Lecture 17 - Head and Face Injuries Flashcards
what type of sport do face and head injuries occur in?
- collision and contact sports
what is the best way to prevent injuries to the head and face?
- education
- protective equipment
what is the cause of facial lacerations?
- penetrating/sharp object or blunt trauma causing direct or indirect compressive force
what are the signs of facial lacerations?
- pain
- substantial bleeding (especially overtop bones)
- (skin cuts very easily)
how do you care for facial lacerations?
- clean with sterile saline
- assess for debris or damage to structures
- apply pressure to control bleeding
- rule out skull/brain trauma
- refer to physician (preferably plastics) for stitches if necessary
what is the cause of scalp injuries?
- blunt trauma or penetrating trauma (usually)
- can occur in conjunction with serious head trauma
what are the signs of scalp injuries?
- blow to the head
- bleeding is extensive and difficult to pinpoint (highly vascular area)
how do you care for scalp injuries?
- clean with antiseptic soap and water
- remove debris
- cut away hair (if necessary to expose area)
- apply pressure to reduce/stop bleeding
- use ice to reduce blood flow
- refer wounds larger than 1/2 inch in length
- treat smaller wounds with protective covering/gauze
when should you refer someone for stitches?
- high tension location (elbow, knee, face, etc.)
- wounds >4 cm in length
- cut goes through all skin layers (showing fat, tendon, bone or vessels)
- within 8-12 hours (ideally within 4-6 hours)
- protect with non-medicated gauze if sending for sutures
how do you care for lacerations that do not require stitches?
- steri-strips
- butterfly bandage
what causes brain injuries?
- a result of a direct blow
- compressive force
- tensile (negative pressure) force
- shearing
what is the purpose of CSF?
- (cerebral spinal fluid)
- converts focal force into compressive stress
- dissipates force over brains full surface
- has minimal impact on shearing force (especially when combined with rotation)
what is battle’s sign? (aka periauricular ecchymosis)
- bruising around the ear (behind the ear)
- indicates a skull fracture
- late finding (24-48 hours after incident)
what is raccoon eyes? (aka periorbital ecchymosis)
- bruising around/under the eyes
- indicates a skull fracture
- late finding (24-48 hours after incident)
what is halo sign?
- clear (yellowish/greenish) drainage that separates from bloody drainage from ears/nose
- indicative of CSF leakage
- indicates skull fracture
what is the PEARL test for vision?
- Pupils Equal And Reactive to Light
- indicates normal eye function
what do equal but dilated/unresponsive pupils indicate?
- cardiac arrest
- CNS injury
what do equal but constricted/unresponsive pupils indicate?
- CNS injury or disease
what do unequal, one dilated/responsive pupils indicate?
- CVA (cerebrovascular accident)
- head injury
- direct trauma to the eye
what is an Epidural Hematoma?
- bleeding between the dura and skull
what is the cause of an epidural hematoma?
- blow to the head
- skull fracture
- tearing of meningeal arteries
- blood accumulation and pressure occur rapidly (minutes to hours)
what are the signs of an epidural hematoma?
- possible brief loss of consciousness followed by lucidity
- gradual progression of signs and symptoms
- severe head pain
- dizziness
- nausea
- dilation of one pupil (anisocoria), on side of the injury
- determination of consciousness
- slowing pulse and respiration (lethargic)
- convulsion
what is the care for an epidural hematoma?
- requires urgent neurosurgical care
- relieve pressure to avoid disability or death
what is a subdural hematoma?
- bleeding under the dura mater in the brain
what is the cause of a subdural hematoma?
- the result of acceleration/deceleration forces
- tearing of the vessels that bridge dura matter and brain
- venous bleeding (little to no damage to the cerebellum, complicated bleeds can damage the cortex)
what are the acute signs of a subdural hematoma?
- LOC in seconds to minutes
- pupillary asymmetry
- headache
- dizziness
- nausea
- sleepiness (if not unconscious)
- falling in and out of consciousness quickly
what is the care for a subdural hematoma?
- immediate emergency medical attention
- CT or MRI to determine extent of injury
how long should you monitor an athlete following head trauma?
- 4-6 hours
- don’t send them home alone
- if in doubt, check it out
what are the steps to recognizing and managing facial injuries?
- assess (ABC’s)
- manage significant bleeding
- check nose and ears for CSF
- take a top-down approach to assess
- evaluation criteria
what are the ABC’s of assessment for facial trauma?
A = airway
B = breathing
C = consciousness (aka mental status)
why do you need to manage significant bleeding in the face?
- to better assess all structures (for better visibility)
how can you check the nose and ears for CSF?
- halo test with a gauze wad (in the nose or ears, wherever there is bloody drainage)
what is the top-down approach to assess facial injuries?
- look for facial asymmetry
- forehead and orbits
- maxilla and nose
- cheekbones (zygoma)
- oral cavity and mandible
what are the evaluation criteria for facial injuries?
- asymmetry
- bony steps
- bony mobility
- bruising
what is the cause of a forehead fracture?
- blunt trauma
- fairly resistant to fractures
- superior portion of the weaker orbital structures reside here
what are the signs of a forehead fracture?
- severe headache and nausea
- possible defect on palpation
- blood in ear, ear canal, and nose
- possible ecchymosis around eyes or behind ear
- halo sign may be seen
what is the cause of an orbital fracture?
- direct trauma to the eyeball
what are the signs of an orbital fracture?
- possible displacement of the eye (enophthalmos)
- diplopia
- restricted upward gaze
- downward displacement of the eye
- soft-tissue swelling and hemorrhaging
- subconjunctival hemorrhaging (red in the white of the eye)
- periorbital ecchymosis
- unilateral epistaxis (nosebleed on the injured side because of sinuses)
- numbness of the cheek, side of nose, upper lip or ipsilateral teeth (because of injury to the infraorbital nerve)
how do you care for an orbital fracture?
- ice
- no blowing nose
- no Valsalva maneuver (keep head upright and limit movement)
- *the risk of infection is high
- x-ray/CT to confirm fracture
- treated surgically or will resolve spontaneously
what are the signs of a midface (maxillary) fracture?
-*must also assess the airway and eyes (especially around the nose)
- visible lengthening and flattening of face
- mobile maxilla
- nasal bleeding
- ecchymosis of cheek
- malocclusion (alteration of bite) –> teeth won’t go together
how do you palpate to confirm a maxillary fracture?
- along maxilla (for major deformities)
- forehead stabilization with one hand, gently pull maxillary incisors (to see if face moves)
what are the 3 levels of maxillary fracture?
- Le Fort I = only under nose
- Le Fort II = up cheek bones and top of nose
- Le Fort III = up to top of eye sockets
what is the cause of a zygomatic complex fracture?
- direct blow to the cheek
what are the signs of a zygomatic complex fracture?
- deformity/ bony discrepancy
- palpable step-offs in the upper lateral orbital rim and inferior orbital rim
- numbness in cheek, side of nose, upper lip and ipsilateral teeth (due to infra-orbital nerve)
- nosebleed (on injured side, sinus fills with blood)
- double vision (diplopia)
- possible restricted eye movements
- possible subconjunctival hemorrhage and periorbital ecchymosis
how can you measure step-offs for a zygomatic complex fracture?
- place a ruler or pencil on the side of the head, should stick relatively straight down
- positive test is if the bottom of the ruler deviates
how do you care for a maxillary and zygomatic complex fracture?
- secure airway
- if conscious, keep upright for blood and saliva drainage (not down the throat)
- transport to emergency for diagnosis and imaging
what is the cause of a mandible fracture?
- direct blow
- often occurs at the angle or condyle (angle = sharp corner, condyle = where it connects to skull)
what are the signs of a mandible fracture?
- pain with biting
- +ve tongue blade test
- deformity
- loss of occlusion
- bleeding around teeth
- lower lip numbness
what is the tongue blade test?
- insert a wooden tongue depressor into patients molars
- tell them to bite down
- if you can twist the tongue depressor and it breaks, they likely didn’t fracture their mandible
- broken mandible will be weak, painful and likely unable to keep strength in bite
how do you care for a mandible fracture?
- secure airway
- immobilize with elastic wrap (around head to keep jaw closed) –> easy to remove in case of vomiting
- emergency medical referral
what is the best way to prevent dental injuries?
- wear a mouthguard - PROPERLY
- any type of mouthguard is effective
what are the three types of mouthguards?
- “boil and bite” mouthguards
- stock mouthpieces
- custom guards
what is the cause of tooth fractures?
- impact to the jaw
- direct dental trauma
what are the signs of the three types of tooth fractures?
- uncomplicated = fragments without bleeding
- complicated = bleeding, tooth chamber exposed, pain and sensitivity with air exposure, touch and temperature
- root fractures = requires an x-ray, may feel loose and have bleeding
how do you care for tooth fractures?
- uncomplicated and complicated do not require immediate attention (just within 24 hours)
- place broken off pieces into milk or save-a-tooth solution (NOT ON ICE)
- control bleeding with gauze
- for root fractures, follow-up immediately following the game
what is the cause of injury for tooth subluxation, luxation, avulsion and intrusion?
- direct blow
what are the signs of tooth subluxation?
- tooth may be loose within the socket
what are the signs of tooth luxation?
- displacement of the tooth, no fracture present
what are the 3 types of tooth luxation?
- intrusion
- extrusion
- lateral displacement
what are the signs of a tooth intrusion?
- tooth is driven back into the socket
- do not try to reposition
- refer to dentist immediately
what are the signs of a tooth extrusion?
- partially downwardly dislodged
- attempt to reposition
- hold in place by biting down
what are the signs of a laterally displaced tooth?
- forward, back or side to side
- do not attempt to reposition
- refer to a dentist immediately
what are the signs of tooth avulsion?
- tooth is completely removed from the oral cavity
how do you manage a tooth avulsion injury?
- locate and protect the tooth
- rinse lightly with milk (if soiled)
- do not rub or rinse with tap water (injures periodontal ligament cells and compromises implantation)
- try to reposition tooth if athlete is conscious (any position is fine, just want to keep viable)
- splint with hand or paper towel to hold in place
- immediate dental evaluation
- if unable to replace, put in milk or save-a-tooth
what is the cause of nasal fracture injuries?
- direct trauma
how do you examine nasal fracture injuries?
- palpate for crepitus or bony asymmetries
- palpate for depression of the nasal dorsum or deviation of the septum
- examine for septal hematoma (if deviated septum) (make athlete breath through each nostril individually)
how do you care for nasal fractures?
- secure airway if needed
- control bleeding by external pressure if needed
- internal packing (nose plugs, etc.)
- protect and transport for x-ray, exam and reduction
- will have little problem for return, may fix with surgery (depending on severity and athlete)
what is the cause of septal hematoma injuries?
- hemorrhage between the two layers of mucose covering the septum
what are the signs of a septal hematoma?
- blueish or dull red bulge on the septum
- nasal pain and difficulty breathing out of one nostril
how do you care for a septal hematoma?
- *untreated will lead to abscess and bone cartilage loss and deformity
- compression
- drain ASAP
- insert wick to allow for further drainage
- pack to prevent the return of hematoma (needs pressure)
what is the cause of injury of epistaxis?
- *aka nosebleed
- direct blow
- foreign body or other facial injuries
what are the signs of an epistaxis injury?
- bleeding from the anterior aspect of the septum
- presents minimal bleeding and resolves spontaneously
- may require medical attention is severe
how do you care for an epistaxis injury?
- blow nose (to clear clots)
- sit upright with head forward
- cold compress over nose and on back of neck
- after 5 minutes, may need septic or astringent
- after bleeding has stopped, player may return to play –> don’t let them blow their nose for 2 hours (may remove clots and cause rebleeding)
what is the mindset as a clinician caring for sport-related ocular injuries?
- salvage the remaining vision (once it’s gone, it’s gone)
- eye injuries have a very high likelihood of being severe
what is a subconjunctival hemorrhage?
- bright red area in the white conjunctiva
- popped blood vessels in the eye
what is the cause of a subconjunctival hemorrhage?
- occur spontaneously
- minor eye trauma or zygomatic fracture
- Valsalva maneuvers, coughing, sneezing, straining
how do you care for a subconjunctival hemorrhage?
- assess for vision issues
- if severe and blocking entire sclera, refer
- resolves in 2-3 weeks
what is a corneal abrasion?
- injury to the anterior layer of the eye
what is the cause of a corneal abrasion?
- poke to the eye
- attempt to remove foreign object by rubbing
what are the signs of a corneal abrasion?
- mild to severe pain
- watering of the eye
- photophobia (sensitive to bright light)
- pain with blinking
- decreased focus ability
- spasm of orbicular muscle of eyelid
how do you care for corneal abrasion?
- refer to the physician
- heal within 24-72 hours
- patch for younger athletes to avoid rubbing
- return to play once their vision is back and symptoms are gone (may require short-term eye protection)
what is hyphema?
- bleeding within the lens or retina of the eye (not present in the white of the eye)
what is the cause of hyphema?
- anterior chamber of eye injured due to blunt trauma
- high force injury! –> rule out penetrating trauma, orbital fracture, abrasion and retinal injury
- (will look like blood in the iris)
what are the signs of hyphema?
- visible reddish tinge (or pea green) in the anterior chamber of the eye
- vision is partially or completely blocked
how do you care for hyphema?
- immediate referral to an ophthalmologist
- bed rest (4 days) and elevation (30-40 degrees)
- patch both eyes (restrict strain)
- discontinue NSAIDs
- irreversible vision damage if not managed properly
what is periorbital ecchymosis?
- black eye
what is the cause of periorbital ecchymosis?
- blow to the area surrounding the eye
what are the signs of periorbital ecchymosis?
- swelling and discolouration
- subconjunctival hemorrhage may be a sign of a more serious condition
how do you care for periorbital ecchymosis?
- cold application for at least 30 minutes
- do not blow nose (may increase hemorrhaging)
what are the 4 steps for a basic eye assessment?
- history (determine force and direction of force)
- check vision (before any manipulation)
- pupil/cornea/conjunctiva
- eye movements
how do you check vision in step 2 of an eye assessment?
- get them to read a chart or newspaper (~ size 12 font)
- diplopia suggests serious injury
how do you examine the pupil/cornea/conjunctiva in step 3 of an eye assessment?
- penlight exam (PEARL)
- foreign bodies
- hyphema or subconjunctival hemorrhaging
how do you examine eye movements in step 4 of an eye assessment?
- full mobility (up, down, all around)
if a chemical injury is present in the eye, how long do you have to flush the eye for?
- flush immediately for 30 minutes
what is an airway injury?
- most dangerous maxillofacial injuries
- airway is compromised
what is the cause of an airway injury?
- blow to the anterior neck
what is laryngospasm?
- closure of the larynx caused by a spasm (may occur within 4-6 hours)
- causes athlete to panic
how do you treat a laryngospasm?
- move the chin forward and place strong anterior pressure behind the angle of the jaw
- hold for 45-60 seconds until you hear inspiration
- the best case scenario, the athlete passes out (this causes them to relax and therefore breathe normally)
what are the signs and symptoms of larynx injury (following trauma) –> aka cartilaginous fracture to thyroid/coricoid cartilage (6)
- speechlessness or hoarse, breathy voice
- loss of prominence (adams apple)
- difficulty breathing
- pain/tenderness when swallowing
- crepitation (crackly sound) on palpation of anterior neck (subcutaneous emphysema)
- hematoma/hemoptysis
* this is a medical emergency, pack and go ASAP
