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Chapter 8 Head, Facial, and Neck Trauma

Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Topics

Introduction to Head, Facial, and Neck Injuries Anatomy and Physiology of the Head, Face, and Neck Pathophysiology of Head, Facial, and Neck Injury Assessment and Management of Head, Facial, and Neck Injuries Head, Facial, and Neck Injury Management Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Introduction to Head, Facial, and Neck Injuries

(1 of 3) Common major trauma.

4 million people experience head trauma annually.

– Severe head injury is most frequent cause of trauma death.

GSW to cranium: 75 –80% mortality At-risk population: – Males 15–24 – Infants – Young children – Elderly Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Introduction to Head, Facial, and Neck Injuries

(2 of 3) Injury Prevention Programs – Motorcycle safety – Bicycle safety – Helmet and head injury awareness programs – Sports Football Rollerblading Contact sports Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Introduction to Head, Facial, and Neck Injuries

(3 of 3) TIME IS CRITICAL.

– Intracranial hemorrhage – Progressing edema Increased ICP Cerebral hypoxia Permanent damage Severity is difficult to recognize.

– Subtle signs – Improve differential diagnosis Improves survivability Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Anatomy and Physiology of the Head, Face, and Neck

Anatomy and Physiology of the Head – Scalp – Cranium – Meninges – Cerebrospinal fluid – Brain – CNS circulation – Blood-brain barrier – Cerebral perfusion pressure – Cranial nerves – Ascending reticular activating system Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Anatomy and Physiology of the Head

(1 of 4) Scalp – Strong flexible mass of Skin Fascia Muscular tissue – Highly vascular – Hair provides insulation Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Anatomy and Physiology of the Head

(2 of 4) Structures beneath the scalp – Galea aponeurotica Between scalp and skull Fibrous connective sheath – Subaponeurotica (areolar) tissue Permits venous blood flow from the dural sinuses to the venous vessels of scalp Emissary veins: Potential route for infection Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Anatomy and Physiology of the Head

(3 of 4) Recalling Structures of the Scalp S - skin C - connective tissue A - aponeurotica L - layer of areolar tissue P - periosteum of skull Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Anatomy and Physiology of the Head

(4 of 4) Skull comprised of – Facial bones – Cranium Vault for the brain Strong, light, rigid, spherical bone Unyielding to increased intracranial pressure (ICP) Bones Frontal Parietal Occipital Temporal Ethmoid Sphenoid Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Sphenoid

Cranium

Parietal Suture Line Frontal Temporal Orbits Maxillae Occiptal Mandible Temporal Mandibular Joint Foramen Magnum (Hole in Base) Nasal Bones Zygomatic Arch Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Bones of the Skull

Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Anatomy and Physiology of the Head

(1 of 3) Skull – Other Structures Foramen Magnum Largest opening of the skull Spinal cord exits Cribriform Plate Inferior aspect (base) Rough surface Brain can be easily injured Abrasion Contusion Laceration Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Anatomy and Physiology of the Head

(2 of 3) Meninges – Protective mechanism for the CNS – Dura Mater Layers Outer: Cranium’s inner periosteum Inner: Dural layer Between: Dural sinuses Venous drains for brain Provides continuous connective tissue Forms partial structural divisions Falx cerebri Tentorium cerebelli Large arteries above Provide blood flow to the surface of the brain Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Anatomy and Physiology of the Head

(3 of 3) Meninges – Pia Mater Closest to brain and spinal cord Delicate tissue Covers all areas of brain and spinal cord Very vascular Supply superficial areas of brain – Arachnoid Membrane “Spider-like” Covers inner dura Suspends brain in cranial cavity Collagen and elastin fibers Subarachnoid space beneath CSF Cushions brain Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

The Meninges and Skull

Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Anatomy and Physiology of the Head

(1 of 18) Cerebrospinal Fluid – Clear, colorless fluid – Comprised of Water Protein Salts – Cushions CNS – Made in largest two ventricles of brain – Medium for nutrients and waste products to diffuse into and out of brain Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Anatomy and Physiology of the Head

(2 of 18) Brain – Occupies 80% of cranium – Comprised of 3 major structures Cerebrum Cerebellum Brainstem – High metabolic rate Receives 15% of cardiac output Consumes 20% of body’s oxygen Requires constant circulation – IF blood supply stops: Unconscious within 10 seconds Death in 4 –6 minutes Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Anatomy and Physiology of the Head

(3 of 18) Cerebrum – Function Center of conscious thought, personality, speech, and motor control Visual, auditory, and tactile perception – Lobes Frontal Personality Parietal Motor and sensory activity Memory and emotion Bledsoe et al.,

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Anatomy and Physiology of the Head

(4 of 18) Occipital – Sight Temporal – Long-term memory – Hearing, speech, taste, and smell Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Anatomy and Physiology of the Head

(5 of 18) Cerebrum – Falx Cerebri Divides cerebrum into right and left hemispheres.

– Central Sulcus Fissure splits cerebrum into right and left hemispheres.

Each hemisphere controls the opposite side of the body.

– Tentorium Fibrous sheet within occipital region.

Brainstem perforates through incisura tentorri cerebelli.

Occulomotor nerve (CN-III) travels along.

Controls pupil size.

Compression results in pupillary disturbances.

Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Anatomy and Physiology of the Head

(6 of 18) Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Anatomy and Physiology of the Head

(7 of 18) Cerebrum – Hemisphere Functions Left: DOMINANT Mathematical computations: Occipital Writing: Parietal Language interpretation: Occipital Speech: Frontal Right: NON-DOMINANT Non-verbal imagery Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Anatomy and Physiology of the Head

(8 of 18) Cerebellum – Located under tentorium – Function “Fine tunes” motor control Allows smooth movement Balance Maintenance of muscle tone Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Anatomy and Physiology of the Head

(9 of 18) Brainstem – Central processing center – Communication junction among Cerebrum Spinal cord Cranial nerves Cerebellum – Structures Midbrain Pons Medulla oblongata Bledsoe et al.,

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Anatomy and Physiology of the Head

(10 of 18) Midbrain – Upper portion of brainstem – Structures Hypothalamus Endocrine function, vomiting reflex, hunger, thirst Kidney function, body temperature, emotion Thalamus Switching center between pons and cerebrum Critical Element in Ascending Reticular Activating System (A-RAS) ESTABLISHES CONSCIOUSNESS Major pathways for optic and olfactory nerves Associated structures Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Anatomy and Physiology of the Head

(11 of 18) Pons – Communication interchange between cerebellum, cerebrum, midbrain, and spinal cord – Bulb-shaped structure above medulla – Sleeping phase of the RAS Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Anatomy and Physiology of the Head

(12 of 18) Medulla Oblongata – Bulge in the top of the spinal cord – Centers Respiratory Center Controls depth, rate, and rhythm Cardiac Center Regulates rate and strength of cardiac contractions Vasomotor Center Distribution of blood Maintains blood pressure Bledsoe et al.,

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Anatomy and Physiology of the Head

(13 of 18) CNS Circulation – Arterial Four Major Arteries 2 Internal Carotid Arteries From the common carotid 2 Vertebral Arteries Circle of Willis Internal Carotids and Vertebral Arteries Encircle the base of the brain – Venous Venous drainage occurs through bridging veins Bridge dural sinuses Drain into internal jugular veins Bledsoe et al.,

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Anatomy and Physiology of the Head

(14 of 18) Blood-Brain Barrier – Less permeable than elsewhere in body – DOES NOT allow flow of interstitial proteins – Reduced lymphatic flow – Very protected environment – Blood acts as irritant resulting in cerebral edema.

Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Anatomy and Physiology of the Head

(15 of 18) Cerebral Perfusion Pressure – Pressure within cranium (ICP) resists blood flow and good perfusion to the CNS.

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 Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Anatomy and Physiology of the Head

(16 of 18) Calculating MAP BP  120/90 DBP  90 Pulse Pressure  120 90  30 MAP  80  1 3  30  90 Calculating CPP MAP  90 & ICP  10 CPP  MAP ICP CPP  90 10  80 Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Anatomy and Physiology of the Head

(17 of 18) Cerebral Perfusion Pressure – Autoregulation Changes in ICP result in compensation.

Increased ICP = Increased BP.

This causes ICP to rise higher and BP to rise.

Brain injury and death become imminent.

– Expanding mass inside cranial vault Displaces CSF.

If pressure increases, brain tissue is displaced.

Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Anatomy and Physiology of the Head

(18 of 18) Cranial Nerves – 12 pair with distinct pathways – Senses, facial innervation, and body function control Ascending Reticular Activation System – Tract of neurons in upper brainstem, pons, and midbrain – Responsible for sleep-wake cycle – Monitors input stimulation – Regulates body functions Respiration Heart rate Peripheral vascular resistance – Injury may result in prolonged waking state.

Bledsoe et al.,

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Cranial Nerves

Bledsoe et al.,

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I II III IV

Name

Olfactory Optic Oculomotor Trochlear V Trigeminal VI Abducens VII Facial VIII IX Acoustic Glossopharyn geal X Vagus XI XII Accessory Hypoglossal M S M M M S M M S M

S S M M S S

Innervation

Smell Sight Pupil Const, rectus and obliques Superior obliques Opthalmic (FH), Maxillary (cheek) Mandible (chin) Chewing muscles Lateral rectus muscle Tongue Face muscles Hearing balance Posterior pharynx, taste to anterior tongue Face muscles Taste to posterior tongue Posterior palate and pharynx Trapezius and sternocleido muscles Tongue Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Anatomy and Physiology of the Head, Face, and Neck

Anatomy and Physiology of the Face – Structure – Ear – Eye Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Anatomy and Physiology of the Face

Structure – Facial Bones Zygoma Prominent bone of the cheek Protects eyes Attachment for muscles controlling eye and jaw movement Maxilla Upper jaw Supports the nasal bone Provides lower border of orbit Mandible Jaw bone Nasal bones Bledsoe et al.,

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Facial Bones

Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Anatomy and Physiology of the Face

(1 of 9) Structure – Covered with skin Flexible and thin Highly vascular – Minimal layer of subcutaneous tissue Circulation – External carotid artery Supplies facial area Branches Facial, temporal, and maxillary arteries Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Anatomy and Physiology of the Face

(2 of 9) Nerves – Trigeminal (CN-V) Facial sensation Some eye motor control Enables chewing process – Facial (CN-VII) Motor control for facial muscles Sensation of taste Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Anatomy and Physiology of the Face

(3 of 9) Nasal Cavity – Upper Border Bones Junction of ethmoid, nasal, and maxillary bones Bony Septum Right and left chamber Turbinates Vascular mucosa support Warm, humidify, and filter incoming air – Lower Border Bony hard palate Soft palate Moves upward during swallowing – Nasal Cartilage Forms nares Bledsoe et al.,

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Anatomy and Physiology of the Face

(4 of 9) Oral Cavity – Formed Structures Maxillary bone Palate Upper teeth meeting the mandible and lower teeth – Floor Tongue Connects to hyoid bone – Mandible Free-floating U-shaped bone inferior and posterior of the mandible Articulates with the TMJ joint Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Anatomy and Physiology of the Face

(5 of 9) Special Structures – Salivary Glands First stage in digestion Location Anterior and inferior to the ear Under tongue Inside the inferior mandible – Tonsils Posterior wall of the pharynx Bledsoe et al.,

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Anatomy and Physiology of the Face

(6 of 9) Sinuses – Hollow spaces in cranium and facial bones – Function Lighten head Protect eyes and nasal cavity Produce resonant tones of voice Strengthen area against trauma Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Anatomy and Physiology of the Face

(7 of 9) Cranial Nerves – CN-XII (Hypoglossal) Swallowing and tongue movement – CN-IX (Glossopharyngeal) Saliva production and taste – CN-V (Trigeminal) Sensations from facial region and aids in chewing – CN-VII (Facial) Muscles of facial expression and taste Bledsoe et al.,

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Anatomy and Physiology of the Face

(8 of 9) Pharynx – Posterior and inferior to the oral cavity – Aids in swallowing Bolus of food propelled back and down by tongue Epiglottis moves downward Larynx moves up Combined effect seals airway Peristaltic wave moves food down esophagus Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Anatomy and Physiology of the Face

(9 of 9) Ear – Function Hearing Positional sense – Structures Pinna Outer visible portion Formed of cartilage and has poor blood supply External Auditory Canal Glands that secrete cerumen (wax) Middle and Inner Ear Structures for hearing and positional sense Bledsoe et al.,

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The Ear

Bledsoe et al.,

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Anatomy and Physiology of the Face

Ear – Structures for Hearing Tympanic membrane Ossicle bones Cochlea Auditory nerve – Structures for Proprioception Semicircular canals Sense position and motion Present when eyes are closed Vertigo Continuous movement sensation Bledsoe et al.,

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The Eye

Bledsoe et al.,

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Anatomy and Physiology of the Face

(1 of 2) Eye – Structures Sclera Cornea Conjunctiva Anterior chamber Aqueous humor Iris Pupil Lens Posterior chamber Vitreous humor Retina – Lacrimal Fluid Bathes, protects, and nourishes cornea Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Anatomy and Physiology of the Face

(2 of 2) Eye – Innervation CN-III (Oculomotor) Pupil dilation Conjugate movement Movement of eyes together Normal range of motion CN-IV (Trochlear) Downward and inward movement CN-VI (Abducens) Abduction (outward) gaze Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Anatomy and Physiology of the Neck

(1 of 6) Vasculature of the Neck – Carotid Arteries Arise from RIGHT: Brachiocephalic artery LEFT: Aorta artery Split Internal and external carotid arteries Upper border of the larynx Carotid bodies and sinuses located Bodies: Monitor CO 2 and O 2 levels Sinuses: Monitor blood pressure Bledsoe et al.,

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Anatomy and Physiology of the Neck

(2 of 6) Jugular Veins – External Superficial, lateral to the trachea – Internal Sheath with the carotid artery and vagus nerve Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Anatomy and Physiology of the Neck

(3 of 6) Airway Structures – Larynx Epiglottis Thyroid and cricoid cartilage – Trachea Posterior border is anterior border of esophagus.

Bledsoe et al.,

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Anatomy and Physiology of the Neck

(4 of 6) Other Structures – Cervical Spine Musculoskeletal Function External skeletal support of the head and neck Attachment point for spinal column ligaments Attachment point for tendons to move head and shoulders Nervous Function Spinal cord contained within Peripheral nerve Exit between vertebrae Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Anatomy and Physiology of the Neck

(5 of 6) Other Structures – Esophagus – Cranial Nerves CN-IX (Glossopharyngeal) Carotid bodies and carotid sinuses CN-X Speech, swallowing, cardiac, respiratory, and visceral function – Thoracic Duct Delivers lymph to the venous system Bledsoe et al.,

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Anatomy and Physiology of the Neck

(6 of 6) Glands – Thyroid Rate of cellular metabolism Systemic levels of calcium Brachial Plexus – Network of nerves in lower neck and shoulder that control arm and hand function Bledsoe et al.,

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Pathophysiology of Head, Facial, and Neck Injury

Mechanism of Injury – Blunt Injury Motor vehicle collisions Assaults Falls – Penetrating Injury Gunshot wounds Stabbing Explosions “Clothesline” Bledsoe et al.,

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Scalp Injury

Contusions Lacerations Avulsions Significant Hemorrhage

ALWAYS reconsider MOI for severe underlying problems.

Bledsoe et al.,

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Cranial Injury

(1 of 3) Trauma must be extreme to fracture.

– Linear – Depressed – Open – Impaled object Basal Skull: – Unprotected – Spaces weaken structure – Relatively easier to fracture Bledsoe et al.,

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Cranial Injury

(2 of 3) Basal Skull Fracture Signs – Battle’s Signs Retroauricular ecchymosis Associated with fracture of auditory canal and lower areas of skull – Raccoon Eyes Bilateral periorbital ecchymosis Associated with orbital fractures Bledsoe et al.,

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Cranial Injury

(3 of 3) Basilar Skull Fracture – May tear dura.

Permit CSF to drain through an external passageway.

May mediate rise of ICP.

Evaluate for “target” or “halo” sign.

Bledsoe et al.,

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Brain Injury

As defined by the National Head Injury Foundation – “A traumatic insult to the brain capable of producing physical, intellectual, emotional, social and vocational changes” – Classification Direct Primary injury caused by forces of trauma Indirect Secondary injury caused by factors resulting from the primary injury Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Direct Brain Injury Types

Coup – Injury at site of impact Contrecoup – Injury on opposite side from impact Bledsoe et al.,

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Direct Brain Injury Categories

Focal – Occur at a specific location in brain – Differentials Cerebral contusion Intracranial hemorrhage Epidural hematoma Subdural hematoma Intracerebral hemorrhage Diffuse – Concussion – Moderate diffuse axonal injury – Severe diffuse axonal injury Bledsoe et al.,

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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 Personality changes Vision changes Speech changes – Results from Coup-contrecoup injury Bledsoe et al.,

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Focal Brain Injury Intracranial Hemorrhage

(1 of 3) Epidural Hematoma – Bleeding between dura mater and skull – Involves arteries Middle meningeal artery most common – Rapid bleeding and reduction of oxygen to tissues – Herniates brain toward foramen magnum Bledsoe et al.,

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Focal Brain Injury Intracranial Hemorrhage

(2 of 3) Subdural Hematoma – Bleeding within meninges Beneath dura mater and within subarachnoid space Above pia mater – Slow bleeding Superior sagittal sinus – Signs progress over several days Slow deterioration of mentation Bledsoe et al.,

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Focal Brain Injury Intracranial Hemorrhage

(3 of 3) Intracerebral Hemorrhage – Ruptured blood vessel within the brain – Presentation similar to stroke symptoms – Signs and symptoms worsen over time Bledsoe et al.,

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Diffuse Brain Injury

Due to stretching forces placed on axons Pathology distributed throughout brain Types – Concussion – Moderate diffuse axonal injury – Severe diffuse axonal injury Bledsoe et al.,

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Diffuse Brain Injury Concussion

Mild to moderate form of diffuse axonal injury (DAI) – 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 Bledsoe et al.,

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Diffuse Brain Injury Moderate Diffuse Axonal Injury

“Classic Concussion” Same mechanism as concussion – Additional: minute bruising of brain tissue Unconsciousness – If cerebral cortex and RAS involved May exist with a basilar skull fracture Signs and Symptoms – Unconsciousness or persistent confusion – Loss of concentration, disorientation – Retrograde and antegrade amnesia – Visual and sensory disturbances – Mood or personality changes Bledsoe et al.,

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Diffuse Brain Injury Severe Diffuse Axonal Injury

Brainstem Injury Significant mechanical disruption of axons – Cerebral hemispheres and brainstem High mortality rate Signs and Symptoms – Prolonged unconsciousness – Cushing’s reflex – Decorticate or decerebrate posturing Bledsoe et al.,

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Intracranial Perfusion

(1 of 3) Review – 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 Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Intracranial Perfusion

(2 of 3) Compensating for Pressure – Compress venous blood vessels – Reduction in free CSF Pushed into spinal cord Decompensating for Pressure – Increase in ICP – Rise in systemic BP to perfuse brain Further increase of ICP Dangerous cycle

ICP BP

Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Intracranial Perfusion

(3 of 3) Role of Carbon Dioxide – Increase of CO 2 in CSF Cerebral vasodilation Encourage blood flow Reduce hypercarbia Reduce hypoxia – Contributes to  – Causes classic ICP Hyperventilation and hypertension – Reduced levels of CO 2 Cerebral vasoconstriction in CSF Results in cerebral anoxia Bledsoe et al.,

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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 Bledsoe et al.,

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Bledsoe et al.,

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Pressure and Structural Displacement

Increased pressure – Compresses brain tissue Against and around Falx cerebri Tentorium cerebelli – Herniates brainstem Compromises blood supply Signs and Symptoms Upper brainstem Vomiting Altered mental status Pupillary dilation Medulla oblongata Respiratory Cardiovascular Blood pressure disturbances Bledsoe et al.,

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Signs and Symptoms of Brain Injury

(1 of 2) Altered Mental Status – Altered orientation – Alteration in personality – Amnesia Retrograde Antegrade Cushing’s Reflex – Increased BP – Bradycardia – Erratic respirations Vomiting – Without nausea – Projectile Body temperature changes Changes in pupil reactivity Decorticate posturing Obtain a blood glucose level on all patients with AMS. Bledsoe et al.,

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Signs and Symptoms of Brain Injury

(2 of 2) Pathophysiology of Changes – Frontal Lobe Injury Alterations in personality – Occipital Lobe Injury Visual disturbances – Cortical Disruption Reduced mental status or amnesia Retrograde Unable to recall events before injury Antegrade Unable to recall events after trauma “Repetitive questioning” – Focal Deficits Hemiplegia, weakness, or seizures Bledsoe et al.,

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Signs and Symptoms of Brain Injury Physiological Changes

(1 of 3) Upper Brainstem Compression – Increasing blood pressure – Reflex bradycardia Vagus nerve stimulation – Cheyne-Stokes respirations – Pupils become small and reactive – Decorticate posturing Neural pathway disruption Bledsoe et al.,

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Signs and Symptoms of Brain Injury Physiological Changes

(2 of 3) Middle Brainstem Compression – Widening pulse pressure – Increasing bradycardia – CNS hyperventilation Deep and rapid – Bilateral pupil sluggishness or inactivity – Decerebrate posturing Bledsoe et al.,

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Signs and Symptoms of Brain Injury Physiological Changes

(3 of 3) 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 Bledsoe et al.,

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Recognition of Herniation

Cushing’s Reflex – Increasing blood pressure – Decreasing pulse rate – Respirations that become erratic Lowering level of consciousness – GCS <9 and dropping Singular or bilaterally dilated and fixed pupils Decerebrate or decorticate posturing No movement with noxious stimuli Bledsoe et al.,

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Signs and Symptoms of Brain Injury

Glasgow Coma Scale Bledsoe et al.,

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Signs and Symptoms of Brain Injury Pediatric Head Trauma

Different pathology than older patients – 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 General Management – Avoid hyperextension of head.

Tongue pushes soft palate closed – Ventilate through mouth and nose.

Bledsoe et al.,

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Signs and Symptoms of Brain Injury

Pediatric Glasgow Coma Scale Bledsoe et al.,

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Signs and Symptoms of Brain Injury Eye Signs

Physiological Issues – Indicate pressure on CN-II, CN-III, CN-IV, and CN-VI CN-III (Oculomotor nerve) Pressure on nerve causes eyes to be sluggish, then dilated, and finally fixed.

– Reduced peripheral blood flow Pupil Size and Reactivity – Reduced pupillary responsiveness Depressant drugs or cerebral hypoxia – Fixed and dilated Extreme hypoxia Bledsoe et al.,

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Facial Injury

(1 of 7) Facial Soft-Tissue Injury – Highly vascular tissue.

Contributes to hypovolemia – Superficial injuries are rarely life threatening and rarely involve the airway.

– Deep injuries can result in blood being swallowed and endanger the airway.

– Soft tissue swelling reduces airflow.

– Consider likelihood of basilar skull fracture or spinal injury.

Bledsoe et al.,

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Facial Injury

(2 of 7) Facial Dislocations and Fractures – Common Fractures Mandibular Deformity along jaw and loss of teeth Possible airway compromise if patient placed supine Evaluate for multiple fracture sites Maxillary and Nasal Le Fort I, II, and III Criteria Orbit Involve zygoma, maxilla, and/or interior shelf Reduction of eye movement Possible diplopia Limitation of jaw movement Bledsoe et al.,

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Facial Injury

(3 of 7) Fractures Bledsoe et al.,

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Facial Injury

(4 of 7) Nasal Injury – Rarely life threatening.

– Swelling and hemorrhage interfere with breathing.

– Epistaxis.

Most common problem – AVOID NASOTRACHEAL INTUBATION.

Passage of ET tube into the cerebral cavity Bledsoe et al.,

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Facial Injury

(5 of 7) Ear Injury – External Ear Pinna frequently injured due to trauma Poor blood supply Poor healing – Internal Ear Well protected from trauma May be injured due to rapid pressure changes Diving, Blast, or Explosions Temporary or permanent hearing loss Tinnitus may occur Bledsoe et al.,

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Facial Injury

(6 of 7) Eye Injury – Penetrating Trauma Can result in long-term damage.

Suspect small foreign body if patient complains of sudden eye pain and sensation of something on the eye.

DO NOT REMOVE ANY FOREIGN OBJECT.

– Corneal Abrasions and Lacerations Common and usually superficial – Hyphema Blunt trauma to the anterior chamber of the eye Blood in front of iris or pupil – Sub-conjunctival Hemorrhage Less serious condition May occur after strong sneeze, severe vomiting or direct trauma Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Facial Injury

(7 of 7) Eye Injury (cont.) – Acute Retinal Artery Occlusion Non-traumatic origin Painless loss of vision in one eye Occlusion of retinal artery – Retinal Detachment Traumatic origin Complaint of dark curtain/obstruction in the field of view Possibly painful depending on type of trauma – Soft-Tissue Lacerations Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Neck Injury

(1 of 2) Blood Vessel Trauma – Blunt trauma Serious hematoma – Laceration Serious exsanguination Entraining of air embolism Cover with occlusive dressing Airway Trauma – Tracheal rupture or dissection from larynx – Airway swelling and compromise Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Neck Injury

(2 of 2) Cervical Spine Trauma – Vertebral fracture Paresthesia, anaesthesia, paresis, or paralysis beneath the level of the injury Neurogenic shock may occur Other Neck Trauma – Subcutaneous emphysema Tension pneumothorax Traumatic asphyxia – Penetrating trauma Esophagus or trachea Vagus nerve disruption Tachycardia and GI disturbances Thyroid and parathyroid glands High vascular Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Assessment of Head, Facial, and Neck Injuries

Scene Size-up Initial Assessment – Airway, breathing, circulation Rapid Trauma Assessment – Head, face, neck – Glasgow Coma Scale score – Vital signs Focused History and Physical Exam Detailed Assessment Ongoing Assessment Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Head, Facial, and Neck Injury Management

Airway – Suctioning – Patient positioning – OPA and NPA use – Endotracheal intubation Orotracheal Digital Nasotracheal Retrograde Direct RSI – Cricothyrotomy Breathing – Oxygen 15 LPM/NRB – Ventilations 12 –20/min Hyperoxygenate ETCO 2 maintained at 35 –40 mmHg Continuous waveform capnogrpahy Circulation – Hemorrhage Control – Blood pressure maintenance Fluid resuscitation to SBP of 90 mmHg Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Needle Cricothyrotomy

Locate site.

– Cricothyroid membrane Cleanse upper anterior neck.

– Aseptic technique Iodine and alcohol Prepare equipment.

– 14 ga IV catheter – Syringe – Transtracheal jet insufflation device – 6.0 ET hub Insert catheter into membrane.

– Downward angle – Feel “pop” Advance catheter.

Attach BVM or jet ventilator.

Evaluate breath sounds.

Secure catheter.

– Similar to impaled object Consider 2nd catheter for exhalation.

Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Surgical Cricothyrotomy

Locate site.

– Cricothyroid membrane Cleanse upper anterior neck.

– Aseptic technique Iodine and alcohol Prepare equipment.

– Commercial device – Scalpel – 4” ET tube Insert scalpel into membrane.

– Downward angle – Feel “pop” Enlarge opening.

Place short ET tube.

Evaluate breath sounds.

Secure device.

Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Head, Facial, and Neck Injury Management

(1 of 2) Hypoxia – Prevent/reduce.

– Hyperoxygenate with BVM prior to intubation.

– Hyperventilate with BVM 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.

Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Head, Facial, and Neck Injury Management

(2 of 2) Hypovolemia – Reduces cerebral perfusion and hypoxia.

– Consider 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.

Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Medications: Oxygen

Primary 1st line drug Administer high flow Hyperventilation contraindicated unless the patient shows clinical signs of herniation because it reduces circulating CO 2 levels NRB: 15 LPM BVM: 12 –20 times per minute Keep SaO 2 >95% Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Medications: Diuretics

Furosemide (Lasix) – Mechanism of Action Loop diuretic Inhibits reabsorption of Na+ in kidneys Increased secretion of water and electrolytes Na+, Cl –, Mg++, Ca++ Venous dilation and reduces cardiac preload May be given in combination with Mannitol – Contraindication Pregnancy: fetal abnormalities – Dose Slow IVP or IM over 1 –2 minutes 0.5

–1 mg/kg: Commonly 40 or 80 mg Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Medications: Paralytics

(1 of 3) Succinylcholine (Anectine) – Mechanism of Action Depolarizing medication Causes fasciculations – Onset and Duration Onset: 30 –60 seconds Duration: 2 –3 minutes – Precaution Paralyzes ALL muscles including those of respiration Increases intraocular eye pressure – Contraindication Penetrating eye injury and Digitalis – Dose 1 –1.5 mg/kg IV Consider administration of Nondepolarizing NMB at 1/10th the paralyzing dose to prevent muscle fasciculations.

Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Medications: Paralytics

(2 of 3) Atracurium (Tracrium) – Mechanism of Action Non-depolarizing agent Does not affect LOC – Onset and Duration Onset: <1 minute Duration: 25 –40 minutes – Precaution Histamine release May induce bradycardia – Dose 0.5 mg/kg IV Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Medications: Paralytics

(3 of 3) Pancuronium (Pavulon) – Mechanism of Action – Non-depolarizing agent Does not affect LOC – Onset and Duration Onset: 3 –5 min Duration: 30 –60 min – Dose Must premed with sedative 0.04

–0.1 mg/kg Vecuronium (Norcuron) – Mechanism of Action – Non-depolarizing agent Does not affect LOC – Onset and Duration Onset: < 1 min Duration: 25 –40 min – Dose Consider premed with sedative 0.08

–0.1 mg/kg Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Medications: Sedatives

(1 of 4) Diazepam (Valium) – Mechanism of Action Benzodiazepine Anti-anxiety Muscle relaxant – Onset and Duration Onset: 1 –15 min Duration: 15 –60 min – Dose 5 –10 mg Midazolam (Versed) – Mechanism of Action Benzodiazepine 3 –4x more potent than Valium – Dose SLOW IVP 1 mg/min 1 –2.5 mg titrate Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Medications: Sedatives

(2 of 4) Morphine – Mechanism of Action Opium alkaloid Analgesic Sedation Anti-anxiety Reduces vascular volume and cardiac preload Increases venous capacitance – Side Effects Respiratory depression Hypovolemia – Dose 5 –10 mg IVP Consider using promethezine to reduce nausea Naloxone (Narcan) is antagonist Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Medications: Sedatives

(3 of 4) Fentanyl (Sublimaze) – Mechanism of Action Synthetic opioid Analgesic Sedation – Side Effects Respiratory depression Skeletal muscle rigidity – Onset/Duration Onset of 2 minutes Duration of 30 –60 minutes – Dose 3 –5 mcg/kg SIVP Naloxone (Narcan) is antagonist Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Medications: Sedatives

(4 of 4) Etomidate (Amidate) – Mechanism of Action Sedative-hypnotic – Side Effects Respiratory depression Trismus – Onset/Duration Onset of less than 1 minute Duration of 5 minutes – Dose 0.1

–0.3 mg/kg IVP Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Medications: Atropine

Mechanism of Action – Anticholinergic Parasympathetic – Reduces parasympathetic stimulation – Reduces oral and airway secretions – Pupillary dilation Dose – 0.5–1 mg rapid IVP Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Medications: Dextrose

Consider if patient is hypoglycemic – Only if VERIFIED by GLUCOMETER Dose – 25 gm IVP – Consider thiamine if known alcoholic 100 mg thiamine Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Medications: Thiamine

Vitamin B1 Essential for the processing of glucose through Krebs cycle Chronic alcoholics can have B1 depletion Dose – 100 mg IV or IM Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Medications: Topical Anesthetic Spray

Medications – Xylocaine or benzocaine Anesthetizes oral and pharyngeal mucosa Reduces gag reflex Reduces likelihood of ICP associated with vomiting Inhibits nerve sensation Onset and Duration Onset: 15 seconds Duration: 15 minutes PRECAUTION Patient has reduced ability to remove oral fluids.

ASPIRATION can occur.

Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Transport Considerations

Limit external stimulation.

– Can increase ICP – Can induce seizures Be cautious about air transport.

– Seizures Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Emotional Support

Have friend or family provide constant reassurance.

Provide constant reorientation to environment if required.

– Keeps patient calm – Reduces anxiety Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Special Injury Care

(1 of 3) 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.

Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Special Injury Care

(2 of 3) Eye Injury – General Injury Cover injured and uninjured eye.

Prevents sympathetic motion Consider sterile dressing soaked in NS.

– Corneal Abrasion Invert eyelid and examine eye for foreign body.

Remove with NS moistened gauze or Morgan’s lens.

– Avulsed or Impaled Eye Cover and protect from injury.

– General Care Calm and reassure patient.

Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Special Injury Care

(3 of 3) 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.

Bledsoe et al.,

Paramedic Care Principles & Practice Volume 4: Trauma

Summary

Paramedic Care Principles & Practice Volume 4: Trauma