Head and Face Flashcards
scalp
-Strong flexible mass of Skin, Fascia, Muscular tissue
-Highly vascular
-Hair provides insulation
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
-abscess, thrombosis of superior sagital sinus, infection, purulent
-laceration to scalp can cause acute blood loss anemia
structures of the scalp
-SCALP
-skin
-connective tissue
-aponeurotica
-layer of areolar tissue
-periosteum of skull
skull bones
-facial bones
-cranium:
-vault fors brain
-strong, light, rigid, spherical bone
-unyielding to increased intracranial pressure (ICP)
-bones:
-frontal
-parietal
-occipital
-temporal
-ethmoid
-sphenoid
skull: foramen magnum
-largest opening of skull
-spinal cord exits
skull: cribriform plate
-inferior aspect (base)
-rough surface
-brain can be easily injured:
-abrasion
-contusion
-laceration
-pt may present with rhinorrhea - CSF -> can cause infection back up to brain
-NO NASAL GASTRIC TUBE WHO HAS BASILAR SKULL FRACUTRE, FACIAL TRAUMA -> worry about putting it through cribriform plate and into brain -> do oral
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
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
CSF
-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
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
occipital
-sight
temporal
-long term memory
-hearing
-speech
-taste
-smell
cerebrum: flax cerebri
-Divides cerebrum into right and left hemispheres
cerebrum: central sulcus
-Fissure splits cerebrum into right and left hemispheres
-Each hemisphere controls the opposite side of the body
cerebrum: tentorium
-Fibrous sheet within occipital region
-Brainstem perforates through incisura tentorium cerebelli.
-Oculomotor nerve (CN-III) travels along:
-Controls pupil size
-Compression results in pupillary disturbances
-dilated nonreactive pupil with injury
cerebrum: hemispheres
-left- DOMINANT:
-mathematical computations- occipital
-writing- parietal
-language interpretation- occipital
-speech- frontal
-right- NON-DOMINANT
-non verbal imagery
cerebellum
-located under tentorium
-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
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
-thalamus is Critical element in Ascending Reticular Activating System (A-RAS) -> ESTABLISHES CONSCIOUSNESS
-thalamus is Major pathways for optic and olfactory nerves
-Associated structures
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 spinal cord
-centers:
-respiratory center- controls depth, rate, and rhythm
-cardiac center- regulates rate and strength of cardia contractions
-vasomotor center- distribution of blood and maintains BP
CNS circulation
-arterial:
-4 major arteries- 2 internal carotid arteries from common carotid AND 2 vertebral arteries
-circle of willis- internal carotids and vertebral arteries -> encircle the base of 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
-DOES NOT allow flow of interstitial proteins
-Reduced lymphatic flow
-Very protected environment
-Blood acts as irritant resulting in cerebral edema
-NO highly charged, large, not lipid soluble can go through
-hepatic disease- fugal flow -> reverse flow ends up into systemic circulation before going through liver -> ammonia -> hepatic encephalopathy
-edema when blood brain barrier abnormal -> irritation of parenchyma -> high 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
-at least MAP 65 and higher than ICP
-ICP > 20 danger zone
-MAP = DBP + 1/3 Pulse Pressure
-Cerebral Perfusion Pressure (CPP):
-Pressure moving blood through the cranium
-CPP = MAP - ICP
-if ICP is higher than MAP -> we cant perfuse -> anoxia
-go up on MAP or go down on ICP -> better flow
-ex. raise the BP and catheter into ventricle to remove pressure
-rapid increase in ICP - herniation at 60
-pressure on the pons
CCP and MAP calculation ex
-BP = 100/70
-DBP = 70
-MAP = 80
-CCP = 80-10 = 70
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
cerebral perfusion pressure: expanding mass inside cranial vault
-displaces CSF
-if pressure increases, brain tissue is displaced
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
facial bones
-zygoma- prominent bone of cheek that protects the eyes -> attachment for muscles controlling eye and jaw movement
-maxilla- upper jaw, supports nasal bone, provides lower border of orbit
-mandible- jaw bone
-nasal bones
face
-covered with skin
-flexible and thin
-highly vascular
-minimal layer of subcutaneous tissue
-circulation- external carotid artery -> supplies fafcial area
-branches- facial, temporal, maxillary arteries
buccinator nerve
-buccal branch of buccinator nerve does not innervate muscle -> innervates cutaneous sensation to zygomatic area and sensory of vestibule of oral cavity
-buccal branch of facial nerve innervates buccinator muscles -> facial nerve does facial expression
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
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 and posterior to the mandible
-Mandible- Articulates with the TMJ joint
salivary glands
-first stage in digestion
-location:
-anterior and inferior to ear
-under tongue
-inside inferior mandible
tonsils
-posterior wall of pharnyx
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
pharynx
-Posterior and inferior to the oral cavity
-Aids in swallowing:
-Bolus of food propelled back and down by tongue
-Epiglottis moves downward
-Larynx moves up- Combined effect seals airway
-Peristaltic wave moves food down esophagus
ear
-Hearing
-Positional sense
-Structures:
-Pinna- Outer visible portion that is 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
structures of hearing
-Tympanic membrane
-Ossicle bones
-Cochlea
-Auditory nerve
structure of proprioception
-Semicircular canals- Sense position and 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
scalp injury
-contusions
-lacerations
-avulsions
-significant hemorrhage
-ALWAYS know MOI
-any type of head injury can cause neck injury
trauma must be extreme to fracture cranial injury
-linear
-depressed
-open
-impaled object
basal skull
-unprotected
-spaces weaken structure
-relatively easier to fracture
basal skull fracture signs: battles signs and raccoon eyes
-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
basilar skull fracutre: dura tear
-permit CSF to drain through external passageway
-may mediate rise of ICP
-evaluate for “target” or “halo” sign
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 (ex. blockage of blood to brain)
-Indirect- Secondary injury caused by factors resulting from the primary injury -> lack of oxygen (ex. pneumothorax -> decreased O2 -> lack of oxygen to brain)
direct brain injury types
-coup- injury at site of impact
-contrecoup- injury on opposite side from impact
-baby’s and elderly have less brain tissue -> more space
-focal: occur at specific location in brain
-focal differentials- cerebral contusion, intracranial hemorrhage (epidural, subdural hematoma), intracerebral hemorrhage
-diffuse: concussion, moderate diffuse axonal injury, severe diffuse axonal 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
-frontal contusion/damage/bleed- personality changes
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
-hematoma -> talking and fine -> all the sudden they arnt -> death
-football- self enhancing
-shift > 5mm -> problem
subdural hematoma
-Bleeding within meninges -Beneath dura mater and within subarachnoid space
-Above pia mater
-Slow bleeding- Superior sagittal sinus
-tears to bridging VEINS MC**
-banana shape
-Signs progress over several days- Slow deterioration of mentation
-can cause cardiac arrhythmias -> medulla oblongata injury
-VENOUS
-no dye given -> blood appears white if acute
-gray shades -> chronic -> alcoholics who hit their head and dont remember
-hygroma
-banana
-shift causes edema
-can drain in ER in emergency bc venous and lower pressure
intracerebral hemorrhage
-Ruptured blood vessel within the brain
-Presentation similar to stroke symptoms
-Signs and symptoms worsen over time
-bleeding within parenchyma of brain
-fall and then stroke or stroke and then fall -> we dont know! but same process
diffuse brain injury (DAI)
-Due to stretching forces placed on axons.
-Pathology distributed throughout brain
-Types:
-Concussion
-Moderate diffuse axonal injury
-Severe diffuse axonal injury
-sheering of axons on brain
-scan- grey white differentiation*
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
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
-RAS takes a while to recover -> concussion require recovery
-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
diffuse brain injury
-Brainstem Injury.
-Significant mechanical disruption of axons: Cerebral hemispheres and brainstem
-High mortality rate.
-Signs and Symptoms:
-Prolonged unconsciousness
-Cushing’s reflex -> increase BP -> increase ICP
-Decorticate (flex) or decerebrate (extend) posturing
intracranial perfusion
-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
intracranial perfusion
-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
intracranial perfusion: role of CO2
-increase of CO2 in CSF
-Cerebral vasodilation:
-Encourage blood flow
-Reduce hypercarbia
-Reduce hypoxia
-Contributes to increase ICP
-Causes classic- Hyperventilation (tidal volume and respiration rate) and hypertension
-Reduced levels of CO2 in CSF- Cerebral vasoconstriction- > Results in cerebral anoxia
factors affecting ICP
-Vasculature Constriction
-Cerebral Edema
-Systolic Blood Pressure:
-Low BP = Poor cerebral perfusion
-High BP = Increased ICP
-Carbon Dioxide
-Reduced respiratory efficiency
pressure and structural displacement: increased pressure***
-compresses brain tissue
-Against and around- Falx cerebri and 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
signs and symptoms of brain injury
-Altered Mental Status: Altered orientation, Alteration in personality, Amnesia, Retrograde, Antegrade
-Cushing’s Reflex*: Increased BP, Bradycardia, Erratic respirations
-Vomiting: Without nausea, Projectile
-Body temperature changes
-Changes in pupil reactivity
-Decorticate posturing
-obtain blood glucose level on all pts with AMS
pathophysiology of changes with brain injury
-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
-new onset seizures in adult without trauma- tumor
upper brainstem compression
-Increasing blood pressure
-Reflex bradycardia- Vagus nerve stimulation
-Cheyne-Stokes respirations
-Pupils become small and reactive
-Decorticate (flexure) posturing -Neural pathway disruption***
middle brainstem compression
-Widening pulse pressure
-Increasing bradycardia
-CNS hyperventilation - Deep and rapid
-Bilateral pupil sluggishness or inactivity
-Decerebrate (extend) posturing***
lower brainstem injury
-Pupils dilated and unreactive
-Ataxic respirations- Erratic with no pattern
-Irregular and erratic pulse rate
-ECG changes**- stimulation altered -> common in subarachnoid hemorrhage
-Hypotension
-Loss of response to painful stimuli
recognition of herniation
-Cushing’s Reflex:
-Increasing blood pressure
-Decreasing pulse rate
-Respirations that become erratic
-Lowering level of consciousness: GCS <9 and dropping
-Singular or bilaterally dilated and fixed pupils* -> very bad -> brain death
-Decerebrate (extend) or decorticate (flex) posturing**
-No movement with noxious stimuli
glasgow coma scale
-eye opening 4-1 - spontaneous, to verbal command, to pain, no response
-verbal response 5-1 - oriented and converses, disoriented and converses, inappropriate words, incomprehensible sounds, no response
-motor 6-1 - obeys verbal commands, localizes pain, withdraws from pain (flexion), abnormal flexion in response to pain (decorticate rigidity), extension in response to pain (decerebrate rigidity), no response
-<8 -> need assistance, tubes, etc.
brain injury eye signs
-Physiological Issues:
-Indicate pressure on CN 2, 3, 4, 6
-CN-3 (Oculomotor nerve)- Pressure 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
intraventricular bleed: eyes
-may not be pupillary changes because the primary brain injury is not causing compression of the cranial nerves
-Do NOT think that because a patient has responsive pupils that they cannot have a brain injury
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 endangering the airway.
-Soft-tissue swelling reduces airflow.
-Consider likelihood of basilar skull fracture or spinal injury
-massive bleeds with facial injury
common facial 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
le fort fracture
-caution applying bag valve mask to pt
-pressure of apply may cause airway obstruction by posterior displacement of maxilla and in some cases mandible
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 -> oral tube
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
-check for rupture of eardrum with explosion
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
-soft tissue lacerations
-self limiting - no pain
acute retinal artery occlusion
-Nontraumatic 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
-curtain down on eye
parts of brain
-Telencephalon is on top: Forebrain/Cerebral Hemispheres
-All others below in alphabetical order
-Diencephalon: Forebrain: Thalamus/hypothalamus
-Mesencephalon: Midbrain/Tectum/Tegementum (tecum: colliculi auditory and visual)
-Tegenebtum: periaqueductal gray (opiate drug mediation), Substantia Nigra/Red Nucleus (Sensorimotor function)
-Metencephalon: Hindbrain: Pons ascending and descending tracts
-Myelencephalon: Hindbrain: Medulla: RAS, sleep, attention (definitely important for language), movement, the maintenance of muscle tone, and various cardiac, circulatory, and respiratory reflexes
scalp injuries and infections
-loose connective tissue layer- danger area of scalp bc pus or blood spreads easily
-Infection can spread to cranial cavity through emissary veins -> pass through calvaria -> reach intracrania like meninges
-infection cant go into neck bc occipital belly of occipitofrontalis muscle attaches to occipital bone and mastoid parts of the temporal bones
-infection cant spread past zygomatic arches bc epicranial aponeurosis is continuous with temporal fascia
-can enter eyelids and root of nose bc frontal belly of occipitofrontalis muscle inserts on skin and not bone -> black eyes
-Ecchymoses as result of extravasation of blood into the subcutaneous tissue
quiz
-dracula expression muscle
-right sided cortical injury- contra/ipsi upper/lower drooping ?
-upper lip bleeding- which artery
-what attaches flexi - cribiform plate?
-pituitary tumor
cortical lesion
-understand that diagram
-one affects upper and lower, other affects just the lower
bell’s palsy
-viral infections- herpes simplex 1
-can happen overnight
-parotid tumors (benign or malignant)- facial nerve
hypoglossal nerve
-hoarseness upon damage
-travels similarly to lower branches of facial nerve
tongue
-posterior 1/3 of tongue- bitter
-lingual nerve- branch of mandibular branch cont.
-injuries, tumors, of neck - many nerves here
superior lingual/labial artery
-injury to upper vermillion border of mouth
-watch for scabbing -> if scab falls off and exanguates
-can lose a lot of blood
-burns
-common in children, fights
fontanelles
-window to intracranial pressure
-depressed fontonelle- child is hypovolemic, dehydrated, pancreatitis, blood loss
-all fluid compartments are connected
-decreased intraocular pressure
-fontanelle can become flat
-bulging fontanelles- tumor, overload
-assess fluid status
-sunset sign- iris/pupil is down at bottom of eye -> increased fontanelle size (hydrocephalus)
pituitary gland
-pressure on optic chiasm
trigeminal neuralgia / tic de leroux
-very painful
-trigeminal nerve compression
-physical exam is important
-MC cause- pressure caused by artery or vein* squashing (compressing) the trigeminal nerve
optic nerve
-big optic nerve
-high intracranial pressure
-U/S
frontal bone
-sinusitis
-abscess on frontal aspect
-can go through bone
-cavernous sinusitis -> even a pimple on the nose
know foramen
-if edema or tumor at that foramen which nerves are affected
optic injury
-optic edema- ultrasound
-optic nerve
-orbital blowout -> hematoma of optic muscles -> lack of movement
-muscles of eye are paper thin
-PE- make an H and see the pt move their eyes
-dendritic pattern- herpes- viral
-vitreous fluid must be clear
-retina detachment- fundoscopy
-retinal blastoma- one red reflex -> one eye not
parenchymal bleed
bleeding inside tissue itself
MC of subarachnoid bleed
trauma
-subarachnoid bleed -> whispy bleed
