Can result in long-term damage – DO NOT REMOVE ANY FOREIGN OBJECT • Corneal Abrasions and Lacerations

Eye Injury

• Hyphema – Blunt trauma to the anterior chamber of the eye – Blood in front of iris or pupil

Eye Injury

• Sub-conjunctival Hemorrhage – – Less serious condition May occur after strong sneeze, severe vomiting or direct trauma

Eye Injury

• Acute Retinal Artery Occlusion – 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

Neck Injury

• • Blood Vessel Trauma – Blunt Trauma • Serious hematoma – Laceration • Serious exsanguination • Entraining of air embolism (occlusive dressing) Airway Trauma – Tracheal rupture or dissection from larynx – Airway swelling and compromis

Neck Injury

• Vertebral Fracture – Paresthesia, anesthesia, paresis, or paralysis beneath the level of injury – Neurogenic shock • Subcutaneous Emphysema – Tension pneumothorax – Traumatic asphyxia

Assessment

• • • • • • Scene Size-up Initial Assessment Rapid Trauma Assessment – Head, face, neck – GCS – Vital Signs Focused History and Physical Exam Detailed Assessment Ongoing Assessment

Management

AIRWAY BREATHING CIRCULATION!

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

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

Special Injury Care

• • Scalp Avulsion – 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

Special Injury Care

• Eye Injury – 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

Special Injury Care

• Dislodged Teeth – Rinse in NS – Wrap in NS-soaked gauze • Impaled Objects – Secure with bulky dressing – Stabilize object to prevent movement – Indirect pressure around wound

Transport Considerations

• Limit external stimulation – Can increase ICP – Can induce seizures • Be cautious about air transport – Seizures

Emotional Support

• Have friend or family provide constant reassurance • Provide constant reorientation to environment if required.

– Keeps patient calm – Reduces anxiety

Questions?