CHAPTER 6 Brain, Craniofacial Trauma
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Transcript of CHAPTER 6 Brain, Craniofacial Trauma
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BRAIN ANDCRANIOFACIAL TRAUMA
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Epidemiology
• Brain and craniofacial injuries account for 40 to 50% of all trauma deaths
• Transportation-related to vehicle use is the leading risk factor
• Primary mechanism of injuries are motor vehicle crashes
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Epidemiology
• Behavior that increases risk
Alcohol Drugs Incorrect or nonuse of safety restraints
Participation in sports without protection
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Mechanism of injury and Biomechanics
• Most common mechanisms
Motor vehicle crashes Fall Intentional assaults
Recreational and sports injuries
Firearm use
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Mechanism of injury and Biomechanics
• Energy forces result in cranial injury
• Forces are : Shearing Tensile
• Coup injury (same side)
Compressive
• Contracoup injury (opposite side)
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Types of Injuries
Blunt injuries areassociated with :
Acceleration forces
Deceleration forces
Combination
Penetrating injuries areassociated with :
Missile type wound
High mortality rate
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Concurrent Injuries
• 30% of patients with brain or craniofacial injuries have at least one additional injury to another body system
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Pathophysiology
• Injury to the brain may result in :
Primary injury (skull fracture, epidural hematoma)
Secondary injury (cerebral ischemia)
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Airway Obstruction
• Occlusion by tongue
• Oral debris
• Accumulation of secretions
• Bleeding
• Facial edema
• Facial fractures
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Cerebral Perfusion
Adequate cerebral perfusion is dependent on Adequacy of cerebral perfusion pressure (CCP)Which is the difference between the mean arterial Pressure (MAP) and the intracranial pressure (ICP) CCP=MAP minus ICP
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Cerebral Perfusion
• Close relationship between cerebral blood flowand cerebral perfusion pressure.
• Cerebral blood flow is a function of: Cerebral perfusion pressure The brain’s ability to autoregulate cerebral
blood vessels• Altered autoregulation
Increased intracranial pressure Decreased cerebral perfusion pressure
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Intracranial Pressure
• Intracranial pressure reflects Brain Cerebrospinal fluid Blood
• As intracranial pressure increases, cerebralperfusion pressure decreases
• Leads to cerebral ischemia and hypoxia
• In a hypotensive patient, even a marginallyelevated ICP can be harmful
• Adequacy of cerebral perfusion pressure is most important
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Intracranial Pressure
• EARLY signs and symptoms of increasedintracranial pressure Headache Nausea and vomiting Amnesia for events Altered level of consciousness Restlessness, drowsiness, change in speech,
loss of judgement
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Intracranial Pressure
• LATE signs and symptoms of increasedintracranial pressure
Dilated, nonreactive pupil Unresponsive to verbal or painful stimuli Abnormal motor posturing patterns Change in respiratory rate and pattern
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Intracranial Pressure
• Cushing Response ( Late Signs )
Increased systolic blood pressure Widening pulse pressure Decreased pulse rate
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Hypotension and hypoxia
• Need to maintain adequate cerebal perfusionpressure
• Early post injury episodes which increasemorbidity and mortality include: Hypotension (blood pressure <90 mm Hg)
with increased ICP Hypoxia
As apnea/cyanosis in the field PaO2 <60 mm Hg
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Herniation Syndromes
Symptoms
• Unilateral or bilateral pupillary dilation
• Asymmetric pupillary reactivity
• Abnormal posturing
• Other evidence of neurologic deterioration
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Herniation Syndromes
Types
• Uncal: Uncus (medial aspect of the temporal lobe)is displaced over the tentorium into posteriorfossa (most common type)
• Central or transtentorial : downward movement ofcerebral hemispheres with herniation of diencephalon and midbrain through gaps oftentorium
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Cerebrospinal Fluid Leakage
• Displaced or nondisplaced fractures or fracturesof the basilar skull or craniofacial area may lacerate the dura mater creating a passage forcerebrospinal fluid from the nose or ear
• Potential entrance of bacteria Meningitis Encephalitis Brain abscess
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Scalp and Facial Abscess
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Concussion
Classifications
Mild : Diffuse brain injury with no identifiablelesion
Classic : Diffuse brain injury associated with (no longer than 6 hours) loss of consciousnesswith no identifiable lesion
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Concussion - Mild
Signs and Symptoms:
• No loss of consciousness
• Headache
• Confusion and disorientation
• Possible memory loss
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Concussion - Classic
Signs and Symptoms:
• Transient loss of consciousness
• Nausea and vomiting
• Confusion and disorientation
• Dizziness
• Memory loss
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Diffuse Axona Injury
• Diffuse brain injury resulting from accelerationand deceleration forces that produce shearing or tensile stresses and damage to axons
• Brain stem and reticular activating system (RES)may be involved leading to prolonged coma
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Diffuse Axona Injury
Signs and Symptoms:
• Immediate unconsciousness (may last a few weeksto 3 months)
• Hypertension : Systolic blood pressure between140 and 160 mm Hg
• Hyperthermia : 40 to 40.5 • Excessive sweating
• Abnormal motor posturing
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Contusion and Intracerebral Hematoma
• Contusion : Common focal brain injury in which tissueis bruised and damaged in a local area (associated with subdural bleed)
Frontal Temporal
• Intracerebral Hematoma : Caused by delayed hemorrhage or evolution of hematoma
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Contusion and Intracerebral Hematoma
Signs and Symptoms:
• Altered level of consciousness
• Unusual behavior
• Abnormal posturing
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Epidural Hematoma
• A focal brain injury results in collection of bloodbetween the skull and dura
• Associated with fractures of the temporal or parietal area that lacerate the middle meningealartery
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Epidural Hematoma
• Bleeding usually arterial
• Immediate surgical intervention required
• Prognosis excellent if treated early
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Epidural Hematoma
Signs and Symptoms:
• Decreased level of consciousness may follow a pattern Initial decrease in the level of consciousness
may followed by return of consciousness(lucid interval) followed by a rapid unconsciousness OR
Persistent decreased level of consciousness
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Epidural Hematoma
Signs and Symptoms: (continued)
• Hemiparesis or hemiplegia on the opposite sideof the hematoma
• Unilateral and fixed dilated pupil on the same sideas the hematoma
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Subdural Hematoma
• Focal brain injury beneath the dura resulting from acceleration, deceleration, or combinationforces
• More common than epidural hematomas
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Subdural Hematoma
Causes:
• Usually venous in origin; tearing of the bridging veins
• Also from injuries to tissue or vessels of cerebralcortex
• Direct injury to brain tissue
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Subdural Hematoma
• Onset may be acute (within 48 hours) orchronic (up to 2 weeks after even)
• Patient types Elderly Those on anticoagulants Chronic alcohol users
• More lethal than most brain lesions
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Subdural Hematoma
Signs and Symptoms:
• Steady decline in level of consciousness
• Hemiparesis or hehiplegia on opposite sideof the hematoma
• Unilateral fixed or dilated pupil on sameside as hematoma
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Skull Fractures
Types:
• Linear : Nondisplaced fracture of cranium;underlying vessels may be lacerated
• Depressed : Extends below the surface of the skullcan cause compression and dural laceration
• Basilar : Fractures of bones of the base of theskull
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Skull Fracture - Linear
Signs and Symptoms:
• Headache
• Possible decreased level of consciousness
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Skull Fracture - Depressed
Signs and Symptoms:
• Headache• Decreased level of consciousness
• Open fracture
• Palpable depression of the skull overfracture site
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Skull Fracture - Basilar
Signs and Symptoms:
• Headache
• Altered level of consciousness
• Raccoon’s eyes : Periorbital ecchymosis• Battle’s sign : Mastoid ecchymosis
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Skull Fracture - Basilar
Signs and Symptoms: (continued)
• Hemotympanun : Blood behind tympanicmembrane
• Facial nerve palsy (cranial nerve VII)
• Cerebrospinal fluid rhinorrhea or otrrhea
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Mandibular Fractures
Common fracture sites : Canine and 3rd molar areaAngle of the mandible, and condyles
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Mandibular Fractures
Signs and Symptoms:
• Maloccusion
• Trismus (inability to open the mouth)
• Pain (especially on movement)
• Facial asymmetry
• Edema or hematoma at the fracture site
• Bloody or ruptured tympanic membrane
• Anesthesia of the lower lip
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Mandibular Fractures
Types:
• Le Fort I : Transverse maxillary fracture
• Le Fort II : Pyramidal fracture involving themidface
• Le Fort III : Complete craniofacial separation
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Mandibular Fractures – Le Fort I
Signs and Symptoms:
• Slightly maxillary area swelling
• Lip laceration or fractures of the teeth
• Independent movement of maxilla• Malocclusion
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Mandibular Fractures – Le Fort II
Signs and Symptoms:
• Massive facial edema• Nasal swelling
• Malocclusion
• Cerebrospinal fluid rhinorrhea
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Mandibular Fractures – Le Fort III
Signs and Symptoms:
• Massive facial edema
• Mobility / depression of the zygomatic bones• Ecchymosis• Anesthesia of the cheek• Diplosia• Open bite or malocclusion
• Cerebrospinal fluid rhinorrhea
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Orbital Fracture
• Orbital fracture is composed of: Frontal bone Zygoma Maxilla Ethmoid bone
• Entrapment of cranial nerve may occur
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Orbital Fracture
Signs and Symptoms:
• Diplopia
• Loss of vision• Altered extraocular eye movements• Enopthalmos• Subconjunctival hemorrhage• Infraorbital pain or sensation loss
• Orbital bony deformity
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Nursing Care - Assessment
History
• If conscious, what are the complaints?• If altered consciousness, does the history
suggest brain and craniofacial trauma?• Any loss of consciousness following injury?
If so, how long?
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Nursing Care - Assessment
History (continued)
• Does the patient have any amnesia
• Any drugs or alcohol used?
• Does the patient have any previousneurologic deficits or seizure history?
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Nursing Care – Physical Assessment
Inspection
• Assess airway
• Observe respiratory rate, pattern, and effort
• Determine level of consciousness
• Assess pupillary size and light response
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Nursing Care – Physical Assessment
Inspection (continued)
• Assess for abnormal posturing patterns
• Inspect craniofacial area for ecchymosis orcontusions, nose and ears for drainage
• Assess extraocular movements and for occlusion of mandible and maxilla
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Nursing Care – Physical Assessment
Palpation
• Palpate craniofacial area
• Assess facial sensory function
• Assess all extremities Motor Sensory
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Diagnostic Procedures
• Radiographic Studies Computerized tomography scan (CT SCAN) Skull series Facial radiographs Magnetic Resonance Imaging (MRI)
• Laboratory Studies Arterial blood gases
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Nursing Diagnoses
• Ineffective airway clearance
• Impaired gas exchange• Altered tissue perfusion
• Aspiration risk
• Injury risk
• Hyperthermia risk
• Infection risk
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Planning and Implementation
• Open and clear the airway
• Administer oxygen via a nonrebreather maskat 12 to 15 L/min
• Assist with early endotracheal intubation
• Chronic prolonged hyperventilation or prophylactic hyperventilation : Only withclinical evidence of increased intracranialpressure refractory to sedation, paralysiscerebrospinal fluid drainage and osmoticdiuretics
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Planning and Implementation
• Apply direct pressure to bleeding sites (except depressed skull fractures)
• Cannulate two veins with large bore cathertersand infuse lactated Ringer’s solution
• Insert an oro or nasogastric tube
• Position the patient as guided by protocols
• Prepare for intracranial pressure monitoringaccording to protocols
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Planning and Implementation
• Administer as prescribed Mannitol Anticonvulsants Antipyretics Antibiotics Tetanus prophylaxis
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Planning and Implementation
• Do not pack the nose and ears if cerebrospinalfluid leaks
• Assist with wound repair
• Prepare the patient for operativeintervention, admission, or transfer
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Nursing Intervention for a Facial Injury
• Position the patient in a high-Fowler’s positionif no spinal injury
• Prepare for endotracheal intubation
• Apply cold compress to the face
• Assist with wound repair
• Administer antibiotics as prescribed
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Evaluation and Ongoing Assessment
• Changes in level of consciousness, computeGlasgow Coma Sclae (GCS)
• Pupillary changes
• Blood pressure trends, pulse SpO2, respiratoryrate, patterns for signs of increased intra cranialpressure, hypotension, hypoxia
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Evaluation and Ongoing Assessment
• Increasing craniofacial edema
• Nausea, vomiting, seizure, severe headache
• Changes in motor and sensory function
• Response to fluid administration and diuretics by monitoring urinary output
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Summary