Head, Facial, and Neck Trauma Bledsoe et al.,

Head, Facial, and Neck Trauma Bledsoe et al.,

Head, Facial, and Neck Trauma Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Topics Introduction to Head, Facial, and Neck Injuries Anatomy and Physiology of the Head, Face, and Neck Pathophysiology of Head, Facial, and Neck Injury Assessment and Management of Head, Facial, and Neck Injuries Head, Facial, and Neck Injury Management

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Introduction to Head, Facial, and Neck Injuries (1 of 3) Common major trauma. 4 million people experience head trauma annually. Severe head injury is most frequent cause of trauma death. GSW to cranium: 7580% mortality At-risk population:

Males 1524 Infants Young children Elderly Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Introduction to Head, Facial, and Neck Injuries (2 of 3) Injury Prevention Programs Motorcycle safety Bicycle safety Helmet and head injury awareness programs

Sports Football Rollerblading Contact sports Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Introduction to Head, Facial, and Neck Injuries (3 of 3) 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 Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Head, Face, and Neck Anatomy and Physiology of the Head

Cranium Meninges Cerebrospinal fluid Brain Cerebral perfusion pressure Cranial nerves Ascending reticular activating system Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Head (4 of 4)

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 Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Cranium Sphenoid Parietal Suture Line Frontal Temporal Orbits Maxillae Mandible Occiptal Temporal Mandibular Joint

Foramen Magnum (Hole in Base) Nasal Bones Zygomatic Arch Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Bones of the Skull Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Head (1 of 3) 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 Abrasion Contusion Laceration Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ FM/CP

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Head (2 of 3) Meninges Protective mechanism for the CNS Dura Mater Layers Outer: Craniums 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 Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Head (3 of 3) 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 and elastin fibers Subarachnoid space beneath CSF Cushions brain Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ EPI VS. SUB

EPI VS SUB WHERE? Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ The Meninges and Skull Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Head (1 of 18) 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 Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Ventricles of the Brain Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Anatomy and Physiology of the Head (2 of 18) Brain Occupies 80% of cranium Comprised of 3 major structures Cerebrum Cerebellum Brainstem High metabolic rate Receives 15% of cardiac output Consumes 20% of bodys oxygen Requires constant circulation IF blood supply stops: Unconscious within 10 seconds

Death in 46 minutes Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Head (3 of 18) Cerebrum Function Center of conscious thought, personality, speech, and motor control Visual, auditory, and tactile perception Lobes Frontal Personality

Parietal Motor and sensory activity Memory and emotion Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Head (4 of 18) Occipital Sight Temporal Long-term memory Hearing, speech, taste, and smell Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma

2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Head (7 of 18) Cerebrum Hemisphere Functions Left: DOMINANT Mathematical computations: Occipital Writing: Parietal Language interpretation: Occipital Speech: Frontal Right: NON-DOMINANT Non-verbal imagery Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma

2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Head (8 of 18) Cerebellum Located under tentorium Function Fine tunes motor control Allows smooth movement Balance Maintenance of muscle tone Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology

of the Head (9 of 18) Brainstem Central processing center Communication junction among Cerebrum Spinal cord Cranial nerves Cerebellum Structures Midbrain Pons Medulla oblongata Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Anatomy and Physiology of the Head (10 of 18) Midbrain Upper portion of brainstem Structures Hypothalamus Endocrine function, vomiting reflex, hunger, thirst Kidney function, body temperature, emotion Thalamus Switching center between pons and cerebrum Critical Element in Ascending Reticular Activating System (A-RAS) ESTABLISHES CONSCIOUSNESS Major pathways for optic and olfactory nerves

Associated structures Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Head (12 of 18) 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 Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Sections Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Head (15 of 18) 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 Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Head (16 of 18) Calculating MAP BP 120/90

DBP 90 Pulse Pressure 120 - 90 30 MAP 90 13 30 100 Calculating CPP MAP 100 & ICP 10 CPP MAP - ICP CPP 100 - 10 90 Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Head (17 of 18) 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. Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Head (18 of 18) Cranial Nerves 12 pair with distinct pathways

Senses, facial innervation, and 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. Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Cranial Nerves Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Cranial Nerves Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ CN

Name F Innervation I Olfactory S Smell II

Optic S Sight III Oculomotor M Pupil Const, rectus and obliques IV

Trochlear M Superior obliques V Trigeminal S Opthalmic (FH), Maxillary (cheek) Mandible (chin) M

Chewing muscles VI Abducens M Lateral rectus muscle S Tongue M

Face muscles VII Facial VIII Acoustic S Hearing balance IX

Glossopharyngeal S Posterior pharynx, taste to anterior tongue M Face muscles X Vagus S

Taste to posterior tongue M Posterior palate and pharynx XI Accessory M Trapezius and sternocleido muscles XII

Hypoglossal M Tongue Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Head, Face, and Neck Anatomy and Physiology of the Face Structure Ear Eye

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Face Structure Facial Bones Zygoma Prominent bone of the cheek Protects eyes Attachment for muscles controlling eye and jaw movement Maxilla Upper jaw Supports the nasal bone

Provides lower border of orbit Mandible Jaw bone Nasal bones Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Facial Bones Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology

of the Face (1 of 9) Structure Covered with skin Flexible and thin Highly vascular Minimal layer of subcutaneous tissue Circulation External carotid artery Supplies facial area Branches Facial, temporal, and maxillary arteries Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Anatomy and Physiology of the Face (2 of 9) Nerves Trigeminal (CN-V) Facial sensation Some eye motor control Enables chewing process Facial (CN-VII) Motor control for facial muscles Sensation of taste Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Facial Nerves Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Face (3 of 9) Nasal Cavity Upper Border Bones Junction of ethmoid, nasal, and maxillary bones Bony Septum Right and 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 Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Face (6 of 9) 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 Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Face (7 of 9) Cranial Nerves CN-XII (Hypoglossal) Swallowing and tongue movement

CN-IX (Glossopharyngeal) Saliva production and taste CN-V (Trigeminal) Sensations from facial region and aids in chewing CN-VII (Facial) Muscles of facial expression and taste Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Cranial Nerves Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma

2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Face (9 of 9) Ear Function Hearing Positional sense Structures Pinna Outer visible portion Formed of cartilage and has poor blood supply External Auditory Canal Glands that secrete cerumen (wax)

Middle and Inner Ear Structures for hearing and positional sense Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ The Ear Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Face Ear Structures for Hearing

Tympanic membrane Ossicle bones Cochlea Auditory nerve Structures for Proprioception Semicircular canals Sense position and motion Present when eyes are closed Vertigo Continuous movement sensation Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Anatomy and Physiology of the Face (1 of 2) Eye Structures Sclera Cornea Conjunctiva Anterior chamber Aqueous humor Iris Pupil Lens Posterior chamber Vitreous humor

Retina Lacrimal Fluid Bathes, protects, and nourishes cornea Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ The Eye Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Face (2 of 2) Eye Innervation

CN-III (Oculomotor) Pupil dilation Conjugate movement Movement of eyes together Normal range of motion CN-IV (Trochlear) Downward and inward movement CN-VI (Abducens) Abduction (outward) gaze Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology

of the Neck (1 of 6) Vasculature of the Neck Carotid Arteries Arise from RIGHT: Brachiocephalic artery LEFT: Aorta artery Split Internal and external carotid arteries Upper border of the larynx Carotid bodies and sinuses located Bodies: Monitor CO2 and O2 levels Sinuses: Monitor blood pressure Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Carotid Arteries Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Neck (2 of 6) Jugular Veins External Superficial, lateral to the trachea Internal Sheath with the carotid artery and vagus nerve Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma

2006 by Pearson Education, Inc. Upper Saddle River, NJ Jugular Veins Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Neck (3 of 6) Airway Structures Larynx Epiglottis Thyroid and cricoid cartilage Trachea Posterior border is anterior border of

esophagus. Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Neck (4 of 6) 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 Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Neck (5 of 6) Other Structures Esophagus Cranial Nerves CN-IX (Glossopharyngeal) Carotid bodies and carotid sinuses CN-X Speech, swallowing, cardiac, respiratory, and

visceral function Thoracic Duct Delivers lymph to the venous system Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Neck (6 of 6) Glands Thyroid Rate of cellular metabolism Systemic levels of calcium Brachial Plexus Network of nerves in lower neck and

shoulder that control arm and hand function Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Thyroid Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Brachail Plexus Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pathophysiology of Head, Facial, and Neck Injury Mechanism of Injury Blunt Injury Motor vehicle collisions Assaults Falls Penetrating Injury Gunshot wounds Stabbing Explosions Clothesline Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Scalp Injury Contusions Lacerations Avulsions Significant Hemorrhage ALWAYS reconsider MOI for severe underlying problems. Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Cranial Injury (1 of 3) Trauma must be extreme to fracture.

Linear Depressed Open Impaled object Basal Skull: Unprotected Spaces weaken structure Relatively easier to fracture Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Cranial Injury (2 of 3)

Basal Skull Fracture Signs Battles Signs Retroauricular ecchymosis Associated with fracture of auditory canal and lower areas of skull Raccoon Eyes Bilateral periorbital ecchymosis Associated with orbital fractures Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Cranial Injury (3 of 3) 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. Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Brain 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 Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Direct Brain Injury Types Coup Injury at site of impact Contrecoup Injury on opposite side from impact Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Direct Brain Injury Categories 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 Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Focal 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 Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Contusion Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Focal Brain Injury Intracranial Hemorrhage (1 of 3) Epidural Hematoma Bleeding between dura mater and skull Involves arteries Middle meningeal artery most common Rapid bleeding and reduction of oxygen to

tissues Herniates brain toward foramen magnum Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Focal Brain Injury Intracranial Hemorrhage (2 of 3) Subdural Hematoma Bleeding within meninges Beneath dura mater and within subarachnoid space Above pia mater

Slow bleeding Superior sagittal sinus Signs progress over several days Slow deterioration of mentation Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Focal Brain Injury Intracranial Hemorrhage (3 of 3) Intracerebral Hemorrhage Ruptured blood vessel within the brain Presentation similar to stroke symptoms Signs and symptoms worsen over time

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Diffuse Brain Injury Due to stretching forces placed on axons Pathology distributed throughout brain Types Concussion Moderate diffuse axonal injury Severe diffuse axonal injury Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Axonal Injury Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Diffuse Brain Injury Concussion 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 ABCs Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Diffuse Brain Injury Moderate Diffuse Axonal Injury 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 and Symptoms Unconsciousness or persistent confusion Loss of concentration, disorientation Retrograde and antegrade amnesia Visual and sensory disturbances Mood or personality changes Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Diffuse Brain Injury

Severe Diffuse Axonal Injury Brainstem Injury Significant mechanical disruption of axons Cerebral hemispheres and brainstem High mortality rate Signs and Symptoms Prolonged unconsciousness Cushings reflex Decorticate or decerebrate posturing Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Intracranial Perfusion (1 of 3) Review

Cranial volume fixed 80% = Cerebrum, cerebellum, and brainstem 12% = Blood vessels and blood 8% = CSF Increase in size of one component diminishes size of another Inability to adjust = increased ICP Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Intracranial Perfusion (2 of 3) 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 Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Intracranial Perfusion (3 of 3)

Role of Carbon Dioxide Increase of CO2 in CSF Cerebral vasodilation Encourage blood flow Reduce hypercarbia Reduce hypoxia Contributes to ICP Causes classic Hyperventilation and hypertension Reduced levels of CO2 in CSF Cerebral vasoconstriction Results in cerebral anoxia Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma

2006 by Pearson Education, Inc. Upper Saddle River, NJ Factors Affecting ICP Vasculature Constriction Cerebral Edema Systolic Blood Pressure Low BP = Poor cerebral perfusion High BP = Increased ICP Carbon Dioxide Reduced respiratory efficiency Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pressure and Structural Displacement Increased pressure Compresses brain tissue Against and around Falx cerebri Tentorium cerebelli Herniates brainstem Compromises blood supply Signs and Symptoms Upper brainstem Vomiting Altered mental status Pupillary dilation

Medulla oblongata Respiratory Cardiovascular Blood pressure disturbances Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Signs and Symptoms of Brain Injury (1 of 2) Altered Mental Status Altered orientation Alteration in personality Amnesia Retrograde Antegrade

Cushings Reflex Increased BP Bradycardia Erratic respirations Vomiting Without nausea Projectile Body temperature changes Changes in pupil reactivity Decorticate posturing Obtain a blood glucose level on all patients with AMS.

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Signs and Symptoms of Brain Injury (2 of 2) Pathophysiology of Changes Frontal Lobe Injury Alterations in personality Occipital Lobe Injury Visual disturbances Cortical Disruption Reduced 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 Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Signs and Symptoms of Brain Injury Physiological Changes (1 of 3) Upper Brainstem Compression Increasing blood pressure Reflex bradycardia

Vagus nerve stimulation Cheyne-Stokes respirations Pupils become small and reactive Decorticate posturing Neural pathway disruption Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Signs and Symptoms of Brain Injury Physiological Changes (2 of 3) Middle Brainstem Compression Widening pulse pressure Increasing bradycardia CNS hyperventilation

Deep and rapid Bilateral pupil sluggishness or inactivity Decerebrate posturing Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Signs and Symptoms of Brain Injury Physiological Changes (3 of 3) Lower Brainstem Injury Pupils dilated and unreactive Ataxic respirations Erratic with no pattern Irregular and erratic pulse rate

ECG changes T-wave inversions/QT prolongation. ST segment elevation / depression this may mimic myocardial ischemia or pericarditis. Increased U wave amplitude Hypotension Loss of response to painful stimuli Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Recognition of Herniation Cushings 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 pupils Decerebrate or decorticate posturing No movement with noxious stimuli Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Signs and Symptoms of Brain Injury Glasgow Coma Scale Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Signs and Symptoms of Brain Injury Pediatric Head Trauma 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 pediatrics General Management Avoid hyperextension of head. Tongue pushes soft palate closed

Ventilate through mouth and nose. Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Signs and Symptoms of Brain Injury Pediatric Glasgow Coma Scale Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Signs and Symptoms of Brain Injury Eye Signs Physiological Issues

Indicate pressure on CN-II, CN-III, CN-IV, and 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 and Reactivity Reduced pupillary responsiveness Depressant drugs or cerebral hypoxia Fixed and dilated Extreme hypoxia Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Facial Injury (1 of 7) Facial Soft-Tissue Injury Highly vascular tissue. Contributes to hypovolemia Superficial injuries are 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. Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Facial Injury (2 of 7) Facial Dislocations and Fractures Common Fractures Mandibular Deformity along jaw and loss of teeth Possible airway compromise if patient placed supine Evaluate for multiple fracture sites Maxillary and 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

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Facial Injury (3 of 7) Fractures Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Facial Injury (4 of 7) 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 Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Facial Injury (5 of 7) Ear Injury External Ear Pinna frequently injured due to trauma Poor blood supply Poor healing Internal Ear

Well protected from trauma May be injured due to rapid pressure changes Diving, Blast, or Explosions Temporary or permanent hearing loss Tinnitus may occur Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Facial Injury (6 of 7) 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 and Lacerations Common and 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 Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Hyphema & SH

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Facial Injury (7 of 7) Eye Injury (cont.) 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 Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Neck Injury (1 of 2) 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 and compromise Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Neck Injury (2 of 2) 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 and GI disturbances Thyroid and parathyroid glands High vascular Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Assessment of Head, Facial, and Neck Injuries Scene Size-up Initial Assessment Airway, breathing, circulation

Rapid Trauma Assessment Head, face, neck Glasgow Coma Scale score Vital signs Focused History and Physical Exam Detailed Assessment Ongoing Assessment Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Head, Facial, and Neck Injury Management

Airway Suctioning Patient positioning OPA and NPA use Endotracheal intubation Orotracheal Digital Nasotracheal Retrograde Direct RSI

Cricothyrotomy Breathing Oxygen 15 LPM/NRB Ventilations 1220/min Hyperoxygenate ETCO2 maintained at 3540 mmHg Continuous waveform capnogrpahy Circulation

Hemorrhage Control Blood pressure maintenance Fluid resuscitation to SBP of 90 mmHg Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Head, Facial, and Neck Injury Management (1 of 2) Hypoxia

Prevent/reduce. Hyperoxygenate with BVM prior to intubation. Hyperventilate with BVM prior to intubation. Hyperventilate with BVM at a rate of 20 immediately following intubation. If not a herniation concern, return to normal ventilations. If herniation is probable, maintain hyperventilation. Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Head, Facial, and Neck Injury Management (2 of 2) Hypovolemia Reduces cerebral perfusion and hypoxia.

Consider early management with 2 large bore IVs and isotonic fluids. Prevents slower compensatory mechanism. Maintain SBP 90100 mmHg in an adult. Maintain SBP 80 mmHg in a child. Maintain SBP 75 mmHg in a young child. Maintain SBP 65 mmHg in an infant. Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Medications: Oxygen Primary 1st line drug Administer high flow Hyperventilation contraindicated unless the patient shows clinical signs of herniation because it reduces circulating CO2 levels

NRB: 15 LPM BVM: 1220 times per minute Keep SaO2 >95% Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Medications: Paralytics (1 of 3) Succinylcholine (Anectine) Mechanism of Action Depolarizing medication Causes fasciculations Onset and Duration Onset: 3060 seconds Duration: 23 minutes

Precaution Paralyzes ALL muscles including those of respiration Increases intraocular eye pressure Contraindication Penetrating eye injury and Digitalis Dose 11.5 mg/kg IV Consider administration of Nondepolarizing NMB at 1/10th the paralyzing dose to prevent muscle fasciculations. Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Medications: Paralytics (3 of 3) Pancuronium (Pavulon) Mechanism of Action Non-depolarizing agent Does not affect LOC Onset and Duration Onset: 35 min Duration: 3060 min Dose Must premed with sedative 0.040.1 mg/kg

Vecuronium (Norcuron) Mechanism of Action Non-depolarizing agent Does not affect LOC Onset and Duration Onset: < 1 min Duration: 2540 min Dose Consider premed with sedative 0.080.1 mg/kg Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma

2006 by Pearson Education, Inc. Upper Saddle River, NJ Medications: Sedatives (1 of 4) Diazepam (Valium) Mechanism of Action Benzodiazepine Anti-anxiety Muscle relaxant Onset and Duration Onset: 115 min Duration: 1560 min Dose 510 mg

Midazolam (Versed) Mechanism of Action Benzodiazepine 34x more potent than Valium Dose SLOW IVP 1 mg/min 12.5 mg titrate Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma

2006 by Pearson Education, Inc. Upper Saddle River, NJ Medications: Sedatives (4 of 4) Etomidate (Amidate) Mechanism of Action Sedative-hypnotic Side Effects Respiratory depression Trismus Onset/Duration Onset of less than 1 minute Duration of 5 minutes Dose

0.10.3 mg/kg IVP Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Medications: Atropine Mechanism of Action Anticholinergic Parasympathetic Reduces parasympathetic stimulation Reduces oral and airway secretions Pupillary dilation Dose 0.51 mg rapid IVP Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma

2006 by Pearson Education, Inc. Upper Saddle River, NJ Medications: Dextrose Consider if patient is hypoglycemic Only if VERIFIED by GLUCOMETER Dose 25 gm IVP Consider thiamine if known alcoholic 100 mg thiamine Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Transport Considerations Limit external stimulation.

Can increase ICP Can induce seizures Be cautious about air transport. Seizures Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Emotional Support Have friend or family provide constant reassurance. Provide constant reorientation to environment if required. Keeps patient calm Reduces anxiety

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Special Injury Care (1 of 3) 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.

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Special Injury Care (2 of 3) 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 Morgans lens. Avulsed or Impaled Eye

Cover and protect from injury. General Care Calm and reassure patient. Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Special Injury Care (3 of 3) 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.

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ Morgan Lens https://www.youtube.com/watch? v=zmXqunkuVR4 Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma 2006 by Pearson Education, Inc. Upper Saddle River, NJ

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