Transcript Head, Facial, & Neck Trauma

Head, Facial, & Neck
Trauma
Sections
 Introduction to Head, Facial, & Neck
Injuries
 Anatomy and Physiology of the Head,
Face, & Neck
 Pathophysiology of Head, Facial, &
Neck Injury
 Assessment and Management of Head,
Facial, & Neck Injuries
 Head, Facial, & Neck Injury
Management
Introduction to Head, Facial,
& Neck Injuries
 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
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Males 15-24
Infants
Young Children
Elderly
Introduction to Head, Facial,
& Neck Injuries
 Injury Prevention Programs
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Motorcycle Safety
Bicycle Safety
Helmet & Head Injury Awareness Programs
Other Sports
 Football
 Rollerblading
 Contact Sports
Introduction to Head, Facial,
& Neck Injuries
 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
Anatomy & Physiology
Head, Face & Neck
 Anatomy & Physiology of the Head
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Scalp
Cranium
Meninges
Cerebrospinal Fluid
Brain
CNS Circulation
Blood-Brain Barrier
Cerebral Perfusion Pressure
Cranial Nerves
Ascending Reticular Activating System
Anatomy & Physiology
of the Head
 Scalp
 Strong Flexible mass of
 Skin
 Fascia
 Muscular Tissue
 Highly Vascular
 Hair provides Insulation
 Structures Beneath
 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
Anatomy & Physiology
of the Head
Recalling Structures of the Scalp
S - skin
C - connective tissue
A - aponeurotica
L - layer of areolar tissue
P - periosteum of skull
Anatomy & Physiology
of the Head
 Skull comprised of
 Facial bones
 Cranium
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Vault for the brain
Strong, light, rigid, spherical bone
Unyielding to increased intracranial pressure (ICP)
Bones
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Frontal
Parietal
Occipital
Temporal
Ethmoid
Sphenoid
Sphenoid
Parietal
Suture Line
Frontal
Temporal
Orbits
Maxillae
Mandible
Temporal Mandibular Joint
Nasal Bones
Foramen Magnum (Hole in Base)
Occiptal Zygomatic Arch
Anatomy & Physiology
of the Head
 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
 Abrade
 Contusion
 Laceration
Anatomy & Physiology
of the Head
 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
Anatomy & Physiology
of the Head
 Meninges
 Pia Mater
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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 & Elastin fibers
 Subarachnoid Space beneath
• CSF
• Cushions brain
Anatomy & Physiology
of the Head
 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
Anatomy & Physiology
of the Head
 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
Anatomy & Physiology
of the Head
 Cerebrum
 Function
 Center of conscious thought, personality, speech, and
motor control
 Visual, auditory, and tactile perception
 Lobes
 Frontal
• Personality
 Parietal
• Motor & Sensory Activity
• Memory & Emotion
(continued)
Anatomy & Physiology
of the Head
 Occipital
• Sight
 Temporal
• Long-term memory
• Hearing, Speech, Taste & Smell
Anatomy & Physiology
of the Head
 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 thru incisura tentorri cerebelli
 Occulomotor Nerve (CN-III) travels along
• Controls pupil size
• Compression results in pupillary disturbances
Anatomy & Physiology
of the Head
 Cerebrum
 Hemisphere Functions
 Left: DOMINANT
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Mathematical computations: Occipital
Writing: Parietal
Language interpretation: Occipital
Speech: Frontal
 Right: NON-DOMINANT
• Non-verbal imagery
Anatomy & Physiology
of the Head
 Cerebellum
 Located under tentorium
 Function
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“Fine tunes” motor control
Allows smooth movement
Balance
Maintenance of muscle tone
Anatomy & Physiology
of the Head
 Brainstem
 Central processing center
 Communication junction among
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Cerebrum
Spinal cord
Cranial nerves
Cerebellum
 Structures
 Midbrain
 Pons
 Medulla Oblongata
Anatomy & Physiology
of the Head
 Midbrain
 Upper portion of brainstem
 Structures
 Hypothalamus
• Endocrine function, vomiting reflex, hunger, thirst
• Kidney function, body temperature, emotion
 Thalamus
• Switching center between pons & cerebrum
• Critical Element in Ascending Reticular Activating System (A-RAS)
 ESTABLISHES CONSCIOUSNESS
• Major pathways for optic & olfactory nerves
 Associated Structures
Anatomy & Physiology
of the Head
 Pons
 Communication interchange between
cerebellum, cerebrum, midbrain, and spinal
cord
 Bulb shaped structure above medulla
 Sleeping phase of the RAS
Anatomy & Physiology
of the Head
 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
Anatomy & Physiology
of the Head
 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
Anatomy & Physiology
of the Head
 Blood-Brain Barrier
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Less permeable than elsewhere in body
DO NOT allow flow of interstitial proteins
Reduced lymphatic flow
Very protected environment
Blood acts as irritant resulting in cerebral
edema
Anatomy & Physiology
of the Head
 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
Anatomy & Physiology
of the Head
 Calculating MAP
BP  120/90
DBP  90
Pulse Pressure 120- 90  30
MAP  80  13  30  90
 Calculating CPP
MAP  90 & ICP  10
CPP  MAP - ICP
CPP  90 - 10  80
Anatomy & Physiology
of the Head
 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
Anatomy & Physiology
of the Head
 Cranial Nerves
 12 pair with distinct pathways
 Senses, facial innervation, & 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
CN
Name
F
Innervation
I
Olfactory
S
Smell
II
Optic
S
Sight
III
Oculomotor
M
Pupil Const, Rectus & Obliques
IV
Trochlear
M
Superior Obliques
Trigeminal
S
Opthalmic (FH), Maxillary (cheek) Mandible (chin)
V
M
Chewing muscles
VI
Abducens
M
Lateral rectus muscle
S
Tongue
M
Face Muscles
VII
Facial
VIII
Acoustic
S
Hearing balance
S
Posterior pharynx, taste to anterior tongue
IX
Glossopharyngeal
M
Face Muscles
S
Taste to posterior tongue
M
Posterior palate and pharynx
X
Vagus
XI
Accessory
M
Trapezius & Sternocleido. Muscles
XII
Hypoglossal
M
Tongue
Anatomy & Physiology
Head, Face & Neck
 Anatomy & Physiology of the Face
 Structure
 Ear
 Eye
Anatomy & Physiology
of the Face
 Structure
 Facial Bones
 Zygoma
• Prominent bone of the cheek
• Protects eyes
• Attachment for muscles controlling eye & jaw movement
 Maxilla
• Upper jaw
• Supports the nasal bone
• Provides lower border of orbit
 Mandible
• Jaw bone
 Nasal Bones
Anatomy & Physiology
of the Face
 Structure
 Covered with skin
 Flexible and thin
 Highly vascular
 Minimal layer of subcutaneous tissue
 Circulation
 External carotid artery
 Supplies facial area
 Branches
• Facial, Temporal & Maxillary Arteries
Anatomy & Physiology
of the Face
 Nerves
 Trigeminal (CN-V)
 Facial Sensation
 Some eye motor control
 Enables chewing process
 Facial (CN-VII)
 Motor control for facial muscles
 Sensation of taste
Anatomy & Physiology
of the Face
 Nasal Cavity
 Upper Border
 Bones
• Junction of Ethmoid, Nasal, & Maxillary Bones
 Bony Septum
• Right & 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
Anatomy & Physiology
of the Face
 Oral Cavity
 Formed Structures
 Maxillary bone
 Palate
 Upper teeth meeting the mandible and lower teeth
 Floor
 Tongue
• Connects to hyoid bone
 Free-floating U-shaped bone inferior & posterior of the
mandible
 Mandible
 Articulates with the TMJ joint
Anatomy & Physiology
of the Face
 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
(continued)
Anatomy & Physiology
of the Face
 Sinuses
 Hollow spaces in cranium and facial bones
 Function
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Lighten head
Protect eyes and nasal cavity
Produce resonant tones of voice
Strengthen area against trauma
Anatomy & Physiology
of the Face
 Cranial Nerves
 CN-XII (Hypoglossal)
 Swallowing & tongue movement
 CN-IX (Glossopharyngeal)
 Saliva production & taste
 CN-V (Trigeminal)
 Sensations from facial region & aids in chewing
 CN-VII (Facial)
 Muscles of facial expression & taste
Anatomy & Physiology
of the Face
 Pharynx
 Posterior & Inferior to the oral cavity
 Aids in swallowing
 Bolus of food propelled back & down by tongue
 Epiglottis moves downward
 Larynx moves up
• Combined effect seals airway
 Peristaltic wave moves food down esophagus
Anatomy & Physiology
of the Face
 Ear
 Function
 Hearing
 Positional sense
 Structures
 Pinna
• Outer visible portion
• Formed of Cartilage & has Poor blood supply
 External Auditory Canal
• Glands that secrete cerumen (wax)
 Middle & Inner Ear
• Structures for hearing and positional sense
Anatomy & Physiology
of the Face
 Ear
 Structures for Hearing
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Tympanic membrane
Ossicle bones
Cochlea
Auditory Nerve
 Structures for Proprioception
 Semicircular canals
• Sense position & motion
 Present when eyes are closed
 Vertigo
• Continuous movement sensation
Anatomy & Physiology
of the Face
 Eye
 Structures
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Sclera
Cornea
Conjunctiva
Anterior Chamber
• Aqueous humor
• Iris
 Pupil
 Lens
 Posterior Chamber
• Vitreous humor
 Retina
 Lacrimal Fluid
 Bathes, protects, and nourishes cornea
Anatomy & Physiology
of the Face
 Eye
 Innervation
 CN-III (Oculomotor)
• Pupil dilation
• Conjugate movement
 Movement of eyes together
• Normal range of motion
 CN-IV (Trochlear)
• Downward & inward movement
 CN-VI (Abducens)
• Abduction (outward) gaze
Anatomy & Physiology
of the Neck
 Vasculature of the Neck
 Carotid Arteries
 Arise from
• RIGHT: Brachiocephalic Artery
• LEFT: Aorta Artery
 Split
• Internal & External Carotid Arteries
• Upper border of the Larynx
• Carotid Bodies & Sinuses located
 Bodies: Monitor CO2 and O2 levels
 Sinuses: Monitor Blood Pressure
(continued)
Anatomy & Physiology
of the Neck
 Jugular Veins
 External
• Superficial, lateral to the trachea
 Internal
• Sheath with the carotid artery and vagus nerve
Anatomy & Physiology
of the Neck
 Airway Structures
 Larynx
 Epiglottis
 Thyroid & Cricoid Cartilage
 Trachea
 Posterior border is anterior border of esophagus
Anatomy & Physiology
of the Neck
 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
Anatomy & Physiology
of the Neck
 Other Structures
 Esophagus
 Cranial Nerves
 CN-IX (Glossopharyngeal)
• Carotid Bodies & Carotid Sinuses
 CN-X
• Speech, swallowing, cardiac, respiratory & visceral function
 Thoracic Duct
 Delivers lymph to the venous system
(continued)
Anatomy & Physiology
of the Neck
 Glands
 Thyroid
• Rate of cellular metabolism
• Systemic levels of calcium
 Brachial Plexus
 Network of nerves in lower neck and should that control
arm and hand function
Pathophysiology of
Head, Facial, & Neck Injury
 Mechanism of Injury
 Blunt Injury
 Motor vehicle collisions
 Assaults
 Falls
 Penetrating Injury
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Gunshot wounds
Stabbing
Explosions
“Clothesline”
Scalp Injury
 Contusions
 Lacerations
 Avulsions
 Significant Hemorrhage
ALWAYS Reconsider MOI for severe
underlying problems
Cranial Injury
 Trauma must be extreme to fracture
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Linear
Depressed
Open
Impaled Object
 Basal Skull
 Unprotected
 Spaces weaken
structure
 Relatively
easier to fracture
Cranial Injury
 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
Cranial Injury
 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
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
Direct Brain Injury Types
 Coup
 Injury at site of
impact
 Contrecoup
 Injury on
opposite side
from impact
Direct Brain Injury Categories
 Focal
 Occur at a specific location in brain
 Differentials
 Cerebral Contusion
 Intracranial Hemorrhage
• Epidural hematoma
• Subdural hematoma
 Intracerebral Hemorrhage
 Diffuse
 Concussion
 Moderate Diffuse Axonal Injury
 Severe Diffuse Axonal Injury
Focal Brain Injury
 Cerebral Contusion
 Blunt trauma to local brain tissue
 Capillary bleeding into brain tissue
 Common with blunt head trauma
 Confusion
 Neurologic deficit
• Personality changes
• Vision changes
• Speech changes
 Results from
 Coup-contrecoup injury
Focal Brain Injury
Intracranial Hemorrhage
 Epidural Hematoma
 Bleeding between dura
mater and skull
 Involves arteries
 Middle meningeal artery
most common
 Rapid bleeding &
reduction of oxygen to
tissues
 Herniates brain toward
foramen magnum
Focal Brain Injury
Intracranial Hemorrhage
 Subdural
Hematoma
 Bleeding within meninges
 Beneath dura mater &
within subarachnoid
space
 Above pia mater
 Slow bleeding
 Superior sagital sinus
 Signs progress over
several days
 Slow deterioration of
mentation
Focal Brain Injury
Intracranial Hemorrhage
 Intracerebral Hemorrhage
 Rupture blood vessel within the brain
 Presentation similar to stroke symptoms
 Signs and symptoms worsen over time
Diffuse Brain Injury
 Due to stretching forces placed on
axons
 Pathology distributed throughout
brain
 Types
 Concussion
 Moderate Diffuse Axonal Injury
 Severe Diffuse Axonal Injury
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
 ABC’s
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 & Symptoms
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Unconsciousness or Persistent confusion
Loss of concentration, disorientation
Retrograde & Antegrade amnesia
Visual and sensory disturbances
Mood or Personality changes
Diffuse Brain Injury
Severe Diffuse Axonal Injury
 Brainstem Injury
 Significant mechanical disruption of
axons
 Cerebral hemispheres and brainstem
 High mortality rate
 Signs & Symptoms
 Prolonged unconsciousness
 Cushing’s reflex
 Decorticate or Decerebrate posturing
Intracranial Perfusion
 Review
 Cranial volume fixed
 80% = Cerebrum, cerebellum & brainstem
 12% = Blood vessels & blood
 8% = CSF
 Increase in size of one component diminishes
size of another
 Inability to adjust = increased ICP
Intracranial Perfusion
 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
Intracranial Pressure
 Role of Carbon Dioxide
 Increase of CO2 in CSF
 Cerebral Vasodilation
• Encourage blood flow
• Reduce hypercarbia
• Reduce hypoxia
 Contributes to  ICP
 Causes classic
 Hyperventilation & Hypertension
 Reduced levels of CO2 in CSF
 Cerebral vasoconstriction
• Results in cerebral anoxia
Factors Affecting ICP
 Vasculature Constriction
 Cerebral Edema
 Systolic Blood Pressure
 Low BP = Poor Cerebral Perfusion
 High BP = Increased ICP
 Carbon Dioxide
 Reduced respiratory efficiency
Pressure & Structural
Displacement
 Increased pressure
 Compresses brain tissue
 Against & around
• Falx Cerebri
• Tentorium Cerebelli
 Herniates brainstem
 Compromises blood supply
 Signs & Symptoms
• Upper Brainstem
 Vomiting
 Altered mental status
 Pupillary dilation
• Medulla Oblongata
 Respiratory
 Cardiovascular
 Blood Pressure disturbances
Signs & Symptoms
of Brain Injury
 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
Signs & Symptoms
of Brain Injury
 Pathophysiology of Changes
 Frontal Lobe Injury
 Alterations in personality
 Occipital Lobe Injury
 Visual disturbances
 Cortical Disruption
 Reduce 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
Signs & Symptoms of Brain Injury
Physiological Changes
 Upper Brainstem Compression
 Increasing blood pressure
 Reflex bradycardia
 Vagus nerve stimulation
 Cheyne-Stokes respirations
 Pupils become small and reactive
 Decorticate posturing
 Neural pathway disruption
Signs & Symptoms of Brain Injury
Physiological Changes
 Middle Brainstem Compression
 Widening pulse pressure
 Increasing bradycardia
 CNS Hyperventilation
 Deep and Rapid
 Bilateral pupil sluggishness or inactivity
 Decerebrate posturing
Signs & Symptoms of Brain Injury
Physiological Changes
 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
Signs & 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 ped’s
 General Management
 Avoid hyperextension of head
 Tongue pushes soft pallet closed
 Ventilate through mouth and nose
Signs & Symptoms of Brain Injury
Glasgow Coma Scale
Signs & Symptoms of Brain Injury
Eye Signs
 Physiological Issues
 Indicate pressure on
 CN-II, CN-III, CN-IV, & 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 & Reactivity
 Reduced Pupillary Responsiveness
 Depressant drugs or Cerebral Hypoxia
 Fixed & Dilated
 Extreme Hypoxia
Facial Injury
 Facial Soft Tissue Injury
 Highly vascular tissue
 Contribute to hypovolemia
 Superficial injuries 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
Facial Injury
 Facial Dislocations & Fractures
 Common Fractures
 Mandibular
• Deformity along jaw & loss of teeth
• Possible airway compromise if patient placed supine
• Evaluate for multiple fracture sites
 Maxillary & 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
Facial Injury
 Nasal Injury
 Rarely life threatening
 Swelling & Hemorrhage interfere with
breathing
 Epistaxis
 Most common problem
 AVOID NASOTRACHEAL INTUBATION
 Passage of ET tube into the cerebral cavity
Facial Injury
 Ear Injury
 External Ear
 Pinna is frequently injured due to trauma
 Poor blood supply
 Poor healing
 Internal Ear
 Well protected from trauma
 My be injured due to rapid pressure changes
• Diving, Blast, or Explosions
• Temporary or permanent hearing loss
• Tinnitus may occur
Facial Injury
 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 & Lacerations
 Common & 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
Facial Injury
 Eye Injury
 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
Neck Injury
 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 & compromise
Neck Injury
 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 & GI disturbances
 Thyroid & Parathyroid glands
• High vascular
Assessment of
Head, Facial & Neck Injuries
 Scene Size-up
 Initial Assessment
 Airway, Breathing, Circulation
 Rapid Trauma Assessment
 Head, Face, Neck
 Glasgow Coma Scale Score
 Vital Signs
 Focused History & Physical Exam
 Detailed Assessment
 Ongoing Assessment
Head, Facial, & Neck
Injury Management
 Airway




Suctioning
Patient Positioning
OPA & NPA Use
Endotracheal
Intubation






Orotracheal
Digital
Nasotracheal
Retrograde
Direct
RSI
 Cricothyrotomy
 Breathing
 Oxygen
 15 LPM/NRB
 Ventilations
 12-20/min
 Hyperoxygenate
 Circulation
 Hemorrhage Control
 Blood Pressure
Maintenance
 Fluid resuscitation
 Consider PASG
Needle Cricothyrostomy
 Locate Site
 Cricothyroid Membrane
 Cleanse upper
anterior neck
 Aseptic Technique
 Iodine & 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
Surgical Cricothyrotomy
 Locate Site
 Cricothyroid Membrane
 Cleanse upper
anterior neck
 Aseptic Technique
 Iodine & 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
Head, Facial, & Neck
Injury Management
 Hypoxia
 Prevent/Reduce
 Hyperoxygenation with BVM
 Hypovolemia
 Reduces cerebral perfusion & hypoxia
 Consider early management with 2 large bore IV’s
and isotonic fluids
 Prevents slower compensatory mechanism
 Maintain SBP 90-100 mmHg
 Consider PASG
Medications: Oxygen
 Primary 1st line drug
 Administer high flow
 Hyperventilation is contraindicated
 Reduces circulating CO2 levels
 NRB: 15 LPM
 BVM: 12-20 times per minute
 Keep SaO2 > 95%
Medications: Diuretics
 Mannitol (osmotrol)
 MOA
 Large glucose molecule
• Does not leave blood stream
• Osmotic Diuretic
 Effective in drawing fluid from brain
 Contraindication
 Hypovolemia & Hypotension
 CHF
 Dose
 1gm/kg
 CAUTION
 Forms crystals at low temperatures
 Reconstitute with rewarming & gentle agitation
 USE IN-LINE filter & PREFLUSH line
Medications: Diuretics
 Furosemide (Lasix)
 MOA
 Loop Diuretic
+
 Inhibits reabsorption of Na in Kidneys
• Increased secretion of water and electrolytes
+
–
++
++
 Na , Cl , Mg , Ca .
 Venous dilation & 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
Medications: Paralytics
 Succinylcholine (Anectine)
 MOA
 Depolarizing Medication
• Causes Fasciculations
 Onset & Duration
 Onset: 30-60 seconds
 Duration: 2-3 minutes
 Precaution
 Paralyzes ALL muscles including those of respiration
 Increases intraoccular eye pressure
 Contraindication
 Penetrating eye injury & Digitalis
 Dose
 1-1.5 mg/kg IV
 Consider administration of 0.5 mg of Atropine to reduce
fasciculations
Medications: Paralytics
Pancuronium
(Pavulon)
 MOA
 Non-depolarizing
agent
 Does not affect LOC
 Onset & Duration
 Onset: 3-5 min
 Duration: 30-60 min
 Dose
 Must premed with
sedative
 0.04-0.1 mg/kg
Vecuronium
(Norcuron)
 MOA
 Non-depolarizing
agent
 Does not affect LOC
 Onset & Duration
 Onset: < 1 min
 Duration: 25-40 min
 Dose
 Consider premed with
sedative
 0.08-0.1 mg/kg
Medications: Sedatives
 Diazepam
(Valium)
 MOA
 Benzodiazepine
 Anti-anxiety
 Muscle relaxant
 Onset & Duration
 Onset: 1-15 min
 Duration: 15-60 min
 Dose
 5-10 mg
 Midazolam
(Versed)
 MOA
 Benzodiazepine
 3-4x potent than
valium
 Dose
 SLOW IVP
• 1 mg/min
 1-2.5 mg titrated
Medications: Sedative
 Morphine
 MOA
 Opium alkaloid
• Analgesic
• Sedation
• Anti-anxiety
 Reduces vascular volume & cardiac preload
• Increases venous capacitance
 Side Effects
 Respiratory depression
 Hypovolemia
 Dose
 5-10 mg IVP
 Consider using promethezine with to reduce nausea
 Naloxone (Narcan) is antagonist
Medications: Atropine
 MOA
 Anticholinergic
 Parasympathetic




Reduces parasympatholyic stimulation
Reduce oral and airway secretions
Reduce fasciculations
Pupillary dilation
 Dose
 0.5-1 mg rapid IVP
Medications: Dextrose
 Consider if patient is hypoglycemic
 Only if VERIFIED by GLUCOMETER
 Dose
 25 gm IVP
 Consider Thiamine if known alcoholic
 100 mg Thiamine
Medications: Thiamine
 Vitamin B1
 Essential for the processing of
glucose through Kreb’s cycle
 Chronic alcoholics can have B1
depletion
 Dose
 100 mg IV or IM
Medications: Topical
Anesthetic Spray
 Medications
 Xylocaine or Benzocaine
 Anesthetize oral and pharyngeal mucosa
• Reduces gag reflex
• Reduces likelihood of ICP associated with vomiting
 Inhibits nerve sensation
 Onset & Duration
• Onset: 15 seconds
• Duration: 15 minutes
 PRECAUTION
• Patient has reduced ability to remove oral fluids
• ASPIRATION can occur
Transport Considerations
 Limit external stimulation
 Can increase ICP
 Can induce seizures
 Cautious about Air Transport
 Seizures
Emotional Support
 Have friend or family provide
constant reassurance
 Provided constant reorientation to
environment if required
 Keeps patient calm
 Reduces anxiety
Special Injury Care
 Scalp Avulsion
 Cover the open wound with bulky dressing
 Pad under the fold of the scalp
 Irrigate with NS to remove gross contamination
 Pinna Injury
 Place in close anatomic position as possible
 Dress and cover with sterile dressing
Special Injury Care
 Eye Injury
 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 & reassure patient
Special Injury Care
 Dislodged Teeth
 Rinse in NS
 Wrap in NS soaked gauze
 Impaled Objects
 Secure with bulky dressing
 Stabilize object to prevent movement
 Indirect pressure around wound