(3) Lecture 17: Head + Face Injuries Flashcards
What kind of injury has the most fatalities in sports?
Head trauma causes more fatalities than any other sports injury
Facial Lacerations
Causes
- may be penetrating or blunt trauma causing direct or indirect compressive force
Signs
- pain
- substantial bleeding (especially on sharp bones)
Care of Facial Lacerations
- facial lac should be cleaned w/ sterile saline and checked for debris
- apply pressure to control bleeding
- RULE OUT SKULL/BRAIN traumas
- refer to physician if stitches are needed (advocate for plastics)
Scalp injuries
highly VASCULAR area (bleeds lots)
Causes
- blunt trauma or penetrating trauma
- can occur in conjunction w/ serious head trauma
Signs
- blow to head
- bleeding is extensive and hard to PINPOINT exact site
Care of scalp injuries
- clean w/ antiseptic soap + water (remove debris)
- cut away hair to expose area
- apply firm PRESSURE to reduce bleeding
- wounds larger than 1/2 inch should be referred
- smaller wounds can be covered w/ protective covering + gauze
When should injuries be sent for stitches?
- tissue adhesive for closure of simple lacerations LESS THAN 4CM that are not at points of high skin tension
Closure w/ stitches when:
- wounds are over 4cm in length of at points of high tension (elbow, knee)
- wound is through ALL skin layers or showing exposed fat, bones, tendons or vessels
place gauze pad over lesion if patient is sent for sutures
- send them within 8-12 hrs MAX
Brain Injuries
Caused by
- compressive force
- tensile (negative pressure) force
- shearing
CSF
mainly help w/ COMPRESSIVE forces
- converts focal forced into COMPRESSIVE stress dissipated over the brain’s full surface
- minimal impact on shearing force, especially combined w/ rotation
Battle’s Sign
Periauricular ecchymosis (bruising around the EAR)
Periauricular: around external ear
Ecchymosis: bleeding under skin
LATE finding (24-48 hours)
Racoon Eyes
Periorbital ecchymosis (2 black eyes)
LATE finding (24-48 hrs)
Battle Sign + Raccoon Eeyes
common w/ SKULL fractures + significant head trauma
Halo Sign
CLEAR drainage that separates from blood drainage suggests the presence of CSF
yellow, greeny discharge around blood = SKULL fracture
Normal pupils
Pupils equal and reactive to light
Equal pupils but dilated/unresponsive
- Cardiac arrest
- CNS injury
Equal pupils but constricted/unresponsive
- CNS injury or disease
Unequal pupils, one dilated/unresponsive to light
- cerebrovascular accident (CVA)
- head injury
- direct trauma to eye
Epidural hematoma
btwn skull + dura
Causes
- blow to head or skull fracture that tears meningeal arteries
- blood accumulation and creation of hematoma and pressure happens RAPIDLY (minutes to hours)
Signs of epidural hematoma
- may or may not have brief LOC followed by lucidity
- GRADUAL progression of signs and symptoms
- severe head pain, dizziness, nausea, dilation of one pupil (anisocoria) on same side of injury, deterioration of consciousness, depression of pulse and respiration, convulsion
Care of epidural hematoma
- needs URGENT neurosurgical care
- must relieve pressure to avoid disability or death
Subdural hematoma
INSIDE DURA
Causes
- result of ACCELERATION/DECELERATION (TENSILE/SHEAR) forces that tear vessels that bridge dura
- CSF doesn’t help much
- VENOUS bleeding (significant bleeding) = can range from little/no damage to cerebellum to cortex damage
Signs of subdural hematoma
- athlete may experience LOC in seconds to minutes
- PUPILLARY ASYMMETRY
- headache, dizziness, nausea or sleeping if not unconscious
Care of subdural hematoma
- IMMEDIATE EMERGENCY medical attention
- CT or MRI needed to determine extent of injury
Subdural vs epidural hematoma
TIMING
subdural is QUICK (seconds to minutes)
epidural is slower (minutes to hours)
Recognition and Management of Facial Injuries
- Assess
- mental status (conscious vs unconscious)
- airway and breathing - Manage significant bleeding
- Check NOSE and EARS for CSF (halo test) - stick gauze
- Take a TOP-DOWN approach to assess
- facial asymmetry
- forehead and orbits(eyes)
- maxilla + nose
- cheekbones
- oral cavity + mandible - Symptoms - asymmetry, bony steps, bruising and mobility
Forehead fracture
Causes
- most common cause is BLUNT TRAUMA
- fairly resistant to fractures
- most superior portions of weaker orbital structures are in forehead
Signs of forehead fracture
- severe headache and nausea
- palpation may show defect in skull (flat or sunken in)
- may be blood in middle ear, ear canal, nose, racoon eyes, Battle’s sign
- CSF may be in ear and nose (halo sign on gauze)
Orbital fracture
Caused by DIRECT TRAUMA to eyeball (common in baseball)
Signs
- posterior displacement of eye (enopthalmos)
- diplopia (double vision)
- restricted upward gaze
- downward displacement of eye
- subconjunctival hemorrhaging
- Racoon eyes
- unilateral epistaxis (nosebleed)
- numbness (due to injury to infra orbital nerve)
Care of orbital fracture
- ice
- NO blowing nose
- NO Valsava maneuvre
- X-Ray/CT needed to confirm fracture
Midface Fracture
aka Maxillary Fracture or Le Fort
Signs
- visible lengthening and flattening of face
- mobile maxilla
- nasal bleeding
- ecchymosis of cheek
- malocclusion (alteration of bite) - can’t bring teeth together
- palpation of facial bones - stabilize forehead w/ one hand and gently pull INCISORS
Le Fort
Midface Fracture
Le Fort I - floating palate
Le Fort II - floating maxilla (pyramidal)
Le Fort III - floating face (transverse)
Zygomatic Complex Fracture
Caused by DIRECT BLOW to CHEEK
Signs
- deformity, or bony discrepancy
- palpable STEP-OFFS in upper lateral orbital rim and inferior orbital rim
- cheek numbness - due to injury to infra orbital nerve
- nosebleed (on injured side - sinus filling w/ blood)
- diplopia and restricted eye movement
- subconjunctival hemorrhage (eye bleeding) and racoon eyes
Care of Maxillary and Zygomatic fractures
- secure airway
- if conscious, keep in UPRIGHT sitting position to help w/ blood and saliva drainage
- transport to emergency for definitive diagnosis/imaging
Mandible fractures
Caused by DIRECT BLOW (often at angle or condyle)
Signs
- pain w/ biting
- (+ ve) TONGUE BLADE TEST
Deformity
- palpate inferior border + mandibular condyle
- loss of occlusion (can they bite down?)
- bleeding around teeth
- lower lip anesthesia
Tongue Blade Test
Tests for mandible fractures
- insert a wooden tongue depressor (TD) into both sides of patient’s mouth
- have patient bite down while you try to pull out TD and rotate TD
- if you cannot pull TD out, test is NEGATIVE
Care of Mandible Fractures
- secure airway
- temporary immobilization w/ elastic wrap then reduction + fixation
- emergency medical referral
Tooth Fractures
Cause
- impact to jaw
- direct dental trauma
Signs
A) UNCOMPLICATED fracture: produces fragments WITHOUT bleeding
B) COMPLICATED: produce BLEEDING w/ tooth chamber being exposed w/ lots of pain + sensitivity to thermal changes, air and touch
C) ROOT fractures: difficult to determine and need X-Ray
Care of Tooth Fractures
- find out if they have a dental appliance/fake teeth
- uncomplicated and complicated crown fractures don’t need immediate attention
- fractured pieces can be put in MILK or SAVE-A-TOOTH solution
- DO NOT place avulse tooth portion in ice
- if not sensitive to air/cold, follow-up within 24 hrs
- bleeding is controlled by gauze
Cause of Tooth Subluxation, luxation, avulsion and intrusion
DIRECT blow
Subluxed tooth
tooth may be LOOSE within socket
Tooth luxation
- no fracture but there is DISPLACEMENT
INTRUSION: tooth is driven BACK into socket
- DO NOT try to reposition. dentist immediately
EXTRUSION: tooth is partially OUTWARDLY dislodged
- try to reposition and hold in place by biting down
LATERALLY displaced tooth (fwd, back or side to side)
- do NOT try to reposition. dentist immediately
Tooth avulsion
tooth is completely removed from oral cavity
TIME-DEPENDENT INJURY
- prognosis is 90% w/ replacement within 30 mins
- after 2 hrs, failure rate is 95%
Care
- locate and protect tooth
- if soiled, rinse lightly w/ MILK or SALINE
- DO NOT RUB. DO NOT USE TAP/DRINKING WATER - could injure periodontal ligament cells`
Nasal Fractures
caused by DIRECT TRAUMA always
Exam
- palpate for crepitus or bony asymmetries (depression of nasal dorsum OR deviation of septum)
- examine for septal hematoma (breathe through each nostril - plug one side and see if they can breathe)
Care for Nasal Fracture
- secure airway
- control bleeding by external pressure or internal packing
- protect and transport for X-ray and reduction
Septal hematoma
Caused by hemorrhage btwn the two layers of mucosa covering septum
Signs
- BLUEISH or DULL RED bulge on septum
- athlete will complain of nasal pain and may have difficulty breathing out of one nostril
Epistaxis
aka nosebleed
Causes
- DIRECT BLOW in sports
- foreign body or serious facial injury
RULE OUT FRACTURE, NASAL DEPRESSION, SEPTAL HEMATOMA
Signs
- bleeding from anterior aspect of septum (Little’s/Kiesselbach’s area)
- minimal bleeding and resolves spontaneously
- more severe bleeding may need more medical attention
Care of epistaxis
- athlete should blow each nostril to clear clots
- sit upright in HEAD-FORWARD position to avoid blood from pooling/going down throat
- cold compress over nose = compress vessels of nasal septum
- if bleeding does not stop in 5 mins, an astringent can be applied w/ gauze to encourage clotting
- ice to back of head/neck = decreases vagal tone = slows bleeding and helps clotting
- DO NOT BLOW NOSE FOR AT LEAST 2 HOURS AFTER BLEEDING STOPS
Subconjunctival hemorrhage
Bright red area in white conjunctiva
Causes
- can happen spontaneously
- due to minor eye trauma or orbital/zygomatic fractures
- Valsalva maneuvers (coughing, sneezing, straining)
Assess for vision issues
- if it covered entire sclera (white part), it may be obscuring a perforation in eye
usually resolves in 2-3 weeks
Corneal abrasions
scratched eye - happens to most ANTERIOR layer of eye
Causes
- poke to eye
- attempt to remove foreign object from eye by running
Signs
- mild to severe pain
- watering of eye
- photophobia (closes eyes w/ bright light)
- pain w/ blinking
- decreased focusing ability
- spasm of orbicular muscle of eyelid
Care of corneal abrasions
- refer to physician (may need to patch)
- usually heals within 24 - 72 hrs
- patch may be needed with younger patients to avoid rubbing
- recent study showed no improvement in pain, symptoms or healing w/ patching
- return to play is based on decrease in symptoms
Hyphema
MOST SERIOUS
- injury that leads to serious problems w/ LENS or RETINA
Cause
- anterior chamber injured due to blunt trauma
- HIGH FORCE injury (must RULE OUT penetrating trauma, orbital fracture, abrasion, retinal injury)
Signs
- visible REDDISH tinge (can be pea green) in anterior chamber of eye
- vision is spatially or completely blocked
Care of hyphema
- IMMEDIATE referral to an ophthalmologist
- bed rest for 4 days and elevation; both eyes patched
- discontinue use of NSAIDs
- irreversible vision damage if not managed properly
Periorbital ecchymosis
Black eye
Caused by BLOW to area surrounding the eye
Signs
- swelling and discoloration
- sign of a more serious condition if accompanied by subconjunctival haemorrhage
Care
- apply cold for at least 30 mins
- do NOT blow nose after acute eye injury - may increase hemorrhaging
Basic Eye Assessment
Chemical injury – Flush immediately for 30 mins
- History - determine force + direction of force
- Check vision - read in 12 pt font from 16” away
- diplopia suggests serious injury (closed head/eye) - Pupil/cornea/conjunctiva
- penlight exam (PEARL)
- foreign bodies
- hyphema or subconjunctival hemorrhaging - Eye movements (full mobility … up, down, all around)
Airway injuries
most DANGEROUS of all maxillofacial injuries
- airway compromise secondary to laryngotracheal (throat) trauma are second most common cause of death
- airway obstruction can be caused by any blow to the ANTERIOR neck
- minor injuries to larynx can worsen due to laryngospasm (closure of larynx) - athlete becomes agitated and panicked
Treating laryngospasm
move chin fwd and place strong anterior pressure behind angle of jaw
Hold for 45-60 seconds until you hear inspiration
Signs and symptoms of larynx injury
Cartilaginous fracture to thyroid/cricoid cartilages
- athlete initially may be speechless or have hoarse voice
- loss of prominence (Adam’s apple) in anteior neck
- difficulty breathing - feeling impending doom
- pain/tenderness w/ swallowing
- crepitation on palpation of anterior neck (subcutaneous emphysema - CRITICAL)
- hematoma/hemoptysis - coughing up frothy, pink blood
