head and facial injury

Head and Facial Head and Facial InjuryInjury

Scott Marquis, MDScott Marquis, MD

OverviewOverview

Head injuryHead injury What to look forWhat to look for Appropriate managementAppropriate management Facial injuryFacial injury ReviewReview

Head and brain traumaHead and brain trauma

~ 1,500,000 head injuries annually~ 1,500,000 head injuries annually ~ 230,000 hospitalized and survive~ 230,000 hospitalized and survive ~ 50,000 deaths~ 50,000 deaths 1/3 all injury-related deaths1/3 all injury-related deaths SeveritySeverity

75% mild75% mild 10% moderate10% moderate 10% severe (35% mortality, 5% c-spine fx)10% severe (35% mortality, 5% c-spine fx)

80,000-90,000 significant long-term 80,000-90,000 significant long-term disabilitydisability

Head & brain traumaHead & brain trauma

Risk GroupsRisk Groups Highest: Males 15-24 yrs of ageHighest: Males 15-24 yrs of age Very young children: 6 mos to 2 yrs of ageVery young children: 6 mos to 2 yrs of age Young school age childrenYoung school age children Elderly >75 yrsElderly >75 yrs

Head injuryHead injury

Broad and Inclusive TermBroad and Inclusive Term Traumatic insult to the head that may result Traumatic insult to the head that may result

in injury to soft tissue, bony structures, in injury to soft tissue, bony structures, and/or brain injuryand/or brain injury

Blunt TraumaBlunt Trauma Penetrating TraumaPenetrating Trauma

Brain injuryBrain injury

““A traumatic insult to the brain capable A traumatic insult to the brain capable of producing physical, intellectual, of producing physical, intellectual, emotional, social and vocational emotional, social and vocational changes”changes”

Three broad categoriesThree broad categories Focal injuryFocal injury

Cerebral contusionCerebral contusion Intracranial hemorrhageIntracranial hemorrhage Epidural hemorrhageEpidural hemorrhage

Subarachnoid hemorrhageSubarachnoid hemorrhage Diffuse Axonal InjuryDiffuse Axonal Injury

ConcussionConcussion

Mechanisms of head injuryMechanisms of head injury Motor vehicle crashes, MVCMotor vehicle crashes, MVC

Most common cause of head traumaMost common cause of head trauma Most common cause of subdural hematomaMost common cause of subdural hematoma

Sports injuriesSports injuries FallsFalls

Common in elderly and in presence of alcoholCommon in elderly and in presence of alcohol Associated with subdural hematomasAssociated with subdural hematomas

Penetrating traumaPenetrating trauma Missiles more common than sharp projectilesMissiles more common than sharp projectiles

Categories of injuryCategories of injury

Coup injuryCoup injury Directly posterior to point of impactDirectly posterior to point of impact More common when front of head struckMore common when front of head struck

Contrecoup injuryContrecoup injury Directly opposite the point of impactDirectly opposite the point of impact More common when back of head struckMore common when back of head struck

Categories of injuryCategories of injury

Diffuse axonal injury (DAI)Diffuse axonal injury (DAI) Shearing, tearing or stretching of nerve Shearing, tearing or stretching of nerve

fibers fibers More common with vehicle occupant and More common with vehicle occupant and

pedestrianpedestrian Focal injuryFocal injury

Limited and identifiable site of injuryLimited and identifiable site of injury

Causes of brain injuryCauses of brain injury

Direct (primary) causesDirect (primary) causes ImpactImpact Mechanical disruption of cellsMechanical disruption of cells Vascular permeability or disruptionVascular permeability or disruption

Indirect (secondary or tertiary) causesIndirect (secondary or tertiary) causes SecondarySecondary

Edema, hemorrhage, infection, inadequate Edema, hemorrhage, infection, inadequate perfusion, tissue hypoxia, pressureperfusion, tissue hypoxia, pressure

TertiaryTertiary Apnea, hypotension, pulmonary resistance, Apnea, hypotension, pulmonary resistance,

ECG changesECG changes

The brain is enclosed in a boxThe brain is enclosed in a box

Brain anatomyBrain anatomy

Occupies 80% of intracranial spaceOccupies 80% of intracranial space DivisionsDivisions

CerebrumCerebrum CerebellumCerebellum Brain StemBrain Stem


Cerebral spinal fluid, CSFCerebral spinal fluid, CSF Clear, colorlessClear, colorless Circulates throughout brain and spinal cordCirculates throughout brain and spinal cord Cushions and protectsCushions and protects VentriclesVentricles

Center of brainCenter of brain Secrete CSF by filtering bloodSecrete CSF by filtering blood Forms blood-brain barrierForms blood-brain barrier


Blood SupplyBlood Supply Vertebral arteries Vertebral arteries

Supply posterior brain (cerebellum and brain Supply posterior brain (cerebellum and brain stem)stem)

Carotid arteriesCarotid arteries Most of cerebrumMost of cerebrum


MeningesMeninges Dura mater: tough outer layer, separates Dura mater: tough outer layer, separates

cerebellum from cerebral structures, landmark cerebellum from cerebral structures, landmark for lesionsfor lesions

Arachnoid: web-like, venous vessels that Arachnoid: web-like, venous vessels that reabsorb CSFreabsorb CSF

Pia mater: directly attached to brain tissuePia mater: directly attached to brain tissue

Scalp lacerationsScalp lacerations

Scalp laceration or avulsionScalp laceration or avulsion Most common injuryMost common injury Vascularity = diffuse bleedingVascularity = diffuse bleeding Generally does not cause hypovolemia in Generally does not cause hypovolemia in

adultsadults Can produce hypovolemia in childrenCan produce hypovolemia in children

Scalp anatomyScalp anatomy

ScalpScalp SS: skin: skin CC: connective tissue: connective tissue AA: aponeurosis (galea): aponeurosis (galea) LL: loose areolar tissue: loose areolar tissue PP: pericranium: pericranium

Scalp very vascularScalp very vascular major blood loss major blood loss watch kids and adults with prolonged watch kids and adults with prolonged

extricationextrication

Skull fractureSkull fracture


Present in 60% of pts with severe head Present in 60% of pts with severe head injuryinjury

Types:Types: Linear: usually incidental finding on CTLinear: usually incidental finding on CT Depressed: mechanism is usually intense Depressed: mechanism is usually intense

blow to scalp with object of small blow to scalp with object of small

surface area. Surgical repair needed surface area. Surgical repair needed

if depressed more than 5mmif depressed more than 5mm


TypesTypes Basilar: blow to temporal (most often), Basilar: blow to temporal (most often),

parietal, occipital areaparietal, occipital area SignsSigns

Hemotympanum or bloody ear dischargeHemotympanum or bloody ear discharge Rhinorrhea or otorrheaRhinorrhea or otorrhea Battle’s sign Battle’s sign Racoon’s eyesRacoon’s eyes Cranial nerve palsiesCranial nerve palsies

Closed head injuriesClosed head injuries

FocalFocal ContusionContusion Epidural hematomaEpidural hematoma Subdural hematomaSubdural hematoma IntracerebralIntracerebral

Diffuse (most common type of head injury)Diffuse (most common type of head injury) Mild concussionMild concussion Classic concussionClassic concussion Diffuse Axonal Injury (DAI)Diffuse Axonal Injury (DAI)

Epidural hematomaEpidural hematoma

Blood between Blood between skull and duraskull and dura

Usually arterial Usually arterial teartear Middle meningeal Middle meningeal

arteryartery Causes increased Causes increased

ICPICP

Epidural hematomaEpidural hematoma

Unconsciousness followed by lucid Unconsciousness followed by lucid intervalinterval

Rapid deteriorationRapid deterioration Decreased LOC, headache, nausea, Decreased LOC, headache, nausea,

vomitingvomiting Hemiparesis, hemiplegiaHemiparesis, hemiplegia Unequal pupils (dilated on side of clot)Unequal pupils (dilated on side of clot) Increase BP, decreased pulse (Cushing’s Increase BP, decreased pulse (Cushing’s

reflex)reflex)

Subdural HematomaSubdural Hematoma

Between dura mater Between dura mater and arachnoidand arachnoid

More commonMore common Usually venousUsually venous

Bridging veins Bridging veins between cortex and between cortex and duradura

Causes increased Causes increased intracranial pressureintracranial pressure

Subdural hematomaSubdural hematoma

Slower onsetSlower onset Increased ICPIncreased ICP Headache, decreased LOC, unequal Headache, decreased LOC, unequal

pupils pupils Increased BP, decreased pulseIncreased BP, decreased pulse Hemiparesis, hemiplegiaHemiparesis, hemiplegia

Intracerebral hematomaIntracerebral hematoma

Usually due to laceration of brainUsually due to laceration of brain Bleeding into cerebral substanceBleeding into cerebral substance Associated with other injuriesAssociated with other injuries

DAIDAI Neuro deficits depend on region Neuro deficits depend on region

involved and sizeinvolved and size Repetitive with frontal lobeRepetitive with frontal lobe

Increased ICPIncreased ICP

ConcussionConcussion

Transient loss of consciousnessTransient loss of consciousness Retrograde amnesia, confusionRetrograde amnesia, confusion Resolves spontaneously without deficitResolves spontaneously without deficit Usually due to blunt head traumaUsually due to blunt head trauma

Diffuse axonal injuryDiffuse axonal injury

Tearing or shearing of nerve fibers at Tearing or shearing of nerve fibers at time of impacttime of impact

Rapid acceleration-deceleration injury Rapid acceleration-deceleration injury (MVA)(MVA)

Functional or physiologic dysfunction Functional or physiologic dysfunction Not gross anatomic abnormalityNot gross anatomic abnormality Most common CT finding after severe Most common CT finding after severe

head traumahead trauma

Diffuse axonal injuryDiffuse axonal injury

Prolonged post-traumatic coma not due Prolonged post-traumatic coma not due to mass lesion or ischemic insultsto mass lesion or ischemic insults

Coma begins at time of traumaComa begins at time of trauma Usually evidence of decorticate or Usually evidence of decorticate or

decerebrate posturing, autonomic decerebrate posturing, autonomic dysfunction (HTN, fever)dysfunction (HTN, fever)

Penetrating head injuryPenetrating head injury Severity depends onSeverity depends on

Energy of missile Energy of missile PathPath Amount of scatter of bone and metal fragmentsAmount of scatter of bone and metal fragments Presence of mass lesionPresence of mass lesion

Accompanied by Accompanied by Severe face and neck injuries Severe face and neck injuries Significant blood lossSignificant blood loss Difficult airwayDifficult airway Spinal instabilitySpinal instability

What the brain needsWhat the brain needs

High metabolic rateHigh metabolic rate Consumes 20% of body’s oxygenConsumes 20% of body’s oxygen Largest user of glucoseLargest user of glucose Requires thiamineRequires thiamine Can not store nutrientsCan not store nutrients

More on brain workingsMore on brain workings

PerfusionPerfusion Cerebral blood flow (CBF)Cerebral blood flow (CBF)

Dependent upon CPPDependent upon CPP Flow requires pressure gradientFlow requires pressure gradient

Cerebral perfusion pressure (CPP)Cerebral perfusion pressure (CPP) Pressure moving the blood through the Pressure moving the blood through the

craniumcranium Autoregulation allows BP change to Autoregulation allows BP change to

maintain CPPmaintain CPP CPP = mean arterial pressure (MAP) - CPP = mean arterial pressure (MAP) -

intracranial pressure (ICP)intracranial pressure (ICP)


PerfusionPerfusion Mean Arterial Pressure (MAP)Mean Arterial Pressure (MAP)

Largely dependent on cerebral vascular Largely dependent on cerebral vascular resistance (CVR) since diastolic is main resistance (CVR) since diastolic is main componentcomponent

Blood volume and myocardial Blood volume and myocardial contractilitycontractility

MAP = diastolic + 1/3 pulse pressureMAP = diastolic + 1/3 pulse pressure Usually require MAP of at least 60 mm Hg Usually require MAP of at least 60 mm Hg

to perfuse brainto perfuse brain


PerfusionPerfusion Intracranial pressure (ICP)Intracranial pressure (ICP)

Edema, hemorrhageEdema, hemorrhage ICP usually 10-15 mm HgICP usually 10-15 mm Hg

Cerebral perfusion pressure Cerebral perfusion pressure

CPP = MAP - ICPCPP = MAP - ICP

What goes wrong in head What goes wrong in head injuryinjury

As ICP As ICP and approaches MAP, cerebral and approaches MAP, cerebral blood flow blood flow Results in Results in CPP CPP Compensatory mechanisms attempt to Compensatory mechanisms attempt to

MAPMAP As CPP As CPP , cerebral vasodilation occurs to , cerebral vasodilation occurs to

blood volumeblood volume This leads to further This leads to further ICP, ICP, CPP and so on CPP and so on


Hypercarbia causes cerebral Hypercarbia causes cerebral vasodilationvasodilation Results in Results in blood volume blood volume ICP ICP

CPPCPP Compensatory mechanisms attempt Compensatory mechanisms attempt

to to MAP MAP As CPP As CPP , cerebral vasodilation , cerebral vasodilation

occurs to occurs to blood volume blood volume And, the cycle continuesAnd, the cycle continues


Hypotension results in Hypotension results in CPP CPP cerebral vasodilationcerebral vasodilation Results in Results in blood volume blood volume ICP ICP CPP CPP And, the cycle continuesAnd, the cycle continues


Pressure exerted downward on brainPressure exerted downward on brain Cerebral cortex or RASCerebral cortex or RAS

Altered level of consciousnessAltered level of consciousness HypothalamusHypothalamus

VomitingVomiting


Pressure exerted downward on brainPressure exerted downward on brain Brain stemBrain stem

BP and bradycardia 2° vagal BP and bradycardia 2° vagal stimulationstimulation

Irregular respirations or tachypneaIrregular respirations or tachypnea Unequal/unreactive pupils 2° oculomotor Unequal/unreactive pupils 2° oculomotor

nerve paralysisnerve paralysis PosturingPosturing

Seizures dependent on location of injurySeizures dependent on location of injury

HerniationHerniation

TranstentorialTranstentorial UncalUncal

What you see on examWhat you see on exam

Levels of increasing ICPLevels of increasing ICP Cerebral cortex and upper brain stemCerebral cortex and upper brain stem

BP rising and pulse rate slowingBP rising and pulse rate slowing Pupils reactivePupils reactive Cheyne-Stokes respirationsCheyne-Stokes respirations Initially try to localize and remove painful Initially try to localize and remove painful

stimulistimuli


Levels of increasing ICPLevels of increasing ICP Middle brain stemMiddle brain stem

Wide pulse pressure and bradycardiaWide pulse pressure and bradycardia Pupils nonreactive or sluggishPupils nonreactive or sluggish Central neurogenic hyperventilationCentral neurogenic hyperventilation ExtensionExtension


Levels of increasing ICPLevels of increasing ICP Lower brain stem / medullaLower brain stem / medulla

Pupil blown (side of injury)Pupil blown (side of injury) Ataxic or absent respirations Ataxic or absent respirations FlaccidFlaccid Irregular or changing pulse rateIrregular or changing pulse rate Decreased BPDecreased BP Usually not survivableUsually not survivable

Global function: Global function: assessmentassessment

LOC = best indicatorLOC = best indicator Altered LOC = Intracranial trauma UPOAltered LOC = Intracranial trauma UPO Trauma patient unable to follow commands Trauma patient unable to follow commands

= chance of = chance of intracranial injury needing surgeryintracranial injury needing surgery

Global functionGlobal function

AVPU scaleAVPU scale A = AlertA = Alert V = Responds to Verbal stimuliV = Responds to Verbal stimuli P = Responds to Painful stimuliP = Responds to Painful stimuli U = UnresponsiveU = Unresponsive

General brain functionGeneral brain function

Glasgow Coma Scale, GCSGlasgow Coma Scale, GCS Eye openingEye opening Verbal responseVerbal response Motor responseMotor response

Reliable measure, repeatableReliable measure, repeatable

Glasgow Coma ScaleGlasgow Coma Scale

EyesEyes VerbalVerbal MotorMotor1: Spontaneous1: Spontaneous 1: Oriented1: Oriented 1: Spontaneous1: Spontaneous

2: Voice2: Voice 2: Confused2: Confused 2: Localizes2: Localizes

3: Pain3: Pain 3: 3: InappropriateInappropriate

3: Withdraws3: Withdraws

4: 4: UnresponsiveUnresponsive

4: Incompre-4: Incompre-hensiblehensible

4: Decorticate4: Decorticate

5: Nonverbal5: Nonverbal 5: Decerebrate5: Decerebrate

6: 6: UnresponsiveUnresponsive

EyesEyes

Window to soul and CNSWindow to soul and CNS Pupil size, equality, and response to Pupil size, equality, and response to

lightlight

EyesEyes

Unequal pupils + decreased LOC =Unequal pupils + decreased LOC = Compression of oculomotor nerveCompression of oculomotor nerve Probable mass lesionProbable mass lesion

Unequal pupils + alert patient = Unequal pupils + alert patient = Direct blow to eye, or Direct blow to eye, or Oculomotor nerve injury, orOculomotor nerve injury, or Normal inequalityNormal inequality

MovementMovement

Is patient able to move all extremities?Is patient able to move all extremities? How do they move?How do they move?

DecorticateDecorticate DecerebrateDecerebrate Hemiparesis or hemiplegiaHemiparesis or hemiplegia Paraplegia or quadraplegiaParaplegia or quadraplegia

MovementMovement

Lateralized or focal signs = Lateralized or focal signs =

lateralized or focal deficits lateralized or focal deficits Altered motor function may be due to Altered motor function may be due to

fracture or dislocationfracture or dislocation

Vital SignsVital Signs

Cushing’s triadCushing’s triad Suggests increased intracranial Suggests increased intracranial

pressurepressure Increased BPIncreased BP Decreased pulseDecreased pulse Irregular respiratory patternIrregular respiratory pattern

Vital SignsVital Signs

Isolated head injury will Isolated head injury will notnot cause cause hypotension in adultshypotension in adults

Look for another life threatening injuryLook for another life threatening injury ChestChest AbdomenAbdomen PelvisPelvis Multiple long bone fracturesMultiple long bone fractures Large scalp lacerationsLarge scalp lacerations

Summary for assessmentSummary for assessment

Most important sign = LOCMost important sign = LOC Direction of changes more important Direction of changes more important

than single observationsthan single observations Importance lies in continued Importance lies in continued

reassessment compared with initial reassessment compared with initial examexam

UPO, altered LOC in trauma = UPO, altered LOC in trauma = intracranial injuryintracranial injury

Goals for treatmentGoals for treatment

Maintain adequate oxygenationMaintain adequate oxygenation Maintain sufficient BP for good brain Maintain sufficient BP for good brain

perfusionperfusion Avoid secondary brain damageAvoid secondary brain damage

Blood pressureBlood pressure

A single episode of hypotension =A single episode of hypotension =

doubles patient mortalitydoubles patient mortality

OxygenationOxygenation

Hypoxemia is a strong predictor of poor Hypoxemia is a strong predictor of poor outcomeoutcome

Airway managementAirway management

OpenOpen Assume C-spine traumaAssume C-spine trauma Jaw thrust with C-spine controlJaw thrust with C-spine control

ClearClear Suction as neededSuction as needed

Maintain or secureMaintain or secure Intubation if no gag reflexIntubation if no gag reflex RSI, lidocaine and vecuroniumRSI, lidocaine and vecuronium Avoid nasal intubationAvoid nasal intubation

BreathingBreathing

Oxygenate - 100% OOxygenate - 100% O22

VentilateVentilate NoNo routine hyperventilation routine hyperventilation

Adults 10-12 BPMAdults 10-12 BPM Children 12-16 BPMChildren 12-16 BPM Infants 16-20 BPMInfants 16-20 BPM

BreathingBreathing

Respiratory PatternsRespiratory Patterns Cheyne StokesCheyne Stokes

Diffuse injury to cerebral hemispheresDiffuse injury to cerebral hemispheres Central neurological hyperventilationCentral neurological hyperventilation

Injury to mid-brainInjury to mid-brain ApneusticApneustic

Injury to ponsInjury to pons

VentilationVentilation

Hyperventilation recommended Hyperventilation recommended onlyonly for for signs of cerebral herniationsigns of cerebral herniation!! Posturing Posturing Pupillary abnormalities Pupillary abnormalities Neurologic deterioration after correction of Neurologic deterioration after correction of

hypotension or hypoxemia hypotension or hypoxemia Decrease in GCS of more than two points in Decrease in GCS of more than two points in

patients with initial GCS less than 9patients with initial GCS less than 9 Adults 16-20 BPMAdults 16-20 BPM Children 20-24 BPMChildren 20-24 BPM Infants 24-28 BPMInfants 24-28 BPM

HyperventilationHyperventilation

BenefitsBenefits Decreased PaCODecreased PaCO22

VasoconstrictionVasoconstriction Decreased ICPDecreased ICP

RisksRisks Decreased cerebral blood flowDecreased cerebral blood flow Decreased oxygen delivery to tissuesDecreased oxygen delivery to tissues Increased edemaIncreased edema

CirculationCirculation

Maintain adequate BP and perfusionMaintain adequate BP and perfusion IV of LR/NS TKO if BP normal or elevatedIV of LR/NS TKO if BP normal or elevated If BP decreasedIf BP decreased

LR/NS bolus titrated to SBP ~ 90 mm Hg LR/NS bolus titrated to SBP ~ 90 mm Hg Consider PASG/MAST if SBP below 80Consider PASG/MAST if SBP below 80

Monitor EKG -- Do not treat bradycardiaMonitor EKG -- Do not treat bradycardia

ImmobilizationImmobilization

Spinal motion restrictionSpinal motion restriction If BP normal or elevated, spine board If BP normal or elevated, spine board

head elevated 30head elevated 3000

Intravenous therapyIntravenous therapy

Drug therapy considerationsDrug therapy considerations Only after:Only after:

Management of ABC’s Management of ABC’s Controlled hyperventilationControlled hyperventilation

Useful drugsUseful drugs

DiazepamDiazepam AnticonvulsantAnticonvulsant Give if patient experiences seizuresGive if patient experiences seizures 5 mg IV5 mg IV May mask changes in LOCMay mask changes in LOC May depress respirations May depress respirations May worsen hypotensionMay worsen hypotension


VecuroniumVecuronium RSIRSI Defasciculating doseDefasciculating dose Decrease brain oxygen demandDecrease brain oxygen demand


LidocaineLidocaine RSI, few minutes priorRSI, few minutes prior 1.5 mg/kg IV1.5 mg/kg IV Prevents increases in ICPPrevents increases in ICP


MannitolMannitol Decreases cerebral edemaDecreases cerebral edema Improves cerebral blood flow and oxygen Improves cerebral blood flow and oxygen

deliverydelivery Plasma expanderPlasma expander Osmotic diureticOsmotic diuretic 1 g/kg IV1 g/kg IV May cause hypotensionMay cause hypotension May worsen intracranial hemorrhageMay worsen intracranial hemorrhage Don’t have it!Don’t have it!

GlucoseGlucose

Assess blood glucoseAssess blood glucose Administer only if hypoglycemicAdminister only if hypoglycemic Hyperglycemia can harm injured brain Hyperglycemia can harm injured brain

secondary to osmotic shiftssecondary to osmotic shifts Consider thiamine in malnourishedConsider thiamine in malnourished

Transport of head injuriesTransport of head injuries

Choose trauma centerChoose trauma center Any moderate and severe (GCS 3-13) Any moderate and severe (GCS 3-13)

need to go to trauma center where need to go to trauma center where neurosurgery is availableneurosurgery is available

Air medical transport if neededAir medical transport if needed Severe injuries need to be recognized Severe injuries need to be recognized

quickly and transported rapidly as early quickly and transported rapidly as early surgical intervention is often only truly surgical intervention is often only truly lifesaving treatmentlifesaving treatment

Helmet removalHelmet removal

Immediate removal if interferes with Immediate removal if interferes with prioritiespriorities Access to airway or airway managementAccess to airway or airway management VentilationVentilation Cervical spine motion restrictionCervical spine motion restriction

May only need to remove face piece to May only need to remove face piece to access airwayaccess airway

TechniqueTechnique Requires adequate assistanceRequires adequate assistance Training in the procedureTraining in the procedure Padding if shoulder pads left onPadding if shoulder pads left on

SummarySummary

Spinal precautionsSpinal precautions Avoid hypoxiaAvoid hypoxia Consider intubation earlyConsider intubation early Avoid hypotensionAvoid hypotension Frequent reassessmentFrequent reassessment Hyperventilate for herniationHyperventilate for herniation Triage wiselyTriage wisely

Any questions?Any questions?

ResourcesResources

www.braintrauma.orgwww.braintrauma.org

Facial injuriesFacial injuries

MortalityMortality Primarily associated with brain and spine Primarily associated with brain and spine

injuryinjury Severe facial fractures may interfere with Severe facial fractures may interfere with

airway and breathingairway and breathing MorbidityMorbidity

Disability concernsDisability concerns Cosmetic concernsCosmetic concerns

Facial traumaFacial trauma

Seldom life-threat unless injury involves Seldom life-threat unless injury involves the airwaythe airway

Spinal motion restrictionSpinal motion restriction Airway is the most difficult and most Airway is the most difficult and most

critical prioritycritical priority Consider early intubationConsider early intubation Suction and control bleedingSuction and control bleeding Critical trauma patient - transport Critical trauma patient - transport

accordinglyaccordingly

Facial traumaFacial trauma

CausesCauses MVC, home accidents, athletic injuries, MVC, home accidents, athletic injuries,

animal bites, violence, industrial accidents…animal bites, violence, industrial accidents… Soft tissueSoft tissue

Lacerations, abrasions, avulsionsLacerations, abrasions, avulsions Vascular area supplied by internal and Vascular area supplied by internal and

external carotidsexternal carotids

Facial bone anatomyFacial bone anatomy

Frontal Frontal NasalNasal Zygoma / zygomatic archZygoma / zygomatic arch MaxillaMaxilla MandibleMandible

Facial fracturesFacial fractures

Mandible, maxilla, nasal bones, zygoma Mandible, maxilla, nasal bones, zygoma & rarely the frontal bone& rarely the frontal bone

Signs and symptomsSigns and symptoms Pain, swelling, deep lacerations, limited Pain, swelling, deep lacerations, limited

ocular movement, facial asymmetry, ocular movement, facial asymmetry, crepitus, deviated nasal septum, bleeding, crepitus, deviated nasal septum, bleeding, depression on palpation, malocclusion, depression on palpation, malocclusion, blurred vision, diplopia, broken or missing blurred vision, diplopia, broken or missing teethteeth

Midface fracturesMidface fractures

May be significant hemorrhageMay be significant hemorrhage C-spine precautionsC-spine precautions Avoid nasotracheal intubation, if Avoid nasotracheal intubation, if

possiblepossible LeFort fractureLeFort fracture Tripod fractureTripod fracture

Midface fracturesMidface fractures

AppearanceAppearance ““Donkey face” (lengthening)Donkey face” (lengthening) ““Pumpkin face” (edema)Pumpkin face” (edema) Nasal flatteningNasal flattening

Often associated with orbital fracturesOften associated with orbital fractures

LeFort fracturesLeFort fractures

Mouth injuriesMouth injuries

MVCMVC Blunt injury to the mouth or chinBlunt injury to the mouth or chin Penetrating injury due to GSW, Penetrating injury due to GSW,

laceration, or puncturelaceration, or puncture

Mouth injuriesMouth injuries

Primary concernsPrimary concerns Airway compromise secondary to bleedingAirway compromise secondary to bleeding FB aspiration secondary to broken or FB aspiration secondary to broken or

avulsed teethavulsed teeth Impaled objectImpaled object

ManagementManagement ABCsABCs

Suction prnSuction prn Stabilize impaled objectStabilize impaled object Collect tissue: tongue or toothCollect tissue: tongue or tooth

Mandibular injuriesMandibular injuries Mandibular FractureMandibular Fracture

Numbness, inability to open or close the Numbness, inability to open or close the mouth, excessive salivation, malocclusionmouth, excessive salivation, malocclusion

Bilateral body or midline injuries may Bilateral body or midline injuries may compromise airwaycompromise airway

C-spine immobilizationC-spine immobilization Anterior dislocationAnterior dislocation

May be caused by extensive dental work, May be caused by extensive dental work, yawningyawning

Condylar heads move forward and muscles Condylar heads move forward and muscles spasmspasm

Dental traumaDental trauma

32 teeth in normal adult, 20 teeth in 32 teeth in normal adult, 20 teeth in childrenchildren

Associated with facial fracturesAssociated with facial fractures May aspirate broken toothMay aspirate broken tooth Avulsed teeth can be replaced so find Avulsed teeth can be replaced so find

them!them! Early hospital notification to find dentistEarly hospital notification to find dentist

Dental traumaDental trauma

<15 minutes, may be asked to replace <15 minutes, may be asked to replace the tooth in socketthe tooth in socket

Do not rinse or scrub (removes Do not rinse or scrub (removes periodontal membrane and ligament)periodontal membrane and ligament)

Preserve in fresh whole milkPreserve in fresh whole milk Saline OK for less than 1 hourSaline OK for less than 1 hour

Nasal injuriesNasal injuries

Variety of mechanisms including blunt Variety of mechanisms including blunt or penetrating traumaor penetrating trauma

Swelling, deformity, crepitanceSwelling, deformity, crepitance Most common injuryMost common injury

Adults - EpistaxisAdults - Epistaxis Children - Foreign bodiesChildren - Foreign bodies

Nasal injuriesNasal injuries

EpistaxisEpistaxis Anterior bleeding from septumAnterior bleeding from septum

Usually venousUsually venous Posterior bleedingPosterior bleeding

Often drains to airwayOften drains to airway May be associated withMay be associated with

Sphenoid and/or ethmoid fracturesSphenoid and/or ethmoid fractures Basilar skull fractureBasilar skull fracture

Nasal injury: managementNasal injury: management

EpistaxisEpistaxis Direct pressure over septumDirect pressure over septum Upright position, leaning forward or in Upright position, leaning forward or in

lateral recumbent positionlateral recumbent position If CSF present, do not apply direct If CSF present, do not apply direct

pressurepressure Allow to drainAllow to drain Needs neurosurgical consultNeeds neurosurgical consult

Eye injury typesEye injury types

PenetratingPenetrating AbrasionsAbrasions Foreign bodies (deep, superficial, impaled)Foreign bodies (deep, superficial, impaled) Lacerations (deep or superficial, eyelid)Lacerations (deep or superficial, eyelid)

BurnsBurns FlashFlash Acid/alkaliAcid/alkali

Eye injury typesEye injury types

BluntBlunt SwellingSwelling Conjunctival hemorrhageConjunctival hemorrhage HyphemaHyphema Ruptured globeRuptured globe Blow-out fracture of orbitBlow-out fracture of orbit Retinal detachmentRetinal detachment

Blow-out orbital fractureBlow-out orbital fracture

Usually result of a direct blow to the eyeUsually result of a direct blow to the eye Flattened face, numbnessFlattened face, numbness Epistaxis, altered visionEpistaxis, altered vision Periorbital swellingPeriorbital swelling DiplopiaDiplopia InophthalmosInophthalmos Impaired ocular movementImpaired ocular movement

Globe injuriesGlobe injuries

Contusion, laceration, hyphema, globe Contusion, laceration, hyphema, globe or scleral ruptureor scleral rupture

Signs and symptoms - loss of visual Signs and symptoms - loss of visual acuity, blood in anterior chamber, acuity, blood in anterior chamber, dilation or constriction of pupil, pain, dilation or constriction of pupil, pain, soft eye, pupil irregularitysoft eye, pupil irregularity

Globe injuriesGlobe injuries

Consider C-spine precautions due to Consider C-spine precautions due to forces required for injuryforces required for injury

No pressure to globe for dressing, cover No pressure to globe for dressing, cover both eyes for protectionboth eyes for protection

Avoid activities that increase intra-Avoid activities that increase intra-ocular pressureocular pressure

Ear injuryEar injury External injuriesExternal injuries

Lacerations, avulsions, amputations, frostbiteLacerations, avulsions, amputations, frostbite Control bleeding with direct pressureControl bleeding with direct pressure

Internal injuriesInternal injuries Spontaneous rupture of eardrum will usually Spontaneous rupture of eardrum will usually

heal spontaneouslyheal spontaneously Penetrating objects should be stabilized, not Penetrating objects should be stabilized, not

removed! removed! Removal may cause deafness or facial Removal may cause deafness or facial

paralysisparalysis Hearing loss may be result of otic nerve Hearing loss may be result of otic nerve

damage in basilar skull fracturedamage in basilar skull fracture

Ear injuryEar injury

Separation of ear cartilageSeparation of ear cartilage Treat as an avulsionTreat as an avulsion Dress and bandageDress and bandage Consider disability and cosmetic concernsConsider disability and cosmetic concerns

Bleeding from ear canalBleeding from ear canal Cover with loose dressing onlyCover with loose dressing only

SummarySummary

Control bleedingControl bleeding Manage airway accordinglyManage airway accordingly Avoid nasal tracheal intubation when Avoid nasal tracheal intubation when

possiblepossible Assume c-spine injury is presentAssume c-spine injury is present Gather parts and stabilize objectsGather parts and stabilize objects Trauma survey for other life-threatsTrauma survey for other life-threats Transport accordinglyTransport accordingly

Questions?Questions?

head and facial injury

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