ch08 head, face, and neck

Paramedic Care:Principles & Practice

Volume 5Trauma Emergencies

Head, Facial, and Neck Trauma

IMPORTANT CONCEPT #1

ETOH + TRAUMA (WITH OR WITHOUT AMS)

= CLOSED HEAD INJURY UNTIL PROVEN OTHERWISE

Anatomy and Physiology


The Brain

Grand Central Station

Anatomy and Physiologyof the Head

CNS Circulation– Arterial

Four Major Arteries2 Internal Carotid Arteries2 Vertebral Arteries

Circle of WillisEncircle the base of the brain

– VenousDrain into internal jugular veins

What’ you talkin ‘bout Willis?

The Meninges and Skull



Blood-Brain Barrier– Less permeable than elsewhere in body– Does not allow flow of interstitial proteins– Reduced lymphatic flow– Very protected environment

Blood Brain Barrier

Proteins Glucose

More Math

MAPICPCPP

CPP

Cerebral Perfusion Pressure– Pressure within cranium (ICP) resists blood flow

and good perfusion to the CNSPressure usually less than 10 mmHg

– Mean Arterial Pressure (MAP)Must be at least 50 mmHg to ensure adequate perfusionMAP = DBP + 1/3 Pulse Pressure

– Cerebral Perfusion Pressure (CPP)Pressure moving blood through the craniumCPP = MAP - ICP

Monroe-Kelly Doctrine

Contents of the Skull–Brain–CSF–Blood–Expanding mass


The Monroe-Kelly Doctrine– The ICP is dynamic

Constantly changing to variations in body physiology – Intracranial Volume (fixed) = Brain Volume + CSF

Volume + Blood Volume + Mass/Lesion Volume – Any added extrinsic factor that occupies space in

the cranial vault increases intracranial volume and pressure


Monroe-Kelly Doctrine– Autoregulation

Changes in ICP result in compensationIncreased ICP = Increased BP

This causes ICP to rise higher and BP to riseBrain injury and death become imminent

– Expanding mass inside cranial vaultDisplaces CSFIf pressure increases, brain tissue is displaced


Cranial Nerves

Face musclesM

Chewing musclesM

Posterior palate and pharynxM

Face musclesM

SightSOpticIIPupil Const, rectus and obliquesMOculomotorIII

Opthalmic (FH), Maxillary (cheek), Mandible (chin)STrigeminalV

Lateral rectus muscleMAbducensVI

Taste to posterior tongueSVagusX

TongueMHypoglossalXIITrapezius and sternocleido musclesMAccessoryXI

Hearing balanceSAcousticVIII

Superior obliquesMTrochlearIV

TongueSFacialVII

Posterior pharynx, taste to anterior tongueSGlossopharyn-gealIX

SmellSOlfactoryIInnervationFNameCN

Cranial Nerves

Anatomy and Physiologyof the Head


Ascending Reticular Activation System– Tract of neurons in upper brainstem, pons, and midbrain– Responsible for sleep-wake cycle– Monitors input stimulation– Regulates body functions

RespirationHeart ratePeripheral vascular resistance


Face Structure– Facial Bones

Zygoma

Maxilla

Mandible

Nasal bones

Anatomy PhysiologyFacial Structure– Covered with skin

Flexible and thinHighly vascular

– Minimal layer of subcutaneous tissue

Circulation– External carotid artery

Supplies facial areaBranches

Facial, temporal, and maxillary arteries

Anatomy and PhysiologyNasal Cavity– Upper Border

BonesJunction of ethmoid, nasal, and maxillary bones

Bony SeptumRight and left chamber

Turbinates– Lower Border

Bony hard palateSoft palate

Moves upward during swallowing– Nasal Cartilage

Forms nares


Oral Cavity– Formed Structures

Maxillary bonePalateUpper teeth meeting the mandible and lower teeth

– FloorTongue

– MandibleArticulates with the TMJ joint


Special Structures– Salivary Glands

First stage in digestionLocation

Anterior and inferior to the earUnder tongueInside the inferior mandible

– TonsilsPosterior wall of the pharynx


Sinuses– Hollow spaces in cranium and facial bones– Function

Lighten headProtect eyes and nasal cavityProduce resonant tones of voiceStrengthen area against trauma


Pharynx– Posterior and inferior to the oral cavity– Aids in swallowing

Bolus of food propelled back and down by tongueEpiglottis moves downwardLarynx moves up

Combined effect seals airway

Peristaltic wave moves food down esophagus

Anatomy and Physiology Ear– Function

HearingPositional sense

– StructuresPinna

Outer visible portionFormed of cartilage and has poor blood supply

External Auditory CanalGlands that secrete cerumen (wax)

Middle and Inner EarStructures for hearing and positional sense

Anatomy and Physiology Structures for HearingStructures for Proprioception– Semicircular

canalsSense position and motion

– Present when eyes are closed

– VertigoContinuous movement sensation

Anatomy and Physiology Eye

Anatomy and Physiology The Neck– Can be divided into three zones

Zone 1Zone 2Zone 3


Vasculature of the Neck– Carotid Arteries

Arise fromBrachiocephalic arteryAorta SplitCarotid bodies and sinuses

Bodies: Monitor CO2 and O2 levelsSinuses: Monitor blood pressure


Jugular Veins– External

Superficial, lateral to the trachea– Internal

Sheath with the carotid artery and vagus nerve


Airway Structures– Larynx

EpiglottisThyroid and cricoid cartilage

– TracheaPosterior border is anterior border of esophagus


Other Structures of the Neck– Cervical Spine

Musculoskeletal FunctionNervous Function


Other Structures of the Neck– Esophagus– Cranial Nerves

CN-IX (Glossopharyngeal)Carotid bodies and carotid sinuses

CN-XSpeech, swallowing, cardiac, respiratory, and visceral function

– Thoracic DuctDelivers lymph to the venous system


Other Structures of the Neck– Glands

ThyroidRate of cellular metabolismSystemic levels of calcium

– Brachial PlexusNetwork of nerves in lower neck and shoulder that control arm and hand function

Pathophysiology of Head, Facial, and Neck Injury

Pathophysiology of Head, Facial, and Neck Injury

Difficult to assess in the prehospital setting Commonly threaten life May expose victims to lifelong disability

Mechanism of Injury

Injuries to the head, neck, and face are divided by mechanisms of injury– Blunt Injury

Head injuries most frequently result from auto and motorcycle crashes The face is frequently subjected to blunt trauma The neck is anatomically well protected from most blunt trauma

– Penetrating InjuryUsually result from either gunshots or stabbings Other types of penetrating injuries

Head Injury

Defined as a traumatic insult to the cranial region– Result in injury to soft tissues, bony structures, and the

brain

Scalp InjuryCommon Injuries– Contusions– Lacerations– Avulsions

Significant hemorrhage may occurReconsider MOI for severe underlying problems

© Photo Researchers, Inc.

Cranial Injury

The skull does not fracture unless trauma is extremeTypes – Linear

Most common– Depressed– Comminuted– Basilar

Cranial Injury

Basilar Skull Fracture– Common type of

skull fracture – Signs of basilar skull

fracture vary with the injury’s location

– May permit cerebrospinal fluid to seep out

© Ray Kemp/911 Imaging

Brain Injury

“A traumatic insult to the brain capable of producing physical, intellectual, emotional, social, and vocational changes.” National Head Injury Foundation

Classification– Direct– Indirect

Direct Brain Injury

Caused by the forces of trauma and can be associated with a variety of mechanismsCoupContrecoup

Direct Brain Injury CategoriesFocal– Occur at a specific location in brain

Cerebral contusionIntracranial hemorrhage

Epidural hematomaSubdural hematoma

Intracerebral hemorrhage

Diffuse– Concussion– Moderate diffuse axonal injury– Severe diffuse axonal injury

Focal Brain Injury

Cerebral Contusion– Capillary bleeding into brain tissue– Common with blunt head trauma– May result from a coup or contrecoup mechanism – Localized form of the injury manifests with

dysfunctions related to the site of the injury

Focal Brain InjuryIntracranial Hemorrhage– Epidural Hematoma

Bleeding between dura mater and skullInvolves arteries

Middle meningeal artery most common

Rapid bleeding and reduction of oxygen to tissuesHerniates brain toward foramen magnumProgression is both rapid and life threatening

Focal Brain Injury

Intracranial Hemorrhage (cont.)– Subdural Hematoma

Bleeding between meningesSlow bleeding

Superior sagittal sinus frequently injured

Signs progress over several days

Slow deterioration of mentation

Focal Brain Injury

Intracranial Hemorrhage (cont.)– Intracerebral Hemorrhage

Ruptured blood vessel within the brainPresentation similar to stroke symptomsSigns and symptoms worsen over time

– Cerebral edema Inflammatory response allows fluid leakage

– HydrocephalusMay occur with hemorrhage into the subarachnoid space

HERNIATION

Diffuse Brain Injury

Due to stretching forces placed on axonsPathology distributed throughout brain– Frequently distributed throughout the brain and

thus is called diffuse axonal injury (DAI) Types– Concussion– Moderate diffuse axonal injury– Severe diffuse axonal injury


Concussion – Mild to moderate form of diffuse axonal injury – 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 mentationABCs


Moderate Diffuse Axonal Injury– Stretching and tearing of neurons with minute

bruising of brain tissue – Unconsciousness

If cerebral cortex and RAS involved– Commonly associated with basilar skull fracture – Signs and Symptoms

Unconsciousness, persistent confusion, inability to concentrate, disorientation, and retrograde and anterograde amnesia


Severe Diffuse Axonal Injury – Significant mechanical disruption of axons

Cerebral hemispheres and brainstem– High mortality rate– Signs and Symptoms

Prolonged unconsciousnessCushing’s reflexDecorticate or decerebrate posturing

Indirect Brain Injury

Indirect (or secondary) injuries are the result of factors that occur because of, though after, the initial (or primary) injury Caused by two distinct pathological processes– Diminishing circulation to brain tissue due to an

increasing ICP– Progressive pressure against, or physical

displacement of, brain tissue

Intracranial Perfusion

Review– Cranial volume fixed

80% = Cerebrum, cerebellum, and brainstem12% = Blood vessels and blood8% = CSF

– Increase in size of one component diminishes size of another

Inability to adjust = increased ICP


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 ICPDangerous cycle


Role of Carbon Dioxide– Increase of CO2 in CSF

Cerebral vasodilation

– Contributes to > ICP– Causes classic symptom

Hyperventilation and hypertension– Reduced levels of CO2 in CSF

Cerebral vasoconstrictionResults in cerebral anoxia

Factors Affecting ICP

Vasculature ConstrictionCerebral EdemaSystolic Blood Pressure– Low BP = Poor cerebral

perfusion– High BP = Increased ICP

Carbon DioxideReduced respiratory efficiency

IMPORTANT CONCEPT #2

HEAD INJURY + SHOCK = DEATH

Pressure and Structural Displacement

Increased pressure– Compresses brain tissue– Herniates brainstem

Compromises blood supply– Signs and Symptoms

Upper brainstemVomitingAltered mental statusPupillary dilation

Medulla oblongataRespiratoryCardiovascularBlood pressure disturbances

Signs and Symptoms of Brain Injury

Altered Mental Status– Altered orientation– Alteration in personality– Amnesia

RetrogradeAntegrade

Cushing’s Reflex– Increased BP– Bradycardia– Erratic respirations

Vomiting– Without nausea– Projectile

Body temperature changesChanges in pupil reactivityDecorticate posturing

Signs and Symptoms of Brain Injury

Physiological Changes– Frontal Lobe Injury

Alterations in personality– Occipital Lobe Injury

Visual disturbances– Cortical Disruption

Reduced mental status or amnesiaRetrograde

Unable to recall events before injury

AntegradeUnable to recall events after trauma“Repetitive questioning”

– Focal DeficitsHemiplegia, weakness, or seizures

Central Syndrome Progressive pressure and structural displacement are somewhat predictable – Known as Central Syndrome

Physiological Changes – Upper Brainstem Compression

Increasing blood pressureReflex bradycardia

Vagus nerve stimulation

Cheyne-Stokes respirationsPupils become small and reactiveDecorticate posturing

Central SyndromePhysiological Changes (cont.)– Middle Brainstem Compression

Widening pulse pressureIncreasing bradycardiaCNS hyperventilationBilateral pupil sluggishness or inactivityDecerebrate posturing

Central SyndromePhysiological Changes (cont.) – Lower Brainstem Injury

Pupils dilated and unreactiveAtaxic respirations

Erratic with no pattern

Irregular and erratic pulse rateECG changesHypotensionLoss of response to painful stimuli

Recognition of HerniationCushing’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 pupilsDecerebrate or decorticate posturing No movement with noxious stimuli

Pediatric Head TraumaDifferent pathology than older patients– Skull can distort due to anterior and posterior

fontanellesBulgingSlows 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

Glascow Coma ScaleStandardized evaluation method – Used to

measure a patient’s level of consciousness

Assesses the best eye opening, verbal, and motor response

Eye Signs

Physiological Issues– Indicate pressure on

CN-II, CN-III, CN-IV, and CN-VI– Reduced peripheral blood flow

Pupil Size and Reactivity– Reduced pupillary responsiveness

Depressant drugs or cerebral hypoxia– Fixed and dilated

Extreme hypoxia

Facial InjuryFacial Soft-Tissue Injury– Highly vascular tissue

Contributes to hypovolemia– Superficial injuries are rarely life threatening– 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

Facial Injury

Facial Dislocations and Fractures– Common

FracturesMandibularMaxillary and Nasal

Le Fort I, II, and III Criteria

Orbit

Facial Injury

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

Facial InjuryEar Injury– External Ear

Pinna frequently injured due to traumaPoor blood supplyPoor healing

– Internal EarWell protected from traumaMay be injured due to rapid pressure changes

Facial InjuryEye Injury– Foreign bodies– Corneal abrasions

and lacerations– Hyphema

Blunt trauma to the anterior chamber of the eye

– Sub-conjunctival hemorrhage

Less serious conditionMay occur after strong sneeze, severe vomiting, or direct trauma

Eye Injury (cont.)– Acute Retinal Artery Occlusion

Non-traumatic originPainless loss of vision in one eyeOcclusion of retinal artery

– Retinal DetachmentTraumatic originComplaint of dark curtain/obstruction in the field of viewPossibly painful depending on type of trauma

– Soft-Tissue Lacerations

Facial Injury

Neck Injury

Blood Vessel Trauma– Blunt trauma

Serious hematoma– Laceration

Serious exsanguinationEntraining of air embolism

Cover with occlusive dressing

Airway Trauma– Tracheal rupture or dissection from larynx– Airway swelling and compromise

Neck Injury

Cervical Spine Trauma– Vertebral fracture

Paresthesia, anaesthesia, paresis, or paralysis beneath the level of the injuryNeurogenic shock may occur

Subcutaneous emphysema– Tension pneumothorax– Traumatic asphyxia

Neck Injury

Penetrating trauma– Esophagus or trachea– Vagus nerve disruption

Tachycardia and GI disturbances– Thyroid and parathyroid glands

High vascular

Assessment of Head, Facial, and Neck Injuries

Assessment of Head, Facial, and Neck Injuries

Assessment follows the standard format – Size-up – Initial assessment – Rapid trauma assessment/focused exam and

history– Detailed assessment

Pay special attention to ensuring airway patencyConsider the need for rapid transport

Scene Size-Up

Consider the circumstances of injury Identify the nature and extent of forces that caused the injury – Spider-web windshield, deformity of the upper

steering wheel, helmet use in motorcycleRule out scene hazards

Initial Assessment

Form an initial impression – Be alert to the patient’s facial skin color,

respiratory effort, and to pupil luster and level of responsiveness throughout the initial assessment

Apply a cervical collar at the end of the initial assessment

Initial Assessment

Airway– Examine the face and neck for any deformity,

swelling, hemorrhage, foreign bodies, or other signs of injury

– Listen for unusual or changing voice patterns – Anticipate vomiting – Suctioning or intubation may worsen ICP

Initial AssessmentBreathing– Ensure that the patient is moving an adequate

volume of air – Head injury is likely to produce irregular breathing

patterns– Ventilations for the serious head injury patient

(GCS ≤8) are guided by capnography Maintain an end-tidal CO2 reading of between 35 and 40 mmHg For patients with suspected herniation, the end-tidal CO2 reading should range between 30 and 35 mmHg

– Apply oxygen via nonrebreather mask to the breathing patient

Initial Assessment

Circulation– Monitor the patient’s pulse rate and rhythm– Look for any hemorrhage from the head, face, and

neck and control any moderate to severe bleeding – Maintain a blood pressure of at least 90 mmHg

Rapid Trauma Assessment

A quick and directed head-to-toe examination of a patientManage any life-threatening injuries and conditions as you find them during the rapid trauma assessment – If the patient shows any signs of pathology within

the cranium, consider rapid transport

Head, Facial, and Neck Injury Management


Management priorities for the patient sustaining head, face, or neck trauma include:– Maintaining the patient’s airway and breathing– Ensuring circulation through hemorrhage control– Taking steps to avoid hypoxia and/or hypovolemia – Providing appropriate medications


Airway– Patients may be unable to control the airway

Altered level of consciousnessDamaged airway structures

– Sellick’s manuever– Suctioning

May increase ICPEmesis is common with head injury


Airway (cont.)– Patient positioning

Initial left-lateral recumbancy with cervical precautions, if possibleApproximately 30° elevation of head of spine board

– Basic airway adjunctsOro and nasopharyngeal airwaysBe prepared for emesis

Endotracheal Intubation

OrotrachealDigitalNasotrachealRetrograde DirectedRapid Sequence


Airway (cont.)– Cricothyrotomy

Needle cricothyrostomy and the open cricothyrotomy


Breathing– Oxygenation

Any indication of lowered level of consciousness, orientation, or arousal is a candidate for high-flow, high-concentration oxygen

– VentilationAvoid hyperventilation

Decreased CO2 results in vasoconstrictionMaintain an end-tidal CO2 reading of between 35 and 40 mmHg


Circulation– Control hemorrhage

An open neck injury carries the risk of air entering the external jugular

– Blood pressure maintenanceGuard against hypotension Maintain systolic BP at 90 mmHg

Medications

Oxygen– First-line drug– There are no contraindications nor side effects of

concern for use of oxygen during prehospital emergency care

Medications

Diuretics– Mannitol

Osmotic diuretic Draws water from the interstitial space and into the cardiovascular system

– Use may reduce ICP– Contraindications

Renal failureHypotension

– Slow IV bolus of 0.25 to 1 g/kg over 10 to 20 minutes

Medications

Paralytics– Drugs that paralyze the skeletal muscles,

permitting intubation in patients with whom the procedure would otherwise be impossible

Rapid Sequence IntubationUses etomidate, diazepam, midazolam, fentanyl, or morphine sulfate to sedate the patient Succinylcholine chloride, atracurium, or vercuronium to paralyze the patient

Medications

Dextrose– Hypoglycemia and hyperglycemia are detrimental

to the patient with head injuryIdentify the blood glucose level on all unresponsive patients

– If significant hypoglycemia is found, administer 25 mg of glucose and 100 mg of thiamine

Medications

Thiamine– Substance obtained from diet and needed for

body metabolism – In malnourished patients (like the chronic

alcoholic), thiamine is depleted Glucose cannot be convertedBrain is very sensitive to lack of Glucose

Medications

Topical Anesthetic Spray– Reduces the gag reflex, making endotracheal

intubation easier Reduces the impact retching has on intracranial pressure

– Effects of the agent are immediate (within 15 seconds), remain local, and last for about 15 minutes

Transport Considerations

Limit external stimulation– Can increase ICP– Can induce seizures

Be cautious about air transport– Seizures

Emotional Support

Have friend or family provide constant reassuranceProvide constant reorientation to environment if required– Keeps patient calm– Reduces anxiety

Special Injury Care

Scalp Avulsion– Cover the open wound with bulky dressing– Pad under the fold of the scalp– Irrigate with NS to remove gross contamination

Special Injury CareEye Injury– General Injury

Cover injured and uninjured eyePrevents sympathetic motion

Consider sterile dressing soaked in NS– Corneal Abrasion

Invert eyelid and examine eye for foreign bodyRemove with NS-moistened gauze or Morgan’s lens

– Avulsed or Impaled EyeCover and protect from injury

– General CareCalm and reassure patient

Special Injury Care

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

ch08 head, face, and neck

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