Head and Facial
Injury
Scott Marquis, MD
Overview
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Head injury
What to look for
Appropriate management
Facial injury
Review
Head and brain trauma
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~ 1,500,000 head injuries annually
~ 230,000 hospitalized and survive
~ 50,000 deaths
1/3 all injury-related deaths
Severity
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75% mild
10% moderate
10% severe (35% mortality, 5% c-spine fx)
80,000-90,000 significant long-term disability
Head & brain trauma
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Risk Groups
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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
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Broad and Inclusive Term
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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
“A traumatic insult to the brain capable of
producing physical, intellectual, emotional,
social and vocational changes”
 Three broad categories
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Focal injury
 Cerebral contusion
 Intracranial hemorrhage
 Epidural hemorrhage
Subarachnoid hemorrhage
Diffuse Axonal Injury
 Concussion
Mechanisms of head injury
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Motor vehicle crashes, MVC
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Most common cause of head trauma
Most common cause of subdural hematoma
Sports injuries
 Falls
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Common in elderly and in presence of alcohol
Associated with subdural hematomas
Penetrating trauma
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Missiles more common than sharp projectiles
Categories of injury
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Coup injury
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Directly posterior to point of impact
More common when front of head struck
Contrecoup injury
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Directly opposite the point of impact
More common when back of head struck
Categories of injury
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Diffuse axonal injury (DAI)
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Shearing, tearing or stretching of nerve fibers
More common with vehicle occupant and
pedestrian
Focal injury
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Limited and identifiable site of injury
Causes of brain injury
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Direct (primary) causes
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Impact
Mechanical disruption of cells
Vascular permeability or disruption
Indirect (secondary or tertiary) causes
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Secondary
 Edema, hemorrhage, infection, inadequate
perfusion, tissue hypoxia, pressure
Tertiary
 Apnea, hypotension, pulmonary resistance,
ECG changes
The brain is enclosed in a box
Brain anatomy
Occupies 80% of intracranial space
 Divisions
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Cerebrum
Cerebellum
Brain Stem
Brain anatomy
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Cerebral spinal fluid, CSF
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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 anatomy
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Blood Supply
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Vertebral arteries
 Supply posterior brain (cerebellum and brain stem)
Carotid arteries
 Most of cerebrum
Brain anatomy
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Meninges
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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
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Scalp laceration or avulsion
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Most common injury
Vascularity = diffuse bleeding
Generally does not cause hypovolemia in adults
Can produce hypovolemia in children
Scalp anatomy
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Scalp
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S: skin
C: connective tissue
A: aponeurosis (galea)
L: loose areolar tissue
P: pericranium
Scalp very vascular
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major blood loss
watch kids and adults with prolonged extrication
Skull fracture
Skull fracture
Present in 60% of pts with severe head injury
 Types:
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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 fracture
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Types
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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
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Focal
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Contusion
Epidural hematoma
Subdural hematoma
Intracerebral
Diffuse (most common type of head injury)
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Mild concussion
Classic concussion
Diffuse Axonal Injury (DAI)
Epidural hematoma
Blood between skull
and dura
 Usually arterial tear
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Middle meningeal
artery
Causes increased
ICP
Epidural hematoma
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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
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Bridging veins
between cortex and
dura
Causes increased
intracranial pressure
Subdural hematoma
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Slower onset
Increased ICP
Headache, decreased LOC, unequal pupils
Increased BP, decreased pulse
Hemiparesis, hemiplegia
Intracerebral hematoma
Usually due to laceration of brain
 Bleeding into cerebral substance
 Associated with other injuries
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Neuro deficits depend on region involved and
size
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DAI
Repetitive with frontal lobe
Increased ICP
Concussion
Transient loss of consciousness
 Retrograde amnesia, confusion
 Resolves spontaneously without deficit
 Usually due to blunt head trauma
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Diffuse axonal injury
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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 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)
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Penetrating head injury
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Severity depends on
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Energy of missile
Path
Amount of scatter of bone and metal fragments
Presence of mass lesion
Accompanied by
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Severe face and neck injuries
Significant blood loss
Difficult airway
Spinal instability
What the brain needs
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High metabolic rate
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Consumes 20% of body’s oxygen
Largest user of glucose
Requires thiamine
Can not store nutrients
More on brain workings
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Perfusion
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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 workings
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Perfusion
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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 workings
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Perfusion
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Intracranial pressure (ICP)
 Edema, hemorrhage
 ICP usually 10-15 mm Hg
Cerebral perfusion pressure
CPP = MAP - ICP
What goes wrong in head
injury
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As ICP  and approaches MAP, cerebral blood
flow 
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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
injury
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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
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What goes wrong in head
injury
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Hypotension results in  CPP  cerebral
vasodilation
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Results in  blood volume   ICP  CPP
And, the cycle continues
What goes wrong in head
injury
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Pressure exerted downward on brain
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Cerebral cortex or RAS
 Altered level of consciousness
Hypothalamus
 Vomiting
What goes wrong in head
injury
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Pressure exerted downward on brain
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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
Transtentorial
 Uncal
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What you see on exam
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Levels of increasing ICP
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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 exam
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Levels of increasing ICP
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Middle brain stem
 Wide pulse pressure and bradycardia
 Pupils nonreactive or sluggish
 Central neurogenic hyperventilation
 Extension
What you see on exam
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Levels of increasing ICP
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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
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LOC = best indicator
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Altered LOC = Intracranial trauma UPO
Trauma patient unable to follow commands =
chance of intracranial injury needing surgery
Global function
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AVPU scale
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A = Alert
V = Responds to Verbal stimuli
P = Responds to Painful stimuli
U = Unresponsive
General brain function
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Glasgow Coma Scale, GCS
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Eye opening
Verbal response
Motor response
Reliable measure, repeatable
Glasgow Coma Scale
Eyes
Verbal
Motor
1: Spontaneous
1: Oriented
1: Spontaneous
2: Voice
2: Confused
2: Localizes
3: Pain
3: Inappropriate
3: Withdraws
4: Unresponsive
4: Incomprehensible
5: Nonverbal
4: Decorticate
5: Decerebrate
6: Unresponsive
Eyes
Window to soul and CNS
 Pupil size, equality, and response to light
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Eyes
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Unequal pupils + decreased LOC =
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Compression of oculomotor nerve
Probable mass lesion
Unequal pupils + alert patient =
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Direct blow to eye, or
Oculomotor nerve injury, or
Normal inequality
Movement
Is patient able to move all extremities?
 How do they move?
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Decorticate
Decerebrate
Hemiparesis or hemiplegia
Paraplegia or quadraplegia
Movement
Lateralized or focal signs =
lateralized or focal deficits
 Altered motor function may be due to fracture
or dislocation
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Vital Signs
Cushing’s triad
 Suggests increased intracranial pressure
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Increased BP
Decreased pulse
Irregular respiratory pattern
Vital Signs
Isolated head injury will not cause
hypotension in adults
 Look for another life threatening injury
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Chest
Abdomen
Pelvis
Multiple long bone fractures
Large scalp lacerations
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
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Goals for treatment
Maintain adequate oxygenation
 Maintain sufficient BP for good brain
perfusion
 Avoid secondary brain damage
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Blood pressure
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A single episode of hypotension =
doubles patient mortality
Oxygenation
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Hypoxemia is a strong predictor of poor
outcome
Airway management
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Open
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Clear
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Assume C-spine trauma
Jaw thrust with C-spine control
Suction as needed
Maintain or secure
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Intubation if no gag reflex
RSI, lidocaine and vecuronium
Avoid nasal intubation
Breathing
Oxygenate - 100% O2
 Ventilate
 No routine hyperventilation
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Adults 10-12 BPM
Children 12-16 BPM
Infants 16-20 BPM
Breathing
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Respiratory Patterns
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Cheyne Stokes
 Diffuse injury to cerebral hemispheres
Central neurological hyperventilation
 Injury to mid-brain
Apneustic
 Injury to pons
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
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Benefits
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Decreased PaCO2
Vasoconstriction
Decreased ICP
Risks
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Decreased cerebral blood flow
Decreased oxygen delivery to tissues
Increased edema
Circulation
Maintain adequate BP and perfusion
 IV of LR/NS TKO if BP normal or elevated
 If BP decreased
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LR/NS bolus titrated to SBP ~ 90 mm Hg
Consider PASG/MAST if SBP below 80
Monitor EKG -- Do not treat bradycardia
Immobilization
Spinal motion restriction
 If BP normal or elevated, spine board head
elevated 300
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Intravenous therapy
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Drug therapy considerations
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Only after:
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Management of ABC’s
Controlled hyperventilation
Useful drugs
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Diazepam
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Anticonvulsant
Give if patient experiences seizures
5 mg IV
May mask changes in LOC
May depress respirations
May worsen hypotension
Useful drugs
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Vecuronium
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RSI
Defasciculating dose
Decrease brain oxygen demand
Useful drugs
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Lidocaine
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RSI, few minutes prior
1.5 mg/kg IV
Prevents increases in ICP
Useful drugs
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Mannitol
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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
Assess blood glucose
 Administer only if hypoglycemic
 Hyperglycemia can harm injured brain
secondary to osmotic shifts
 Consider thiamine in malnourished
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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
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Helmet removal
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Immediate removal if interferes with priorities
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Access to airway or airway management
Ventilation
Cervical spine motion restriction
May only need to remove face piece to access
airway
 Technique
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Requires adequate assistance
Training in the procedure
Padding if shoulder pads left on
Summary
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Spinal precautions
Avoid hypoxia
Consider intubation early
Avoid hypotension
Frequent reassessment
Hyperventilate for herniation
Triage wisely
Any questions?
Resources
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www.braintrauma.org
Facial injuries
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Mortality
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Primarily associated with brain and spine injury
Severe facial fractures may interfere with airway
and breathing
Morbidity
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Disability concerns
Cosmetic concerns
Facial trauma
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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 trauma
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Causes
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MVC, home accidents, athletic injuries, animal
bites, violence, industrial accidents…
Soft tissue
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Lacerations, abrasions, avulsions
Vascular area supplied by internal and external
carotids
Facial bone anatomy
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Frontal
Nasal
Zygoma / zygomatic arch
Maxilla
Mandible
Facial fractures
Mandible, maxilla, nasal bones, zygoma &
rarely the frontal bone
 Signs and symptoms
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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
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May be significant hemorrhage
C-spine precautions
Avoid nasotracheal intubation, if possible
LeFort fracture
Tripod fracture
Midface fractures
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Appearance
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“Donkey face” (lengthening)
“Pumpkin face” (edema)
Nasal flattening
Often associated with orbital fractures
LeFort fractures
Mouth injuries
MVC
 Blunt injury to the mouth or chin
 Penetrating injury due to GSW, laceration, or
puncture

Mouth injuries

Primary concerns
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Airway compromise secondary to bleeding
FB aspiration secondary to broken or avulsed
teeth
Impaled object
Management
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ABCs
 Suction prn
Stabilize impaled object
Collect tissue: tongue or tooth
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
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May be caused by extensive dental work, yawning
Condylar heads move forward and muscles spasm
Dental trauma
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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 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
Variety of mechanisms including blunt or
penetrating trauma
 Swelling, deformity, crepitance
 Most common injury
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Adults - Epistaxis
Children - Foreign bodies
Nasal injuries

Epistaxis
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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

Epistaxis
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Direct pressure over septum
Upright position, leaning forward or in lateral
recumbent position
If CSF present, do not apply direct pressure

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Allow to drain
Needs neurosurgical consult
Eye injury types
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Penetrating
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Abrasions
Foreign bodies (deep, superficial, impaled)
Lacerations (deep or superficial, eyelid)
Burns
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Flash
Acid/alkali
Eye injury types
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Blunt
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Swelling
Conjunctival hemorrhage
Hyphema
Ruptured globe
Blow-out fracture of orbit
Retinal detachment
Blow-out orbital fracture
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Usually result of a direct blow to the eye
Flattened face, numbness
Epistaxis, altered vision
Periorbital swelling
Diplopia
Inophthalmos
Impaired ocular movement
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 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

External injuries
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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 injury

Separation of ear cartilage

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Treat as an avulsion
Dress and bandage
Consider disability and cosmetic concerns
Bleeding from ear canal

Cover with loose dressing only
Summary
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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
Questions?