Head and Facial Injury
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Head and Facial Head and Facial InjuryInjury
Scott Marquis, MDScott Marquis, MD
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OverviewOverview
Head injuryHead injury What to look forWhat to look for Appropriate managementAppropriate management Facial injuryFacial injury ReviewReview
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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
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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
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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
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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
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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
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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
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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
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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
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The brain is enclosed in a boxThe brain is enclosed in a box
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Brain anatomyBrain anatomy
Occupies 80% of intracranial spaceOccupies 80% of intracranial space DivisionsDivisions
CerebrumCerebrum CerebellumCerebellum Brain StemBrain Stem
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Brain anatomyBrain anatomy
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
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Brain anatomyBrain anatomy
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
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Brain anatomyBrain anatomy
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
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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
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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
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Skull fractureSkull fracture
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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
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Skull fractureSkull fracture
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
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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)
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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
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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)
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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
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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
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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
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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
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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
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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)
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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
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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
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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)
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More on brain workingsMore on brain workings
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
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More on brain workingsMore on brain workings
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
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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
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What goes wrong in head What goes wrong in head injuryinjury
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
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What goes wrong in head What goes wrong in head injuryinjury
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
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What goes wrong in head What goes wrong in head injuryinjury
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
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What goes wrong in head What goes wrong in head injuryinjury
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
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HerniationHerniation
TranstentorialTranstentorial UncalUncal
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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
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What you see on examWhat you see on exam
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
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What you see on examWhat you see on exam
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
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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
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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
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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
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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
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EyesEyes
Window to soul and CNSWindow to soul and CNS Pupil size, equality, and response to Pupil size, equality, and response to
lightlight
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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
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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
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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
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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
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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
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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
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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
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Blood pressureBlood pressure
A single episode of hypotension =A single episode of hypotension =
doubles patient mortalitydoubles patient mortality
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OxygenationOxygenation
Hypoxemia is a strong predictor of poor Hypoxemia is a strong predictor of poor outcomeoutcome
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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
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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
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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
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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
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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
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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
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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
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Intravenous therapyIntravenous therapy
Drug therapy considerationsDrug therapy considerations Only after:Only after:
Management of ABC’s Management of ABC’s Controlled hyperventilationControlled hyperventilation
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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
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Useful drugsUseful drugs
VecuroniumVecuronium RSIRSI Defasciculating doseDefasciculating dose Decrease brain oxygen demandDecrease brain oxygen demand
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Useful drugsUseful drugs
LidocaineLidocaine RSI, few minutes priorRSI, few minutes prior 1.5 mg/kg IV1.5 mg/kg IV Prevents increases in ICPPrevents increases in ICP
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Useful drugsUseful drugs
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!
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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
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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
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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
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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
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Any questions?Any questions?
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ResourcesResources
www.braintrauma.orgwww.braintrauma.org
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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
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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
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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
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Facial bone anatomyFacial bone anatomy
Frontal Frontal NasalNasal Zygoma / zygomatic archZygoma / zygomatic arch MaxillaMaxilla MandibleMandible
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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
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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
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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
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LeFort fracturesLeFort fractures
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Questions?Questions?