Head, Facial, and Neck Trauma Flashcards
The populations most at risk for serious head injury are ___ between the years of ___ and ___, ___ and ___ ___, and the ___.
males ; 15 ; 24 ; infants ; young children ; elderly
What is the most frequent cause of trauma death?
Severe head injury
Mechanisms of injury: The structures of the ___, ___, and ___ protect very well against most blunt trauma.
head ; face ; neck
Mechanisms of injury: Why are significant facial injuries less likely to occur?
- Head’s frontal or parietal regions are more likely to impact (in things like auto crashes)
- Conscious victims try to protect facial area from injury and head/chest/arms absorb energy
Mechanisms of injury: How is the neck protected from blunt trauma?
Head and chest protrude more anteriorly; laterally protected as shoulders protrude a significant distance from the neck
Mechanisms of injury: Penetrating injuries to the head, face, and neck usually result from either ___ or ___.
gunshots ; stabbings
Mechanisms of injury: ___ wounds to the head and face tend to be superficial because of the region’s extensive ___ components.
Knife ; skeletal
Mechanisms of injury: What are some examples of penetrating injuries that involve the head, face, and neck?
- “Clothesline” impact with a wire fence while a victim is riding an all-terrain vehicle
- Bites from humans, dogs, or animals
- Tongue bitten when victim traps between teether during an impact
How is head injury defined?
Traumatic insult to the cranial region that may result in injury to soft tissues, bony structures, and the brain.
Head injury: Most superficial head injuries involve the ___. Its blood vessels lack the ability to constrict a effectively as those elsewhere, so the wound tends to bleed ___.
scalp ; heavily
Head injury: What are some concerns with scalp wounds?
- Serious blood loss from scalp wounds can contribute to shock - and could cause hypovolemia - if left untreated
- Provide a route for infection because emissary veins drain from dural sinuses, through the cranium, ad into the superficial venous circulation
Head injury: What is a common and special type of scalp wound? Describe what happens.
Avulsion - areolar tissues is only loosely attached to the skull, an glancing blows can create a shearing force against the scalp’s border; frequently tears a flap of scalp loose and folds it back against the uninjured scalp exposing portion of cranium
Head injury: What are the four ways cranial fractures present?
Linear, depressed, comminuted, or basilar
Head injury: ___ fractures are small cracks in the cranium and represent about 80% of all skull fractures.
Linear
Head injury: What is the thinnest and most frequently fracture cranial bone?
Temporal bone
Head injury: What is a depressed cranial fracture?
Inward displacement of the skull’s surface with greater likelihood of intracranial damage
Head injury: What is a comminuted cranial fracture?
Multiple skull fragments that may penetrate the meninges and cause physical harm to the structures beneath
Head injury: What are the scalp/head injury presentations?
- Hematoma: blow disrupts blood vessels, resulting in accumulating blood and a hematoma
- Depression: blow may tear fascial layers und the scalp and result in a depression, with or without a depressed skull fracture
- Normal scalp contour: blood may fill the space vacated by the torn fascial layers OR blood may fill the area vacated by a depressed skull fracture
Head injury: A common type of skull fracture involves the ___ of the skull because it is permeated with foramina (openings) for the ___ ___, ___ ___, and various ___ ___.
base ; spinal cord ; cranial nerves ; blood vessels
Head injury: What are the hollow or open structures on the basilar skull that weaken it and leave the basilar area prone to fracture?
Sinuses, orbits of the eye, nasal cavities, external auditory canals, and middle/inner ears
Head injury: What are signs of basilar skull fractures?
Varies by location:
- If fracture involves auditory canal/lower later areas of skull: hemorrhage may migrate to the mastoid region (just posterior and slightly inferior to the ear)
- —Causes characteristic discoloration called retroauricular ecchymosis or “Battle’s sign”
-Bilateral periorbital ecchymosis sometimes referred to as “raccoon eyes”, which is dramatic discoloration around the eyes associated with orbital fractures and hemorrhage into surrounding tissue
Head injury: Basilar skull fracture can tear the ___ ___, opening a wound between the brain and body’s exterior. This may permit cerebrospinal fluid to seep out through a nasal cavity or external auditory canal.
dura mater
Head injury: The “halo” sign (dark red circle surrounded by a lighter, yellowish one indicating blood mixed with cerebrospinal fluid) is most reliable when associated with fluid leaking from the ___.
ear
Head injury: The ___ level of CSF (cerebrospinal fluid) is normally half that of the blood. If you are unsure whether a clear fluid is water or CSF, check the ___ level of the fluid and compare it to the patient’s blood ___ level.
glucose (all blanks)
Head injury: How many wounds are produced with a bullet to the cranium?
2 - entrance wound often producing a comminuted fracture sending bone fragments in to the brain; exit wound blown outward and more severe in appearance
Head injury: What effect does the energy of the projectile’s passage have on the cranium?
- Can cause cavitational wave of extreme pressure, which is contained and enhanced by the rigid container of the skull, resulting in extreme damage to the cranial contents
- —If kinetic energy strong enough: skull may fracture and “explode” outward
Head injury: What type of injury does a bullet entering at an angle potentially cause? Why?
Deflected within cranium and continues to move along craniums interior until energy is exhausted - devastating damage to the cerebral cortex and rarely survivable
Head injury: T or F. You should remove an impaled object causing cranial injury.
False - removal may cause further injury and increase blood accumulation
*Steve Irwin flashback :( *
Head injury: A ___ fracture by itself is a skeletal injury that will heal with time; however, the forces necessary to fracture the ___ are often sufficient to induce ___ injury.
cranial ; skull ; brain
Brain injury: What is the definition of brain injury?
A traumatic insult to the brain capable of producing physical, intellectual, emotional, social, and vocational changes; classified as direct or indirect injury to the tissue of the cerebrum, cerebellum, or brainsteml
Brain injury: What are some potential damages resulting from direct (or primary) brain injury?
- Mechanical injury to nervous system cells and impair their function
- Disrupt blood vessels - both restricting blood flow through the injured area and causing irritation of nervous tissue as blood flows into it
- Disrupt blood-brain barrier
- Serious jarring may damage capillary walls, affect their permeability, and cause fluid shift to the interstitial space, or tissue edema
Brain injury: What are the two specific types of direct brain injury?
Coup
Contrecoup
Brain injury: What are coup injuries?
Injury to the brain occurring on the same side as the impact
Brain injury: What are contrecoup injuries?
An injury to the brain opposite the site of impact
Brain injury: What are the two categories of direct brain injuries?
Focal or diffuse
Brain injury: Focal injuries occur at a ___ loction in the brain and include ___ and ___ ___.
specific ; contusion ; intracranial hemorrhages
Brain injury: Define and describe cerebral contusions.
- Caused by blunt trauma to local brain tissue that produces capillary bleeding into the substance of the brain
- Often produces prolonged confusion or other types or neurologic deficit
- May result from a coup or contrecoup mechanism
- May occur at one or several sites in the brain
Brain injury: What is the most commonly injured lobe?
Frontal
Brain injury: What is intracranial hemorrhage?
Bleeding directly into the tissue of the brain
Brain injury: What are the three types of bleeding brain injuries (ordered from most superficial to the deepest)?
- Epidural hematoma
- Subdural hematoma
- Intracerebral hemorrhage
Brain injury: What is epidural hematoma?
Accumulation of blood between the dura mater and the cranium; usually involves arterial vessels (often the middle meningeal artery in the temporal region); intracranial pressure builds rapidly - patient moves quickly towards unresponsiveness as pressure builds
Brain injury: What is subdural hematoma?
- Collection of blood directly beneath the dura mater and within the subarachnoid space;
- occurs very slowly;
- subtle presentation because usually due to rupture of small venous vessel (often one of those bridging to dural sinuses);
- free blood in CSF may clog structures responsible for fluid’s reabsorption and result in increasing intracranial pressure
Brain injury: Suspect ___ ___ in medical (nontrauma) patient who demonstrates neurologic signs and symptoms.
subdural hematoma
Brain injury: The ___ process and chronic ___ reduce the size of the brain, thus causing greater and less controlled motion of the brain; increases likelihood of injury (specifically subdural hematoma)
aging ; alcoholic
Brain injury: What can happen with intracerebral hemorrhage brain injuries?
Tissue edema resulting from free blood irritating the nervous tissue
Brain injury: List and describe two other local insults to the brain that result in increasing intracranial pressure.
- Cerebral edema: inflammation response initiated when cerebral tissue injured which permits fluid and proteins to pass through cerebral capillary walls; exert an osmotic pressure and draw water into and expand the interstitial space
- Hydrocephalus: hemorrhage into the subarachnoid space which then clogs the arachnoid villi (small structures that permit fluids in CSF to re-enter blood stream); accounts for accumulation of CSF and increase in ICP
Brain injury: What do diffuse injuries involve and include?
- Involve more general scenario of injury
- Include mild (concussions), moderate, and severe axonal disruptions
Brain injury: What is diffuse axonal injury (DAI)?
Type of brain injury characterized by shearing, stretching, or tearing of nerve fibers with subsequent axonal damage
Brain injury: What are axons?
Long communication pathways of the nerve cells
Brain injury: A ___ is a mild to moderate form of DAI and most common outcome of blunt trauma. Represents nerve dysfunction without substantial anatomic damage.
Concussion
Brain injury: How will a patient present with a concussion?
- Transient episode of neuronal dysfunction (confusion, disorientation, event amnesia)
- Followed by a rapid return to normal neurologic activity
Brain injury: A ___, ___, ___ ___, ___ ___, and ___ ___ may occur alone or in combination.
concussion, contusion, intracerebral hemorrhage, subdural hematoma, and epidural hematoma
Brain injury: What is a moderate DAI?
Shearing, stretching, or tearing of the axon occurs, but minute bruising of brain tissue occurs too; referred to as “classic concussion”
Brain injury: Occurs in 20% of all severe head injuries and comprises 45% of all DAI cases; Moderate DAI is commonly associated with ___ ___ fracture.
Basilar skull
Brain injury: What are signs and symptoms of moderate DAI?
- Immediate unconsciousness
- Followed by persistent confusion
- Inability to concentrate
- Disorientation
- Retro-/anterograde amnesia
- Patient may complain of headache, focal neurologic deficits, light sensitivity (photophobia), and disturbances to smell and other senses
- Anxiety
- Significant mood swings
Brain injury: What is severe DAI?
Previously known as brainstem injury; significant mechanical disruption of many axons in both cerebral hemispheres with extension into brainstem
Brain injury: approximately 16% of all severe head injuries and 36% of all DAI cases are classified as severe. Many patients don’t survive this type of injury; those that do have some degree of permanent ___ impairment.
Neurologic
Brain injury: How does a patient present with severe DAI?
Unconscious for prolonged period of time and displays signs of increased ICP (Cushing’s response and decerebrate or decorticate posturing)
Brain injury: What are indirect (or secondary) injuries?
Result of factors that occur because of (though after) the initial/primary injury; processes are progressive and cause the patient deterioration often associated with serious head injuries
Brain injury: What are the two pathological processes that cause indirect injuries?
(1) Diminishing circulation to brain tissue (intracranial perfusion) due to increasing intracranial pressure and possible exacerbated by hypoxia/hypercarbia/systemic hypotension
(2) Progressive pressure against - or physical displacement of - brain tissue secondary to an expanding mass within the cranium
BOTH pathologies continue and expand nervous tissue injury and cause some of the specific/progressive signs and symptoms associated with head injury
What is the one of the body’s most perfusion-sensitive organs?
The brain
Brain injury: Cranial volume is fixed and does not vary. Any increase in the size by one component must be matched by a similar ___ in another component otherwise the ___ ___ will rise.
reduction ; intracranial pressure (ICP)
*** The cerebrum, cerebellum, and brainstem account for 80% (1,200 mL). Venous, capillary, and arterial blood accounts for about 12% (150 mL). Cerebrospinal fluid accounts for the remaining 8% (90 mL).
Brain injury: What is the first means of compensating for expansion in the cranium?
Compression of the venous blood vessels
Brain injury: What is the second means of compensating for expansion in the cranium?
Cerebrospinal fluid is bused out of the cranium and into the spinal cord
Brain injury: What happens once the components reach their compensatory limits in the cranium?
- Intracranial pressure rises quickly and begins to restrict arterial blood flow
- Reduction in cerebral blood flow triggers a rise in systemic B to ensure adequate cerebral perfusion (known as autoregulation)
- The greater the pressure of arterial blood flow, the greater the ICP which further increases the resistance to cerebral blood flow
- —This produces more hypoxia and hypercarbia
- Cycle continues
Brain injury what is another factor affecting ICP and circulation throught eh brain?
Level of carbon dioxide in CSF
Brain injury: The brain’s response to high ___ ___ concentrations and the increasing ___ causes the classical ___ and ___ associated with head injury.
carbon dioxide ; ICP ; hyperventilation ; hypertension
Brain injury: ___ is a valuable tool in the reassessment of head injury patients especially if you’re ventilating them.
Capnography
Low ___ ___ and poor ___ ___ seriously compound any existing head injury.
blood pressure ; respiratory exchange
Diminished cerebral circulation causes increasing ___ (retained carbon dioxide) and ___ ___.
acidosis ; anaerobic metabolism
Brain injury: ___ (in response to increasing acidosis and carbon dioxide levels) elevates any existing intracranial pressure.
Vasodilation
Brain injury: If the compression results from a building mass along the central region of the cerebrum, pressure is first directed to the ___, then the ___, and finally to the ___ ___. The signs and symptoms of this progressive pressure and structural displacement are somewhat predictable and known as the ___ ___.
midbrain ; pons ; medulla oblongata ; central syndrome
Brain injury: In the central syndrome, upper brainstem compression produces an increase in BP to maintain cerebral perfusion pressure (called ___ ___) and a reflex decrease in heart rate in response to vagus nerve (parasympathetic) stimulate of the SA node and AV junction.
Cushing’s reflex
Brain injury: Central syndrome patients might also exhibit a characteristic cyclic breathing pattern called ___-___ ___. This consists of increasing, then decreasing, respiratory volumes, followed by a period of apnea.
Cheyne-Stokes respirations.
Brain injury: What is Cushing’s triad?
The combinations of increasing BP, slowing pulse, and erratic respirations in response to increased intracranial pressure
Brain injury: As the middle brainstem becomes involved the pulse pressure ___ and the heart rate becomes ___. Respirations now may be deep and rapid (___ ___ ___). Increasing ICP may also induce ___ sluggishness and nonreactivty (bilaterally since the pathology involves compression from above).
widens ; bradycardic ; central neurologic hyperventilation ; pupil
Brain injury: As the pressure reaches the lower brainstem the pupils become fully dilated and unresponsive. Respirations become ___ (erratic with no characteristic rhythm) or even cease. The ___ rate is often very irregular with great swings in rate. ECG conduction disturbances become apparent, including ___ complex, ___ segment, and ___ wave changes.
ataxic ; pulse ; QRS ; ST ; T
Brain injury: How can you asses whether a patient has cerebral herniation?
- Likely to display increasing BP, decreasing pulse rate, and respirations that become irregular (Cushing’s triad)
- May have a lowering level of consciousness (Glasgow Coma scale
Brain injury: How does pediatric head trauma differ from older patients?
Generally the softer skeletal structure increases the direct injury associated with head trauma (in the very young pediatric patient) but slows the progression of increasing ICP
Brain injury: Intracranial hemorrhage may significantly contribute to ___ in pediatric patients.
Hypovolemia
Brain injury: What is the standardized evaluation tool used to measure a patent’s level of consciousness by assessing and awarding points for the best eye opening, verbal, and motor responses?
Glasgow coma scale (GCS)
Brain injury: Why is it important to pay attention to a patient’s eye signs when evaluating them for possible head trauma?
- Eyes are specialized body tissue (like CNS tissue)
- Very visible special sense organ
- Give indications of problems with cranial nerves CN II, III, IV, and VI and with perfusion associated cerebral blood flow
- Pupil size and reactivity give clues (depressant drugs and cerebral hypoxia will reduce responsiveness while extreme hypoxia causes them to dilate and fix)
Brain injury: IF one pupil is fixed yet shows some response to consensual stimulation (light variations in the other eye), the problem most likely lies with the ___ ___.
oculomotor nerve
Facial injury: Why is facial injury a serious trauma complication?
- Cosmetic importance to people
- Region’s vasculature and location of the initial airway and alimentary canal structures and the organs of sight, smell, taste, and hearing present there
- Facial injuries suggest associated head and spinal injuries
Facial injury: Facial injuries may threaten patient’s ___, and contribute to ___ because the region bleeds heavily.
airway ; hypovolemia
Facial injury: ___ caused by aspiration is more likely caused by ___ than by other fluids or physical obstruction.
Hypoxia ; blood
Facial injury: What should be considered a likelihood with serious facial soft-tissue injuries?
Associated injury especially basilar skull fracture and spine injury
Facial injury: What do facial injuries commonly include?
Mandibular, maxillary, nasal, and orbital fractures and dislocations
Facial injury: What is it called when the condylar process displaces from the temporomandibular joint just anterior to the ear?
Mandibular dislocation
Facial injury: What are some results of mandibular dislocation?
- Malocclusion of the mouth
- Misalignment of teeth
- Deformity of facial region at/around joint
- Immobility of the jaw
- Pain
- Decreased ability to control airway
Facial injury: ___ fracture may represent a serious life threat if the patient is placed ___. Why?
Mandibular ; supine
The tongue is no longer supported at its base and may displace posteriorly blocking the airway (even in conscious patients)
Facial injury: Always look for ___ fracture site with mandibular fracture patients.
second
Facial injury: What type of fracture is classified according to Le Fort criteria?
Maxillary fractures
Facial injury: What are the Le Fort criterions?
- Le Fort I fracture: slight instability involving the maxilla alone usually presents with no associated displacement
- Le Fort II fracture: fractures of both the maxilla and nasal bones
- Le Fort III fracture: characteristically involve the entire facial region below the brow ridge including the zygoma, nasal bone, and maxilla
Le fort ___ and ____ fractures usually result in CSF leakage and may endanger the patency of the ___ and ___ portions of the airway.
II and III ; nasal ; oral
Facial injury: ___ (blowout) fractures most commonly involve the zygoma or maxilla of the inferior shelf.
Orbital
Facial injury: What type of facial fracture might entrap the extraocular muscles, reduce the eye’s range or motion, can cause blurred or double vision (diplopia), entrap the masseter muscle, and limit jaw movement?
Zygomatic arch fractures
Facial injury: What are the bigger threats to the airway with nasal injuries?
Swelling and associate hemorrhage
Facial injury: What are the two classifications of epistaxis (nosebleed)?
Anterior and posterior
Facial injury: ___ ___ comes from the septum and is usually due to bleeding from a network of vessels called Kiesselbach’s plexus. This hemorrhage bleeds slowly and is usually self limiting.
Anterior hemorrhage
Facial injury: ___ ___ may be sever and cause blood to drain down the back of the patient’s throat. In epistaxis secondary to severe head trauma with likely basilar skull fracture, the integrity of the ___ cavity’s ___ wall may be compromised. Tube insertion may permit the tube to enter the cerebral cavity and directly damage the brain.
Posterior hemorrhage ; nasal ; posterior
Facial injury: The external ear, or ___, which is exposed to the environment, is frequently subjected to trauma.
pinna
Facial injury: Internal portions of the ear - ___ ___ ___ and the ___ and ___ ear - are well protected from trauma by the structure of the skull. Injury only results from objects forced into the ear or from rapid changes in ___.
external auditory canal ; middle and inner ; pressure
Facial injury: What kind of fracture may also disrupt the external auditory canal and tear the tympanum?
Basilar skull fracture - may leak CSF if dura mater torn
Facial injury: An eye injury resulting from a penetrating object is likely to disturb the integrity of the ___ and possibly ____ chamber. Removal of the object may allow fluids to leak from the chambers and threaten the patient’s vision.
anterior ; posterior
Facial injury: Corneal abrasions and lacerations often cause intense and continuing pain but are often ___ but can be deep.
superficial
Facial injury: What is the condition where hemorrhage occurs in the anterior chamber and pools, displaying a collection of blood in front of the iris and pupil - and is a potential threat to patient’s vision?
Hyphema
–Occasionally blood will completely fill the anterior chamber resulting in what is called an “eight-ball” hyphema
Facial injury: When small blood vessels in the subconjunctival space burst leaving a portion of the eye’s surface blood red, it is called a ___ ___. It can occur after a strong sneeze, vomiting episode, or direct eye trauma.
subconjunctival hemorrhage
Facial injury: What is it called when blunt trauma fractures the orbital structures surrounding the eye, and the eye appears to protrude from the wound as the structure of the orbit is crushed and depressed?
Eye avulsion - eye is not really avulsed
Facial injury: What is acute retinal artery occlusion?
Non-traumatic occlusion of the retinal artery resulting in a sudden, painless loss of vision in one eye.
Facial injury: What is retinal detachment?
Condition that may be of traumatic origin an presents with patient complaint of a dark curtain obstructing a portion of the field of view
Neck injury: Skeletal structures and muscles of the neck protect ___, ___ and ___ blood vessels, and the ___ from all but ___ blunt trauma and deep ___ trauma.
airway ; carotid and jugular ; esophagus ; anterior ; penetrating
Neck injury: What happens if blunt trauma to a blood vessel produces a rapidly expanding hematoma?
Hematoma may be trapped within the fascia region and apply restrictive pressure to the jugular veins.
Neck injury: Laceration and subsequent hemorrhage of the jugular veins or carotid arteries can lead to what?
Hypovolemia and shock
Neck injury: ___ interruption may cause subsequent brain ___ and ___, mimicking the signs and symptoms of a stroke.
Arterial ; hypoxia ; infarct
Neck injury: Open neck wound affecting the external jugular vein may permit formation of an ___ ___ as the venous pressure drops below atmospheric pressure with deep respirations.
air embolism
Neck injury: Separation of the larynx from the trachea, fracture or crushing of either structure, or open trachea to the environment may result in what?
Serious hemorrhage that results in threat to airway, vocal cord contusion or swelling, destruction of the integrity of the airway and collapse of inspiration, disruption of normal airway landmarks, and restrictive soft-tissue swelling.
Neck injury: What are some examples of severe blunt trauma causes to the cervical spine?
- Cervical spine instability
- Vertebral fractures
- Wounds may cause pressure on spinal cord, cord contusion, or severing of the cord
Neck injuries: What can cervical spine injuries cause?
- Bilateral paresthesia
- Anesthesia
- Weakness (paresis)
- Paralysis generally at or below the dermatome controlled by the peripheral nerve branch leaving the spinal column at the level of the injury
- Serious pain and limited motion
Neck injury: Neck may demonstrate ___ ___ due to tension ___ (air pushed into the skin from intrathoracic pressure that migrates to the neck) or from ___ injury in the neck.
subcutaneous emphysema ; pneumothorax ; tracheal
Assessment of head, facial, and neck injuries: Follows standard format including scene size-up, ___ ___, rapid ___ assessment/___ exam and ___, and ___ assessment as appropriate.
primary assessment; secondary ; focused exam and history ; detailed
Assessment of head, facial, and neck injuries: How do you determine the minute volume for breathing during the primary assessment?
- Estimate the amount of air moved with each breath
- Determine the rate of respirations and their rhythms
Minute volume = Tidal volume X Respiratory rate
Assessment of head, facial, and neck injuries: Iff patient s breathing fewer than __ times per minute, moving significantly less than ___ mL of air with each breath, or has a minute volume of less than ___ L, consider ventilating the patient.
10 ; 500 ; 5
Assessment of head, facial, and neck injuries: Ventilate at __ to __ full breaths per minute with a volume between ___ and ___ mL. Do not hyperventilate the patient if suspect brain injury because it will blow off ___ ___ and cause ___. Ventilations for serious head injury patients (GSC >/= 8) are guided by capnography.
12 to 20 ; 800 and 1,200 ; carbon dioxide ; vasoconstriction
Assessment of head, facial, and neck injuries: Ventilations for patients without signs of herniation -
-Adjust ventilation rates to maintain an end-tidal CO2 reading between 35 and 40 mmHg (adults at about 10 breaths per minute, children at 20 breaths per minute, and infants ate about 25 breaths per minute)
Assessment of head, facial, and neck injuries: Ventilations for patients with signs of herniation -
End-tidal CO2 reading should range between 30-35 mmHg using ventilation rates about 10 breaths per minute faster than for patients without herniation; ensure O2 saturation level is at least 95%
Assessment of head, facial, and neck injuries: For patient who is breathing adequately on his own, apply oxygen via ___ mask with a flow of ___ L per minute.
nonrebreather ; 15
Assessment of head, facial, and neck injuries: Eye reactivity and luster reflect the ___ status of the brain.
oxygenation
Assessment of head, facial, and neck injuries: Restricted eye movement suggests eye muscle ___, nerve ___, or injury and ___.
entrapment ; compression ; paralysis
Assessment of head, facial, and neck injuries: When examining the pupil, iris, ad conjunctiva, what should you see and do?
- Pupil and iris should be round
- Anterior chamber clear
- Sclera free of accumulating blood
- Check for contact lenses and remove (especially in unconscious patients)
Assessment of head, facial, and neck injuries: On the Glasgow coma scale, what are the ranges for mild, moderate, and severe head injuries?
-13 to 15 is mild
-9 to 12 is moderate
-
Assessment of head, facial, and neck injuries: What is of special concern for head injury patients? What is the expectation and correction?
Blood glucose level - should be above 60 mg/dL; administer IV glucose if not
H, F, N injury management: What are airway management techniques appropriate for soft tissue trauma to the airway patients?
- Suctioning
- Patient positioning
- Oral/nasal airway insertion
- Endotracheal intubation
- Cricothyrotomy
H, F, N injury management: What is the Sellick maneuver and when/why is it used?
- Apply pressure directed posteriorly to the cricoid ring with the thumb and index finger, moving it downward toward the vertebral column
- Useful in the time between determining the need for endotracheal intubation and its successful insertion
- Compresses esophagus and reduces the likelihood of vomitus entering the upper airway during intubation
H, F, N injury management: How can soft-tissue hemorrhage compromise the airway?
- Sheer volume of blood may block the airway
- Blood is a gastric irritant that frequently induces emesis; patient may vomit thus endangering airway
H, F, N injury management: T or F. Aspiration of gastric contents is associated with a high patient mortality.
True
H, F, N injury management: Be prepared to suction aggressively in any patients with what kinds of trauma?
nasal, oral, or head
H, F, N injury management: What is the best position for patients with suspected head injury?
Left side with head turned slightly and facing downward - the left lateral recumbent position - remember head injury patients require spinal precautions, though
H, F, N injury management: Have the patient do what if experiencing serious oral, nasal (epistaxis) or facial bleeding and they are conscious and alert with no serious spinal injury suspected?
Sit leaning forward to promote drainage and keep fluid from flowing into the posterior airway
H, F, N injury management: If the patient is has an open neck injury with danger of neck embolism, what do you do?
- Place the patient on spine board in the Trendelenburg position, with the lower part of the patient’s body elevated about 12 inches;
- Otherwise position the patient with potential brain injury by elevating the head of the spine board about 30 degrees (reduce both external hemorrhage and ICP)
H, F, N injury management: What are the advantages of nasopharyngeal airways compared t oropharyngeal?
- Nasal airway doesn’t trigger gag reflex as easily
- Better tolerated by semiconscious patients
- Reduction in transient increases in ICP (because gag reflex not stimulated)
H, F, N injury management: What is a hazard of nasal airway use if suspect patient has a fracture?
Insertion ofthe tube directly into the cranium through a fracture
H, F, N injury management: What is the general process for inserting nasal airway?
- Insert nasal airway straight back through the largest of the nares (nostrils), and use only gentle force in its introduction
- If suspect basilar skull fracture - use oral airway or endotracheal intubation
H, F, N injury management: What endotracheal intubation techniques are useful in caring for head injury patients?
Orotracheal, digital, nasotracheal, retrograde, directed, and rapid-sequence intubation
H, F, N injury management: What are key highlights of orotracheal intubation?
- Most common and usually most successful
- To improve visualization (esp with patients needing spina immobilization), employ BURP maneuver
- —Use thumb and first finger, displace the larynx Backward (posteriorly), Upward (cephalid), and just slightly to the patient’s Right with slight Pressure
H, F, N injury management: What are key highlights of digital intubation?
- Endotracheal tube is positioned without visualization; tube is directed by intubator’s fingers
- Major benefit is it does not require any extension of the neck
H, F, N injury management: What is the general process for digital intubation?
- Hold patient’s mouth open with a bite block
- Insert first two fingers and”walk” them back to tongue’s base
- Located and lift epiglottis
- Advance tube with other hand along back of tongue and 1.5 to 2.5 inches past the epiglottis - use slight anterior pressure along posterior surface of epiglottis
- Ensure placement in trachea not esophagus
H, F, N injury management: What are key hazards/disadvantages of nasotracheal intubation?
- Lower rate of success
- Tends to raise ICP because takes longer and more aggressively stimulates posterior nasal and oral pharynxes
- Necessity of having a breathing patient and quiet environment
H, F, N injury management: What is the general process for nasotracheal intubation?
- Insert endotracheal tube into largest of the nares
- Direct it posteriorly, curving it towards the floor of the nasal cavity
- Listen for sounds of respirations and slowly continue insertion until sounds are loudest
- Advance tube during inspiration - tube should pass directly into trachea
H, F, N injury management: What are key highlights of retrograde intubation?
- Process in which a wire is introduced through the cricothyroid membrane into the larynx, then the pharynx, and then out through the mouth
- Effective technique when normal landmarks are disrupted by severe facial and airway trauma
H, F, N injury management: What are key highlights of directed intubation?
- Technique for when landmarks of upper airway are disrupted or destroyed
- Use the laryngoscope to attempt to visualize elements of the oro- laryngopharynx
- Another form uses device called the um elastic bougie
H, F, N injury management: What are key highlights of rapid-sequence intubation (RSI)?
- Used for patients with airway concerns whose teeth are clenched (trismus) and with serious oral trauma with risk of swelling/progressive airway obstruction
- Sedative/amnestic is administered
- Quick-acting paralytic agent is given to induce muscle relaxation, eliminate gag reflex
H, F, N injury management: What paralytics and sedatives are most commonly used for RSIs?
Paralytics: succinylcholine, atracurium, vecuronium
Sedatives: etomidate, diazepam, midazolam, fentanyl, morphine
H, F, N injury management: T or F. Iff you hear good breath sounds unilaterally, detect no epigastric sounds, and see the chest wall move with each breath, the tube is most likely in the trachea.
False - need good breath sounds bilaterally; chest wall should move equally
H, F, N injury management: T or F. Use of waveform capnography is not recommended.
False - it is highly recommened
DO YOU NEED TO KNOW CRICOTHYROTOMY????
If so - see page 989 for details
Breathing: Who is a candidate for high-flow, high concentration oxygen and how should it be administered?
- Any patient who has sustained a signifiant head injury or who displays indication of lower level of consciousness, orientation, or arousal
- Administer at 15 liters per minute
Breathing: What are key highlights of hyperventilation?
- May increase intrathoracic pressure
- Secreasing venous return and effectiveness of circulation
Breathing: What are key highlights of hypoventilation?
-Increases circulating CO2 levels causing cerebral vasodilation and increase in ICP
Circulation: Evalute any other open wounds for frothy blood suggestive of ___ involvement, seal those wounds with ___ dressings, and monitor respirations.
tracheal ; occlusive
Circulation: Blunt trauma to the neck may produce the equivalent of ___ ___.
compartment syndrome
Hypoxia: Assure that th patient is well oxygenated before any intubation attempt and ___ (at ___ times per minute) for a short time after intubation.
hyperventilated ; 20
Hypovolemia: Provide aggressive ___ ___ for any patient with significant head injury in whom you suspect ___ injury or who shows signs of ___ compensation.
fluid resuscitation ; brain ; shock
Hypovolemia: What is the general process to address hypovolemia?
- Insert two large-bore catheters and administer lactate Ringer’s solution/saline at a wide-open rate through nonrestrictive trauma IV tubing
- Administer 1,000 mL of an isotonic solution followed by additional fluids as needed to maintain systolic BP of 90 mmHg - child (6-12) at 80, young child (20-5) at 76, infant (0-1) at 65
Hypovolemia: In a patient with probable brain injury, do not treat ___.
hypertension
DO YOU NEED MED SPECIFICS HERE?
If so - see pages 992-995
Battle’s signs and raccoon eyes indicate -
basilar skull fracture
A sigh-threatening injury, involving hemorrhage into the anterior chamber is known as -
hyphema
Patients with a Glasgow Coma Scale sore of ___ or less should immediately be intubated.
8
Your patient has been involved in an accident and has received open trauma to the neck and blood vessels therein. Your concern should be directed toward the danger of exsanguination and:
air embolism
Sudden painless loss of sight in one eye is most generally associated with:
acute retinal artery occlusion
A classic sign of increasing ICP, which includes increasing blood pressure, slowing pulse, and irregular respirations, is referred to as:
Cushing’s triad
The inability to remember events tht occurred after a traumatic event is knon for:
anterograde amnesia
What drug may cause fasciculations and raises ICP?
succinylcholine
For the head injury patient without signes of herniation, you should adjust ventilation rates to mainain a end-todal CO2 reading of between:
35 and 40
Your patient has presented with facial injury secondary to blunt trauma. You note left facial abrasions and lacerations, depression over the prominence of the left cheek, diminished movement of the left ocular muscles, and diplopia. This patter is consistent with:
orbital fracture
Medications: What is the name of the drug that is an osmotic diuretic that draws water from the interstitial space and into the cardiovascular system?
Mannitol
Medications: What patients require caution when using mannitol and why?
- Patients with reduced kidney function because may induce hypertension
- Do not us in patients with hypotension (SBP below 90) because it will further reduce BP
Medications: How is mannitol administered?
As a slow IV bolus of 0.25 to 1 g/kg over 10 to 20 minutes
Medications: What is the name of the drug that is an ultra-short-acting depolarizing skeletal muscle relaxant which acts upon cholinergic receptors to cause the muscles to contract (depolarize)?
Succinylcholine
Medications: What action does the depolarizing paralytic succinylcholine cause?
Fasciculations, which is individual muscle contractions seen beneath the skin
Medications: How long does it take succinylcholine to induce complete paralysis and how long does it persist?
30 to 60 seconds and lasts 2 to 3 minutes with IV administration; onset of paralysis occurs in 75 seconds to 3 minutes with IM administration
Medications: Why should succinylcholine use follow the administration of a sedative/amnestic agent?
Because it does not affect the patient’s level of consciousness, cerebration, anxiety, or pain perception
Medications: Succinylcholine increases ___, may induce ___, and should be used wit caution (if at all) in cases of ___ injury.
ICP ; vomiting ; head
Medications: When is succinylcholine contraindicated and why?
Because it slightly increases intraoccular pressure, contraindicated for penetrating eye injuries and used with caution in patients who are taking digitalis because of the risk of hypokalemia
Medications: How is succinylcholine administered IV?
rapidly in a dosage of 1 to 1.5 mg/kg (per book) or 2 mg/kg (per class)
Medications: How is succinylcholine administered IM?
Supplied in a single-use vial with 10 mL of a 20 mg/mL solution
Medications: Frequently 0.5 mg of ____ is administered prior to succinylcholine to halt the fasciculations and reduce secretions.
atropine
Medications: What are the names of the two drugs that are nondepolarizing skeletal muscle relaxants?
Atracurium (tracrium) and vecuronium (Norcuron)
Medication: How is vecuronium is administered?
Rapidly in a dose of 0.08 to 0.1 mg/kg IV
Medications: How is vecuronium supplied?
10-mg vials of powder that must be reconstituted with saline (either 5 or 10 mL) prior to administration
Medications: What is the name of the drug that is very rapid-acting, short-duration, nonbarbiturate hypnotic with no analgesic properties?
Etomidate
Medications: What is the name of the drug that is a benzodiazepine similar to diazepam though it is three to four times more potent?
Midazolam (versed)
Medications: When does midazolam (versed) onset of effects occur?
3 to 5 minutes
Medications: Midazolam (versed) does not protect against increasing ___ that follows ___ and ___ administration.
ICP ; succinylcholine ; pancuronium
Medications: How is midazolam (versed) administered?
Slowly in small increments (no more than 1 mg/min) titrated to the desired effect or the maximum administration of 2.5 mg
Medications: How is midazolam (versed) supplied?
in 2-, 5-, and 10-ml vials of a 1 mg/ml concentration and may be mixed in the same syringe with morphine, meperidine, or atropine or diluted with normal saline
Medications: What is the name of the drug that is an anticholinergic (parasympatholytic) agent sometimes administered as part of the rapid-sequence intubation routine?
Atropine
Medications: When and why is atropine administered?
- Given before paralytics
- Reduces parasympathetic (vagal) stimulation associated with intubation
Medication: What are some key highlights of atropine?
- May reduce oral and airway secretions and limit fasciculations associated with administration of succinylcholine
- May cause pupil dilation and other CNS signs frequently associated with head injury (headache, nausea, vomiting, and blurred vision)
Medications: If signification hypoglycemia is found, administer ___ mg of glucose and ___ mg of thiamine.
25 ; 100
Medications: When should thiamine be administered?
Before or with glucose
Medications: What are two names of drugs that use an anesthetic agent to anesthetize the oral and pharyngeal mucosa to reduce the gag reflex thus making endotracheal intubation easier and reducing the impact retching has on ICP?
xylocaine or benzocaine
Medications: How long does it take for topical anesthetic spray effects to start?
within 15 seconds, remains local, and last for about 15 minutes
What are the two most common dental traumas?
Fractures and avulsions of anterior teeth
How should a knocked out tooth be cared for?
Store in pH-balanced isotonic calcium fluid (whole milk)
If major neck laceration and shock are developing, where should IVs be placed?
One in upper one in lower extremity
Decorticating posturing is?
Arms flexed
Decerebrate posturing is?
Arms extended
What is cushings triad?
INCREASED BP DECREASED pulse WIDENING pulse pressure Projectile vomiting Irregular respirations
