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

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

Head and Facial Conditions Chapter 10

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.)

• 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

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.)

• 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

Skull Fracture

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

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 – 48-72 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.)

• 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.

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

Cognitive Physical

Feeling like in a “fog” Headache Feeling slowed down Nausea or vomiting Difficulty concentrating Difficulty remembering Forgetful of recent information Confused about recent events Answers questions slowly Repeats questions Balance problems Visual problems Fatigued Photophobia Sensitivity to noise Dazed or stunned

Emotional

Irritability Sadness

Sleep

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 Sport-specific exercise (e.g., skating in hockey, running in soccer); Noncontact training drills; Progression to more complex training drills; may start progressive resistance training Full-contact practice -- after medical clearance 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!!!

Assessment of Cranial Conditions

• ALWAYS ASSUME A CERVICAL INJURY IS PRESENT!!!!!!!!!!!!!

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.) pulse respiration blood pressure pulse pressure

slow bounding pulse accelerated pulse bradypnea Cheyne-Stokes breathing Ataxic (Biot’s) breathing apneustic breathing  systolic BP or  diastolic BP  BP (rare in head injury) pulse pressure  50 mm Hg  intracranial pressure pressure on base of brain  intracranial pressure brain damage brain damage, typically at the medullary level indicates trauma to the pons  intracranial pressure possible cervical injury or serious blood loss from an injury elsewhere in the body  intracranial bleeding 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.)

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!

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) – – • Corneal abrasion – – S&S: itching, burning, watering, red appearance Management: infectious; refer to physician 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

Eye Conditions (cont.)

• 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 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) Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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

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

Skull Fracture (cont.)

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