Head, Facial, & Neck Trauma. Sections Introduction to Head, Facial, & Neck Injuries Anatomy and Physiology of the Head, Face, & Neck Pathophysiology.

Head, Facial, & Head, Facial, & Neck TraumaNeck Trauma

SectionsSections Introduction to Head, Facial, & Neck

Injuries Anatomy and Physiology of the Head,

Face, & Neck Pathophysiology of Head, Facial, &

Neck Injury Assessment and Management of Head,

Facial, & Neck Injuries Head, Facial, & Neck Injury Management

Introduction to Head, Facial, & Neck Injuries

Anatomy and Physiology of the Head, Face, & Neck

Pathophysiology of Head, Facial, & Neck Injury

Assessment and Management of Head, Facial, & Neck Injuries

Head, Facial, & Neck Injury Management

Common major trauma 4 million people experience head

trauma annually Severe head injury is most frequent cause of trauma

death GSW to cranium: 75-80% mortality

At Risk population Males 15-24 Infants Young Children Elderly

Common major trauma 4 million people experience head

trauma annually Severe head injury is most frequent cause of trauma

death GSW to cranium: 75-80% mortality

At Risk population Males 15-24 Infants Young Children Elderly

Introduction to Head, Introduction to Head, Facial, Facial,

& Neck Injuries& Neck Injuries

Injury Prevention Programs Motorcycle Safety Bicycle Safety Helmet & Head Injury Awareness Programs Other Sports

Football Rollerblading Contact Sports

Injury Prevention Programs Motorcycle Safety Bicycle Safety Helmet & Head Injury Awareness Programs Other Sports

Football Rollerblading Contact Sports



TIME IS CRITICAL Intracranial Hemorrhage Progressing Edema

Increased ICP Cerebral Hypoxia Permanent Damage

Severity is difficult to recognize Subtle signs Improve differential diagnosis

Improves survivability

TIME IS CRITICAL Intracranial Hemorrhage Progressing Edema

Increased ICP Cerebral Hypoxia Permanent Damage

Severity is difficult to recognize Subtle signs Improve differential diagnosis

Improves survivability



Anatomy & Physiology of the Head Scalp Cranium Meninges Cerebrospinal Fluid Brain CNS Circulation Blood-Brain Barrier Cerebral Perfusion Pressure Cranial Nerves Ascending Reticular Activating System

Anatomy & Physiology of the Head Scalp Cranium Meninges Cerebrospinal Fluid Brain CNS Circulation Blood-Brain Barrier Cerebral Perfusion Pressure Cranial Nerves Ascending Reticular Activating System

Anatomy & PhysiologyAnatomy & PhysiologyHead, Face & NeckHead, Face & Neck

Scalp Strong Flexible mass of

Skin Fascia Muscular Tissue

Highly Vascular Hair provides Insulation Structures Beneath

Galea Aponeurotica• Between scalp and skull• Fibrous connective sheath

Subaponeurotica (Areolar) Tissue• Permits venous blood flow from the dural sinuses to the venous

vessels of scalp Emissary Veins: Potential route for Infection

Scalp Strong Flexible mass of

Skin Fascia Muscular Tissue

Highly Vascular Hair provides Insulation Structures Beneath

Galea Aponeurotica• Between scalp and skull• Fibrous connective sheath

Subaponeurotica (Areolar) Tissue• Permits venous blood flow from the dural sinuses to the venous

vessels of scalp Emissary Veins: Potential route for Infection

Anatomy & Anatomy & Physiology Physiology of the Headof the Head

Recalling Structures of the ScalpS - skinC - connective tissueA - aponeuroticaL - layer of areolar tissueP - periosteum of skull

Recalling Structures of the ScalpS - skinC - connective tissueA - aponeuroticaL - layer of areolar tissueP - periosteum of skull


Skull comprised of Facial bones Cranium

Vault for the brain Strong, light, rigid, spherical bone Unyielding to increased intracranial pressure (ICP) Bones

• Frontal• Parietal• Occipital• Temporal• Ethmoid• Sphenoid

Skull comprised of Facial bones Cranium

Vault for the brain Strong, light, rigid, spherical bone Unyielding to increased intracranial pressure (ICP) Bones

• Frontal• Parietal• Occipital• Temporal• Ethmoid• Sphenoid


Parietal

Suture Line

Frontal

TemporalOrbits

Maxillae

Mandible

Temporal Mandibular Joint

OcciptalNasal Bones

Zygomatic Arch

Sphenoid

Foramen Magnum (Hole in Base)

Skull Other Structures

Foramen Magnum• Largest opening of the skull

• Spinal cord exits

Cribriform Plate• Inferior aspect (Base)

• Rough surface

• Brain can be easily injured Abrade Contusion Laceration

Skull Other Structures

Foramen Magnum• Largest opening of the skull

• Spinal cord exits

Cribriform Plate• Inferior aspect (Base)

• Rough surface

• Brain can be easily injured Abrade Contusion Laceration


MeningesProtective mechanism for the CNS Dura Mater

Layers• Outer: Cranium’s inner periosteum• Inner: Dural Layer• Between: Dural Sinuses:

Venous drains for brain Provides continuous connective tissue Forms partial structural divisions

• Falx cerebri• Tentorium cerebelli

Large arteries above• Provide blood flow to the surface of the brain

MeningesProtective mechanism for the CNS Dura Mater

Layers• Outer: Cranium’s inner periosteum• Inner: Dural Layer• Between: Dural Sinuses:

Venous drains for brain Provides continuous connective tissue Forms partial structural divisions

• Falx cerebri• Tentorium cerebelli

Large arteries above• Provide blood flow to the surface of the brain


Meninges Pia Mater

Closest to brain and spinal cord Delicate tissue Covers all areas of brain and spinal cord Very Vascular

• Supply superficial areas of brain

Arachnoid Membrane “Spider-like” Covers inner dura Suspends brain in cranial cavity

• Collagen & Elastin fibers

Subarachnoid Space beneath• CSF

• Cushions brain

Meninges Pia Mater

Closest to brain and spinal cord Delicate tissue Covers all areas of brain and spinal cord Very Vascular

• Supply superficial areas of brain

Arachnoid Membrane “Spider-like” Covers inner dura Suspends brain in cranial cavity

• Collagen & Elastin fibers

Subarachnoid Space beneath• CSF

• Cushions brain


Cerebrospinal Fluid Clear, colorless fluid Comprised of

Water Protein Salts

Cushions CNS Made in largest two ventricles of brain Medium for nutrients and waste products to

diffuse into and out of brain

Cerebrospinal Fluid Clear, colorless fluid Comprised of

Water Protein Salts

Cushions CNS Made in largest two ventricles of brain Medium for nutrients and waste products to

diffuse into and out of brain


Brain Occupies 80% of cranium Comprised of 3 Major Structures

Cerebrum Cerebellum Brainstem

High metabolic rate Receives 15% of cardiac output Consumes 20% of body’s oxygen Requires constant circulation

IF Blood supply stops Unconscious within 10 seconds Death in 4-6 minutes

Brain Occupies 80% of cranium Comprised of 3 Major Structures

Cerebrum Cerebellum Brainstem

High metabolic rate Receives 15% of cardiac output Consumes 20% of body’s oxygen Requires constant circulation

IF Blood supply stops Unconscious within 10 seconds Death in 4-6 minutes


Cerebrum Function

Center of conscious thought, personality, speech, and motor control

Visual, auditory, and tactile perception Lobes

Frontal• Personality

Parietal• Motor & Sensory Activity• Memory & Emotion

Cerebrum Function

Center of conscious thought, personality, speech, and motor control

Visual, auditory, and tactile perception Lobes

Frontal• Personality

Parietal• Motor & Sensory Activity• Memory & Emotion


(continued)

Occipital• Sight

Temporal• Long-term memory• Hearing, Speech, Taste & Smell

Occipital• Sight

Temporal• Long-term memory• Hearing, Speech, Taste & Smell


Cerebrum Falx Cerebri

Divides cerebrum into right and left hemispheres

Central Sulcus Fissure splits cerebrum into right and left hemispheres Each hemisphere controls the opposite side of the body

Tentorium Fibrous sheet within occipital region Brainstem perforates thru incisura tentorri cerebelli Occulomotor Nerve (CN-III) travels along

• Controls pupil size• Compression results in pupillary disturbances

Cerebrum Falx Cerebri

Divides cerebrum into right and left hemispheres

Central Sulcus Fissure splits cerebrum into right and left hemispheres Each hemisphere controls the opposite side of the body

Tentorium Fibrous sheet within occipital region Brainstem perforates thru incisura tentorri cerebelli Occulomotor Nerve (CN-III) travels along

• Controls pupil size• Compression results in pupillary disturbances


Cerebrum Hemisphere Functions

Left: DOMINANT• Mathematical computations: Occipital

• Writing: Parietal

• Language interpretation: Occipital

• Speech: Frontal

Right: NON-DOMINANT• Non-verbal imagery

Cerebrum Hemisphere Functions

Left: DOMINANT• Mathematical computations: Occipital

• Writing: Parietal

• Language interpretation: Occipital

• Speech: Frontal

Right: NON-DOMINANT• Non-verbal imagery


Cerebellum Located under tentorium Function

“Fine tunes” motor control Allows smooth movement Balance Maintenance of muscle tone

Cerebellum Located under tentorium Function

“Fine tunes” motor control Allows smooth movement Balance Maintenance of muscle tone


Brainstem Central processing center Communication junction among

Cerebrum Spinal cord Cranial nerves Cerebellum

Structures Midbrain Pons Medulla Oblongata

Brainstem Central processing center Communication junction among

Cerebrum Spinal cord Cranial nerves Cerebellum

Structures Midbrain Pons Medulla Oblongata


Midbrain Upper portion of brainstem Structures

Hypothalamus• Endocrine function, vomiting reflex, hunger, thirst• Kidney function, body temperature, emotion

Thalamus• Switching center between pons & cerebrum• Critical Element in Ascending Reticular Activating System (A-RAS)

ESTABLISHES CONSCIOUSNESS• Major pathways for optic & olfactory nerves

Associated Structures

Midbrain Upper portion of brainstem Structures

Hypothalamus• Endocrine function, vomiting reflex, hunger, thirst• Kidney function, body temperature, emotion

Thalamus• Switching center between pons & cerebrum• Critical Element in Ascending Reticular Activating System (A-RAS)

ESTABLISHES CONSCIOUSNESS• Major pathways for optic & olfactory nerves

Associated Structures


Pons Communication interchange between

cerebellum, cerebrum, midbrain, and spinal cord

Bulb shaped structure above medulla Sleeping phase of the RAS

Pons Communication interchange between

cerebellum, cerebrum, midbrain, and spinal cord

Bulb shaped structure above medulla Sleeping phase of the RAS


Medulla Oblongata Bulge in the top of the spinal cord Centers

Respiratory Center• Controls depth, rate and rhythm

Cardiac Center• Regulates rate and strength of cardiac contractions

Vasomotor Center• Distribution of blood

• Maintains blood pressure

Medulla Oblongata Bulge in the top of the spinal cord Centers

Respiratory Center• Controls depth, rate and rhythm

Cardiac Center• Regulates rate and strength of cardiac contractions

Vasomotor Center• Distribution of blood

• Maintains blood pressure


CNS Circulation Arterial

Four Major Arteries• 2 Internal Carotid Arteries

From the common carotid• 2 Vertebral Arteries

Circle of Willis• Internal Carotids and Vertebral Arteries• Encircle the base of the brain

Venous Venous drainage occurs through bridging veins Bridge Dural Sinuses Drain into internal jugular veins

CNS Circulation Arterial

Four Major Arteries• 2 Internal Carotid Arteries

From the common carotid• 2 Vertebral Arteries

Circle of Willis• Internal Carotids and Vertebral Arteries• Encircle the base of the brain

Venous Venous drainage occurs through bridging veins Bridge Dural Sinuses Drain into internal jugular veins


Blood-Brain Barrier Less permeable than elsewhere in body DO NOT allow flow of interstitial proteins Reduced lymphatic flow Very protected environment Blood acts as irritant resulting in cerebral

edema

Blood-Brain Barrier Less permeable than elsewhere in body DO NOT allow flow of interstitial proteins Reduced lymphatic flow Very protected environment Blood acts as irritant resulting in cerebral

edema


Cerebral Perfusion Pressure Pressure within cranium (ICP) resists blood

flow and good perfusion to the CNS 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

Cerebral Perfusion Pressure Pressure within cranium (ICP) resists blood

flow and good perfusion to the CNS 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


Calculating MAP

Calculating CPP

Calculating MAP

Calculating CPP


9030 80 MAP

30 90-120 Pressure Pulse

90DBP

120/90 BP

31

80 10-90 CPP

ICP - MAP CPP

10 ICP & 90 MAP

Cerebral Perfusion Pressure Autoregulation

Changes in ICP result in compensation Increased ICP = Increased BP

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

Expanding mass inside cranial vault Displaces CSF If pressure increases, brain tissue is displaced

Cerebral Perfusion Pressure Autoregulation

Changes in ICP result in compensation Increased ICP = Increased BP

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

Expanding mass inside cranial vault Displaces CSF If pressure increases, brain tissue is displaced


Cranial Nerves 12 pair with distinct pathways Senses, facial innervation, & body function control

Ascending Reticular Activation System Tract of neurons in upper brainstem, pons, and

midbrain Responsible for sleep-wake cycle Monitors input stimulation Regulates body functions

Respiration Heart Rate Peripheral Vascular Resistance

Injury may result in prolonged waking state

Cranial Nerves 12 pair with distinct pathways Senses, facial innervation, & body function control

Ascending Reticular Activation System Tract of neurons in upper brainstem, pons, and

midbrain Responsible for sleep-wake cycle Monitors input stimulation Regulates body functions

Respiration Heart Rate Peripheral Vascular Resistance

Injury may result in prolonged waking state


Face MusclesM

Chewing musclesM

Posterior palate and pharynxM

Face MusclesM

SightSOpticII

Pupil Const, Rectus & ObliquesMOculomotorIII

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

Lateral rectus muscleMAbducensVI

Taste to posterior tongueSVagusX

TongueMHypoglossalXII

Trapezius & Sternocleido. MusclesMAccessoryXI

Hearing balanceSAcousticVIII

Superior ObliquesMTrochlearIV

TongueSFacialVII

Posterior pharynx, taste to anterior tongueSGlossopharyn-geal

IX

SmellSOlfactoryI

InnervationFNameCN

Anatomy & Physiology of the Face Structure Ear Eye

Anatomy & Physiology of the Face Structure Ear Eye

Anatomy & Anatomy & PhysiologyPhysiology

Head, Face & NeckHead, Face & Neck

Structure Facial Bones

Zygoma• Prominent bone of the cheek• Protects eyes• Attachment for muscles controlling eye & jaw movement

Maxilla• Upper jaw• Supports the nasal bone• Provides lower border of orbit

Mandible• Jaw bone

Nasal Bones

Structure Facial Bones

Zygoma• Prominent bone of the cheek• Protects eyes• Attachment for muscles controlling eye & jaw movement

Maxilla• Upper jaw• Supports the nasal bone• Provides lower border of orbit

Mandible• Jaw bone

Nasal Bones

Anatomy & Anatomy & Physiology Physiology of the Faceof the Face

Structure Covered with skin

Flexible and thin Highly vascular

Minimal layer of subcutaneous tissue

Circulation External carotid artery

Supplies facial area Branches

• Facial, Temporal & Maxillary Arteries

Structure Covered with skin

Flexible and thin Highly vascular

Minimal layer of subcutaneous tissue

Circulation External carotid artery

Supplies facial area Branches

• Facial, Temporal & Maxillary Arteries


Nerves Trigeminal (CN-V)

Facial Sensation Some eye motor control Enables chewing process

Facial (CN-VII) Motor control for facial muscles Sensation of taste

Nerves Trigeminal (CN-V)

Facial Sensation Some eye motor control Enables chewing process

Facial (CN-VII) Motor control for facial muscles Sensation of taste


Nasal Cavity Upper Border

Bones• Junction of Ethmoid, Nasal, & Maxillary Bones

Bony Septum• Right & Left Chamber

Turbinates• Vascular mucosa support• Warm, Humidify, and Filter incoming air

Lower Border Bony Hard Palate Soft Palate

• Moves upward during swallowing Nasal Cartilage

Forms Nares

Nasal Cavity Upper Border

Bones• Junction of Ethmoid, Nasal, & Maxillary Bones

Bony Septum• Right & Left Chamber

Turbinates• Vascular mucosa support• Warm, Humidify, and Filter incoming air

Lower Border Bony Hard Palate Soft Palate

• Moves upward during swallowing Nasal Cartilage

Forms Nares


Oral Cavity Formed Structures

Maxillary bone Palate Upper teeth meeting the mandible and lower teeth

Floor Tongue

• Connects to hyoid bone Free-floating U-shaped bone inferior & posterior of the

mandible

Mandible Articulates with the TMJ joint

Oral Cavity Formed Structures

Maxillary bone Palate Upper teeth meeting the mandible and lower teeth

Floor Tongue

• Connects to hyoid bone Free-floating U-shaped bone inferior & posterior of the

mandible

Mandible Articulates with the TMJ joint


Special Structures Salivary Glands

First stage in digestion Location

• Anterior and inferior to the ear• Under tongue• Inside the inferior mandible

Tonsils Posterior wall of the pharynx

Special Structures Salivary Glands

First stage in digestion Location

• Anterior and inferior to the ear• Under tongue• Inside the inferior mandible

Tonsils Posterior wall of the pharynx


(continued)

Sinuses Hollow spaces in cranium and facial bones Function

• Lighten head• Protect eyes and nasal cavity• Produce resonant tones of voice• Strengthen area against trauma

Sinuses Hollow spaces in cranium and facial bones Function

• Lighten head• Protect eyes and nasal cavity• Produce resonant tones of voice• Strengthen area against trauma


Cranial Nerves CN-XII (Hypoglossal)

Swallowing & tongue movement

CN-IX (Glossopharyngeal) Saliva production & taste

CN-V (Trigeminal) Sensations from facial region & aids in chewing

CN-VII (Facial) Muscles of facial expression & taste

Cranial Nerves CN-XII (Hypoglossal)

Swallowing & tongue movement

CN-IX (Glossopharyngeal) Saliva production & taste

CN-V (Trigeminal) Sensations from facial region & aids in chewing

CN-VII (Facial) Muscles of facial expression & taste


Pharynx Posterior & Inferior to the oral cavity Aids in swallowing

Bolus of food propelled back & down by tongue Epiglottis moves downward Larynx moves up

• Combined effect seals airway

Peristaltic wave moves food down esophagus

Pharynx Posterior & Inferior to the oral cavity Aids in swallowing

Bolus of food propelled back & down by tongue Epiglottis moves downward Larynx moves up

• Combined effect seals airway

Peristaltic wave moves food down esophagus


Ear Function

Hearing Positional sense

Structures Pinna

• Outer visible portion

• Formed of Cartilage & has Poor blood supply External Auditory Canal

• Glands that secrete cerumen (wax) Middle & Inner Ear

• Structures for hearing and positional sense

Ear Function

Hearing Positional sense

Structures Pinna

• Outer visible portion

• Formed of Cartilage & has Poor blood supply External Auditory Canal

• Glands that secrete cerumen (wax) Middle & Inner Ear

• Structures for hearing and positional sense


Ear Structures for Hearing

Tympanic membrane Ossicle bones Cochlea Auditory Nerve

Structures for Proprioception Semicircular canals

• Sense position & motion Present when eyes are closed Vertigo

• Continuous movement sensation

Ear Structures for Hearing

Tympanic membrane Ossicle bones Cochlea Auditory Nerve

Structures for Proprioception Semicircular canals

• Sense position & motion Present when eyes are closed Vertigo

• Continuous movement sensation


Eye Structures

Sclera Cornea Conjunctiva Anterior Chamber

• Aqueous humor• Iris

Pupil Lens Posterior Chamber

• Vitreous humor Retina

Lacrimal Fluid Bathes, protects, and nourishes cornea

Eye Structures

Sclera Cornea Conjunctiva Anterior Chamber

• Aqueous humor• Iris

Pupil Lens Posterior Chamber

• Vitreous humor Retina

Lacrimal Fluid Bathes, protects, and nourishes cornea


Eye Innervation

CN-III (Oculomotor)• Pupil dilation

• Conjugate movement Movement of eyes together

• Normal range of motion

CN-IV (Trochlear)• Downward & inward movement

CN-VI (Abducens)• Abduction (outward) gaze

Eye Innervation

CN-III (Oculomotor)• Pupil dilation

• Conjugate movement Movement of eyes together

• Normal range of motion

CN-IV (Trochlear)• Downward & inward movement

CN-VI (Abducens)• Abduction (outward) gaze


Vasculature of the Neck Carotid Arteries

Arise from• RIGHT: Brachiocephalic Artery• LEFT: Aorta Artery

Split• Internal & External Carotid Arteries• Upper border of the Larynx• Carotid Bodies & Sinuses located

Bodies: Monitor CO2 and O2 levels Sinuses: Monitor Blood Pressure

Vasculature of the Neck Carotid Arteries

Arise from• RIGHT: Brachiocephalic Artery• LEFT: Aorta Artery

Split• Internal & External Carotid Arteries• Upper border of the Larynx• Carotid Bodies & Sinuses located

Bodies: Monitor CO2 and O2 levels Sinuses: Monitor Blood Pressure

Anatomy & Anatomy & Physiology Physiology of the Neckof the Neck

(continued)

Jugular Veins External

• Superficial, lateral to the trachea Internal

• Sheath with the carotid artery and vagus nerve

Jugular Veins External

• Superficial, lateral to the trachea Internal

• Sheath with the carotid artery and vagus nerve


Airway Structures Larynx

Epiglottis Thyroid & Cricoid Cartilage

Trachea Posterior border is anterior border of esophagus

Airway Structures Larynx

Epiglottis Thyroid & Cricoid Cartilage

Trachea Posterior border is anterior border of esophagus


Other Structures Cervical Spine

Musculoskeletal Function• External Skeletal support of the head and neck

• Attachment point for spinal column ligaments

• Attachment point for tendons to move head and shoulders

Nervous Function• Spinal Cord contained within

• Peripheral Nerve Exit between vertebrae

Other Structures Cervical Spine

Musculoskeletal Function• External Skeletal support of the head and neck

• Attachment point for spinal column ligaments

• Attachment point for tendons to move head and shoulders

Nervous Function• Spinal Cord contained within

• Peripheral Nerve Exit between vertebrae


Other Structures Esophagus Cranial Nerves

CN-IX (Glossopharyngeal)• Carotid Bodies & Carotid Sinuses

CN-X• Speech, swallowing, cardiac, respiratory & visceral function

Thoracic Duct Delivers lymph to the venous system

Other Structures Esophagus Cranial Nerves

CN-IX (Glossopharyngeal)• Carotid Bodies & Carotid Sinuses

CN-X• Speech, swallowing, cardiac, respiratory & visceral function

Thoracic Duct Delivers lymph to the venous system


(continued)

Glands Thyroid

• Rate of cellular metabolism• Systemic levels of calcium

Brachial Plexus Network of nerves in lower neck and should that control

arm and hand function

Glands Thyroid

• Rate of cellular metabolism• Systemic levels of calcium

Brachial Plexus Network of nerves in lower neck and should that control

arm and hand function


Mechanism of Injury Blunt Injury

Motor vehicle collisions Assaults Falls

Penetrating Injury Gunshot wounds Stabbing Explosions “Clothesline”

Mechanism of Injury Blunt Injury

Motor vehicle collisions Assaults Falls

Penetrating Injury Gunshot wounds Stabbing Explosions “Clothesline”

Pathophysiology ofPathophysiology ofHead, Facial, & Neck Head, Facial, & Neck

InjuryInjury

Scalp InjuryScalp Injury

Contusions Lacerations Avulsions Significant Hemorrhage

ALWAYS Reconsider MOI for severe underlying problems

Contusions Lacerations Avulsions Significant Hemorrhage

ALWAYS Reconsider MOI for severe underlying problems

Cranial InjuryCranial Injury Trauma must be extreme to fracture

Linear Depressed Open Impaled Object

Basal Skull Unprotected Spaces weaken

structure Relatively

easier to fracture

Trauma must be extreme to fracture Linear Depressed Open Impaled Object

Basal Skull Unprotected Spaces weaken

structure Relatively

easier to fracture

Cranial InjuryCranial Injury

Basal Skull Fracture Signs Battle’s Signs

Retroauricular Ecchymosis Associated with fracture of

auditory canal and lower areas of skull

Raccoon Eyes Bilateral Periorbital

Ecchymosis Associated with orbital

fractures

Basal Skull Fracture Signs Battle’s Signs

Retroauricular Ecchymosis Associated with fracture of

auditory canal and lower areas of skull

Raccoon Eyes Bilateral Periorbital

Ecchymosis Associated with orbital

fractures

Cranial InjuryCranial Injury

Basilar Skull Fracture May tear dura

Permit CSF to drain through an external passageway

• May mediate rise of ICP

• Evaluate for “Target” or “Halo” sign

Basilar Skull Fracture May tear dura

Permit CSF to drain through an external passageway

• May mediate rise of ICP

• Evaluate for “Target” or “Halo” sign

Brain InjuryBrain Injury

As defined by the National Head Injury Foundation “a traumatic insult to the brain capable of

producing physical, intellectual, emotional, social and vocational changes.”

Classification Direct

• Primary injury caused by forces of trauma

Indirect• Secondary injury caused by factors resulting from the

primary injury

As defined by the National Head Injury Foundation “a traumatic insult to the brain capable of

producing physical, intellectual, emotional, social and vocational changes.”

Classification Direct

• Primary injury caused by forces of trauma

Indirect• Secondary injury caused by factors resulting from the

primary injury

Direct Brain Injury Direct Brain Injury TypesTypes Coup

Injury at site of impact

Contrecoup Injury on

opposite side from impact

Coup Injury at site of

impact

Contrecoup Injury on

opposite side from impact

Direct Brain Injury Direct Brain Injury CategoriesCategories

Focal Occur at a specific location in brain Differentials

Cerebral Contusion Intracranial Hemorrhage

• Epidural hematoma• Subdural hematoma

Intracerebral Hemorrhage

Diffuse Concussion Moderate Diffuse Axonal Injury Severe Diffuse Axonal Injury

Focal Occur at a specific location in brain Differentials

Cerebral Contusion Intracranial Hemorrhage

• Epidural hematoma• Subdural hematoma

Intracerebral Hemorrhage

Diffuse Concussion Moderate Diffuse Axonal Injury Severe Diffuse Axonal Injury

Focal Brain InjuryFocal Brain Injury

Cerebral Contusion Blunt trauma to local brain tissue Capillary bleeding into brain tissue Common with blunt head trauma

Confusion Neurologic deficit

• Personality changes

• Vision changes

• Speech changes

Results from Coup-contrecoup injury

Cerebral Contusion Blunt trauma to local brain tissue Capillary bleeding into brain tissue Common with blunt head trauma

Confusion Neurologic deficit

• Personality changes

• Vision changes

• Speech changes

Results from Coup-contrecoup injury

Epidural Hematoma Bleeding between dura

mater and skull Involves arteries

Middle meningeal artery most common

Rapid bleeding & reduction of oxygen to tissues

Herniates brain toward foramen magnum

Epidural Hematoma Bleeding between dura

mater and skull Involves arteries

Middle meningeal artery most common

Rapid bleeding & reduction of oxygen to tissues

Herniates brain toward foramen magnum

Focal Brain InjuryFocal Brain InjuryIntracranial HemorrhageIntracranial Hemorrhage

Subdural Hematoma Bleeding within meninges

Beneath dura mater & within subarachnoid space

Above pia mater

Slow bleeding Superior sagital sinus

Signs progress over several days Slow deterioration of

mentation

Subdural Hematoma Bleeding within meninges

Beneath dura mater & within subarachnoid space

Above pia mater

Slow bleeding Superior sagital sinus

Signs progress over several days Slow deterioration of

mentation


Intracerebral Hemorrhage Rupture blood vessel within the brain Presentation similar to stroke symptoms Signs and symptoms worsen over time

Intracerebral Hemorrhage Rupture blood vessel within the brain Presentation similar to stroke symptoms Signs and symptoms worsen over time


Diffuse Brain InjuryDiffuse Brain Injury

Due to stretching forces placed on axons

Pathology distributed throughout brain

Types Concussion Moderate Diffuse Axonal Injury Severe Diffuse Axonal Injury

Due to stretching forces placed on axons

Pathology distributed throughout brain

Types Concussion Moderate Diffuse Axonal Injury Severe Diffuse Axonal Injury

Mild to moderate form of Diffuse Axonal Injury (DAI) 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 ABC’s

Mild to moderate form of Diffuse Axonal Injury (DAI) 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 ABC’s

Diffuse Brain InjuryDiffuse Brain InjuryConcussionConcussion

“Classic Concussion” Same mechanism as concussion

Additional: Minute bruising of brain tissue

Unconsciousness If cerebral cortex and RAS involved

May exist with a basilar skull fracture Signs & Symptoms

Unconsciousness or Persistent confusion Loss of concentration, disorientation Retrograde & Antegrade amnesia Visual and sensory disturbances Mood or Personality changes

“Classic Concussion” Same mechanism as concussion

Additional: Minute bruising of brain tissue

Unconsciousness If cerebral cortex and RAS involved

May exist with a basilar skull fracture Signs & Symptoms

Unconsciousness or Persistent confusion Loss of concentration, disorientation Retrograde & Antegrade amnesia Visual and sensory disturbances Mood or Personality changes

Diffuse Brain InjuryDiffuse Brain InjuryModerate Diffuse Axonal Moderate Diffuse Axonal

InjuryInjury

Brainstem Injury Significant mechanical disruption of

axons Cerebral hemispheres and brainstem

High mortality rate Signs & Symptoms

Prolonged unconsciousness Cushing’s reflex Decorticate or Decerebrate posturing

Brainstem Injury Significant mechanical disruption of

axons Cerebral hemispheres and brainstem

High mortality rate Signs & Symptoms

Prolonged unconsciousness Cushing’s reflex Decorticate or Decerebrate posturing

Diffuse Brain InjuryDiffuse Brain InjurySevere Diffuse Axonal Severe Diffuse Axonal

InjuryInjury

Intracranial Intracranial PerfusionPerfusion Review

Cranial volume fixed 80% = Cerebrum, cerebellum & brainstem 12% = Blood vessels & blood 8% = CSF

Increase in size of one component diminishes size of another Inability to adjust = increased ICP

Review Cranial volume fixed

80% = Cerebrum, cerebellum & brainstem 12% = Blood vessels & blood 8% = CSF

Increase in size of one component diminishes size of another Inability to adjust = increased ICP

Intracranial Intracranial PerfusionPerfusion 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 ICP• Dangerous cycle

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 ICP• Dangerous cycle ICP BP

Intracranial PressureIntracranial Pressure

Role of Carbon Dioxide Increase of CO2 in CSF

Cerebral Vasodilation• Encourage blood flow

• Reduce hypercarbia

• Reduce hypoxia

Contributes to ICP Causes classic

Hyperventilation & Hypertension

Reduced levels of CO2 in CSF Cerebral vasoconstriction

• Results in cerebral anoxia

Role of Carbon Dioxide Increase of CO2 in CSF

Cerebral Vasodilation• Encourage blood flow

• Reduce hypercarbia

• Reduce hypoxia

Contributes to ICP Causes classic

Hyperventilation & Hypertension

Reduced levels of CO2 in CSF Cerebral vasoconstriction

• Results in cerebral anoxia

Factors Affecting ICPFactors Affecting ICP

Vasculature Constriction Cerebral Edema Systolic Blood Pressure

Low BP = Poor Cerebral Perfusion High BP = Increased ICP

Carbon Dioxide Reduced respiratory efficiency

Vasculature Constriction Cerebral Edema Systolic Blood Pressure

Low BP = Poor Cerebral Perfusion High BP = Increased ICP

Carbon Dioxide Reduced respiratory efficiency

Increased pressure Compresses brain tissue

Against & around• Falx Cerebri

• Tentorium Cerebelli

Herniates brainstem Compromises blood supply Signs & Symptoms

• Upper Brainstem Vomiting Altered mental status Pupillary dilation

• Medulla Oblongata Respiratory Cardiovascular Blood Pressure disturbances

Increased pressure Compresses brain tissue

Against & around• Falx Cerebri

• Tentorium Cerebelli

Herniates brainstem Compromises blood supply Signs & Symptoms

• Upper Brainstem Vomiting Altered mental status Pupillary dilation

• Medulla Oblongata Respiratory Cardiovascular Blood Pressure disturbances

Pressure & Pressure & Structural Structural

DisplacementDisplacement

Altered Mental Status Altered orientation Alteration in

personality Amnesia

Retrograde Antegrade

Cushing’s Reflex Increased BP Bradycardia Erratic respirations

Altered Mental Status Altered orientation Alteration in

personality Amnesia

Retrograde Antegrade

Cushing’s Reflex Increased BP Bradycardia Erratic respirations

Signs & Symptoms Signs & Symptoms of Brain Injuryof Brain Injury

Vomiting Without nausea Projectile

Body temperature changes

Changes in pupil reactivity

Decorticate posturing

Vomiting Without nausea Projectile

Body temperature changes

Changes in pupil reactivity

Decorticate posturing

Pathophysiology of Changes Frontal Lobe Injury

Alterations in personality

Occipital Lobe Injury Visual disturbances

Cortical Disruption Reduce mental status or Amnesia

• Retrograde Unable to recall events before injury

• Antegrade Unable to recall events after trauma “Repetitive Questioning”

Focal Deficits Hemiplegia, Weakness or Seizures

Pathophysiology of Changes Frontal Lobe Injury

Alterations in personality

Occipital Lobe Injury Visual disturbances

Cortical Disruption Reduce mental status or Amnesia

• Retrograde Unable to recall events before injury

• Antegrade Unable to recall events after trauma “Repetitive Questioning”

Focal Deficits Hemiplegia, Weakness or Seizures

Signs & Symptoms Signs & Symptoms of Brain Injuryof Brain Injury

Upper Brainstem Compression Increasing blood pressure Reflex bradycardia

Vagus nerve stimulation

Cheyne-Stokes respirations Pupils become small and reactive Decorticate posturing

Neural pathway disruption

Upper Brainstem Compression Increasing blood pressure Reflex bradycardia

Vagus nerve stimulation

Cheyne-Stokes respirations Pupils become small and reactive Decorticate posturing

Neural pathway disruption

Signs & Symptoms of Brain Signs & Symptoms of Brain InjuryInjury

Physiological ChangesPhysiological Changes

Middle Brainstem Compression Widening pulse pressure Increasing bradycardia CNS Hyperventilation

Deep and Rapid

Bilateral pupil sluggishness or inactivity Decerebrate posturing

Middle Brainstem Compression Widening pulse pressure Increasing bradycardia CNS Hyperventilation

Deep and Rapid

Bilateral pupil sluggishness or inactivity Decerebrate posturing



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

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



Different pathology than older patients Skull can distort due to anterior and posterior

fontanelles Bulging Slows progression of increasing ICP

Intracranial hemorrhage contributes to hypovolemia Decreased blood volume in ped’s

General Management Avoid hyperextension of head

Tongue pushes soft pallet closed Ventilate through mouth and nose

Different pathology than older patients Skull can distort due to anterior and posterior

fontanelles Bulging Slows progression of increasing ICP

Intracranial hemorrhage contributes to hypovolemia Decreased blood volume in ped’s

General Management Avoid hyperextension of head

Tongue pushes soft pallet closed Ventilate through mouth and nose


Pediatric Head TraumaPediatric Head Trauma


Glasgow Coma ScaleGlasgow Coma Scale

Physiological Issues Indicate pressure on

CN-II, CN-III, CN-IV, & CN-VI• CN-III (Oculomotor Nerve)

Pressure on nerve causes eyes to be sluggish, then dilated, and finally fixed

Reduced peripheral blood flow

Pupil Size & Reactivity Reduced Pupillary Responsiveness

Depressant drugs or Cerebral Hypoxia Fixed & Dilated

Extreme Hypoxia

Physiological Issues Indicate pressure on

CN-II, CN-III, CN-IV, & CN-VI• CN-III (Oculomotor Nerve)

Pressure on nerve causes eyes to be sluggish, then dilated, and finally fixed

Reduced peripheral blood flow

Pupil Size & Reactivity Reduced Pupillary Responsiveness

Depressant drugs or Cerebral Hypoxia Fixed & Dilated

Extreme Hypoxia


Eye SignsEye Signs

Facial InjuryFacial Injury

Facial Soft Tissue Injury Highly vascular tissue

Contribute to hypovolemia

Superficial injuries rarely life threatening and rarely involve the airway

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 Soft Tissue Injury Highly vascular tissue

Contribute to hypovolemia

Superficial injuries rarely life threatening and rarely involve the airway

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 InjuryFacial Injury Facial Dislocations & Fractures

Common Fractures Mandibular

• Deformity along jaw & loss of teeth• Possible airway compromise if patient placed supine• Evaluate for multiple fracture sites

Maxillary & Nasal• Le Fort I, II and III Criteria

Orbit• Involve Zygoma, Maxilla, and/or interior shelf• Reduction of eye movement

Possible Diplopia• Limitation of jaw movement

Facial Dislocations & Fractures Common Fractures

Mandibular• Deformity along jaw & loss of teeth• Possible airway compromise if patient placed supine• Evaluate for multiple fracture sites

Maxillary & Nasal• Le Fort I, II and III Criteria

Orbit• Involve Zygoma, Maxilla, and/or interior shelf• Reduction of eye movement

Possible Diplopia• Limitation of jaw movement

Facial InjuryFacial Injury

Nasal Injury Rarely life threatening Swelling & Hemorrhage interfere with

breathing Epistaxis

Most common problem

AVOID NASOTRACHEAL INTUBATION Passage of ET tube into the cerebral cavity

Nasal Injury Rarely life threatening Swelling & Hemorrhage interfere with

breathing Epistaxis

Most common problem

AVOID NASOTRACHEAL INTUBATION Passage of ET tube into the cerebral cavity

Facial InjuryFacial Injury Ear Injury

External Ear Pinna is frequently injured due to trauma Poor blood supply Poor healing

Internal Ear Well protected from trauma My be injured due to rapid pressure changes

• Diving, Blast, or Explosions• Temporary or permanent hearing loss• Tinnitus may occur

Ear Injury External Ear

Pinna is frequently injured due to trauma Poor blood supply Poor healing

Internal Ear Well protected from trauma My be injured due to rapid pressure changes

• Diving, Blast, or Explosions• Temporary or permanent hearing loss• Tinnitus may occur

Facial InjuryFacial Injury Eye Injury

Penetrating trauma can result in long term damage Suspect small foreign body if patient complains of sudden

eye pain and sensation of something on the eye DO NOT REMOVE ANY FOREIGN OBJECT

Corneal Abrasions & Lacerations Common & usually superficial

Hyphema Blunt trauma to the anterior chamber of the eye Blood in front of iris or pupil

Sub-conjunctival Hemorrhage Less serious condition May occur after strong sneeze, severe vomiting or direct

trauma

Eye Injury Penetrating trauma

can result in long term damage Suspect small foreign body if patient complains of sudden

eye pain and sensation of something on the eye DO NOT REMOVE ANY FOREIGN OBJECT

Corneal Abrasions & Lacerations Common & usually superficial

Hyphema Blunt trauma to the anterior chamber of the eye Blood in front of iris or pupil

Sub-conjunctival Hemorrhage Less serious condition May occur after strong sneeze, severe vomiting or direct

trauma

Facial InjuryFacial Injury Eye Injury

Acute Retinal Artery Occlusion Non-traumatic origin Painless loss of vision in one eye Occlusion of retinal artery

Retinal Detachment Traumatic origin Complaint of dark curtain/obstruction in the field of

view Possibly painful depending on type of trauma

Soft Tissue Lacerations

Eye Injury Acute Retinal Artery Occlusion

Non-traumatic origin Painless loss of vision in one eye Occlusion of retinal artery

Retinal Detachment Traumatic origin Complaint of dark curtain/obstruction in the field of

view Possibly painful depending on type of trauma

Soft Tissue Lacerations

Neck InjuryNeck Injury Blood Vessel Trauma

Blunt trauma Serious hematoma

Laceration Serious exsanguination Entraining of air embolism

• Cover with occlusive dressing

Airway Trauma Tracheal rupture or dissection from larynx Airway swelling & compromise

Blood Vessel Trauma Blunt trauma

Serious hematoma Laceration

Serious exsanguination Entraining of air embolism

• Cover with occlusive dressing

Airway Trauma Tracheal rupture or dissection from larynx Airway swelling & compromise

Neck InjuryNeck Injury Cervical Spine Trauma

Vertebral fracture Paresthesia, anaesthesia, paresis or paralysis beneath the

level of the injury Neurogenic shock may occur

Other Neck Trauma Subcutaneous emphysema

Tension pneumothorax Traumatic asphyxia

Penetrating Trauma Esophagus or Trachea Vagus nerve disruption

• Tachycardia & GI disturbances Thyroid & Parathyroid glands

• High vascular

Cervical Spine Trauma Vertebral fracture

Paresthesia, anaesthesia, paresis or paralysis beneath the level of the injury

Neurogenic shock may occur

Other Neck Trauma Subcutaneous emphysema

Tension pneumothorax Traumatic asphyxia

Penetrating Trauma Esophagus or Trachea Vagus nerve disruption

• Tachycardia & GI disturbances Thyroid & Parathyroid glands

• High vascular

Scene Size-up Initial Assessment

Airway, Breathing, Circulation

Rapid Trauma Assessment Head, Face, Neck Glasgow Coma Scale Score Vital Signs

Focused History & Physical Exam Detailed Assessment Ongoing Assessment

Scene Size-up Initial Assessment

Airway, Breathing, Circulation

Rapid Trauma Assessment Head, Face, Neck Glasgow Coma Scale Score Vital Signs

Focused History & Physical Exam Detailed Assessment Ongoing Assessment

Assessment ofAssessment ofHead, Facial & Neck Head, Facial & Neck

InjuriesInjuries

Airway Suctioning Patient Positioning OPA & NPA Use Endotracheal

Intubation Orotracheal Digital Nasotracheal Retrograde Direct RSI

Cricothyrotomy

Airway Suctioning Patient Positioning OPA & NPA Use Endotracheal

Intubation Orotracheal Digital Nasotracheal Retrograde Direct RSI

Cricothyrotomy

Head, Facial, & NeckHead, Facial, & NeckInjury ManagementInjury Management

Breathing Oxygen

15 LPM/NRB Ventilations

12-20/min Hyperoxygenate

Circulation Hemorrhage Control Blood Pressure

Maintenance Fluid resuscitation Consider PASG

Breathing Oxygen

15 LPM/NRB Ventilations

12-20/min Hyperoxygenate

Circulation Hemorrhage Control Blood Pressure

Maintenance Fluid resuscitation Consider PASG

Needle Needle CricothyrostomyCricothyrostomy Locate Site

Cricothyroid Membrane

Cleanse upper anterior neck Aseptic Technique

Iodine & Alcohol

Prepare Equipment 14 ga IV catheter Syringe Transtracheal jet

insufflation device 6.0 ET Hub

Locate Site Cricothyroid Membrane


Iodine & Alcohol

Prepare Equipment 14 ga IV catheter Syringe Transtracheal jet

insufflation device 6.0 ET Hub

Insert Catheter into membrane Downward Angle Feel “pop”

Advance Catheter Attach BVM or jet

ventilator Evaluate breath

sounds Secure Catheter

• Similar to impaled object

Consider 2nd catheter for exhalation

Insert Catheter into membrane Downward Angle Feel “pop”

Advance Catheter Attach BVM or jet

ventilator Evaluate breath

sounds Secure Catheter

• Similar to impaled object

Consider 2nd catheter for exhalation

Surgical Surgical CricothyrotomyCricothyrotomy Locate Site

Cricothyroid Membrane


Iodine & Alcohol

Prepare Equipment Commercial device Scalpel 4” ET Tube

Locate Site Cricothyroid Membrane


Iodine & Alcohol

Prepare Equipment Commercial device Scalpel 4” ET Tube

Insert scalpel into membrane Downward Angle Feel “pop”

Enlarge opening Place short ET tube Evaluate breath

sounds Secure device

Insert scalpel into membrane Downward Angle Feel “pop”

Enlarge opening Place short ET tube Evaluate breath

sounds Secure device

Hypoxia Prevent/Reduce Hyperoxygenation with BVM

Hypovolemia Reduces cerebral perfusion & hypoxia Consider early management with 2 large bore IV’s

and isotonic fluids Prevents slower compensatory mechanism Maintain SBP 90-100 mmHg

Consider PASG

Hypoxia Prevent/Reduce Hyperoxygenation with BVM

Hypovolemia Reduces cerebral perfusion & hypoxia Consider early management with 2 large bore IV’s

and isotonic fluids Prevents slower compensatory mechanism Maintain SBP 90-100 mmHg

Consider PASG

Head, Facial, & NeckHead, Facial, & NeckInjury ManagementInjury Management

Medications: Medications: OxygenOxygen Primary 1st line drug

Administer high flow Hyperventilation is contraindicated

Reduces circulating CO2 levels

NRB: 15 LPM BVM: 12-20 times per minute Keep SaO2 > 95%

Primary 1st line drug Administer high flow Hyperventilation is contraindicated

Reduces circulating CO2 levels

NRB: 15 LPM BVM: 12-20 times per minute Keep SaO2 > 95%

Medications: Medications: DiureticsDiuretics Mannitol (osmotrol)

MOA Large glucose molecule

• Does not leave blood stream• Osmotic Diuretic

Effective in drawing fluid from brain Contraindication

Hypovolemia & Hypotension CHF

Dose 1gm/kg

CAUTION Forms crystals at low temperatures Reconstitute with rewarming & gentle agitation USE IN-LINE filter & PREFLUSH line

Mannitol (osmotrol) MOA

Large glucose molecule• Does not leave blood stream• Osmotic Diuretic

Effective in drawing fluid from brain Contraindication

Hypovolemia & Hypotension CHF

Dose 1gm/kg

CAUTION Forms crystals at low temperatures Reconstitute with rewarming & gentle agitation USE IN-LINE filter & PREFLUSH line

Medications: Medications: DiureticsDiuretics Furosemide (Lasix)

MOA Loop Diuretic Inhibits reabsorption of Na+ in Kidneys

• Increased secretion of water and electrolytes Na+, Cl–, Mg++, Ca++.

Venous dilation & Reduces cardiac preload May be given in combination with Mannitol

Contraindication Pregnancy: fetal abnormalities

Dose Slow IVP or IM over 1-2 minutes 0.5-1 mg/kg: Commonly 40 or 80 mg

Furosemide (Lasix) MOA

Loop Diuretic Inhibits reabsorption of Na+ in Kidneys

• Increased secretion of water and electrolytes Na+, Cl–, Mg++, Ca++.

Venous dilation & Reduces cardiac preload May be given in combination with Mannitol

Contraindication Pregnancy: fetal abnormalities

Dose Slow IVP or IM over 1-2 minutes 0.5-1 mg/kg: Commonly 40 or 80 mg

Medications: Medications: ParalyticsParalytics Succinylcholine (Anectine)

MOA Depolarizing Medication

• Causes Fasciculations

Onset & Duration Onset: 30-60 seconds Duration: 2-3 minutes

Precaution Paralyzes ALL muscles including those of respiration Increases intraoccular eye pressure

Contraindication Penetrating eye injury & Digitalis

Dose 1-1.5 mg/kg IV Consider administration of 0.5 mg of Atropine to reduce

fasciculations

Succinylcholine (Anectine) MOA

Depolarizing Medication• Causes Fasciculations

Onset & Duration Onset: 30-60 seconds Duration: 2-3 minutes

Precaution Paralyzes ALL muscles including those of respiration Increases intraoccular eye pressure

Contraindication Penetrating eye injury & Digitalis

Dose 1-1.5 mg/kg IV Consider administration of 0.5 mg of Atropine to reduce

fasciculations

Medications: Medications: ParalyticsParalyticsPancuronium

(Pavulon) MOA

Non-depolarizing agent

Does not affect LOC Onset & Duration

Onset: 3-5 min Duration: 30-60 min

Dose Must premed with

sedative 0.04-0.1 mg/kg

Pancuronium (Pavulon)

MOA Non-depolarizing

agent Does not affect LOC

Onset & Duration Onset: 3-5 min Duration: 30-60 min

Dose Must premed with


Vecuronium(Norcuron)



Onset & Duration Onset: < 1 min Duration: 25-40 min

Dose Consider premed with


Vecuronium(Norcuron)



Onset & Duration Onset: < 1 min Duration: 25-40 min

Dose Consider premed with


Medications: Medications: SedativesSedatives Diazepam

(Valium) MOA

Benzodiazepine Anti-anxiety Muscle relaxant


Dose 5-10 mg

Diazepam (Valium) MOA

Benzodiazepine Anti-anxiety Muscle relaxant


Dose 5-10 mg

Midazolam (Versed) MOA

Benzodiazepine 3-4x potent than

valium

Dose SLOW IVP

• 1 mg/min

1-2.5 mg titrated

Midazolam (Versed) MOA

Benzodiazepine 3-4x potent than

valium

Dose SLOW IVP

• 1 mg/min

1-2.5 mg titrated

Medications: Medications: SedativeSedative Morphine

MOA Opium alkaloid

• Analgesic• Sedation• Anti-anxiety

Reduces vascular volume & cardiac preload• Increases venous capacitance

Side Effects Respiratory depression Hypovolemia

Dose 5-10 mg IVP Consider using promethezine with to reduce nausea Naloxone (Narcan) is antagonist

Morphine MOA

Opium alkaloid• Analgesic• Sedation• Anti-anxiety

Reduces vascular volume & cardiac preload• Increases venous capacitance

Side Effects Respiratory depression Hypovolemia

Dose 5-10 mg IVP Consider using promethezine with to reduce nausea Naloxone (Narcan) is antagonist

Medications: Medications: AtropineAtropine MOA

Anticholinergic Parasympathetic

Reduces parasympatholyic stimulation Reduce oral and airway secretions Reduce fasciculations Pupillary dilation

Dose 0.5-1 mg rapid IVP

MOA Anticholinergic

Parasympathetic

Reduces parasympatholyic stimulation Reduce oral and airway secretions Reduce fasciculations Pupillary dilation

Dose 0.5-1 mg rapid IVP

Medications: Medications: DextroseDextrose Consider if patient is hypoglycemic

Only if VERIFIED by GLUCOMETER

Dose 25 gm IVP Consider Thiamine if known alcoholic

100 mg Thiamine

Consider if patient is hypoglycemic Only if VERIFIED by GLUCOMETER

Dose 25 gm IVP Consider Thiamine if known alcoholic

100 mg Thiamine

Medications: Medications: ThiamineThiamine Vitamin B1

Essential for the processing of glucose through Kreb’s cycle

Chronic alcoholics can have B1 depletion

Dose 100 mg IV or IM

Vitamin B1 Essential for the processing of

glucose through Kreb’s cycle Chronic alcoholics can have B1

depletion Dose

100 mg IV or IM

Medications Xylocaine or Benzocaine

Anesthetize oral and pharyngeal mucosa• Reduces gag reflex

• Reduces likelihood of ICP associated with vomiting

Inhibits nerve sensation Onset & Duration

• Onset: 15 seconds

• Duration: 15 minutes

PRECAUTION• Patient has reduced ability to remove oral fluids

• ASPIRATION can occur

Medications Xylocaine or Benzocaine

Anesthetize oral and pharyngeal mucosa• Reduces gag reflex

• Reduces likelihood of ICP associated with vomiting

Inhibits nerve sensation Onset & Duration

• Onset: 15 seconds

• Duration: 15 minutes

PRECAUTION• Patient has reduced ability to remove oral fluids

• ASPIRATION can occur

Medications: Topical Medications: Topical Anesthetic SprayAnesthetic Spray

Transport Transport ConsiderationsConsiderations Limit external stimulation

Can increase ICP Can induce seizures

Cautious about Air Transport Seizures

Limit external stimulation Can increase ICP Can induce seizures

Cautious about Air Transport Seizures

Emotional SupportEmotional Support

Have friend or family provide constant reassurance

Provided constant reorientation to environment if required Keeps patient calm Reduces anxiety

Have friend or family provide constant reassurance

Provided constant reorientation to environment if required Keeps patient calm Reduces anxiety

Special Injury CareSpecial 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

Pinna Injury Place in close anatomic position as possible Dress and cover with sterile dressing

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

Pinna Injury Place in close anatomic position as possible Dress and cover with sterile dressing

Special Injury CareSpecial Injury Care Eye Injury

General Injury Cover injured and uninjured eye

• Prevents sympathetic motion

Consider sterile dressing soaked in NS

Corneal Abrasion Invert eyelid and examine eye for foreign body Remove with NS moistened gauze or Morgan’s Lens

Avulsed or Impaled Eye Cover and Protect from injury

General Care Calm & reassure patient

Eye Injury General Injury

Cover injured and uninjured eye• Prevents sympathetic motion

Consider sterile dressing soaked in NS

Corneal Abrasion Invert eyelid and examine eye for foreign body Remove with NS moistened gauze or Morgan’s Lens

Avulsed or Impaled Eye Cover and Protect from injury

General Care Calm & reassure patient

Special Injury CareSpecial 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

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

Head, Facial, & Neck Trauma. Sections Introduction to Head, Facial, & Neck Injuries Anatomy and Physiology of the Head, Face, & Neck Pathophysiology.

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