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CEN prep 2021 > Head and Maxillofacial Trauma, ENT Emergencies > Flashcards

Head and Maxillofacial Trauma, ENT Emergencies Flashcards

1
Q

Intubation - avoid nasotracheal intubation in patients with facial fractures due to the possibility of cerebral penetration with a ____ ____ Fx.

A

Cribriform plate

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2
Q

What is a LeFort Fx 1

A

I - just the teeth, mustache

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3
Q

What is a LeFort Fx 2

A

muzzle

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4
Q

What is a LeFort Fx 3 What is the defining characteristic?

A

sunglasses, with Fx zygomatic bone Lengthening of the face

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5
Q

when should you inspect the eyes?

A

inspect before lid edema makes it more difficult to assess for vision loss

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6
Q

when assessing the eyes, Note a teardrop shaped pupil that suggests a what?

A

ruptured globe

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7
Q

what is Hyphema

A
  • is a pooling or collection of blood inside the anterior chamber of the eye, indicates a serious eye injury
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8
Q

Because the face is highly vascular, wound closure may be delayed up to __ hours, although a delay of no more than __ to __ hours is preferable

A

20 8 12

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9
Q

Clean all bite wounds with ____ ____. What should you avoid and why?

A

normal saline Avoid using detergent, hydrogen peroxide and concentrated povidone-iodine solutions because they are highly toxic to the tissues

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10
Q

Cat bites are typically puncture wounds and are usually left ____

A

open

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11
Q

Human and other animal bites on the face are normally treated how?

A

usually sutured because they can be disfiguring. Many experts suggest closing the wound after meticulous irrigation and debridement

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12
Q

Facial abrasions - how are they usually treated?

A

Debride as soon as possible to avoid permanent tattooing from the grease and asphalt after the area is injected with local anesthetic

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13
Q

How are lacerations of the lip treated?

A

the lip borders should be perfectly aligned, expect a consultation with a plastic surgeon

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14
Q

How are lacerations of the tongue usually treated?

A

suture and ABX

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15
Q

How are lacerations of the ear NOT treated?

A

do not use local anesthetics with epinephrine on the ear because of the harmful effects of vasoconstriction

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16
Q

How are lacerations of the ear NOT treated?

A

do not use local anesthetics with epinephrine on the ear because of the harmful effects of vasoconstriction

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17
Q

Nasal Fractures If the cribriform plate is affected and the dura is torn, assess for what?

A

for cerebrospinal fluid leakage

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18
Q

Nasal Fractures Septal hematoma, how does it appear? What does it require? What is the result deformity if it is not treated?

A

appears as a bluish bulging mass that feels doughy when palpated Requires emergent drainage to prevent an airway obstruction and the necrosis of nasal cartilage An untreated septal hematoma causes a permanent nasal deformity called a saddle deformity

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19
Q

Nasal Fractures When is it appropriate to set the Fx?

A

The fracture may not be set until the swelling goes down

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20
Q

Nasal Fractures If the fracture involves the lacrimal system, instruct the patient NOT to do what?

A

to blow the nose, may cause intracranial air or subcutaneous emphysema that can result in a localized infection or meningitis

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21
Q

Naso-orbital-ethmoid Fractures What are the S/S? (6)

A

S/S - Diplopia, massive periorbital and upper facial edema with ecchymosis, epistaxis, traumatic telecanthus, foreshortening of the nose with telescoping, associated intracranial injuries

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22
Q

Where is the ethmoid bone?

A
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23
Q

Where is the Maxilla bone?

A
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24
Q

Where is the Zygomatic bone?

A
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25
Q

Maxillary Fractures

Patients with maxillary fractures report severe facial pain and anesthesia or paresthesia of the what?

A

upper lip

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26
Q

Patients with maxillary fractures also report having what S/S? (7)

A

Also; facial swelling, ecchymosis, periorbital or orbital swelling, vision disturbances, subconjunctival hemorrhage, elongation of the face, malocclusion

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27
Q

Zygomatic Fractures

Patients will typically report…

Pain in the ____ ____

Inability to do what?

Swelling and crepitus over the ____

A

lateral cheek

close the jaw

arch

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28
Q

What is a tripod fracture?

A

Tripod Fracture

The zygoma fractures in three places; the zygomatic arch, the posterior half of the infraorbital rim, and the frontozygomatic suture.

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29
Q

What type of fracture is this?

A

Tripod fracture

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30
Q

Diplopia, numbness of the lower lid, and bilateral nasal area are all S/S of what type of fracture?

A

Tripod fracture

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31
Q

The orbit is composed of multiple bones, including what?

(5)

A

the zygoma, maxilla, and frontal, sphenoid, and ethmoid bones

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32
Q

Orbital blowout fractures

What are the S/S?

(4)

A

S/S include - diplopia, altered extraocular eye movements, orbital pain or loss of sensation, enophthalmos

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33
Q

Orbital blowout fractures

What interventions are indicated?

A

Interventions - CT, Sx after the swelling goes down, ice, broad spectrum ABx and nasal decongestants, remind the patient to avoid blowing the nose

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34
Q

The second most common type of facial fracture is what?

A

Mandibular Fractures

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35
Q

What are the most common head/facial fractures?

A

simple nose fracture

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36
Q

What type of fracture is this?

A

Mandibular condylar fracture

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37
Q

The specific symptoms of a mandibular condyle fracture are pain at the fracture site and referred pain to the ____

A

ear

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38
Q

What is the treatment for a madibular condyle fracture?

A

Treatment - consists of surgical open reduction of the jaw with wiring.

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39
Q

Head Trauma

After assessing the patients ABC’s, focus on the D, which is what?

A

disability by assessing the patients neurologic function

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40
Q

Head Trauma

In an unconscious patient, test cranial nerves __, __, __, and __, because these nerves have involuntary responses that do not require the patients participation and provide information about brainstem function

(4)

A

III gag reflex

V corneal reflex

Gag reflex

X vagus nerve

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41
Q

Here is a handy-dandy mnemonic for you for remembering the cranial nerves

A

On Old Olympus Towering Top A Famous Vocal German Viewed Some Hops. The bold letters stand for: olfactory, optic, oculomotor, trochlear, trigeminal, abducens, facial, vestibulocochlear, glossopharyngeal, vagus, spinal accessory, hypoglossal.

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42
Q

Cranial nerves

I

A

I olfactory nerve, sensory

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43
Q

Cranial nerves

II

A

II optic nerve, sensory

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44
Q

Cranial nerves

III

A

III ocular, motor ,nerve

Eyelid

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45
Q

Cranial nerves

IV

A

IV Trochlear eye, motor, up and down

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46
Q

Cranial nerves

V

A

V Trigeminal nerve, sensory and motor, teeth and skin of the head, jaw motor

Jaw clench, corneal reflex

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47
Q

Cranial nerves

VI

A

VI Abducens, motor, lateral movements of eye

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48
Q

Cranial nerves

VII

A

VII Facial, motor and sensory, facial expression and taste, eyebrows, cheek puff

Lacrimation, salivation, facial movement

49
Q

Cranial nerves

VIII

A

VIII Auditory, sensory, Hearing and equilibrium

50
Q

Cranial nerves

XI

A

IX Glossopharyngeal, Sensory and motor, taste, ability to speak, swallow, gag

51
Q

Cranial nerves

X

A

X Vagus, Sensory and motor, say AH, assess movement of palate and pharynx

52
Q

Cranial nerves

XI

A

XI Spinal accessory, motor, shrug shoulders

53
Q

Cranial nerves

XII

A

XII Hypoglossal, motor, stick out tongue and move from side to side

54
Q

Cold water into the patients ear.

What is this test called and what would indicate a normal result?

A

Cold water (cold caloric) into the patient’s ear and the eyes should direct toward the noxious stimuli for a normal result?

55
Q

Dolls eyes

How is this test performed and what should you look for?

A

Dolls eyes - move the head and the eyes with focus on one point (like a chicken head)

56
Q

Intracranial pressure

Normal ICP is __ to __ mmHg

A

0

10

57
Q

Early S/S of increasing ICP include (9)

A

HA, NV, restlessness, confusion, agitation, speech and vision disturbances, increasing motor deficits, sluggish pupils, ovoid pupil (oval)

58
Q

Late S/S of increased ICP include, (6)

Two postures

This triade

A

progressive decline in responsiveness, impaired brainstem reflexes including cough, gag, and corneal, irregular breathing, fixed pupils

Decerebrate (extensor)

Decorticate (flexion

Cushing’s triad (cushing’s response) - HTN, widening pulse pressure, bradycardia

59
Q

What is Cushing’s triad (cushing’s response)

A
  • HTN, widening pulse pressure, bradycardia
60
Q

Before trying to reduce HTN, keep in mind the cerebral perfusion pressure equals what?

A

a mean arterial pressure minus intracranial pressure

CPP = MAP - ICP

When the ICP rises, the body increases the blood pressure to try to sustain brain perfusion

61
Q

When the ICP rises, the body does what?

A

increases the blood pressure to try to sustain brain perfusion

62
Q

Hyperthermia may occur if the ____, which controls temperature, has been injured.

How does this affect ICP?

A

hypothalamus

Elevated body temperature increases the metabolic rate and elevates ICP

Hypothermia triggers shivering, which also raises the metabolic rate and ICP

63
Q

Head injuries can be categorized by (3)

A

Mechanism; as blunt or penetrating

Severity; mild, moderate, or severe

Type; as primary or secondary and as focal or diffuse

64
Q

What bone is this?

A

sphenoid bone

65
Q

How do you determine a head injury as mild, moderate, or severe?

A

Mild = GCS of 14 or 15

Moderate = GCS of 9 to 13

Severe GCS of 8 or less

66
Q

How do you determine a primary from a secindary head injury?

A

Primary; from traumatic forces applied, contusion, laceration, shearing, hemorrhage

Secondary; from resultant changes, ischemia, hypotension, hypercapnia, cerebral edema, metabolic derangements

67
Q

How do you determine a focal from a diffuse head injury?

A

Focal or diffuse

Focal - occurs in a specific area and causes grossly observable brain lesion

Diffuse injury - is more widespread and causes no grossly observable brain lesion

68
Q

Basilar Skull Fx

What bones of the skull can be involved?

What can it increase the risk of?

A

Can occur wherever the skull ends, such as in the occipital, temporal, sphenoid, or ethmoid bones

Can increase the risk for meningitis

69
Q

What are the S/S of a Basilar Skull Fx

A

Combative behavior, periorbital ecchymosis, battles sign hemotympanum

Cerebrospinal fluid leaks; otorrhea, rhinorrhea

Deficits in the CN VII and VIII, depending on the fracture location

70
Q

Focal injuries

Contusions

Coup countercoup

S/S include

A

decreased LOC, HA, NV, vision changes, difficulty speaking, signs of ICP

71
Q

Focal injuries

Contusions

Contusions will usually “blossom” in __ to __ hours, increasing in size and developing the surrounding cerebral edema.

Results in increased ___

Requires frequent ____ examinations

May require a what? (surgical procedure)

A

12

24

ICP

neurologic

bone flap (remove a segment of the skull and leave it off)

72
Q

Intraventricular Hemorrhage and Intracranial Hematoma

Can arise from ____ and ____ unrelated to trauma

Patients with these focal injuries are at risk for increased ___ and require close assessment and frequent neurologic examinations

Neurologic deterioration can occur as late as (timeframe) after injury.

In most patients deterioration occurs in the first (timeframe)

A

aneurysms and strokes

ICP

7 to 10 days

48 to 72 hours

73
Q

Epidural Hematoma

arterial or venous?

Location of bleeding?

typically associated with what?

A

Arterial bleeding between the skull and the dura mater

Typically associated with a laceration of the middle meningeal artery caused by a Fx of the temporal or parietal skull.

Arterial bleeding can quickly form a hematoma large enough to shift the brain contents making rapid Dx extremely important to minimize permanent injury.

74
Q

Epidural Hematoma S/S

LOC

Neurologic

Hemiplegia

pupils

interventions

A

brief loss of consciousness followed by a lucid period

Rapid neurologic deterioration after the lucid period

HA, NV

Hemiplegia on the opposite side of the injury

Fixed and dilated pupil on the same side as the injury

Interventions; may only require close observation

75
Q

Subdural Hematoma

Arterial or Venous?

Onset of S/S? And what are they?

Interventions?

A

Venous bleeding, so signs may take up to 48 hours to show

S/S include; Decreased level of consciousness and motor function on opposite side, fixed pupil on the same side, confusion and speech difficulties

Usually requires Sx

76
Q

Subdural Hematoma

What is the difference between subactue and chronic?

A

Subacute - symptoms may arise 48 to 2 weeks after initial injury but can maifest rapidly after decompensation occurs

Chronic - Bleeding can continue for weeks or months before impairment occurs and

77
Q

Subdural Hematoma

Who does it normally affect?

A

most commonly affects geriatric patients receiving anticoagulants

More common in chronic alcoholics who may have brain atrophy and coagulopathies

78
Q

Subdural Hematoma

S/S include

A

HA, clumsiness in one arm or leg, confusion or speech difficulties, increasing falls or near misses

79
Q

What would you expect in a CT scan for a patient with Diffuse Axonal Injuries?

A

Injuries are microscopic, so CT may look normal at first, later scans may show diffuse cerebral edema and areas of microvascular hemorrhage

80
Q

What S/S would you see in a patient with Diffuse Axonal Injuries initially?

How about later on?

A

S/S; immediate LOC, abnormal motor posturing, HTN, S/S of ICP

Later signs that might not be seen in the ER include

Hyperthermia, excessive sweating

81
Q

What S/S would you expect to see in a patient with Mild Diffuse Axonal Injuries?

A

Mild - LOC for 6 to 24 hours, abnormal posturing, return to baseline over several days, may have lingering effects similar post concussion syndrome

82
Q

What S/S would you expect to see in a patient with Moderate Diffuse Axonal Injuries?

A

Moderate - produces coma for 24 hours to several days, causes abnormal posturing from the beginning of coma until the patient begins to regain consciousness

Does not allow complete recovery to full preinjury neurologic status

Commonly leaves the patient with impaired memory, cognition, and behavior

83
Q

What S/S would you expect to see in a patient with Severe Diffuse Axonal Injuries?

A

Severe Diffuse Axonal injury

Characterized by prolonged coma and brainstem impairment

May result in persistent vegetative state if the reticular activating system is damaged

Can cause hyperthermia, HTN, and excessive sweating due to autonomic dysfunction

84
Q

This type of Brain injury Occurs at the time of trauma such as Tearing of the vessels, Bruising and deforming of tissues, and Stretching and distortion of axions.

A

Primary Brain Injury

85
Q

This type of Brain injury Developes hours to days after the primary injury as a result of mismatch between cerebral blood flow and the cerebral metabolic rate.

A

Secondary Brain injury

86
Q

Secondary Brain injury resullts in (5)

A

hypotension, less than 90 mmHg

hypoxia, PaO2 less than 60mmHg or spO2 <90

Sustained elevation of ICP greater than 20mmHg

anemia,

hyperpyrexia

87
Q

Prevention of secondary brain injury includes what type of fluids?

What does isotonic do?

What does hypotonic do?

A

Prevent hypotension with isotonic IV fluids. Hypotonic fluids such as dextrose and water can increase cerebral edema by shifting fluids

88
Q

For all patients with head injuries, what should you do?

A

Start with 2 large bore IV catheters for rapid fluids

Control bleeding

Consider blood products

89
Q

Initial resuscitation For all patients with head injuries includes (GCS lower than 9)

A

Artificial airway for a patient with a GCS lower than 9

90
Q

ICP monitoring should be initiated if the patient

(GCS)

(TBI)

A

GCS lower than 8 and a abnormal CT scan

TBI, even with a normal CT scan, if the patient meets two or more of criteria

Age 40 or older

Unilateral or bilateral posturing

SBP of less than 90

Pressures of up to 22mmHg ICP are associated with increased mortality

91
Q

Interventions to reduce ICP fall into three general categories, what are they?

A

Environmental

Pharmacologic

Surgical

92
Q

Environmental Interventions to reduce ICP include

(3 medications)

(2 other interventions)

A

Pain control and sedation

Fentanyl and morphine for pain

Midazolam (versed) and lorazepam for sedation

Propofol - does not have analgesic effects

Temperature control

Hypothermia not recommended for pt with TBI, causes shivering and increased ICP

Hyperthermia increases metabolic rate

Reduction of stimuli

93
Q

Pharmacologic Interventions to reduce ICP include

A

Hyperosmolar medications

Mannitol(Osmitrol) - reduces blood viscosity by drawing fluid from the cells and returning this fluid to the circulating blood volume

Produces osmotic gradient, pulling fluid from cerebral tissue into the vascular space

Also has renal diuretic effect

Hypertonic saline solution - avoid serum Na of > 160

94
Q

Surgical Interventions to reduce ICP include (4)

A

Drain placement

Burr hole

Craniotomy

Bone flap

95
Q

What is Pericoronitis?

A

Pericoronitis an inflammation of the tissue around the crown of the tooth, usually associated with the eruption of a third molar

96
Q

What is Ludwig’s angina?

A

Ludwig’s angina - a severe, potentially life threatening form of cellulitis in the region of the submandibular gland, distorting the floor of the mouth and making swallowing difficult. The glottis may swell suddenly and obstruct the airway. ABx are usually the treatment

97
Q

What are the S/S of Ludwig’s angina?

What are the treatments?

A

S/S include swelling of the anterior neck, trismus, muffled voice, dysphagia, drooling, fever or chills

Treatment - ABCs, pain relief, ABx

98
Q

What is a Fractured tooth Class I?

A

Injured area is white

Cosmetic restoration is possible is dental care occurs within 24 to 48 hours

99
Q

What is a Class II Fractured tooth?

A

injury passes through the enamel and expose the dentin

Fractured area appears ivory-yellow

100
Q

What is a Class III Fractured tooth?

A

is a dental emergency, pink or bloody area

Bacteria can pass easily to the pulp and cause infection or abscess

101
Q

Tooth avulsion treatment within (timeframe) reimplantation greatly increases success

If not impossible, place tooth in what?

Pediatric teeth (do/do not) get reimplanted

A

20 minutes

Hanks solution, NSS, milk, or under the patient’s tongue

do not

102
Q

What is the treatment for Dental abscess?

A
  • penicillin, azithromycin, may need extraction or root canal
103
Q

What part of the Ear does Otitis affect?

A

Otitis (ear inflammation) may affect the external, middle, or internal ear

104
Q

Otitis media usually affects patients between the ages of when?

Three pathogenic organisms are typically what?

Treatment includes what?

A

6 months and 3 years

Strep pneumonia, Haemophilus influenzae, and Moraxella

ABx amoxicillin

105
Q

Complications of Otitis media can cause serious complications such as (6)

If symptoms do not improve in (timeframe), reevaluate the patient.

A

tympanic membrane rupture, meningitis, acute mastoiditis, intracranial abscess, facial nerve damage, or hearing loss

48 to 72 hours

106
Q

Inner ear disturbances can cause Severe vertigo that usually lasts for (timefram)

A

3 to 5 days but may last for weeks

107
Q

Besides vertigo, Inner ear disturbances can also cause (5)

A

Nystagmus, dizziness, NV, hearing loss in the affected ear, tinnitus

108
Q

Inner ear disturbances treatments includes (5)

A

Treatment; bedrest, Meclizine (antivert), ABx to treat purulent labyrinthitis, antihistamines, anticholinergics (benzos if contraindicated)

109
Q

What is Mastoiditis?

What are the S/S?

A

Pain in the mastoid area behind the ear

Persistent fever, reddened, bulging

110
Q

What are the treatments for Mastoiditis?

(ABX)

(infants)

A

Initiate broad spectrum ABx such as Rocephin

Infants admission for 24 to 48 hours of IV ABx

Refer the patient to ENT consultation for ongoing evaluation.

111
Q

Ruptured Tympanic membrane is usually the result of

A

bacterial infection such as otitis media or trauma

112
Q

Ruptured Tympanic membrane S/S usually include what?

A

pain, bloody or purulent discharge, hearing loss, vertigo, fever, hearing loss. The rupture will relieve pain

113
Q

Treatments for Ruptured Tympanic membrane include

A

Trauma induced - check for drainage, cerebrospinal fluid and signs of basilar skull fx.

Obtain Cx from drainage,

do not irrigate or allow water to enter when bathing

90% of perforations heal spontaneously

114
Q

What do you do about a bug in the ear?

Ok, insect, I’ll keep it sounding professional

A

Insects - kill the insect with mineral oil and lidocaine and remove the dead insect

115
Q

What are 4 things that can cause Epistaxis?

A

Hx, coughing, sneezing, vomiting, HTN

116
Q

How do you treat Epistaxis?

(posture)

(compression)

What happens with the wrong posture?

A

Keep the patient seated upright with the head tilted down and firm sustained compression to the lower third of the nose for at least 5 minutes

Encourage patient to lean forward, leaning back can cause the patient to swallow blood and subsequently vomit

117
Q

What are 4 treatments for Epistaxis other than posture and compression?

A

Topical vasoconstrictor - cocaine hydrochloride (Neo-Synephrine)

Direct pressure

Chemical (silver nitrate) or electric cautery

Packing if needed

Leave packing in place for 3 to 5 days

118
Q

Posterior Epistaxis treatment

Bleeding harder to control, expect what physical intervention?

Posterior packs must be left in place for (timeframe), admit the patient for what?

Prepare for surgical ____ of ____ to control severe epistaxis

A

balloon pack or 21 fr Foley

72 to 96 hours

airway monitoring

ligation of vessels

119
Q

Pharyngitis - treatment; CxS, screen for ____

Usually ____

Encourage the patient to do what?

Severe cases may require ____.

Complications of bacterial include (4)

A

strep

viral

gargle frequently with warm salt water

tonsillectomy.

retropharyngeal abscess, glomular nephritis, acute rheumatic fever, toxic shock syndrome

CEN prep 2021 (36 decks)

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