Head and Maxillofacial Trauma, ENT Emergencies Flashcards
Intubation - avoid nasotracheal intubation in patients with facial fractures due to the possibility of cerebral penetration with a ____ ____ Fx.
Cribriform plate
What is a LeFort Fx 1
I - just the teeth, mustache
What is a LeFort Fx 2
muzzle
What is a LeFort Fx 3 What is the defining characteristic?
sunglasses, with Fx zygomatic bone Lengthening of the face
when should you inspect the eyes?
inspect before lid edema makes it more difficult to assess for vision loss
when assessing the eyes, Note a teardrop shaped pupil that suggests a what?
ruptured globe
what is Hyphema
- is a pooling or collection of blood inside the anterior chamber of the eye, indicates a serious eye injury
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
20 8 12
Clean all bite wounds with ____ ____. What should you avoid and why?
normal saline Avoid using detergent, hydrogen peroxide and concentrated povidone-iodine solutions because they are highly toxic to the tissues
Cat bites are typically puncture wounds and are usually left ____
open
Human and other animal bites on the face are normally treated how?
usually sutured because they can be disfiguring. Many experts suggest closing the wound after meticulous irrigation and debridement
Facial abrasions - how are they usually treated?
Debride as soon as possible to avoid permanent tattooing from the grease and asphalt after the area is injected with local anesthetic
How are lacerations of the lip treated?
the lip borders should be perfectly aligned, expect a consultation with a plastic surgeon
How are lacerations of the tongue usually treated?
suture and ABX
How are lacerations of the ear NOT treated?
do not use local anesthetics with epinephrine on the ear because of the harmful effects of vasoconstriction
How are lacerations of the ear NOT treated?
do not use local anesthetics with epinephrine on the ear because of the harmful effects of vasoconstriction
Nasal Fractures If the cribriform plate is affected and the dura is torn, assess for what?
for cerebrospinal fluid leakage
Nasal Fractures Septal hematoma, how does it appear? What does it require? What is the result deformity if it is not treated?
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
Nasal Fractures When is it appropriate to set the Fx?
The fracture may not be set until the swelling goes down
Nasal Fractures If the fracture involves the lacrimal system, instruct the patient NOT to do what?
to blow the nose, may cause intracranial air or subcutaneous emphysema that can result in a localized infection or meningitis
Naso-orbital-ethmoid Fractures What are the S/S? (6)
S/S - Diplopia, massive periorbital and upper facial edema with ecchymosis, epistaxis, traumatic telecanthus, foreshortening of the nose with telescoping, associated intracranial injuries
Where is the ethmoid bone?
Where is the Maxilla bone?
Where is the Zygomatic bone?
Maxillary Fractures
Patients with maxillary fractures report severe facial pain and anesthesia or paresthesia of the what?
upper lip
Patients with maxillary fractures also report having what S/S? (7)
Also; facial swelling, ecchymosis, periorbital or orbital swelling, vision disturbances, subconjunctival hemorrhage, elongation of the face, malocclusion
Zygomatic Fractures
Patients will typically report…
Pain in the ____ ____
Inability to do what?
Swelling and crepitus over the ____
lateral cheek
close the jaw
arch
What is a tripod fracture?
Tripod Fracture
The zygoma fractures in three places; the zygomatic arch, the posterior half of the infraorbital rim, and the frontozygomatic suture.
What type of fracture is this?
Tripod fracture
Diplopia, numbness of the lower lid, and bilateral nasal area are all S/S of what type of fracture?
Tripod fracture
The orbit is composed of multiple bones, including what?
(5)
the zygoma, maxilla, and frontal, sphenoid, and ethmoid bones
Orbital blowout fractures
What are the S/S?
(4)
S/S include - diplopia, altered extraocular eye movements, orbital pain or loss of sensation, enophthalmos
Orbital blowout fractures
What interventions are indicated?
Interventions - CT, Sx after the swelling goes down, ice, broad spectrum ABx and nasal decongestants, remind the patient to avoid blowing the nose
The second most common type of facial fracture is what?
Mandibular Fractures
What are the most common head/facial fractures?
simple nose fracture
What type of fracture is this?
Mandibular condylar fracture
The specific symptoms of a mandibular condyle fracture are pain at the fracture site and referred pain to the ____
ear
What is the treatment for a madibular condyle fracture?
Treatment - consists of surgical open reduction of the jaw with wiring.
Head Trauma
After assessing the patients ABC’s, focus on the D, which is what?
disability by assessing the patients neurologic function
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)
III gag reflex
V corneal reflex
Gag reflex
X vagus nerve
Here is a handy-dandy mnemonic for you for remembering the cranial nerves
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.
Cranial nerves
I
I olfactory nerve, sensory
Cranial nerves
II
II optic nerve, sensory
Cranial nerves
III
III ocular, motor ,nerve
Eyelid
Cranial nerves
IV
IV Trochlear eye, motor, up and down
Cranial nerves
V
V Trigeminal nerve, sensory and motor, teeth and skin of the head, jaw motor
Jaw clench, corneal reflex
Cranial nerves
VI
VI Abducens, motor, lateral movements of eye
Cranial nerves
VII
VII Facial, motor and sensory, facial expression and taste, eyebrows, cheek puff
Lacrimation, salivation, facial movement
Cranial nerves
VIII
VIII Auditory, sensory, Hearing and equilibrium
Cranial nerves
XI
IX Glossopharyngeal, Sensory and motor, taste, ability to speak, swallow, gag
Cranial nerves
X
X Vagus, Sensory and motor, say AH, assess movement of palate and pharynx
Cranial nerves
XI
XI Spinal accessory, motor, shrug shoulders
Cranial nerves
XII
XII Hypoglossal, motor, stick out tongue and move from side to side
Cold water into the patients ear.
What is this test called and what would indicate a normal result?
Cold water (cold caloric) into the patient’s ear and the eyes should direct toward the noxious stimuli for a normal result?
Dolls eyes
How is this test performed and what should you look for?
Dolls eyes - move the head and the eyes with focus on one point (like a chicken head)
Intracranial pressure
Normal ICP is __ to __ mmHg
0
10
Early S/S of increasing ICP include (9)
HA, NV, restlessness, confusion, agitation, speech and vision disturbances, increasing motor deficits, sluggish pupils, ovoid pupil (oval)
Late S/S of increased ICP include, (6)
Two postures
This triade
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
What is Cushing’s triad (cushing’s response)
- HTN, widening pulse pressure, bradycardia
Before trying to reduce HTN, keep in mind the cerebral perfusion pressure equals what?
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
When the ICP rises, the body does what?
increases the blood pressure to try to sustain brain perfusion
Hyperthermia may occur if the ____, which controls temperature, has been injured.
How does this affect ICP?
hypothalamus
Elevated body temperature increases the metabolic rate and elevates ICP
Hypothermia triggers shivering, which also raises the metabolic rate and ICP
Head injuries can be categorized by (3)
Mechanism; as blunt or penetrating
Severity; mild, moderate, or severe
Type; as primary or secondary and as focal or diffuse
What bone is this?
sphenoid bone
How do you determine a head injury as mild, moderate, or severe?
Mild = GCS of 14 or 15
Moderate = GCS of 9 to 13
Severe GCS of 8 or less
How do you determine a primary from a secindary head injury?
Primary; from traumatic forces applied, contusion, laceration, shearing, hemorrhage
Secondary; from resultant changes, ischemia, hypotension, hypercapnia, cerebral edema, metabolic derangements
How do you determine a focal from a diffuse head injury?
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
Basilar Skull Fx
What bones of the skull can be involved?
What can it increase the risk of?
Can occur wherever the skull ends, such as in the occipital, temporal, sphenoid, or ethmoid bones
Can increase the risk for meningitis
What are the S/S of a Basilar Skull Fx
Combative behavior, periorbital ecchymosis, battles sign hemotympanum
Cerebrospinal fluid leaks; otorrhea, rhinorrhea
Deficits in the CN VII and VIII, depending on the fracture location
Focal injuries
Contusions
Coup countercoup
S/S include
decreased LOC, HA, NV, vision changes, difficulty speaking, signs of ICP
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)
12
24
ICP
neurologic
bone flap (remove a segment of the skull and leave it off)
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)
aneurysms and strokes
ICP
7 to 10 days
48 to 72 hours
Epidural Hematoma
arterial or venous?
Location of bleeding?
typically associated with what?
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.
Epidural Hematoma S/S
LOC
Neurologic
Hemiplegia
pupils
interventions
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
Subdural Hematoma
Arterial or Venous?
Onset of S/S? And what are they?
Interventions?
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
Subdural Hematoma
What is the difference between subactue and chronic?
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
Subdural Hematoma
Who does it normally affect?
most commonly affects geriatric patients receiving anticoagulants
More common in chronic alcoholics who may have brain atrophy and coagulopathies
Subdural Hematoma
S/S include
HA, clumsiness in one arm or leg, confusion or speech difficulties, increasing falls or near misses
What would you expect in a CT scan for a patient with Diffuse Axonal Injuries?
Injuries are microscopic, so CT may look normal at first, later scans may show diffuse cerebral edema and areas of microvascular hemorrhage
What S/S would you see in a patient with Diffuse Axonal Injuries initially?
How about later on?
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
What S/S would you expect to see in a patient with Mild Diffuse Axonal Injuries?
Mild - LOC for 6 to 24 hours, abnormal posturing, return to baseline over several days, may have lingering effects similar post concussion syndrome
What S/S would you expect to see in a patient with Moderate Diffuse Axonal Injuries?
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
What S/S would you expect to see in a patient with Severe Diffuse Axonal Injuries?
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
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.
Primary Brain Injury
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.
Secondary Brain injury
Secondary Brain injury resullts in (5)
hypotension, less than 90 mmHg
hypoxia, PaO2 less than 60mmHg or spO2 <90
Sustained elevation of ICP greater than 20mmHg
anemia,
hyperpyrexia
Prevention of secondary brain injury includes what type of fluids?
What does isotonic do?
What does hypotonic do?
Prevent hypotension with isotonic IV fluids. Hypotonic fluids such as dextrose and water can increase cerebral edema by shifting fluids
For all patients with head injuries, what should you do?
Start with 2 large bore IV catheters for rapid fluids
Control bleeding
Consider blood products
Initial resuscitation For all patients with head injuries includes (GCS lower than 9)
Artificial airway for a patient with a GCS lower than 9
ICP monitoring should be initiated if the patient
(GCS)
(TBI)
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
Interventions to reduce ICP fall into three general categories, what are they?
Environmental
Pharmacologic
Surgical
Environmental Interventions to reduce ICP include
(3 medications)
(2 other interventions)
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
Pharmacologic Interventions to reduce ICP include
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
Surgical Interventions to reduce ICP include (4)
Drain placement
Burr hole
Craniotomy
Bone flap
What is Pericoronitis?
Pericoronitis an inflammation of the tissue around the crown of the tooth, usually associated with the eruption of a third molar
What is Ludwig’s angina?
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
What are the S/S of Ludwig’s angina?
What are the treatments?
S/S include swelling of the anterior neck, trismus, muffled voice, dysphagia, drooling, fever or chills
Treatment - ABCs, pain relief, ABx
What is a Fractured tooth Class I?
Injured area is white
Cosmetic restoration is possible is dental care occurs within 24 to 48 hours
What is a Class II Fractured tooth?
injury passes through the enamel and expose the dentin
Fractured area appears ivory-yellow
What is a Class III Fractured tooth?
is a dental emergency, pink or bloody area
Bacteria can pass easily to the pulp and cause infection or abscess
Tooth avulsion treatment within (timeframe) reimplantation greatly increases success
If not impossible, place tooth in what?
Pediatric teeth (do/do not) get reimplanted
20 minutes
Hanks solution, NSS, milk, or under the patient’s tongue
do not
What is the treatment for Dental abscess?
- penicillin, azithromycin, may need extraction or root canal
What part of the Ear does Otitis affect?
Otitis (ear inflammation) may affect the external, middle, or internal ear
Otitis media usually affects patients between the ages of when?
Three pathogenic organisms are typically what?
Treatment includes what?
6 months and 3 years
Strep pneumonia, Haemophilus influenzae, and Moraxella
ABx amoxicillin
Complications of Otitis media can cause serious complications such as (6)
If symptoms do not improve in (timeframe), reevaluate the patient.
tympanic membrane rupture, meningitis, acute mastoiditis, intracranial abscess, facial nerve damage, or hearing loss
48 to 72 hours
Inner ear disturbances can cause Severe vertigo that usually lasts for (timefram)
3 to 5 days but may last for weeks
Besides vertigo, Inner ear disturbances can also cause (5)
Nystagmus, dizziness, NV, hearing loss in the affected ear, tinnitus
Inner ear disturbances treatments includes (5)
Treatment; bedrest, Meclizine (antivert), ABx to treat purulent labyrinthitis, antihistamines, anticholinergics (benzos if contraindicated)
What is Mastoiditis?
What are the S/S?
Pain in the mastoid area behind the ear
Persistent fever, reddened, bulging
What are the treatments for Mastoiditis?
(ABX)
(infants)
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.
Ruptured Tympanic membrane is usually the result of
bacterial infection such as otitis media or trauma
Ruptured Tympanic membrane S/S usually include what?
pain, bloody or purulent discharge, hearing loss, vertigo, fever, hearing loss. The rupture will relieve pain
Treatments for Ruptured Tympanic membrane include
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
What do you do about a bug in the ear?
Ok, insect, I’ll keep it sounding professional
Insects - kill the insect with mineral oil and lidocaine and remove the dead insect
What are 4 things that can cause Epistaxis?
Hx, coughing, sneezing, vomiting, HTN
How do you treat Epistaxis?
(posture)
(compression)
What happens with the wrong posture?
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
What are 4 treatments for Epistaxis other than posture and compression?
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
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
balloon pack or 21 fr Foley
72 to 96 hours
airway monitoring
ligation of vessels
Pharyngitis - treatment; CxS, screen for ____
Usually ____
Encourage the patient to do what?
Severe cases may require ____.
Complications of bacterial include (4)
strep
viral
gargle frequently with warm salt water
tonsillectomy.
retropharyngeal abscess, glomular nephritis, acute rheumatic fever, toxic shock syndrome
