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Head, Facial and Neck Trauma

Head, Facial and Neck Trauma

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Head, Facial and Neck Trauma

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  1. Chapter 22 and 23 Head, Facial and Neck Trauma

  2. Outline • Introduction • Anatomy & Physiology • Pathophysiology • Assessment and Management

  3. Introduction • Common major trauma • 4 million people experience head trauma annually • Severe head injury is most common frequent cause of trauma death • At-risk population: • Males 15 – 24 • Infants, Young children, Elderly

  4. Introduction • Injury Prevention Programs • Motorcycle safety • Bicycle Safety • Helmet and head injury awareness • Sports • Football • Rollerblading • Contact Sports

  5. Introduction • TIME IS CRITICAL • Intracranial hemorrhage • Progressing edema • Increased ICP • Cerebral hypoxia • Permanent damage • Severity is difficult to recognize • Subtle signs • Improve differential diagnosis

  6. Anatomy & Physiology

  7. Head • Scalp • Strong flexible mass of skin and muscle • Hair provides insulation • Highly vascular

  8. Head • Skull comprised of • Facial bones • Cranium • Unyielding to increased intracranial pressure • Bones • Frontal - Ethmoid • Parietal - Sphenoid • Occipital - Temporal

  9. Meninges • Protective Mechanism • Dura Mater • Blood flow to surface of the brain • Arachnoid • Suspends brain in cranialcavity • Pia Mater • Covers brain and spinal cord

  10. The Meninges and Skull

  11. Brain • Occupies 80% of cranium • 3 Major Structures • Cerebrum • Cerebellum • Brain Stem • Receives 15% of cardiac output • Consumes 20% of body’s oxygen

  12. Cerebrum • Function • Center of conscious thought, personality, speech and motor control • Visual, auditory, and tactile perception • Structures • Central Sulcus • Tentorium

  13. Lobes • Frontal • Personality • Parietal • Motor and sensory • Memory and emotion

  14. Lobes • Occipital • Sight • Temporal • Long-term memory • Hearing • Speech • Taste • Smell

  15. Cerebellum • Located under tentorium • Function • “Fine tunes” motor control • Allows smooth movement • Balance • Maintenance of muscle tone

  16. Brain Stem • Central processing center • Communication junction among • Cerebrum - Cranial Nerves • Spinal Cord - Cerebellum • Structures • Midbrain • Pons • Medulla Oblongata

  17. Midbrain • Hypothalamus • Vomiting Reflex • Hunger • Thirst • Thalamus • Switching Center • Ascending Reticular Activating System (A-RAS)

  18. Pons • Communication interchange • Bulb-shaped structure

  19. Medulla Oblongata • Respiratory Center • Depth, rate, rhythm • Cardiac Center • Rate and strength • Vasomotor Center • Maintains BP • Distribution of blood

  20. Cerebral Perfusion Pressure • Pressure within cranium (ICP) • 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

  21. Calculating MAP CPP MAP = 90 & ICP = 10 CPP = MAP – ICP CPP = 100 – 10 = 90 BP = 120/90 DBP = 90 Pulse Pressure = 120 – 90 = 30 MAP 90 + 1/3(30) = 100

  22. Cerebral Perfusion Pressure • Autoregulation • Changes in ICP result in compensation • Increased ICP = Increased BP • Expanding mass inside cranial vault • Displaces CSF • If pressure increases, brain tissue is displaced

  23. Mechanism of Injury Blunt Injury Penetrating Injury Gunshot Wounds Stabbing Explosions • MVA • Assaults • Falls

  24. Scalp Injury • Contusions • Lacerations • Avulsions • Significant Hemorrhage ALWAYS reconsider MOI for severe underlying problems.

  25. Cranial Injury • Trauma must be extreme to fracture • Linear • Depressed • Open • Impaled object • Basal Skull • Unprotected • Spaces weakened structure • Easier to fracture

  26. Basal Skull Fracture Signs • Battle’s Signs • Retroauricular ecchymosis • Associated with fracture of auditory canal and lower area of skull • Raccoon Eyes • Bilateral periorbital ecchymosis • Associated with orbital fractures

  27. Basilar Skull Fracture • May tear dura • Permit CSF to drain through an external passageway • May mediate rise of ICP • Evaluate for “halo” sign

  28. Brain Injury • Classification • Direct • Primary injury caused by forces of trauma • Indirect • Secondary injury cased by factors resulting from the primary injury

  29. Direct Brain Injury Types • Coup • Injury at site of impact • Contrecoup • Injury on opposite side from impact

  30. Direct Brain Injury Categories • Focal • Occur at a specific location in brain • Differentials • Cerebral contusion • Intracranial hemorrhage • Intracerebral hemorrhage • Diffuse • Concussion • Moderate • Diffuse • Concussion • Moderate diffuse axonal injury • Severe diffuse axonal injury

  31. Focal Brain Injury • Cerebral Contusion • Blunt trauma to local brain tissue • Capillary bleeding into brain tissue • Common with blunt head trauma • Confusion • Neurologic deficit • Results from • Coup-contrecoup injury

  32. Epidural Hematoma • Bleeding between duramater and skull • Involves arteries • Rapid bleeding and reduction of oxygen • Herniates brain

  33. Subdural Hematoma • Bleeding within meninges • Beneath dura mater and within subarachnoid space • Slow bleeding • Signs progress over several days

  34. Intracerebral Hemorrhage • Ruptured blood vessel within the brain • Presentation similar to stroke symptoms • Signs and symptoms worsen over time

  35. Diffuse Brain Injury • Types • Concussion • Moderate diffuse axonal injury • Severe diffuse axonal injury

  36. Concussion • 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

  37. Moderate Diffuse Axonal Injury • Same mechanism as concussion • Unconsciousness • If cerebral cortex and RAS involved • Signs and Symptoms • Unconsciousness or persistent confusion • Loss of concentration, disorientation • Retrograde and antegrade amnesia • Visual and sensory disturbances • Mood and personality changes

  38. Severe Diffuse Axonal Injury • Brainstem Injury • Significant mechanical disruption of axons • High mortality rate • Signs & Symptoms • Prolonged unconsciousness • Cushing’s reflex • Decorticate or decerebrate posturing

  39. Intracranial Perfusion • 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

  40. ICP BP Compensating for Pressure • Compress venous blood vessels • Reduction in free CSF • Pushed into spinal cord

  41. ICP BP Decompensating for Pressure • Increase in ICP • Rise in systemic BP to perfuse brain • Further increase of ICP

  42. Role of Carbon Dioxide • Increase of C02 in CSF • Cerebral vasodilation • Encourage blood flow • Reduce hypercarbia • Reduce hypoxia • Contributes to increase in ICP • Causes classic HTN and hyperventilation • Reduce levels of C02 in CSF • Cerebral vasoconstriction  anoxia

  43. Factors Affecting ICP • Vasculature Constriction • Cerebral Edema • Systolic Blood Pressure • Low BP = Poor cerebral perfusion • High BP = Increased ICP • Carbon Dioxide • Reduced respiratory efficiency

  44. Brain Injury • Altered Mental Status • Cushing’s Reflex • Increased BP • Bradycardia • Erratic Respirations • Vomiting • Without nausea • Projectile • Body temp changes • Changes in pupils • Decorticate posturing Obtain a blood glucose level on all patients with AMS.

  45. Brain Injury • Pathophysiology of Changes • Front Lobe Injury • Occipital Lobe Injury • Retrograde Amnesia • Unable to recall events before injury • Antegrade Amnesia • Unable to recall events after trauma • Repetitive questioning • Hemiplegia, weakness, or seizures

  46. Upper Brainstem Compression • Increasing blood pressure • Reflex bradycardia • Vagus nerve stimulation • Cheyne-Stokes respirations • Pupils become small and reactive • Decorticate posturing

  47. Middle Brainstem Compression • Widening pulse pressure • Increasing bradycardia • CNS hyperventilation • Deep and rapid • Bilateral pupil sluggishness or inactivity • Decerebrate posturing

  48. Lower Brainstem Injury • Pupils dilated and unreactive • Ataxic respirations • Erratic with no pattern • Irregular and erratic pulse rate • ECG changes • Hypotension • Loss of response to painful stimuli