Transcript Head, Neck and Face Trauma - Madison County Emergency

Head, Facial, and Neck
Trauma
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Topics
Introduction to Head, Facial, and Neck
Injuries
Anatomy and Physiology of the Head, Face,
and Neck
Pathophysiology of Head, Facial, and Neck
Injury
Assessment and Management of Head,
Facial, and Neck Injuries
Head, Facial, and Neck Injury Management
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Introduction to Head, Facial,
and Neck Injuries (1 of 3)
Common major trauma.
4 million people experience head trauma
annually.
– Severe head injury is most frequent cause of
trauma death.
GSW to cranium: 75–80% mortality
At-risk population:
–
–
–
–
Males 15–24
Infants
Young children
Elderly
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Introduction to Head, Facial,
and Neck Injuries (2 of 3)
Injury Prevention Programs
– Motorcycle safety
– Bicycle safety
– Helmet and head injury awareness
programs
– Sports
Football
Rollerblading
Contact sports
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Introduction to Head, Facial,
and Neck Injuries (3 of 3)
TIME IS CRITICAL.
– Intracranial hemorrhage
– Progressing edema
Increased ICP
Cerebral hypoxia
Permanent damage
Severity is difficult to recognize.
– Subtle signs
– Improve differential diagnosis
Improves survivability
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
of the Head, Face, and Neck
Anatomy and Physiology of the Head
–
–
–
–
–
–
–
Cranium
Meninges
Cerebrospinal fluid
Brain
Cerebral perfusion pressure
Cranial nerves
Ascending reticular activating system
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
of the Head (4 of 4)
Skull comprised of
– Facial bones
– Cranium
Vault for the brain
Strong, light, rigid, spherical bone
Unyielding to increased intracranial pressure (ICP)
Bones
Frontal
Parietal
Occipital
Temporal
Ethmoid
Sphenoid
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Cranium
Sphenoid
Parietal
Suture Line
Frontal
Temporal
Orbits
Maxillae
Mandible
Temporal Mandibular Joint
Occiptal
Foramen Magnum (Hole in Base)
Nasal Bones
Zygomatic Arch
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bones of the Skull
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
of the Head (1 of 3)
Skull
– Other Structures
Foramen Magnum
Largest opening of the skull
Spinal cord exits
Cribriform Plate
Inferior aspect (base)
Rough surface
Brain can be easily injured
Abrasion
Contusion
Laceration
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
FM/CP
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
of the Head (2 of 3)
Meninges
– Protective mechanism for the CNS
– Dura Mater
Layers
Outer: Cranium’s inner periosteum
Inner: Dural layer
Between: Dural sinuses
Venous drains for brain
Provides continuous connective tissue
Forms partial structural divisions
Falx cerebri
Tentorium cerebelli
Large arteries above
Provide blood flow to the surface of the brain
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
of the Head (3 of 3)
Meninges
– Pia Mater
Closest to brain and spinal cord
Delicate tissue
Covers all areas of brain and spinal cord
Very vascular
Supply superficial areas of brain
– Arachnoid Membrane
“Spider-like”
Covers inner dura
Suspends brain in cranial cavity
Collagen and elastin fibers
Subarachnoid space beneath
CSF
Cushions brain
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
EPI VS. SUB
EPI VS SUB
– WHERE?
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
The Meninges and Skull
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
of the Head (1 of 18)
Cerebrospinal Fluid
– Clear, colorless fluid
– Comprised of
Water
Protein
Salts
– Cushions CNS
– Made in largest two ventricles of brain
– Medium for nutrients and waste products
to diffuse into and out of brain
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Ventricles of the Brain
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
of the Head (2 of 18)
Brain
– Occupies 80% of cranium
– Comprised of 3 major structures
Cerebrum
Cerebellum
Brainstem
– High metabolic rate
Receives 15% of cardiac output
Consumes 20% of body’s oxygen
Requires constant circulation
– IF blood supply stops:
Unconscious within 10 seconds
Death in 4–6 minutes
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
of the Head (3 of 18)
Cerebrum
– Function
Center of conscious thought, personality,
speech, and motor control
Visual, auditory, and tactile perception
– Lobes
Frontal
Personality
Parietal
Motor and sensory activity
Memory and emotion
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
of the Head (4 of 18)
Occipital
– Sight
Temporal
– Long-term memory
– Hearing, speech, taste, and smell
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
of the Head (7 of 18)
Cerebrum
– Hemisphere Functions
Left: DOMINANT
Mathematical computations: Occipital
Writing: Parietal
Language interpretation: Occipital
Speech: Frontal
Right: NON-DOMINANT
Non-verbal imagery
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
of the Head (8 of 18)
Cerebellum
– Located under tentorium
– Function
“Fine tunes” motor control
Allows smooth movement
Balance
Maintenance of muscle tone
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
of the Head (9 of 18)
Brainstem
– Central processing center
– Communication junction among
Cerebrum
Spinal cord
Cranial nerves
Cerebellum
– Structures
Midbrain
Pons
Medulla oblongata
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
of the Head (10 of 18)
Midbrain
– Upper portion of brainstem
– Structures
Hypothalamus
Endocrine function, vomiting reflex, hunger, thirst
Kidney function, body temperature, emotion
Thalamus
Switching center between pons and cerebrum
Critical Element in Ascending Reticular Activating System
(A-RAS)
ESTABLISHES CONSCIOUSNESS
Major pathways for optic and olfactory nerves
Associated structures
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
of the Head (12 of 18)
Medulla Oblongata
– Bulge in the top of the spinal cord
– Centers
Respiratory Center
Controls depth, rate, and rhythm
Cardiac Center
Regulates rate and strength of cardiac contractions
Vasomotor Center
Distribution of blood
Maintains blood pressure
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Sections
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
of the Head (15 of 18)
Cerebral Perfusion Pressure
– Pressure within cranium (ICP) resists blood flow
and good perfusion to the CNS.
Pressure usually less than 10 mmHg
– Mean Arterial Pressure (MAP):
Must be at least 50 mmHg to ensure adequate
perfusion
MAP = DBP + 1/3 Pulse Pressure
– Cerebral Perfusion Pressure (CPP):
Pressure moving blood through the cranium
CPP = MAP - ICP
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
of the Head (16 of 18)
Calculating MAP
BP  120/90
DBP  90
Pulse Pressure  120 - 90  30
MAP  90  13  30  100
Calculating CPP
MAP  100 & ICP  10
CPP  MAP - ICP
CPP  100 - 10  90
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
of the Head (17 of 18)
Cerebral Perfusion Pressure
– Autoregulation
Changes in ICP result in compensation.
Increased ICP = Increased BP.
This causes ICP to rise higher and BP to rise.
Brain injury and death become imminent.
– Expanding mass inside cranial vault
Displaces CSF.
If pressure increases, brain tissue is
displaced.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
of the Head (18 of 18)
Cranial Nerves
– 12 pair with distinct pathways
– Senses, facial innervation, and body function control
Ascending Reticular Activation System
–
–
–
–
Tract of neurons in upper brainstem, pons, and midbrain
Responsible for sleep-wake cycle
Monitors input stimulation
Regulates body functions
Respiration
Heart rate
Peripheral vascular resistance
– Injury may result in prolonged waking state.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Cranial Nerves
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Cranial Nerves
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
CN
Name
F
Innervation
I
Olfactory
S
Smell
II
Optic
S
Sight
III
Oculomotor
M
Pupil Const, rectus and obliques
IV
Trochlear
M
Superior obliques
V
Trigeminal
S
Opthalmic (FH), Maxillary (cheek) Mandible (chin)
M
Chewing muscles
VI
Abducens
M
Lateral rectus muscle
VII
Facial
S
Tongue
M
Face muscles
VIII
Acoustic
S
Hearing balance
Glossopharyngeal
S
Posterior pharynx, taste to anterior tongue
IX
M
Face muscles
S
Taste to posterior tongue
M
Posterior palate and pharynx
X
Vagus
XI
Accessory
M
Trapezius and sternocleido muscles
XII
Hypoglossal
M
Tongue
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
of the Head, Face, and Neck
Anatomy and Physiology of the Face
– Structure
– Ear
– Eye
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
of the Face
Structure
– Facial Bones
Zygoma
Prominent bone of the cheek
Protects eyes
Attachment for muscles controlling eye and jaw
movement
Maxilla
Upper jaw
Supports the nasal bone
Provides lower border of orbit
Mandible
Jaw bone
Nasal bones
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Facial Bones
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
of the Face (1 of 9)
Structure
– Covered with skin
Flexible and thin
Highly vascular
– Minimal layer of subcutaneous tissue
Circulation
– External carotid artery
Supplies facial area
Branches
Facial, temporal, and maxillary arteries
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
of the Face (2 of 9)
Nerves
– Trigeminal (CN-V)
Facial sensation
Some eye motor control
Enables chewing process
– Facial (CN-VII)
Motor control for facial muscles
Sensation of taste
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Facial Nerves
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
of the Face (3 of 9)
Nasal Cavity
– Upper Border
Bones
Junction of ethmoid, nasal, and maxillary bones
Bony Septum
Right and left chamber
Turbinates
Vascular mucosa support
Warm, humidify, and filter incoming air
– Lower Border
Bony hard palate
Soft palate
Moves upward during swallowing
– Nasal Cartilage
Forms nares
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
of the Face (6 of 9)
Sinuses
– Hollow spaces in cranium and facial
bones
– Function
Lighten head
Protect eyes and nasal cavity
Produce resonant tones of voice
Strengthen area against trauma
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
of the Face (7 of 9)
Cranial Nerves
– CN-XII (Hypoglossal)
Swallowing and tongue movement
– CN-IX (Glossopharyngeal)
Saliva production and taste
– CN-V (Trigeminal)
Sensations from facial region and aids in
chewing
– CN-VII (Facial)
Muscles of facial expression and taste
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Cranial Nerves
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
of the Face (9 of 9)
Ear
– Function
Hearing
Positional sense
– Structures
Pinna
Outer visible portion
Formed of cartilage and has poor blood supply
External Auditory Canal
Glands that secrete cerumen (wax)
Middle and Inner Ear
Structures for hearing and positional sense
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
The Ear
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
of the Face
Ear
– Structures for Hearing
Tympanic membrane
Ossicle bones
Cochlea
Auditory nerve
– Structures for Proprioception
Semicircular canals
Sense position and motion
Present when eyes are closed
Vertigo
Continuous movement sensation
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
of the Face (1 of 2)
Eye
– Structures
Sclera
Cornea
Conjunctiva
Anterior chamber
Aqueous humor
Iris
Pupil
Lens
Posterior chamber
Vitreous humor
Retina
– Lacrimal Fluid
Bathes, protects, and nourishes cornea
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
The Eye
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
of the Face (2 of 2)
Eye
– Innervation
CN-III (Oculomotor)
Pupil dilation
Conjugate movement
Movement of eyes together
Normal range of motion
CN-IV (Trochlear)
Downward and inward movement
CN-VI (Abducens)
Abduction (outward) gaze
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
of the Neck (1 of 6)
Vasculature of the Neck
– Carotid Arteries
Arise from
RIGHT: Brachiocephalic artery
LEFT: Aorta artery
Split
Internal and external carotid arteries
Upper border of the larynx
Carotid bodies and sinuses located
Bodies: Monitor CO2 and O2 levels
Sinuses: Monitor blood pressure
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Carotid Arteries
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
of the Neck (2 of 6)
Jugular Veins
– External
Superficial, lateral to the trachea
– Internal
Sheath with the carotid artery and vagus
nerve
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Jugular Veins
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
of the Neck (3 of 6)
Airway Structures
– Larynx
Epiglottis
Thyroid and cricoid cartilage
– Trachea
Posterior border is anterior border of
esophagus.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
of the Neck (4 of 6)
Other Structures
– Cervical Spine
Musculoskeletal Function
External skeletal support of the head and neck
Attachment point for spinal column ligaments
Attachment point for tendons to move head and
shoulders
Nervous Function
Spinal cord contained within
Peripheral nerve
Exit between vertebrae
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
of the Neck (5 of 6)
Other Structures
– Esophagus
– Cranial Nerves
CN-IX (Glossopharyngeal)
Carotid bodies and carotid sinuses
CN-X
Speech, swallowing, cardiac, respiratory, and
visceral function
– Thoracic Duct
Delivers lymph to the venous system
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
of the Neck (6 of 6)
Glands
– Thyroid
Rate of cellular metabolism
Systemic levels of calcium
Brachial Plexus
– Network of nerves in lower neck and
shoulder that control arm and hand
function
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Thyroid
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Brachail Plexus
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of
Head, Facial, and Neck Injury
Mechanism of Injury
– Blunt Injury
Motor vehicle collisions
Assaults
Falls
– Penetrating Injury
Gunshot wounds
Stabbing
Explosions
“Clothesline”
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Scalp Injury
Contusions
Lacerations
Avulsions
Significant Hemorrhage
ALWAYS reconsider MOI for severe
underlying problems.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Cranial Injury (1 of 3)
Trauma must be extreme to fracture.
–
–
–
–
Linear
Depressed
Open
Impaled object
Basal Skull:
– Unprotected
– Spaces weaken
structure
– Relatively
easier to fracture
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Cranial Injury (2 of 3)
Basal Skull Fracture Signs
– Battle’s Signs
Retroauricular ecchymosis
Associated with fracture of
auditory canal and lower
areas of skull
– Raccoon Eyes
Bilateral periorbital
ecchymosis
Associated with orbital
fractures
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Cranial Injury (3 of 3)
Basilar Skull
Fracture
– May tear dura.
Permit CSF to
drain through an
external
passageway.
May mediate rise of
ICP.
Evaluate for “target”
or “halo” sign.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Brain Injury
As defined by the National Head Injury
Foundation
– “A traumatic insult to the brain capable of
producing physical, intellectual, emotional,
social and vocational changes”
– Classification
Direct
Primary injury caused by forces of trauma
Indirect
Secondary injury caused by factors resulting from the
primary injury
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Direct Brain Injury Types
Coup
– Injury at
site of
impact
Contrecoup
– Injury on
opposite
side from
impact
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Direct Brain Injury Categories
Focal
– Occur at a specific location in brain
– Differentials
Cerebral contusion
Intracranial hemorrhage
Epidural hematoma
Subdural hematoma
Intracerebral hemorrhage
Diffuse
– Concussion
– Moderate diffuse axonal injury
– Severe diffuse axonal injury
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Focal Brain Injury
Cerebral Contusion
– Blunt trauma to local brain tissue
– Capillary bleeding into brain tissue
– Common with blunt head trauma
Confusion
Neurologic deficit
Personality changes
Vision changes
Speech changes
– Results from
Coup-contrecoup injury
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Contusion
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Focal Brain Injury
Intracranial Hemorrhage (1 of 3)
Epidural Hematoma
– Bleeding between dura
mater and skull
– Involves arteries
Middle meningeal artery
most common
– Rapid bleeding and
reduction of oxygen to
tissues
– Herniates brain toward
foramen magnum
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Focal Brain Injury
Intracranial Hemorrhage (2 of 3)
Subdural Hematoma
– Bleeding within
meninges
Beneath dura mater and
within subarachnoid
space
Above pia mater
– Slow bleeding
Superior sagittal sinus
– Signs progress over
several days
Slow deterioration of
mentation
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Focal Brain Injury
Intracranial Hemorrhage (3 of 3)
Intracerebral Hemorrhage
– Ruptured blood vessel within the brain
– Presentation similar to stroke symptoms
– Signs and symptoms worsen over time
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Diffuse Brain Injury
Due to stretching forces placed on
axons
Pathology distributed throughout brain
Types
– Concussion
– Moderate diffuse axonal injury
– Severe diffuse axonal injury
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Axonal Injury
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Diffuse Brain Injury
Concussion
Mild to moderate form of diffuse axonal
injury (DAI)
– Nerve dysfunction without anatomic damage
Transient episode of
– Confusion, disorientation, event amnesia
Suspect if patient has a momentary loss of
consciousness
Management
– Frequent reassessment of mentation
– ABCs
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Diffuse Brain Injury
Moderate Diffuse Axonal Injury
“Classic Concussion”
Same mechanism as concussion
– Additional: minute bruising of brain tissue
Unconsciousness
– If cerebral cortex and RAS involved
May exist with a basilar skull fracture
Signs and Symptoms
–
–
–
–
–
Unconsciousness or persistent confusion
Loss of concentration, disorientation
Retrograde and antegrade amnesia
Visual and sensory disturbances
Mood or personality changes
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Diffuse Brain Injury
Severe Diffuse Axonal Injury
Brainstem Injury
Significant mechanical disruption of
axons
– Cerebral hemispheres and brainstem
High mortality rate
Signs and Symptoms
– Prolonged unconsciousness
– Cushing’s reflex
– Decorticate or decerebrate posturing
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Intracranial Perfusion (1 of 3)
Review
– Cranial volume fixed
80% = Cerebrum, cerebellum, and brainstem
12% = Blood vessels and blood
8% = CSF
– Increase in size of one component
diminishes size of another
Inability to adjust = increased ICP
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Intracranial Perfusion (2 of 3)
Compensating for Pressure
– Compress venous blood vessels
– Reduction in free CSF
Pushed into spinal cord
Decompensating for Pressure
– Increase in ICP
– Rise in systemic BP to perfuse brain
Further increase of ICP
Dangerous cycle
ICP
BP
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Intracranial Perfusion (3 of 3)
Role of Carbon Dioxide
– Increase of CO2 in CSF
Cerebral vasodilation
Encourage blood flow
Reduce hypercarbia
Reduce hypoxia
– Contributes to  ICP
– Causes classic
Hyperventilation and hypertension
– Reduced levels of CO2 in CSF
Cerebral vasoconstriction
Results in cerebral anoxia
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Factors Affecting ICP
Vasculature Constriction
Cerebral Edema
Systolic Blood Pressure
– Low BP = Poor cerebral perfusion
– High BP = Increased ICP
Carbon Dioxide
Reduced respiratory efficiency
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pressure and Structural
Displacement
Increased pressure
– Compresses brain tissue
Against and around
Falx cerebri
Tentorium cerebelli
– Herniates brainstem
Compromises blood supply
Signs and Symptoms
Upper brainstem
Vomiting
Altered mental status
Pupillary dilation
Medulla oblongata
Respiratory
Cardiovascular
Blood pressure disturbances
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Signs and Symptoms
of Brain Injury (1 of 2)
Altered Mental Status
– Altered orientation
– Alteration in personality
– Amnesia
Retrograde
Antegrade
Cushing’s Reflex
– Increased BP
– Bradycardia
– Erratic respirations
Vomiting
– Without nausea
– Projectile
Body temperature
changes
Changes in pupil
reactivity
Decorticate posturing
Obtain a blood glucose level
on all patients with AMS.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Signs and Symptoms
of Brain Injury (2 of 2)
Pathophysiology of Changes
– Frontal Lobe Injury
Alterations in personality
– Occipital Lobe Injury
Visual disturbances
– Cortical Disruption
Reduced mental status or amnesia
Retrograde
Unable to recall events before injury
Antegrade
Unable to recall events after trauma
“Repetitive questioning”
– Focal Deficits
Hemiplegia, weakness, or seizures
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Signs and Symptoms of
Brain Injury
Physiological Changes (1 of 3)
Upper Brainstem Compression
– Increasing blood pressure
– Reflex bradycardia
Vagus nerve stimulation
– Cheyne-Stokes respirations
– Pupils become small and reactive
– Decorticate posturing
Neural pathway disruption
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Signs and Symptoms of
Brain Injury
Physiological Changes (2 of 3)
Middle Brainstem Compression
– Widening pulse pressure
– Increasing bradycardia
– CNS hyperventilation
Deep and rapid
– Bilateral pupil sluggishness or inactivity
– Decerebrate posturing
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Signs and Symptoms of
Brain Injury
Physiological Changes (3 of 3)
Lower Brainstem Injury
– Pupils dilated and unreactive
– Ataxic respirations
Erratic with no pattern
– Irregular and erratic pulse rate
– ECG changes
T-wave inversions/QT prolongation.
ST segment elevation / depression — this may mimic myocardial ischemia or pericarditis.
Increased U wave amplitude
– Hypotension
– Loss of response to painful stimuli
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Recognition of Herniation
Cushing’s Reflex
– Increasing blood pressure
– Decreasing pulse rate
– Respirations that become erratic
Lowering level of consciousness
– GCS <9 and dropping
Singular or bilaterally dilated and fixed pupils
Decerebrate or decorticate posturing
No movement with noxious stimuli
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Signs and Symptoms of
Brain Injury
Glasgow Coma Scale
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Signs and Symptoms of
Brain Injury
Pediatric Head Trauma
Different pathology than older patients
– Skull can distort due to anterior and posterior
fontanelles.
Bulging
Slows progression of increasing ICP
– Intracranial hemorrhage contributes to
hypovolemia.
Decreased blood volume in pediatrics
General Management
– Avoid hyperextension of head.
Tongue pushes soft palate closed
– Ventilate through mouth and nose.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Signs and Symptoms of
Brain Injury
Pediatric Glasgow Coma Scale
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Signs and Symptoms of
Brain Injury
Eye Signs
Physiological Issues
– Indicate pressure on
CN-II, CN-III, CN-IV, and CN-VI
CN-III (Oculomotor nerve)
Pressure on nerve causes eyes to be sluggish, then
dilated, and finally fixed.
– Reduced peripheral blood flow
Pupil Size and Reactivity
– Reduced pupillary responsiveness
Depressant drugs or cerebral hypoxia
– Fixed and dilated
Extreme hypoxia
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Facial Injury (1 of 7)
Facial Soft-Tissue Injury
– Highly vascular tissue.
Contributes to hypovolemia
– Superficial injuries are rarely life
threatening and rarely involve the airway.
– Deep injuries can result in blood being
swallowed and endanger the airway.
– Soft tissue swelling reduces airflow.
– Consider likelihood of basilar skull
fracture or spinal injury.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Facial Injury (2 of 7)
Facial Dislocations and Fractures
– Common Fractures
Mandibular
Deformity along jaw and loss of teeth
Possible airway compromise if patient placed supine
Evaluate for multiple fracture sites
Maxillary and Nasal
Le Fort I, II, and III Criteria
Orbit
Involve zygoma, maxilla, and/or interior shelf
Reduction of eye movement
Possible diplopia
Limitation of jaw movement
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Facial Injury (3 of 7)
Fractures
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Facial Injury (4 of 7)
Nasal Injury
– Rarely life threatening.
– Swelling and hemorrhage interfere with
breathing.
– Epistaxis.
Most common problem
– AVOID NASOTRACHEAL INTUBATION.
Passage of ET tube into the cerebral cavity
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Facial Injury (5 of 7)
Ear Injury
– External Ear
Pinna frequently injured due to trauma
Poor blood supply
Poor healing
– Internal Ear
Well protected from trauma
May be injured due to rapid pressure
changes
Diving, Blast, or Explosions
Temporary or permanent hearing loss
Tinnitus may occur
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Facial Injury (6 of 7)
Eye Injury
– Penetrating Trauma
Can result in long-term damage.
Suspect small foreign body if patient complains of sudden
eye pain and sensation of something on the eye.
DO NOT REMOVE ANY FOREIGN OBJECT.
– Corneal Abrasions and Lacerations
Common and usually superficial
– Hyphema
Blunt trauma to the anterior chamber of the eye
Blood in front of iris or pupil
– Sub-conjunctival Hemorrhage
Less serious condition
May occur after strong sneeze, severe vomiting or direct
trauma
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Hyphema & SH
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Facial Injury (7 of 7)
Eye Injury (cont.)
– Acute Retinal Artery Occlusion
Non-traumatic origin
Painless loss of vision in one eye
Occlusion of retinal artery
– Retinal Detachment
Traumatic origin
Complaint of dark curtain/obstruction in the field of
view
Possibly painful depending on type of trauma
– Soft-Tissue Lacerations
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Neck Injury (1 of 2)
Blood Vessel Trauma
– Blunt trauma
Serious hematoma
– Laceration
Serious exsanguination
Entraining of air embolism
Cover with occlusive dressing
Airway Trauma
– Tracheal rupture or dissection from larynx
– Airway swelling and compromise
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Neck Injury (2 of 2)
Cervical Spine Trauma
– Vertebral fracture
Paresthesia, anaesthesia, paresis, or paralysis beneath the
level of the injury
Neurogenic shock may occur
Other Neck Trauma
– Subcutaneous emphysema
Tension pneumothorax
Traumatic asphyxia
– Penetrating trauma
Esophagus or trachea
Vagus nerve disruption
Tachycardia and GI disturbances
Thyroid and parathyroid glands
High vascular
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment of
Head, Facial, and Neck Injuries
Scene Size-up
Initial Assessment
– Airway, breathing, circulation
Rapid Trauma Assessment
– Head, face, neck
– Glasgow Coma Scale score
– Vital signs
Focused History and Physical Exam
Detailed Assessment
Ongoing Assessment
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Head, Facial, and Neck
Injury Management
Airway
–
–
–
–
Suctioning
Patient positioning
OPA and NPA use
Endotracheal intubation
Orotracheal
Digital
Nasotracheal
Retrograde
Direct
RSI
– Cricothyrotomy
Breathing
– Oxygen
15 LPM/NRB
– Ventilations
12–20/min
Hyperoxygenate
ETCO2 maintained at
35–40 mmHg
Continuous waveform
capnogrpahy
Circulation
– Hemorrhage Control
– Blood pressure
maintenance
Fluid resuscitation to
SBP of 90 mmHg
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Head, Facial, and Neck
Injury Management (1 of 2)
Hypoxia
–
–
–
–
Prevent/reduce.
Hyperoxygenate with BVM prior to intubation.
Hyperventilate with BVM prior to intubation.
Hyperventilate with BVM at a rate of 20
immediately following intubation.
If not a herniation concern, return to normal
ventilations.
If herniation is probable, maintain hyperventilation.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Head, Facial, and Neck
Injury Management (2 of 2)
Hypovolemia
– Reduces cerebral perfusion and hypoxia.
– Consider early management with 2 large
bore IVs and isotonic fluids.
Prevents slower compensatory mechanism.
Maintain SBP 90–100 mmHg in an adult.
Maintain SBP 80 mmHg in a child.
Maintain SBP 75 mmHg in a young child.
Maintain SBP 65 mmHg in an infant.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Medications: Oxygen
Primary 1st line drug
Administer high flow
Hyperventilation contraindicated unless the
patient shows clinical signs of herniation
because it reduces circulating CO2 levels
NRB: 15 LPM
BVM: 12–20 times per minute
Keep SaO2 >95%
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Medications: Paralytics (1 of 3)
Succinylcholine (Anectine)
– Mechanism of Action
Depolarizing medication
Causes fasciculations
– Onset and Duration
Onset: 30–60 seconds
Duration: 2–3 minutes
– Precaution
Paralyzes ALL muscles including those of respiration
Increases intraocular eye pressure
– Contraindication
Penetrating eye injury and Digitalis
– Dose
1–1.5 mg/kg IV
Consider administration of Nondepolarizing NMB at 1/10th
the paralyzing dose to prevent muscle fasciculations.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Medications: Paralytics (3 of 3)
Pancuronium
(Pavulon)
– Mechanism of Action
– Non-depolarizing agent
Does not affect LOC
– Onset and Duration
Onset: 3–5 min
Duration: 30–60 min
– Dose
Must premed with
sedative
0.04–0.1 mg/kg
Vecuronium
(Norcuron)
– Mechanism of Action
– Non-depolarizing agent
Does not affect LOC
– Onset and Duration
Onset: < 1 min
Duration: 25–40 min
– Dose
Consider premed with
sedative
0.08–0.1 mg/kg
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Medications: Sedatives (1 of 4)
Diazepam (Valium)
– Mechanism of
Action
Benzodiazepine
Anti-anxiety
Muscle relaxant
– Onset and Duration
Onset: 1–15 min
Duration: 15–60 min
– Dose
5–10 mg
Midazolam
(Versed)
– Mechanism of
Action
Benzodiazepine
3–4x more potent
than Valium
– Dose
SLOW IVP
1 mg/min
1–2.5 mg titrate
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Medications: Sedatives (4 of 4)
Etomidate (Amidate)
– Mechanism of Action
Sedative-hypnotic
– Side Effects
Respiratory depression
Trismus
– Onset/Duration
Onset of less than 1 minute
Duration of 5 minutes
– Dose
0.1–0.3 mg/kg IVP
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Medications: Atropine
Mechanism of Action
– Anticholinergic
Parasympathetic
– Reduces parasympathetic stimulation
– Reduces oral and airway secretions
– Pupillary dilation
Dose
– 0.5–1 mg rapid IVP
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Medications: Dextrose
Consider if patient is hypoglycemic
– Only if VERIFIED by GLUCOMETER
Dose
– 25 gm IVP
– Consider thiamine if known alcoholic
100 mg thiamine
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Transport Considerations
Limit external stimulation.
– Can increase ICP
– Can induce seizures
Be cautious about air transport.
– Seizures
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Emotional Support
Have friend or family provide constant
reassurance.
Provide constant reorientation to
environment if required.
– Keeps patient calm
– Reduces anxiety
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Special Injury Care (1 of 3)
Scalp Avulsion
– Cover the open wound with bulky
dressing.
– Pad under the fold of the scalp.
– Irrigate with NS to remove gross
contamination.
Pinna Injury
– Place in close anatomic position as
possible.
– Dress and cover with sterile dressing.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Special Injury Care (2 of 3)
Eye Injury
– General Injury
Cover injured and uninjured eye.
Prevents sympathetic motion
Consider sterile dressing soaked in NS.
– Corneal Abrasion
Invert eyelid and examine eye for foreign body.
Remove with NS-moistened gauze or Morgan’s lens.
– Avulsed or Impaled Eye
Cover and protect from injury.
– General Care
Calm and reassure patient.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Special Injury Care (3 of 3)
Dislodged Teeth
– Rinse in NS.
– Wrap in NS-soaked gauze.
Impaled Objects
– Secure with bulky dressing.
– Stabilize object to prevent movement.
– Indirect pressure around wound.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Morgan Lens
https://www.youtube.com/watch?v=zm
XqunkuVR4
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ