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Head and Facial Injury. Scott Marquis, MD. Overview. Head injury What to look for Appropriate management Facial injury Review. Head and brain trauma. ~ 1,500,000 head injuries annually ~ 230,000 hospitalized and survive ~ 50,000 deaths 1/3 all injury-related deaths Severity 75% mild

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head and facial injury

Head and Facial Injury

Scott Marquis, MD

overview
Overview
  • Head injury
  • What to look for
  • Appropriate management
  • Facial injury
  • Review
head and brain trauma
Head and brain trauma
  • ~ 1,500,000 head injuries annually
  • ~ 230,000 hospitalized and survive
  • ~ 50,000 deaths
  • 1/3 all injury-related deaths
  • Severity
    • 75% mild
    • 10% moderate
    • 10% severe (35% mortality, 5% c-spine fx)
  • 80,000-90,000 significant long-term disability
head brain trauma
Head & brain trauma
  • Risk Groups
    • Highest: Males 15-24 yrs of age
    • Very young children: 6 mos to 2 yrs of age
    • Young school age children
    • Elderly >75 yrs
head injury
Head injury
  • Broad and Inclusive Term
    • Traumatic insult to the head that may result in injury to soft tissue, bony structures, and/or brain injury
    • Blunt Trauma
    • Penetrating Trauma
brain injury
Brain injury
  • “A traumatic insult to the brain capable of producing physical, intellectual, emotional, social and vocational changes”
  • Three broad categories
    • Focal injury
      • Cerebral contusion
      • Intracranial hemorrhage
      • Epidural hemorrhage
    • Subarachnoid hemorrhage
    • Diffuse Axonal Injury
      • Concussion
mechanisms of head injury
Mechanisms of head injury
  • Motor vehicle crashes, MVC
    • Most common cause of head trauma
    • Most common cause of subdural hematoma
  • Sports injuries
  • Falls
    • Common in elderly and in presence of alcohol
    • Associated with subdural hematomas
  • Penetrating trauma
    • Missiles more common than sharp projectiles
categories of injury
Categories of injury
  • Coup injury
    • Directly posterior to point of impact
    • More common when front of head struck
  • Contrecoup injury
    • Directly opposite the point of impact
    • More common when back of head struck
categories of injury1
Categories of injury
  • Diffuse axonal injury (DAI)
    • Shearing, tearing or stretching of nerve fibers
    • More common with vehicle occupant and pedestrian
  • Focal injury
    • Limited and identifiable site of injury
causes of brain injury
Causes of brain injury
  • Direct (primary) causes
    • Impact
    • Mechanical disruption of cells
    • Vascular permeability or disruption
  • Indirect (secondary or tertiary) causes
    • Secondary
      • Edema, hemorrhage, infection, inadequate perfusion, tissue hypoxia, pressure
    • Tertiary
      • Apnea, hypotension, pulmonary resistance, ECG changes
brain anatomy
Brain anatomy
  • Occupies 80% of intracranial space
  • Divisions
    • Cerebrum
    • Cerebellum
    • Brain Stem
brain anatomy1
Brain anatomy
  • Cerebral spinal fluid, CSF
    • Clear, colorless
    • Circulates throughout brain and spinal cord
    • Cushions and protects
    • Ventricles
      • Center of brain
      • Secrete CSF by filtering blood
      • Forms blood-brain barrier
brain anatomy2
Brain anatomy
  • Blood Supply
    • Vertebral arteries
      • Supply posterior brain (cerebellum and brain stem)
    • Carotid arteries
      • Most of cerebrum
brain anatomy3
Brain anatomy
  • Meninges
    • Dura mater: tough outer layer, separates cerebellum from cerebral structures, landmark for lesions
    • Arachnoid: web-like, venous vessels that reabsorb CSF
    • Pia mater: directly attached to brain tissue
scalp lacerations
Scalp lacerations
  • Scalp laceration or avulsion
    • Most common injury
    • Vascularity = diffuse bleeding
    • Generally does not cause hypovolemia in adults
    • Can produce hypovolemia in children
scalp anatomy
Scalp anatomy
  • Scalp
    • S: skin
    • C: connective tissue
    • A: aponeurosis (galea)
    • L: loose areolar tissue
    • P: pericranium
  • Scalp very vascular
    • major blood loss
    • watch kids and adults with prolonged extrication
skull fracture1
Skull fracture
  • Present in 60% of pts with severe head injury
  • Types:
    • Linear: usually incidental finding on CT
    • Depressed: mechanism is usually intense

blow to scalp with object of small

surface area. Surgical repair needed

if depressed more than 5mm

skull fracture2
Skull fracture
  • Types
    • Basilar: blow to temporal (most often), parietal, occipital area
    • Signs
      • Hemotympanum or bloody ear discharge
      • Rhinorrhea or otorrhea
      • Battle’s sign
      • Racoon’s eyes
      • Cranial nerve palsies
closed head injuries
Closed head injuries
  • Focal
    • Contusion
    • Epidural hematoma
    • Subdural hematoma
    • Intracerebral
  • Diffuse (most common type of head injury)
    • Mild concussion
    • Classic concussion
    • Diffuse Axonal Injury (DAI)
epidural hematoma
Blood between skull and dura

Usually arterial tear

Middle meningeal artery

Causes increased ICP

Epidural hematoma
epidural hematoma1
Epidural hematoma
  • Unconsciousness followed by lucid interval
  • Rapid deterioration
  • Decreased LOC, headache, nausea, vomiting
  • Hemiparesis, hemiplegia
  • Unequal pupils (dilated on side of clot)
  • Increase BP, decreased pulse (Cushing’s reflex)
subdural hematoma
Between dura mater and arachnoid

More common

Usually venous

Bridging veins between cortex and dura

Causes increased intracranial pressure

Subdural Hematoma
subdural hematoma1
Subdural hematoma
  • Slower onset
  • Increased ICP
  • Headache, decreased LOC, unequal pupils
  • Increased BP, decreased pulse
  • Hemiparesis, hemiplegia
intracerebral hematoma
Intracerebral hematoma
  • Usually due to laceration of brain
  • Bleeding into cerebral substance
  • Associated with other injuries
    • DAI
  • Neuro deficits depend on region involved and size
    • Repetitive with frontal lobe
  • Increased ICP
concussion
Concussion
  • Transient loss of consciousness
  • Retrograde amnesia, confusion
  • Resolves spontaneously without deficit
  • Usually due to blunt head trauma
diffuse axonal injury
Diffuse axonal injury
  • Tearing or shearing of nerve fibers at time of impact
  • Rapid acceleration-deceleration injury (MVA)
  • Functional or physiologic dysfunction
  • Not gross anatomic abnormality
  • Most common CT finding after severe head trauma
diffuse axonal injury1
Diffuse axonal injury
  • Prolonged post-traumatic coma not due to mass lesion or ischemic insults
  • Coma begins at time of trauma
  • Usually evidence of decorticate or decerebrate posturing, autonomic dysfunction (HTN, fever)
penetrating head injury
Penetrating head injury
  • Severity depends on
    • Energy of missile
    • Path
    • Amount of scatter of bone and metal fragments
    • Presence of mass lesion
  • Accompanied by
    • Severe face and neck injuries
    • Significant blood loss
    • Difficult airway
    • Spinal instability
what the brain needs
What the brain needs
  • High metabolic rate
    • Consumes 20% of body’s oxygen
    • Largest user of glucose
    • Requires thiamine
    • Can not store nutrients
more on brain workings
More on brain workings
  • Perfusion
    • Cerebral blood flow (CBF)
      • Dependent upon CPP
      • Flow requires pressure gradient
    • Cerebral perfusion pressure (CPP)
      • Pressure moving the blood through the cranium
      • Autoregulation allows BP change to maintain CPP
      • CPP = mean arterial pressure (MAP) - intracranial pressure (ICP)
more on brain workings1
More on brain workings
  • Perfusion
    • Mean Arterial Pressure (MAP)
      • Largely dependent on cerebral vascular resistance (CVR) since diastolic is main component
      • Blood volume and myocardial contractility
      • MAP = diastolic + 1/3 pulse pressure
      • Usually require MAP of at least 60 mm Hg to perfuse brain
more on brain workings2
More on brain workings
  • Perfusion
    • Intracranial pressure (ICP)
      • Edema, hemorrhage
      • ICP usually 10-15 mm Hg
  • Cerebral perfusion pressure

CPP = MAP - ICP

what goes wrong in head injury
What goes wrong in head injury
  • As ICP  and approaches MAP, cerebral blood flow 
    • Results in  CPP
    • Compensatory mechanisms attempt to  MAP
    • As CPP , cerebral vasodilation occurs to  blood volume
    • This leads to further  ICP,  CPP and so on
what goes wrong in head injury1
What goes wrong in head injury
  • Hypercarbia causes cerebral vasodilation
    • Results in  blood volume   ICP  CPP
    • Compensatory mechanisms attempt to  MAP
    • As CPP , cerebral vasodilation occurs to  blood volume
    • And, the cycle continues
what goes wrong in head injury2
What goes wrong in head injury
  • Hypotension results in  CPP  cerebral vasodilation
    • Results in  blood volume   ICP  CPP
    • And, the cycle continues
what goes wrong in head injury3
What goes wrong in head injury
  • Pressure exerted downward on brain
    • Cerebral cortex or RAS
      • Altered level of consciousness
    • Hypothalamus
      • Vomiting
what goes wrong in head injury4
What goes wrong in head injury
  • Pressure exerted downward on brain
    • Brain stem
      •  BP and bradycardia 2° vagal stimulation
      • Irregular respirations or tachypnea
      • Unequal/unreactive pupils 2° oculomotor nerve paralysis
      • Posturing
    • Seizures dependent on location of injury
herniation
Herniation
  • Transtentorial
  • Uncal
what you see on exam
What you see on exam
  • Levels of increasing ICP
    • Cerebral cortex and upper brain stem
      • BP rising and pulse rate slowing
      • Pupils reactive
      • Cheyne-Stokes respirations
      • Initially try to localize and remove painful stimuli
what you see on exam1
What you see on exam
  • Levels of increasing ICP
    • Middle brain stem
      • Wide pulse pressure and bradycardia
      • Pupils nonreactive or sluggish
      • Central neurogenic hyperventilation
      • Extension
what you see on exam2
What you see on exam
  • Levels of increasing ICP
    • Lower brain stem / medulla
      • Pupil blown (side of injury)
      • Ataxic or absent respirations
      • Flaccid
      • Irregular or changing pulse rate
      • Decreased BP
      • Usually not survivable
global function assessment
Global function: assessment
  • LOC = best indicator
    • Altered LOC = Intracranial trauma UPO
    • Trauma patient unable to follow commands = chance of intracranial injury needing surgery
global function
Global function
  • AVPU scale
    • A = Alert
    • V = Responds to Verbal stimuli
    • P = Responds to Painful stimuli
    • U = Unresponsive
general brain function
General brain function
  • Glasgow Coma Scale, GCS
    • Eye opening
    • Verbal response
    • Motor response
  • Reliable measure, repeatable
slide66
Eyes
  • Window to soul and CNS
  • Pupil size, equality, and response to light
slide67
Eyes
  • Unequal pupils + decreased LOC =
    • Compression of oculomotor nerve
    • Probable mass lesion
  • Unequal pupils + alert patient =
    • Direct blow to eye, or
    • Oculomotor nerve injury, or
    • Normal inequality
movement
Movement
  • Is patient able to move all extremities?
  • How do they move?
    • Decorticate
    • Decerebrate
    • Hemiparesis or hemiplegia
    • Paraplegia or quadraplegia
movement1
Movement
  • Lateralized or focal signs =

lateralized or focal deficits

  • Altered motor function may be due to fracture or dislocation
vital signs
Vital Signs
  • Cushing’s triad
  • Suggests increased intracranial pressure
    • Increased BP
    • Decreased pulse
    • Irregular respiratory pattern
vital signs1
Vital Signs
  • Isolated head injury will not cause hypotension in adults
  • Look for another life threatening injury
    • Chest
    • Abdomen
    • Pelvis
    • Multiple long bone fractures
    • Large scalp lacerations
summary for assessment
Summary for assessment
  • Most important sign = LOC
  • Direction of changes more important than single observations
  • Importance lies in continued reassessment compared with initial exam
  • UPO, altered LOC in trauma = intracranial injury
goals for treatment
Goals for treatment
  • Maintain adequate oxygenation
  • Maintain sufficient BP for good brain perfusion
  • Avoid secondary brain damage
blood pressure
Blood pressure
  • A single episode of hypotension =

doubles patient mortality

oxygenation
Oxygenation
  • Hypoxemia is a strong predictor of poor outcome
airway management
Airway management
  • Open
    • Assume C-spine trauma
    • Jaw thrust with C-spine control
  • Clear
    • Suction as needed
  • Maintain or secure
    • Intubation if no gag reflex
    • RSI, lidocaine and vecuronium
    • Avoid nasal intubation
breathing
Breathing
  • Oxygenate - 100% O2
  • Ventilate
  • No routine hyperventilation
    • Adults 10-12 BPM
    • Children 12-16 BPM
    • Infants 16-20 BPM
breathing1
Breathing
  • Respiratory Patterns
    • Cheyne Stokes
      • Diffuse injury to cerebral hemispheres
    • Central neurological hyperventilation
      • Injury to mid-brain
    • Apneustic
      • Injury to pons
ventilation
Ventilation
  • Hyperventilation recommended only for signs of cerebral herniation!
    • Posturing
    • Pupillary abnormalities
    • Neurologic deterioration after correction of hypotension or hypoxemia
    • Decrease in GCS of more than two points in patients with initial GCS less than 9
      • Adults 16-20 BPM
      • Children 20-24 BPM
      • Infants 24-28 BPM
hyperventilation
Hyperventilation
  • Benefits
    • Decreased PaCO2
    • Vasoconstriction
    • Decreased ICP
  • Risks
    • Decreased cerebral blood flow
    • Decreased oxygen delivery to tissues
    • Increased edema
circulation
Circulation
  • Maintain adequate BP and perfusion
  • IV of LR/NS TKO if BP normal or elevated
  • If BP decreased
    • LR/NS bolus titrated to SBP ~ 90 mm Hg
    • Consider PASG/MAST if SBP below 80
  • Monitor EKG -- Do not treat bradycardia
immobilization
Immobilization
  • Spinal motion restriction
  • If BP normal or elevated, spine board head elevated 300
intravenous therapy
Intravenous therapy
  • Drug therapy considerations
  • Only after:
    • Management of ABC’s
    • Controlled hyperventilation
useful drugs
Useful drugs
  • Diazepam
    • Anticonvulsant
    • Give if patient experiences seizures
    • 5 mg IV
    • May mask changes in LOC
    • May depress respirations
    • May worsen hypotension
useful drugs1
Useful drugs
  • Vecuronium
    • RSI
    • Defasciculating dose
    • Decrease brain oxygen demand
useful drugs2
Useful drugs
  • Lidocaine
    • RSI, few minutes prior
    • 1.5 mg/kg IV
    • Prevents increases in ICP
useful drugs3
Useful drugs
  • Mannitol
    • Decreases cerebral edema
    • Improves cerebral blood flow and oxygen delivery
    • Plasma expander
    • Osmotic diuretic
    • 1 g/kg IV
    • May cause hypotension
    • May worsen intracranial hemorrhage
    • Don’t have it!
glucose
Glucose
  • Assess blood glucose
  • Administer only if hypoglycemic
  • Hyperglycemia can harm injured brain secondary to osmotic shifts
  • Consider thiamine in malnourished
transport of head injuries
Transport of head injuries
  • Choose trauma center
  • Any moderate and severe (GCS 3-13) need to go to trauma center where neurosurgery is available
  • Air medical transport if needed
  • Severe injuries need to be recognized quickly and transported rapidly as early surgical intervention is often only truly lifesaving treatment
helmet removal
Helmet removal
  • Immediate removal if interferes with priorities
    • Access to airway or airway management
    • Ventilation
    • Cervical spine motion restriction
  • May only need to remove face piece to access airway
  • Technique
    • Requires adequate assistance
    • Training in the procedure
    • Padding if shoulder pads left on
summary
Summary
  • Spinal precautions
  • Avoid hypoxia
  • Consider intubation early
  • Avoid hypotension
  • Frequent reassessment
  • Hyperventilate for herniation
  • Triage wisely
resources
Resources
  • www.braintrauma.org
facial injuries
Facial injuries
  • Mortality
    • Primarily associated with brain and spine injury
    • Severe facial fractures may interfere with airway and breathing
  • Morbidity
    • Disability concerns
    • Cosmetic concerns
facial trauma
Facial trauma
  • Seldom life-threat unless injury involves the airway
  • Spinal motion restriction
  • Airway is the most difficult and most critical priority
  • Consider early intubation
  • Suction and control bleeding
  • Critical trauma patient - transport accordingly
facial trauma1
Facial trauma
  • Causes
    • MVC, home accidents, athletic injuries, animal bites, violence, industrial accidents…
  • Soft tissue
    • Lacerations, abrasions, avulsions
    • Vascular area supplied by internal and external carotids
facial bone anatomy
Facial bone anatomy
  • Frontal
  • Nasal
  • Zygoma / zygomatic arch
  • Maxilla
  • Mandible
facial fractures
Facial fractures
  • Mandible, maxilla, nasal bones, zygoma & rarely the frontal bone
  • Signs and symptoms
    • Pain, swelling, deep lacerations, limited ocular movement, facial asymmetry, crepitus, deviated nasal septum, bleeding, depression on palpation, malocclusion, blurred vision, diplopia, broken or missing teeth
midface fractures
Midface fractures
  • May be significant hemorrhage
  • C-spine precautions
  • Avoid nasotracheal intubation, if possible
  • LeFort fracture
  • Tripod fracture
midface fractures1
Midface fractures
  • Appearance
    • “Donkey face” (lengthening)
    • “Pumpkin face” (edema)
    • Nasal flattening
  • Often associated with orbital fractures
mouth injuries
Mouth injuries
  • MVC
  • Blunt injury to the mouth or chin
  • Penetrating injury due to GSW, laceration, or puncture
mouth injuries1
Mouth injuries
  • Primary concerns
    • Airway compromise secondary to bleeding
    • FB aspiration secondary to broken or avulsed teeth
    • Impaled object
  • Management
    • ABCs
      • Suction prn
    • Stabilize impaled object
    • Collect tissue: tongue or tooth
mandibular injuries
Mandibular injuries
  • Mandibular Fracture
    • Numbness, inability to open or close the mouth, excessive salivation, malocclusion
  • Bilateral body or midline injuries may compromise airway
  • C-spine immobilization
  • Anterior dislocation
    • May be caused by extensive dental work, yawning
    • Condylar heads move forward and muscles spasm
dental trauma
Dental trauma
  • 32 teeth in normal adult, 20 teeth in children
  • Associated with facial fractures
  • May aspirate broken tooth
  • Avulsed teeth can be replaced so find them!
  • Early hospital notification to find dentist
dental trauma1
Dental trauma
  • <15 minutes, may be asked to replace the tooth in socket
  • Do not rinse or scrub (removes periodontal membrane and ligament)
  • Preserve in fresh whole milk
  • Saline OK for less than 1 hour
nasal injuries
Nasal injuries
  • Variety of mechanisms including blunt or penetrating trauma
  • Swelling, deformity, crepitance
  • Most common injury
    • Adults - Epistaxis
    • Children - Foreign bodies
nasal injuries1
Nasal injuries
  • Epistaxis
    • Anterior bleeding from septum
      • Usually venous
    • Posterior bleeding
      • Often drains to airway
    • May be associated with
      • Sphenoid and/or ethmoid fractures
      • Basilar skull fracture
nasal injury management
Nasal injury: management
  • Epistaxis
    • Direct pressure over septum
    • Upright position, leaning forward or in lateral recumbent position
  • If CSF present, do not apply direct pressure
    • Allow to drain
    • Needs neurosurgical consult
eye injury types
Eye injury types
  • Penetrating
    • Abrasions
    • Foreign bodies (deep, superficial, impaled)
    • Lacerations (deep or superficial, eyelid)
  • Burns
    • Flash
    • Acid/alkali
eye injury types1
Eye injury types
  • Blunt
    • Swelling
    • Conjunctival hemorrhage
    • Hyphema
    • Ruptured globe
    • Blow-out fracture of orbit
    • Retinal detachment
blow out orbital fracture
Blow-out orbital fracture
  • Usually result of a direct blow to the eye
  • Flattened face, numbness
  • Epistaxis, altered vision
  • Periorbital swelling
  • Diplopia
  • Inophthalmos
  • Impaired ocular movement
globe injuries
Globe injuries
  • Contusion, laceration, hyphema, globe or scleral rupture
  • Signs and symptoms - loss of visual acuity, blood in anterior chamber, dilation or constriction of pupil, pain, soft eye, pupil irregularity
globe injuries1
Globe injuries
  • Consider C-spine precautions due to forces required for injury
  • No pressure to globe for dressing, cover both eyes for protection
  • Avoid activities that increase intra-ocular pressure
ear injury
Ear injury
  • External injuries
    • Lacerations, avulsions, amputations, frostbite
    • Control bleeding with direct pressure
  • Internal injuries
    • Spontaneous rupture of eardrum will usually heal spontaneously
    • Penetrating objects should be stabilized, not removed!
      • Removal may cause deafness or facial paralysis
      • Hearing loss may be result of otic nerve damage in basilar skull fracture
ear injury1
Ear injury
  • Separation of ear cartilage
    • Treat as an avulsion
    • Dress and bandage
    • Consider disability and cosmetic concerns
  • Bleeding from ear canal
    • Cover with loose dressing only
summary1
Summary
  • Control bleeding
  • Manage airway accordingly
  • Avoid nasal tracheal intubation when possible
  • Assume c-spine injury is present
  • Gather parts and stabilize objects
  • Trauma survey for other life-threats
  • Transport accordingly