chapter 24 head and facial traumas -...

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Chapter 24Chapter 24Head and Facial TraumaHead and Facial Trauma

Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

ObjectivesObjectivesDescribe mechanism of injury, assessment, Describe mechanism of injury, assessment, and management of:and management of:

Maxillofacial injuriesMaxillofacial injuriesEar, eye, and dental injuriesEar, eye, and dental injuriesAnterior neck traumaAnterior neck traumaInjuries to the scalp, cranial vault, or cranial Injuries to the scalp, cranial vault, or cranial nervesnerves


ObjectivesObjectivesDistinguish between types of traumatic brain Distinguish between types of traumatic brain injuryinjury

Outline the prehospital management of patients Outline the prehospital management of patients with cerebral injurywith cerebral injury

Calculate a Glasgow Coma Scale, trauma Calculate a Glasgow Coma Scale, trauma score, revised trauma score, and pediatric score, revised trauma score, and pediatric trauma score for a given scenariotrauma score for a given scenario


Mosby, Inc. items and derived items © 2007, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Sanders: Mosby's Paramedic Textbook, Revised 3rd Edition PowerPoint Lecture Notes

Chapter 24: Head and Facial Traumas

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ScenarioScenarioA10A10--yearyear--old boy is carried into your station, his arms old boy is carried into your station, his arms and legs draped limply over his frantic fatherand legs draped limply over his frantic father’’s arms. He s arms. He fell off an ATV about an hour ago, was knocked out fell off an ATV about an hour ago, was knocked out briefly, then seemed fine until he suddenly had a briefly, then seemed fine until he suddenly had a seizure and seizure and ““passed out.passed out.”” Your crew carefully Your crew carefully immobilizes him while you determine the following: his immobilizes him while you determine the following: his airway is noisy, and he has no gag reflex; he is airway is noisy, and he has no gag reflex; he is breathing irregularly about 10 times/min; BP 72/50 mm breathing irregularly about 10 times/min; BP 72/50 mm Hg; P 68/min; right pupil 2 mm and reacts to light, left Hg; P 68/min; right pupil 2 mm and reacts to light, left pupil 5 mm and unreactive; flaccid response to pain; wt pupil 5 mm and unreactive; flaccid response to pain; wt 35 kg. 35 kg.


DiscussionDiscussionWhat are your immediate priorities for his care?What are your immediate priorities for his care?

Calculate his GCS, RTS, and PTSCalculate his GCS, RTS, and PTS

What type of brain injury is likely in this child?What type of brain injury is likely in this child?

Explain the significance of his pupillary findingsExplain the significance of his pupillary findings

Why might his blood pressure be low?Why might his blood pressure be low?


Maxillofacial InjuryMaxillofacial Injury

ArteriesArteriesNervesNerves

5th cranial nerve (trigeminal)5th cranial nerve (trigeminal)7th cranial nerve (facial)7th cranial nerve (facial)

Frontal boneFrontal boneNasal bonesNasal bonesMaxillaMaxillaZygomatic boneZygomatic boneMandibleMandible



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Maxillofacial InjuryMaxillofacial InjuryCausesCauses

Motor vehicle crashesMotor vehicle crashesHome accidentsHome accidentsAthletic injuriesAthletic injuriesAnimal bitesAnimal bitesIntentional violent actsIntentional violent actsIndustrial injuriesIndustrial injuries

Maxillofacial trauma classified as:Maxillofacial trauma classified as:Soft tissue injuriesSoft tissue injuriesFacial fracturesFacial fractures


Soft Tissue InjuriesSoft Tissue InjuriesFacial soft tissue injuries often appear seriousFacial soft tissue injuries often appear serious

Seldom life threateningSeldom life threateningExceptionsExceptions

•• Compromised upper airwayCompromised upper airway•• Potential for significant bleedingPotential for significant bleeding


Soft Tissue InjurySoft Tissue InjuryAppearance of patient after being attacked and after cleansing



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HistoryHistoryMechanism of injuryMechanism of injury

Events leading up to injuryEvents leading up to injury

Time of injuryTime of injury

Associated medical problemsAssociated medical problems

AllergiesAllergies

MedicationsMedications

Last oral intakeLast oral intake


ManagementManagementSpinal precautionsSpinal precautions

Assess for airway obstruction Assess for airway obstruction Apply suction as neededApply suction as needed

Secure and maintain airway Secure and maintain airway

Ensure ventilation and oxygenationEnsure ventilation and oxygenation

Control bleedingControl bleedingDirect pressure and pressure bandagesDirect pressure and pressure bandages


Facial FracturesFacial FracturesCommon after blunt traumaCommon after blunt trauma

Signs and symptoms Signs and symptoms

Fractures of the mandibleFractures of the mandible

Dislocations of the mandibleDislocations of the mandible



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Fractures of the MidfaceFractures of the MidfaceMiddle third of faceMiddle third of face

MaxillaMaxillaZygomaZygomaFloor of the orbitFloor of the orbitNoseNose

Fracture of middle 1/3 of face


Le Fort FracturesLe Fort Fractures

I II III


Fractures of the ZygomaFractures of the ZygomaZygoma articulates with Zygoma articulates with frontal, maxillary, and frontal, maxillary, and temporal bonestemporal bones

Associated with orbital Associated with orbital fractures and has fractures and has similar clinical signssimilar clinical signs

Signs and symptomsSigns and symptoms



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Fractures of the OrbitFractures of the OrbitBlowout fractures to orbitBlowout fractures to orbit

Periorbital edema, Periorbital edema, subconjunctival ecchymosis, subconjunctival ecchymosis, diplopia, enopthalmos, diplopia, enopthalmos, epistaxis, anesthesia, epistaxis, anesthesia, impaired EOMimpaired EOM

Suspect injury to orbital Suspect injury to orbital contents with any facial contents with any facial fracturefracture

Blowout fracture caused by ball’s impact


Fractures of the NoseFractures of the NoseMost often fractured structureMost often fractured structure

Injuries mayInjuries mayDepress dorsum of noseDepress dorsum of noseDisplace it to one sideDisplace it to one sideResult in epistaxis and swelling (without skeletal Result in epistaxis and swelling (without skeletal deformity)deformity)

Orbital fractures may also be presentOrbital fractures may also be present


EpistaxisEpistaxisApply external pressure to anterior naresApply external pressure to anterior nares

Conscious patientConscious patientSeated upright or leaning forward while paramedic compresses Seated upright or leaning forward while paramedic compresses naresnares

Unconscious patientUnconscious patientPositioned on side (if no spinal injury is suspected)Positioned on side (if no spinal injury is suspected)

Treat for shock if bleeding is severeTreat for shock if bleeding is severe



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Management of Facial FracturesManagement of Facial FracturesAssume spine is injuredAssume spine is injured

Use spinal precautionsUse spinal precautions

Assess airway for obstructionAssess airway for obstructionApply suction as needed Apply suction as needed

Ensure adequate ventilation and oxygenationEnsure adequate ventilation and oxygenation

Control bleeding through direct pressure and Control bleeding through direct pressure and pressure bandagespressure bandages

Control epistaxis by external direct pressure Control epistaxis by external direct pressure


Nasal and Ear Foreign BodiesNasal and Ear Foreign BodiesForeign bodies in nose or ear common in childrenForeign bodies in nose or ear common in children

May need transport for physician evaluationMay need transport for physician evaluation

Remove foreign body in ear if easily retrievedRemove foreign body in ear if easily retrieved

Do not remove nasal foreign body in field unless Do not remove nasal foreign body in field unless it:it:

Compromises airway Compromises airway Can be easily removed without equipmentCan be easily removed without equipment


Ear TraumaEar TraumaLacerations and contusionsLacerations and contusions

Usually blunt traumaUsually blunt traumaTreated by direct pressure to control bleeding and Treated by direct pressure to control bleeding and ice or cold compresses ice or cold compresses

•• To decrease swellingTo decrease swelling



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Ear TraumaEar TraumaRetrieve avulsed tissue if possibleRetrieve avulsed tissue if possible

Wrap in moist gauzeWrap in moist gauzeSeal in plasticSeal in plasticPlace on icePlace on iceTransport with patient for surgical repairTransport with patient for surgical repair


Ear TraumaEar TraumaPartially detached pinna Loss of rim


Ear TraumaEar TraumaThermal injuriesThermal injuries

Chemical injuriesChemical injuries

Traumatic perforationsTraumatic perforationsImpaled objectsImpaled objects

BarotitisBarotitis



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Eye TraumaEye TraumaCommon causes of eye injuryCommon causes of eye injury

Motor vehicle crashesMotor vehicle crashesSports and recreational activitiesSports and recreational activitiesViolent altercationsViolent altercationsChemical exposure Chemical exposure Foreign bodiesForeign bodiesAnimal bites and scratchesAnimal bites and scratches

EvaluationEvaluation


Eye Trauma Evaluation Eye Trauma Evaluation HistoryHistory

Exact mode of injuryExact mode of injuryUse of corrective glasses or contact lensesUse of corrective glasses or contact lenses

Visual acuityVisual acuityTest injured eye first; compare to uninjured eyeTest injured eye first; compare to uninjured eye

Pupillary reactionPupillary reaction

Extraocular movementExtraocular movement


Specific Eye InjuriesSpecific Eye InjuriesOcular trauma should be evaluated by physicianOcular trauma should be evaluated by physicianForeign bodiesForeign bodiesCorneal abrasionCorneal abrasionBlunt traumaBlunt traumaPenetrating injuryPenetrating injuryProtruding intraocular foreign bodiesProtruding intraocular foreign bodiesChemical injuries to the eyeChemical injuries to the eye



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Avulsion of LidAvulsion of Lid


HyphemaHyphema


Ruptured GlobeRuptured Globe



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Acid BurnAcid Burn


Alkali BurnAlkali Burn


Corneal Abrasion CareCorneal Abrasion Care



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Contact LensesContact LensesHard lensesHard lenses

Soft hydrophilic lensesSoft hydrophilic lenses

Rigid gasRigid gas--permeable lensespermeable lenses

As a rule, EMS personnel should not attempt As a rule, EMS personnel should not attempt to remove contact lenses in patients with eye to remove contact lenses in patients with eye injuriesinjuries


Dental TraumaDental Trauma32 teeth in adult32 teeth in adultSectionsSections

CrownCrownRootRoot

Hard tissues of teeth Hard tissues of teeth Soft tissues of teeth Soft tissues of teeth Tooth fracture Tooth fracture Tooth avulsionTooth avulsion


Anterior Neck TraumaAnterior Neck Trauma

Blunt and Blunt and penetrating traumapenetrating trauma

Can damage:Can damage:Skeletal structuresSkeletal structuresVascular structuresVascular structuresNerves, muscles, Nerves, muscles, and glands of neck and glands of neck Self-inflicted stab wound that had entered pharynx



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Common Mechanisms of InjuryCommon Mechanisms of Injury

Motor vehicle crashesMotor vehicle crashes

Sports and recreational activitiesSports and recreational activities

Industrial accidentsIndustrial accidents

Violent altercationsViolent altercations

HangingsHangings


Evaluation of the NeckEvaluation of the NeckZone IZone I

Injuries carry highest mortality Injuries carry highest mortality

Zone IIZone IIMost common injuries but Most common injuries but lower mortality than zone I lower mortality than zone I injuriesinjuries

Zone IIIZone IIIGreatest risk of injury to distal Greatest risk of injury to distal carotid artery, salivary glands, carotid artery, salivary glands, and pharynxand pharynx


Hematomas and EdemaHematomas and EdemaEdema of pharynx, larynx, trachea, epiglottis, Edema of pharynx, larynx, trachea, epiglottis, and vocal cords may obstruct airway and vocal cords may obstruct airway completelycompletely

Consider oral or nasal intubation with spinal Consider oral or nasal intubation with spinal precautions in patients with airway precautions in patients with airway compromisecompromise

Smaller ET tube may be neededSmaller ET tube may be needed



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Hematomas and EdemaHematomas and EdemaOther measures to treat edematous airwaysOther measures to treat edematous airways

Cool, humidified oxygenCool, humidified oxygenSlight elevation of patient's head (if not Slight elevation of patient's head (if not contraindicated)contraindicated)


Lacerations and Puncture WoundsLacerations and Puncture Wounds

Superficial injuriesSuperficial injuriesUsually managed by covering wound Usually managed by covering wound

Deep penetrating woundsDeep penetrating woundsSerious injuries may require:Serious injuries may require:

•• Aggressive airway therapy and ventilatory supportAggressive airway therapy and ventilatory support•• SuctionSuction•• Hemorrhage control by direct pressureHemorrhage control by direct pressure•• Fluid replacementFluid replacement


Lacerations and Puncture WoundsLacerations and Puncture Wounds

Signs and symptoms of significant penetrating neck traumaSigns and symptoms of significant penetrating neck traumaShockShockActive bleedingActive bleedingTenderness on palpationTenderness on palpationMobility and crepitusMobility and crepitusLarge or expanding hematomaLarge or expanding hematomaPulse deficitPulse deficitNeurological deficit Neurological deficit

DyspneaDyspneaHoarsenessHoarsenessStridorStridorSubcutaneous emphysemaSubcutaneous emphysemaHemoptysisHemoptysisDysphagiaDysphagiaHematemesisHematemesis



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Vascular InjuryVascular InjuryBlood vessels are most commonly injured structures Blood vessels are most commonly injured structures in the neckin the neck

Blunt or penetrating traumaBlunt or penetrating trauma

Vessels at risk of injuryVessels at risk of injuryCarotidCarotidVertebralVertebralSubclavianSubclavianInnominateInnominateInternal mammary arteriesInternal mammary arteriesJugular and subclavian veinsJugular and subclavian veins


Vascular InjuryVascular Injury——ManagementManagementSecure airway with spinal precautionsSecure airway with spinal precautions

Adequate ventilatory supportAdequate ventilatory support

Control hemorrhage by direct pressureControl hemorrhage by direct pressure

Fluid replacement for hypovolemia guided by Fluid replacement for hypovolemia guided by medical direction medical direction


Laryngeal or Tracheal InjuryLaryngeal or Tracheal InjuryBlunt or penetrating trauma to anterior neck Blunt or penetrating trauma to anterior neck may cause:may cause:

Fracture or dislocation of the laryngeal and Fracture or dislocation of the laryngeal and tracheal cartilagestracheal cartilagesHemorrhageHemorrhageSwelling of air passagesSwelling of air passages

Rapid airway control can save patient Rapid airway control can save patient



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Laryngeal or Tracheal InjuryLaryngeal or Tracheal InjuryHigh degree of suspicion for:High degree of suspicion for:

Vascular disruptionVascular disruptionEsophageal, chest, and abdominal injuryEsophageal, chest, and abdominal injury

Emergency airway management in these Emergency airway management in these injuries is controversial injuries is controversial


Esophageal InjuryEsophageal InjurySuspect in patients with trauma to neck or Suspect in patients with trauma to neck or chestchest

Specific injuries that require a high degree of Specific injuries that require a high degree of suspicion for associated esophageal injury suspicion for associated esophageal injury include:include:

Tracheal fracturesTracheal fracturesPenetrating trauma from stab or gunshot woundsPenetrating trauma from stab or gunshot woundsIngestion of caustic substancesIngestion of caustic substances


Esophageal Injury Esophageal Injury Signs and symptoms may include:Signs and symptoms may include:

Subcutaneous emphysemaSubcutaneous emphysemaNeck hematomaNeck hematomaOropharyngeal or nasogastric blood (indicating Oropharyngeal or nasogastric blood (indicating esophageal perforation)esophageal perforation)



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Head TraumaHead TraumaAnatomical components of skullAnatomical components of skull

ScalpScalpCranial vaultCranial vault

•• Dural membraneDural membrane•• Arachnoid membraneArachnoid membrane•• PiaPia•• Brain substancesBrain substances


ScalpScalpHairHair

Subcutaneous tissueSubcutaneous tissueMajor scalp veins bleed profuselyMajor scalp veins bleed profusely

MuscleMuscleAttached above eyebrows and at base of occiputAttached above eyebrows and at base of occiput

GaleaGaleaFreely movable sheet of connective tissueFreely movable sheet of connective tissueHelps deflect blowsHelps deflect blows

Loose connective tissueLoose connective tissueContains emissary veins that drain intracraniallyContains emissary veins that drain intracranially


Soft Tissue Injuries to the ScalpSoft Tissue Injuries to the Scalp

Irregular linear laceration Irregular linear laceration common common

May lead to profuse May lead to profuse bleeding and hypovolemiableeding and hypovolemia

Particularly in infants and Particularly in infants and childrenchildren



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Soft Tissue Injuries to the ScalpSoft Tissue Injuries to the Scalp

ManagementManagementPrevent contamination of open woundsPrevent contamination of open woundsDirect pressure or pressure dressings to decrease Direct pressure or pressure dressings to decrease blood lossblood lossIV fluid replacement if neededIV fluid replacement if neededConsider potential for underlying skull fracture and Consider potential for underlying skull fracture and brain and spinal trauma brain and spinal trauma


SkullSkullFacial bonesFacial bones

Cranial bonesCranial bonesDouble layer of solid bone surrounds spongy middle layerDouble layer of solid bone surrounds spongy middle layerFrontal, occipital, temporal, parietal, and mastoidFrontal, occipital, temporal, parietal, and mastoid

Middle meningeal arteryMiddle meningeal arteryUnder temporal boneUnder temporal boneCan tear artery if fracturedCan tear artery if fractured

Skull floorSkull floor——many ridgesmany ridges

Foramen magnumForamen magnumOpening at base of skull for spinal cordOpening at base of skull for spinal cord


Classification of Skull FracturesClassification of Skull Fractures

Linear fracturesLinear fractures

Basilar fracturesBasilar fractures

Depressed fracturesDepressed fractures

Open vault fracturesOpen vault fractures



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Linear FracturesLinear Fractures80% of all skull fractures80% of all skull fractures

Not usually depressedNot usually depressed

May occur without an May occur without an overlying scalp lacerationoverlying scalp laceration

Generally low Generally low complication rate (if complication rate (if isolated injury)isolated injury)


Basilar Skull FractureBasilar Skull Fracture


Basilar Skull FractureBasilar Skull Fracture——Signs and SymptomsSigns and Symptoms

Ecchymosis over mastoid Ecchymosis over mastoid processprocess

Temporal bone fractureTemporal bone fractureBattle's signBattle's sign

Blood behind tympanic Blood behind tympanic membranemembrane

Fractures of temporal boneFractures of temporal boneHemotympanumHemotympanum



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Basilar Skull FractureBasilar Skull Fracture——Signs and SymptomsSigns and Symptoms

Ecchymosis of one or Ecchymosis of one or both orbitsboth orbits

Fracture of base of Fracture of base of sphenoid sinussphenoid sinusRaccoon's eyesRaccoon's eyes

CSF leakageCSF leakageCan result in bacterial Can result in bacterial meningitismeningitis


Depressed Skull FracturesDepressed Skull Fractures

Relatively small object Relatively small object strikes head at high speedstrikes head at high speed

Often scalp lacerationsOften scalp lacerations

Frontal and parietal bones Frontal and parietal bones most often affectedmost often affected


Open Vault FracturesOpen Vault Fractures

Direct communication Direct communication between a scalp laceration between a scalp laceration and cerebral substanceand cerebral substance

Often occur with multisystem Often occur with multisystem traumatraumaHigh mortality rateHigh mortality rateMay lead to infection May lead to infection (meningitis)(meningitis)

Prehospital managementPrehospital management



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Severe Fracture of Base of SkullSevere Fracture of Base of Skull


Skull FracturesSkull Fractures——ComplicationsComplicationsCranial nerve injuryCranial nerve injury

Vascular involvementVascular involvementMeningeal arteryMeningeal arteryDural sinusesDural sinuses

InfectionInfection

Underlying brain injuryUnderlying brain injury

Dural defects caused by depressed bone fragmentsDural defects caused by depressed bone fragments


Cranial Nerve InjuriesCranial Nerve InjuriesUsually associated with skull fracturesUsually associated with skull fractures

Cranial nerve I (olfactory nerve)Cranial nerve I (olfactory nerve)Loss of smellLoss of smellImpairment of taste (dependent on food aroma)Impairment of taste (dependent on food aroma)Sign of basilar skull fractureSign of basilar skull fracture

Cranial nerve II (optic nerve)Cranial nerve II (optic nerve)Blindness in one or both eyesBlindness in one or both eyesVisual field defectsVisual field defects



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Cranial NervesCranial NervesCranial nerve III (oculomotor)Cranial nerve III (oculomotor)

Origin from midbrainOrigin from midbrainControls pupil sizeControls pupil sizePressure on nerve paralyzes nervePressure on nerve paralyzes nerve

•• Pupil nonreactivePupil nonreactive

Cranial nerve X (vagus)Cranial nerve X (vagus)Origin in medullaOrigin in medullaNerves that supply SA and AV node, stomach, and GI tractNerves that supply SA and AV node, stomach, and GI tractPressure on nerve stimulates bradycardiaPressure on nerve stimulates bradycardia


Cranial Nerve InjuriesCranial Nerve InjuriesCranial nerve III (oculomotor nerve)Cranial nerve III (oculomotor nerve)

Ipsilateral, dilated, fixed pupilIpsilateral, dilated, fixed pupilVulnerable to compression by temporal lobeVulnerable to compression by temporal lobeMimic direct ocular traumaMimic direct ocular trauma

Cranial nerve VII (facial nerve)Cranial nerve VII (facial nerve)Immediate or delayed facial paralysisImmediate or delayed facial paralysisBasilar skull fractureBasilar skull fracture

Cranial nerve VIII (auditory nerve)Cranial nerve VIII (auditory nerve)DeafnessDeafnessBasilar skull fracture Basilar skull fracture


Brain TraumaBrain TraumaTraumatic insult to the brain is capable of Traumatic insult to the brain is capable of producing physical, intellectual, emotional, producing physical, intellectual, emotional, social, and vocational changesocial, and vocational change

Primary brain injuryPrimary brain injury

Secondary brain injurySecondary brain injury



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Brain TraumaBrain TraumaBrain occupies 80% of intracranial spaceBrain occupies 80% of intracranial space

ComponentsComponentsBrain stemBrain stemDiencephalonDiencephalonCerebrumCerebrumCerebellumCerebellum


Brain TraumaBrain TraumaCategoriesCategories

Mild diffuse injuryMild diffuse injuryModerate diffuse injuryModerate diffuse injuryDiffuse axonal injuryDiffuse axonal injuryFocal injuryFocal injury


Mild Diffuse Injury (Concussion)Mild Diffuse Injury (Concussion)

Fully reversible brain injuryFully reversible brain injury

No structural damage to brainNo structural damage to brain

CausesCauses


ManagementManagement



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Moderate Diffuse InjuryModerate Diffuse InjuryMinute petechial bruising of brain tissueMinute petechial bruising of brain tissue

Brain stem and reticular activating system Brain stem and reticular activating system involvement lead to unconsciousnessinvolvement lead to unconsciousness




Diffuse Axonal Injury (DAI)Diffuse Axonal Injury (DAI)Most severe brain injuryMost severe brain injury

Brain movement within skull secondary to Brain movement within skull secondary to acceleration or deceleration forcesacceleration or deceleration forces

DAI may be classified as mild, moderate, or DAI may be classified as mild, moderate, or severesevere


Diffuse Axonal InjuryDiffuse Axonal InjuryMild DAIMild DAI

Coma of 6Coma of 6-- 24 hrs24 hrs

Moderate DAIModerate DAIMore commonMore commonComa >24 hrs and abnormal posturingComa >24 hrs and abnormal posturing

Severe DAISevere DAIFormerly known as brainstem injuryFormerly known as brainstem injurySevere shearing of axons in both cerebral hemispheres Severe shearing of axons in both cerebral hemispheres extending to brain stemextending to brain stem



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Focal InjuryFocal InjurySpecific, grossly observable brain lesionsSpecific, grossly observable brain lesions

Result from:Result from:Skull fractureSkull fractureContusionContusionEdema with associated increased ICPEdema with associated increased ICPIschemiaIschemiaHemorrhageHemorrhage


Intracranial ContentsIntracranial ContentsBrain water: 58%Brain water: 58%

Brain solids: 25%Brain solids: 25%

Cerebrospinal fluid: 7%Cerebrospinal fluid: 7%

Intracranial blood: 10%Intracranial blood: 10%


Cerebral ContusionCerebral ContusionBruising of brain around cortex or deeper within Bruising of brain around cortex or deeper within frontal, temporal, or occipital lobesfrontal, temporal, or occipital lobes

Structural change in brain tissueStructural change in brain tissueGreater neurological deficits and abnormalities than Greater neurological deficits and abnormalities than with concussionwith concussionCoup injuriesCoup injuriesContrecoup injuriesContrecoup injuries



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EdemaEdemaSignificant brain injuries may result in Significant brain injuries may result in swelling of brain tissue swelling of brain tissue

With or without associated hemorrhageWith or without associated hemorrhage

Swelling results from humoral and metabolic Swelling results from humoral and metabolic responses to injuryresponses to injury

Increase in intracranial pressureIncrease in intracranial pressureMay be decreased cerebral perfusion or herniationMay be decreased cerebral perfusion or herniation


IschemiaIschemiaCan result from:Can result from:

Vascular injuriesVascular injuriesSecondary vascular spasmSecondary vascular spasmIncreased intracranial pressureIncreased intracranial pressureFocal or more global infarcts can resultFocal or more global infarcts can result


HemorrhageHemorrhageInto or around brain tissueInto or around brain tissue

Epidural or subdural hematomas can compress Epidural or subdural hematomas can compress underlying brain tissue or intraparenchymal underlying brain tissue or intraparenchymal hemorrhagehemorrhage

Often associated with:Often associated with:Cerebral contusionsCerebral contusionsSkull fracturesSkull fractures



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Cerebral Blood FlowCerebral Blood Flow

Oxygen and glucose delivery are controlled by Oxygen and glucose delivery are controlled by cerebral blood flowcerebral blood flow

A function of cerebral perfusion pressure (CPP) and A function of cerebral perfusion pressure (CPP) and resistance of the cerebral vascular bedresistance of the cerebral vascular bedCPP = MAP CPP = MAP -- ICPICP

•• MAP = Diastolic pressure + 1/3 Pulse pressureMAP = Diastolic pressure + 1/3 Pulse pressure


Cerebral Blood FlowCerebral Blood FlowAs ICP approaches MAP:As ICP approaches MAP:

Gradient for flow decreasesGradient for flow decreasesCerebral blood flow is restrictedCerebral blood flow is restricted

When ICP increases, CPP decreasesWhen ICP increases, CPP decreasesCerebral vasodilation occursCerebral vasodilation occursIncreased cerebral blood volume (increasing ICP)Increased cerebral blood volume (increasing ICP)


Cerebral Blood FlowCerebral Blood FlowVascular tone in brain regulated by:Vascular tone in brain regulated by:

Carbon dioxide pressure (PCOCarbon dioxide pressure (PCO22))Oxygen pressure (POOxygen pressure (PO22))Autonomic and neurohumoral controlAutonomic and neurohumoral control

PCOPCO22 has greatest effect on intracerebral has greatest effect on intracerebral vascular diameter and subsequent resistancevascular diameter and subsequent resistance



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Intracranial Pressure (ICP)Intracranial Pressure (ICP)Normal range is 0Normal range is 0--15 torr15 torr

When ICP rises above this levelWhen ICP rises above this levelCerebral blood flow decreasesCerebral blood flow decreases

Body tries to compensate for decline in CPP by a rise in Body tries to compensate for decline in CPP by a rise in MAP: MAP:

Further elevates ICP, and CSF is displaced to compensate for Further elevates ICP, and CSF is displaced to compensate for the expansionthe expansion

If unresolved, brain substance herniates If unresolved, brain substance herniates


Effects of Increased Intracranial PressureEffects of Increased Intracranial Pressure


Increased Intracranial PressureIncreased Intracranial PressureEarlyEarly

HeadacheHeadacheNausea and vomitingNausea and vomitingAltered level of consciousnessAltered level of consciousness

Eventually, CushingEventually, Cushing’’s triads triadIncreased systolic pressure (widened pulse pressure)Increased systolic pressure (widened pulse pressure)Decreased pulse rate Decreased pulse rate Irregular respiratory patternIrregular respiratory pattern



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Increased Intracranial PressureIncreased Intracranial Pressure

Herniation through temporal lobe causes Herniation through temporal lobe causes compression of cranial nerve III (oculomotor)compression of cranial nerve III (oculomotor)

Patient rapidly unresponsive to verbal and Patient rapidly unresponsive to verbal and painful stimulipainful stimuli

Exhibits decorticate posturing or decerebrate Exhibits decorticate posturing or decerebrate posturingposturing


PosturingPosturing

Abnormal extension (decerebrate posturing)

Abnormal flexion (decorticate posturing)


Critical Signs of HerniationCritical Signs of HerniationUnresponsive patient with:Unresponsive patient with:

Bilateral, dilated, unresponsive pupils Bilateral, dilated, unresponsive pupils OROR

Asymmetric pupils (>1 mm)Asymmetric pupils (>1 mm)ANDAND

Abnormal extension (decerebrate) posturing Abnormal extension (decerebrate) posturing OROR

No motor response to painful stimulusNo motor response to painful stimulus



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Respiratory PatternsRespiratory Patterns

Associated with increased intracranial pressure Associated with increased intracranial pressure and brain stem injury:and brain stem injury:

HypoventilationHypoventilationCheyneCheyne--Stokes breathingStokes breathing

•• May accompany decorticate posturingMay accompany decorticate posturing

Central neurogenic hyperventilationCentral neurogenic hyperventilation•• May accompany decerebrate posturingMay accompany decerebrate posturing

Ataxic breathingAtaxic breathing


Respiratory PatternsRespiratory Patterns


Types of Brain HemorrhageTypes of Brain Hemorrhage

Classified according to Classified according to location:location:

EpiduralEpiduralSubduralSubduralSubarachnoidSubarachnoidCerebral (intraparenchymal)Cerebral (intraparenchymal)



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Epidural HematomaEpidural HematomaCollection of blood between Collection of blood between cranium and dura in cranium and dura in epidural spaceepidural space

Rapidly developing lesion Rapidly developing lesion from laceration of middle from laceration of middle meningeal arterymeningeal artery

Common causes Common causes




Subdural HematomaSubdural Hematoma

Blood between dura Blood between dura and surface of brain and surface of brain in subdural spacein subdural space

Usually bleeding from Usually bleeding from veins that bridge veins that bridge subdural spacesubdural space


Subdural HematomaSubdural HematomaClassifications Classifications

AcuteAcute—— symptoms symptoms <<24 hours24 hoursSubacuteSubacute——symptoms 2symptoms 2--10 days10 daysChronicChronic——symptoms >2 weekssymptoms >2 weeks




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Subarachnoid BleedingSubarachnoid Bleeding

Intracranial bleeding Intracranial bleeding into CSF, resulting in into CSF, resulting in bloody CSF and bloody CSF and meningeal irritationmeningeal irritation



Intracerebral HematomaIntracerebral Hematoma> 5 mL blood somewhere within brain> 5 mL blood somewhere within brain

Commonly frontal or temporal lobeCommonly frontal or temporal lobe

CausesCauses



Penetrating InjuryPenetrating InjuryMissiles fired from handgunsMissiles fired from handguns

Stab woundsStab woundsFallsFallsHighHigh--velocity motor vehicle crashesvelocity motor vehicle crashes

Associated injuriesAssociated injuries

ComplicationsComplications

Definitive careDefinitive care



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Assessment and EvaluationAssessment and EvaluationConsider:Consider:

Mechanism and severity of injuryMechanism and severity of injuryLevel of consciousnessLevel of consciousnessAssociated injuriesAssociated injuries

Assess GCS every 5 minAssess GCS every 5 min

Determine pupilDetermine pupilSizeSizeReactivityReactivity


Assessment and ManagementAssessment and ManagementMaintain airwayMaintain airway

Maintain SaOMaintain SaO22 >90%>90%

NS or LR fluid bolus if adult BP <90 mm HgNS or LR fluid bolus if adult BP <90 mm Hg

Hyperventilate only when critical signs of herniation Hyperventilate only when critical signs of herniation are presentare present

Neurological examNeurological exam


Assessment and ManagementAssessment and ManagementDrug therapyDrug therapy

Medical direction may prescribe drugs for head Medical direction may prescribe drugs for head injuries (considered controversial)injuries (considered controversial)

•• Mannitol for cerebral edemaMannitol for cerebral edema•• Lorazepam and diazepam for seizure activityLorazepam and diazepam for seizure activity

Rarely used in prehospital setting in HI due to sedationRarely used in prehospital setting in HI due to sedation•• Lidocaine to control ICP that occurs with ET intubationLidocaine to control ICP that occurs with ET intubation•• Sedatives and paralytics for airway managementSedatives and paralytics for airway management



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Glasgow Coma Scale (GCS)Glasgow Coma Scale (GCS)Evaluates:Evaluates:

Eye openingEye openingVerbal responsesVerbal responsesBrain stem reflex functionBrain stem reflex function

Evaluate at least every 5 minEvaluate at least every 5 minMild head injury: GCS 13Mild head injury: GCS 13--1515Moderate head injury: GCS 9Moderate head injury: GCS 9--1212Severe head injury: GCS Severe head injury: GCS <<88


Trauma Score (TS)Trauma Score (TS)Predicts outcome of patients with blunt or Predicts outcome of patients with blunt or penetrating injuriespenetrating injuries

Modified trauma index to include systolic Modified trauma index to include systolic blood pressure, respiratory rate, and the GCSblood pressure, respiratory rate, and the GCS

Limited use in prehospital settingLimited use in prehospital setting


Revised Trauma Score (RTS)Revised Trauma Score (RTS)GCS with systolic blood pressure and respiratory GCS with systolic blood pressure and respiratory rate rate

RTS essentially same as TS except for RTS essentially same as TS except for consideration of capillary refillconsideration of capillary refill

Patients with RTS of Patients with RTS of <<11 should be transferred 11 should be transferred to a level I trauma center to a level I trauma center



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Pediatric Trauma Score (PTS)Pediatric Trauma Score (PTS)Evaluates:Evaluates:

Size (weight)Size (weight)AirwayAirwayCentral nervous systemCentral nervous systemSystolic blood pressureSystolic blood pressureOpen woundOpen woundSkeletal injurySkeletal injury

Pediatric trauma patient with PTS <8 should be Pediatric trauma patient with PTS <8 should be transported to a level I trauma centertransported to a level I trauma center


Other MethodsOther Methods

CUPS systemCUPS systemAssigns patients to one of four categoriesAssigns patients to one of four categories

Constant monitoring of patient is crucialConstant monitoring of patient is crucial

Changes in patientChanges in patient’’s status may alter the s status may alter the course of a treatment plancourse of a treatment plan


ConclusionConclusionHead injuries affect nearly 4 million people each Head injuries affect nearly 4 million people each year in the United States. Approximately 50,000 year in the United States. Approximately 50,000 patients with severe head trauma die each year patients with severe head trauma die each year

before reaching the emergency department. before reaching the emergency department. Accurate assessment and appropriate Accurate assessment and appropriate

prehospital intervention can improve survival and prehospital intervention can improve survival and brain function for patients with these injuries.brain function for patients with these injuries.



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Questions?Questions?



chapter 24 head and facial traumas -...

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