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Head, Facial, & Neck Trauma. Sections  Introduction to Head, Facial, & Neck Injuries  Anatomy and Physiology of the Head, Face, & Neck  Pathophysiology.

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Presentation on theme: "Head, Facial, & Neck Trauma. Sections  Introduction to Head, Facial, & Neck Injuries  Anatomy and Physiology of the Head, Face, & Neck  Pathophysiology."— Presentation transcript:

1 Head, Facial, & Neck Trauma

2 Sections  Introduction to Head, Facial, & Neck Injuries  Anatomy and Physiology of the Head, Face, & Neck  Pathophysiology of Head, Facial, & Neck Injury  Assessment and Management of Head, Facial, & Neck Injuries  Head, Facial, & Neck Injury Management  Introduction to Head, Facial, & Neck Injuries  Anatomy and Physiology of the Head, Face, & Neck  Pathophysiology of Head, Facial, & Neck Injury  Assessment and Management of Head, Facial, & Neck Injuries  Head, Facial, & Neck Injury Management

3  Common major trauma  4 million people experience head trauma annually  Severe head injury is most frequent cause of trauma death  GSW to cranium: 75-80% mortality  At Risk population  Males  Infants  Young Children  Elderly  Common major trauma  4 million people experience head trauma annually  Severe head injury is most frequent cause of trauma death  GSW to cranium: 75-80% mortality  At Risk population  Males  Infants  Young Children  Elderly Introduction to Head, Facial, & Neck Injuries

4  Injury Prevention Programs  Motorcycle Safety  Bicycle Safety  Helmet & Head Injury Awareness Programs  Other Sports  Football  Rollerblading  Contact Sports  Injury Prevention Programs  Motorcycle Safety  Bicycle Safety  Helmet & Head Injury Awareness Programs  Other Sports  Football  Rollerblading  Contact Sports Introduction to Head, Facial, & Neck Injuries

5  TIME IS CRITICAL  Intracranial Hemorrhage  Progressing Edema  Increased ICP  Cerebral Hypoxia  Permanent Damage  Severity is difficult to recognize  Subtle signs  Improve differential diagnosis  Improves survivability  TIME IS CRITICAL  Intracranial Hemorrhage  Progressing Edema  Increased ICP  Cerebral Hypoxia  Permanent Damage  Severity is difficult to recognize  Subtle signs  Improve differential diagnosis  Improves survivability Introduction to Head, Facial, & Neck Injuries

6  Anatomy & Physiology of the Head  Scalp  Cranium  Meninges  Cerebrospinal Fluid  Brain  CNS Circulation  Blood-Brain Barrier  Cerebral Perfusion Pressure  Cranial Nerves  Ascending Reticular Activating System  Anatomy & Physiology of the Head  Scalp  Cranium  Meninges  Cerebrospinal Fluid  Brain  CNS Circulation  Blood-Brain Barrier  Cerebral Perfusion Pressure  Cranial Nerves  Ascending Reticular Activating System Anatomy & Physiology Head, Face & Neck

7  Scalp  Strong Flexible mass of  Skin  Fascia  Muscular Tissue  Highly Vascular  Hair provides Insulation  Structures Beneath  Galea Aponeurotica Between scalp and skull Fibrous connective sheath  Subaponeurotica (Areolar) Tissue Permits venous blood flow from the dural sinuses to the venous vessels of scalp  Emissary Veins: Potential route for Infection  Scalp  Strong Flexible mass of  Skin  Fascia  Muscular Tissue  Highly Vascular  Hair provides Insulation  Structures Beneath  Galea Aponeurotica Between scalp and skull Fibrous connective sheath  Subaponeurotica (Areolar) Tissue Permits venous blood flow from the dural sinuses to the venous vessels of scalp  Emissary Veins: Potential route for Infection Anatomy & Physiology of the Head

8 Recalling Structures of the Scalp S - skin C - connective tissue A - aponeurotica L - layer of areolar tissue P - periosteum of skull Recalling Structures of the Scalp S - skin C - connective tissue A - aponeurotica L - layer of areolar tissue P - periosteum of skull Anatomy & Physiology of the Head

9  Skull comprised of  Facial bones  Cranium  Vault for the brain  Strong, light, rigid, spherical bone  Unyielding to increased intracranial pressure (ICP)  Bones Frontal Parietal Occipital Temporal Ethmoid Sphenoid  Skull comprised of  Facial bones  Cranium  Vault for the brain  Strong, light, rigid, spherical bone  Unyielding to increased intracranial pressure (ICP)  Bones Frontal Parietal Occipital Temporal Ethmoid Sphenoid Anatomy & Physiology of the Head

10 Parietal Suture Line Frontal Temporal Orbits Maxillae Mandible Temporal Mandibular Joint Occiptal Nasal Bones Zygomatic Arch Sphenoid Foramen Magnum (Hole in Base)

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12  Skull  Other Structures  Foramen Magnum Largest opening of the skull Spinal cord exits  Cribriform Plate Inferior aspect (Base) Rough surface Brain can be easily injured  Abrade  Contusion  Laceration  Skull  Other Structures  Foramen Magnum Largest opening of the skull Spinal cord exits  Cribriform Plate Inferior aspect (Base) Rough surface Brain can be easily injured  Abrade  Contusion  Laceration Anatomy & Physiology of the Head

13  Meninges Protective mechanism for the CNS  Dura Mater  Layers Outer: Cranium’s inner periosteum Inner: Dural Layer Between: Dural Sinuses:  Venous drains for brain  Provides continuous connective tissue  Forms partial structural divisions Falx cerebri Tentorium cerebelli  Large arteries above Provide blood flow to the surface of the brain  Meninges Protective mechanism for the CNS  Dura Mater  Layers Outer: Cranium’s inner periosteum Inner: Dural Layer Between: Dural Sinuses:  Venous drains for brain  Provides continuous connective tissue  Forms partial structural divisions Falx cerebri Tentorium cerebelli  Large arteries above Provide blood flow to the surface of the brain Anatomy & Physiology of the Head

14  Meninges  Pia Mater  Closest to brain and spinal cord  Delicate tissue  Covers all areas of brain and spinal cord  Very Vascular Supply superficial areas of brain  Arachnoid Membrane  “Spider-like”  Covers inner dura  Suspends brain in cranial cavity Collagen & Elastin fibers  Subarachnoid Space beneath CSF Cushions brain  Meninges  Pia Mater  Closest to brain and spinal cord  Delicate tissue  Covers all areas of brain and spinal cord  Very Vascular Supply superficial areas of brain  Arachnoid Membrane  “Spider-like”  Covers inner dura  Suspends brain in cranial cavity Collagen & Elastin fibers  Subarachnoid Space beneath CSF Cushions brain Anatomy & Physiology of the Head

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16  Cerebrospinal Fluid  Clear, colorless fluid  Comprised of  Water  Protein  Salts  Cushions CNS  Made in largest two ventricles of brain  Medium for nutrients and waste products to diffuse into and out of brain  Cerebrospinal Fluid  Clear, colorless fluid  Comprised of  Water  Protein  Salts  Cushions CNS  Made in largest two ventricles of brain  Medium for nutrients and waste products to diffuse into and out of brain Anatomy & Physiology of the Head

17  Brain  Occupies 80% of cranium  Comprised of 3 Major Structures  Cerebrum  Cerebellum  Brainstem  High metabolic rate  Receives 15% of cardiac output  Consumes 20% of body’s oxygen  Requires constant circulation  IF Blood supply stops  Unconscious within 10 seconds  Death in 4-6 minutes  Brain  Occupies 80% of cranium  Comprised of 3 Major Structures  Cerebrum  Cerebellum  Brainstem  High metabolic rate  Receives 15% of cardiac output  Consumes 20% of body’s oxygen  Requires constant circulation  IF Blood supply stops  Unconscious within 10 seconds  Death in 4-6 minutes Anatomy & Physiology of the Head

18  Cerebrum  Function  Center of conscious thought, personality, speech, and motor control  Visual, auditory, and tactile perception  Lobes  Frontal Personality  Parietal Motor & Sensory Activity Memory & Emotion  Cerebrum  Function  Center of conscious thought, personality, speech, and motor control  Visual, auditory, and tactile perception  Lobes  Frontal Personality  Parietal Motor & Sensory Activity Memory & Emotion Anatomy & Physiology of the Head (continued)

19  Occipital Sight  Temporal Long-term memory Hearing, Speech, Taste & Smell  Occipital Sight  Temporal Long-term memory Hearing, Speech, Taste & Smell Anatomy & Physiology of the Head

20  Cerebrum  Falx Cerebri  Divides cerebrum into right and left hemispheres  Central Sulcus  Fissure splits cerebrum into right and left hemispheres  Each hemisphere controls the opposite side of the body  Tentorium  Fibrous sheet within occipital region  Brainstem perforates thru incisura tentorri cerebelli  Occulomotor Nerve (CN-III) travels along Controls pupil size Compression results in pupillary disturbances  Cerebrum  Falx Cerebri  Divides cerebrum into right and left hemispheres  Central Sulcus  Fissure splits cerebrum into right and left hemispheres  Each hemisphere controls the opposite side of the body  Tentorium  Fibrous sheet within occipital region  Brainstem perforates thru incisura tentorri cerebelli  Occulomotor Nerve (CN-III) travels along Controls pupil size Compression results in pupillary disturbances Anatomy & Physiology of the Head

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22  Cerebrum  Hemisphere Functions  Left: DOMINANT Mathematical computations: Occipital Writing: Parietal Language interpretation: Occipital Speech: Frontal  Right: NON-DOMINANT Non-verbal imagery  Cerebrum  Hemisphere Functions  Left: DOMINANT Mathematical computations: Occipital Writing: Parietal Language interpretation: Occipital Speech: Frontal  Right: NON-DOMINANT Non-verbal imagery Anatomy & Physiology of the Head

23  Cerebellum  Located under tentorium  Function  “Fine tunes” motor control  Allows smooth movement  Balance  Maintenance of muscle tone  Cerebellum  Located under tentorium  Function  “Fine tunes” motor control  Allows smooth movement  Balance  Maintenance of muscle tone Anatomy & Physiology of the Head

24  Brainstem  Central processing center  Communication junction among  Cerebrum  Spinal cord  Cranial nerves  Cerebellum  Structures  Midbrain  Pons  Medulla Oblongata  Brainstem  Central processing center  Communication junction among  Cerebrum  Spinal cord  Cranial nerves  Cerebellum  Structures  Midbrain  Pons  Medulla Oblongata Anatomy & Physiology of the Head

25  Midbrain  Upper portion of brainstem  Structures  Hypothalamus Endocrine function, vomiting reflex, hunger, thirst Kidney function, body temperature, emotion  Thalamus Switching center between pons & cerebrum Critical Element in Ascending Reticular Activating System (A-RAS)  ESTABLISHES CONSCIOUSNESS Major pathways for optic & olfactory nerves  Associated Structures  Midbrain  Upper portion of brainstem  Structures  Hypothalamus Endocrine function, vomiting reflex, hunger, thirst Kidney function, body temperature, emotion  Thalamus Switching center between pons & cerebrum Critical Element in Ascending Reticular Activating System (A-RAS)  ESTABLISHES CONSCIOUSNESS Major pathways for optic & olfactory nerves  Associated Structures Anatomy & Physiology of the Head

26  Pons  Communication interchange between cerebellum, cerebrum, midbrain, and spinal cord  Bulb shaped structure above medulla  Sleeping phase of the RAS  Pons  Communication interchange between cerebellum, cerebrum, midbrain, and spinal cord  Bulb shaped structure above medulla  Sleeping phase of the RAS Anatomy & Physiology of the Head

27  Medulla Oblongata  Bulge in the top of the spinal cord  Centers  Respiratory Center Controls depth, rate and rhythm  Cardiac Center Regulates rate and strength of cardiac contractions  Vasomotor Center Distribution of blood Maintains blood pressure  Medulla Oblongata  Bulge in the top of the spinal cord  Centers  Respiratory Center Controls depth, rate and rhythm  Cardiac Center Regulates rate and strength of cardiac contractions  Vasomotor Center Distribution of blood Maintains blood pressure Anatomy & Physiology of the Head

28  CNS Circulation  Arterial  Four Major Arteries 2 Internal Carotid Arteries  From the common carotid 2 Vertebral Arteries  Circle of Willis Internal Carotids and Vertebral Arteries Encircle the base of the brain  Venous  Venous drainage occurs through bridging veins  Bridge Dural Sinuses  Drain into internal jugular veins  CNS Circulation  Arterial  Four Major Arteries 2 Internal Carotid Arteries  From the common carotid 2 Vertebral Arteries  Circle of Willis Internal Carotids and Vertebral Arteries Encircle the base of the brain  Venous  Venous drainage occurs through bridging veins  Bridge Dural Sinuses  Drain into internal jugular veins Anatomy & Physiology of the Head

29  Blood-Brain Barrier  Less permeable than elsewhere in body  DO NOT allow flow of interstitial proteins  Reduced lymphatic flow  Very protected environment  Blood acts as irritant resulting in cerebral edema  Blood-Brain Barrier  Less permeable than elsewhere in body  DO NOT allow flow of interstitial proteins  Reduced lymphatic flow  Very protected environment  Blood acts as irritant resulting in cerebral edema Anatomy & Physiology of the Head

30  Cerebral Perfusion Pressure  Pressure within cranium (ICP) resists blood flow and good perfusion to the CNS  Pressure usually less than 10 mmHg  Mean Arterial Pressure (MAP)  Must be at least 50 mmHg to ensure adequate perfusion  MAP = DBP + 1/3 Pulse Pressure  Cerebral Perfusion Pressure (CPP)  Pressure moving blood through the cranium  CPP = MAP - ICP  Cerebral Perfusion Pressure  Pressure within cranium (ICP) resists blood flow and good perfusion to the CNS  Pressure usually less than 10 mmHg  Mean Arterial Pressure (MAP)  Must be at least 50 mmHg to ensure adequate perfusion  MAP = DBP + 1/3 Pulse Pressure  Cerebral Perfusion Pressure (CPP)  Pressure moving blood through the cranium  CPP = MAP - ICP Anatomy & Physiology of the Head

31  Calculating MAP  Calculating CPP  Calculating MAP  Calculating CPP Anatomy & Physiology of the Head

32  Cerebral Perfusion Pressure  Autoregulation  Changes in ICP result in compensation  Increased ICP = Increased BP This causes ICP to rise higher and BP to rise  Brain injury and death become imminent  Expanding mass inside cranial vault  Displaces CSF  If pressure increases, brain tissue is displaced  Cerebral Perfusion Pressure  Autoregulation  Changes in ICP result in compensation  Increased ICP = Increased BP This causes ICP to rise higher and BP to rise  Brain injury and death become imminent  Expanding mass inside cranial vault  Displaces CSF  If pressure increases, brain tissue is displaced Anatomy & Physiology of the Head

33  Cranial Nerves  12 pair with distinct pathways  Senses, facial innervation, & body function control  Ascending Reticular Activation System  Tract of neurons in upper brainstem, pons, and midbrain  Responsible for sleep-wake cycle  Monitors input stimulation  Regulates body functions  Respiration  Heart Rate  Peripheral Vascular Resistance  Injury may result in prolonged waking state  Cranial Nerves  12 pair with distinct pathways  Senses, facial innervation, & body function control  Ascending Reticular Activation System  Tract of neurons in upper brainstem, pons, and midbrain  Responsible for sleep-wake cycle  Monitors input stimulation  Regulates body functions  Respiration  Heart Rate  Peripheral Vascular Resistance  Injury may result in prolonged waking state Anatomy & Physiology of the Head

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35 Face MusclesM Chewing musclesM Posterior palate and pharynxM Face MusclesM SightS OpticII Pupil Const, Rectus & ObliquesM OculomotorIII Opthalmic (FH), Maxillary (cheek) Mandible (chin) S TrigeminalV Lateral rectus muscleM AbducensVI Taste to posterior tongueS VagusX TongueM HypoglossalXII Trapezius & Sternocleido. MusclesM AccessoryXI Hearing balanceS AcousticVIII Superior ObliquesM TrochlearIV TongueS FacialVII Posterior pharynx, taste to anterior tongueS Glossopharyn- geal IX SmellS OlfactoryI InnervationFNameCN

36  Anatomy & Physiology of the Face  Structure  Ear  Eye  Anatomy & Physiology of the Face  Structure  Ear  Eye Anatomy & Physiology Head, Face & Neck

37  Structure  Facial Bones  Zygoma Prominent bone of the cheek Protects eyes Attachment for muscles controlling eye & jaw movement  Maxilla Upper jaw Supports the nasal bone Provides lower border of orbit  Mandible Jaw bone  Nasal Bones  Structure  Facial Bones  Zygoma Prominent bone of the cheek Protects eyes Attachment for muscles controlling eye & jaw movement  Maxilla Upper jaw Supports the nasal bone Provides lower border of orbit  Mandible Jaw bone  Nasal Bones Anatomy & Physiology of the Face

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39  Structure  Covered with skin  Flexible and thin  Highly vascular  Minimal layer of subcutaneous tissue  Circulation  External carotid artery  Supplies facial area  Branches Facial, Temporal & Maxillary Arteries  Structure  Covered with skin  Flexible and thin  Highly vascular  Minimal layer of subcutaneous tissue  Circulation  External carotid artery  Supplies facial area  Branches Facial, Temporal & Maxillary Arteries Anatomy & Physiology of the Face

40  Nerves  Trigeminal (CN-V)  Facial Sensation  Some eye motor control  Enables chewing process  Facial (CN-VII)  Motor control for facial muscles  Sensation of taste  Nerves  Trigeminal (CN-V)  Facial Sensation  Some eye motor control  Enables chewing process  Facial (CN-VII)  Motor control for facial muscles  Sensation of taste Anatomy & Physiology of the Face

41  Nasal Cavity  Upper Border  Bones Junction of Ethmoid, Nasal, & Maxillary Bones  Bony Septum Right & Left Chamber  Turbinates Vascular mucosa support Warm, Humidify, and Filter incoming air  Lower Border  Bony Hard Palate  Soft Palate Moves upward during swallowing  Nasal Cartilage  Forms Nares  Nasal Cavity  Upper Border  Bones Junction of Ethmoid, Nasal, & Maxillary Bones  Bony Septum Right & Left Chamber  Turbinates Vascular mucosa support Warm, Humidify, and Filter incoming air  Lower Border  Bony Hard Palate  Soft Palate Moves upward during swallowing  Nasal Cartilage  Forms Nares Anatomy & Physiology of the Face

42  Oral Cavity  Formed Structures  Maxillary bone  Palate  Upper teeth meeting the mandible and lower teeth  Floor  Tongue Connects to hyoid bone  Free-floating U-shaped bone inferior & posterior of the mandible  Mandible  Articulates with the TMJ joint  Oral Cavity  Formed Structures  Maxillary bone  Palate  Upper teeth meeting the mandible and lower teeth  Floor  Tongue Connects to hyoid bone  Free-floating U-shaped bone inferior & posterior of the mandible  Mandible  Articulates with the TMJ joint Anatomy & Physiology of the Face

43  Special Structures  Salivary Glands  First stage in digestion  Location Anterior and inferior to the ear Under tongue Inside the inferior mandible  Tonsils  Posterior wall of the pharynx  Special Structures  Salivary Glands  First stage in digestion  Location Anterior and inferior to the ear Under tongue Inside the inferior mandible  Tonsils  Posterior wall of the pharynx Anatomy & Physiology of the Face (continued)

44  Sinuses  Hollow spaces in cranium and facial bones  Function Lighten head Protect eyes and nasal cavity Produce resonant tones of voice Strengthen area against trauma  Sinuses  Hollow spaces in cranium and facial bones  Function Lighten head Protect eyes and nasal cavity Produce resonant tones of voice Strengthen area against trauma Anatomy & Physiology of the Face

45  Cranial Nerves  CN-XII (Hypoglossal)  Swallowing & tongue movement  CN-IX (Glossopharyngeal)  Saliva production & taste  CN-V (Trigeminal)  Sensations from facial region & aids in chewing  CN-VII (Facial)  Muscles of facial expression & taste  Cranial Nerves  CN-XII (Hypoglossal)  Swallowing & tongue movement  CN-IX (Glossopharyngeal)  Saliva production & taste  CN-V (Trigeminal)  Sensations from facial region & aids in chewing  CN-VII (Facial)  Muscles of facial expression & taste Anatomy & Physiology of the Face

46  Pharynx  Posterior & Inferior to the oral cavity  Aids in swallowing  Bolus of food propelled back & down by tongue  Epiglottis moves downward  Larynx moves up Combined effect seals airway  Peristaltic wave moves food down esophagus  Pharynx  Posterior & Inferior to the oral cavity  Aids in swallowing  Bolus of food propelled back & down by tongue  Epiglottis moves downward  Larynx moves up Combined effect seals airway  Peristaltic wave moves food down esophagus Anatomy & Physiology of the Face

47  Ear  Function  Hearing  Positional sense  Structures  Pinna Outer visible portion Formed of Cartilage & has Poor blood supply  External Auditory Canal Glands that secrete cerumen (wax)  Middle & Inner Ear Structures for hearing and positional sense  Ear  Function  Hearing  Positional sense  Structures  Pinna Outer visible portion Formed of Cartilage & has Poor blood supply  External Auditory Canal Glands that secrete cerumen (wax)  Middle & Inner Ear Structures for hearing and positional sense Anatomy & Physiology of the Face

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49  Ear  Structures for Hearing  Tympanic membrane  Ossicle bones  Cochlea  Auditory Nerve  Structures for Proprioception  Semicircular canals Sense position & motion  Present when eyes are closed  Vertigo Continuous movement sensation  Ear  Structures for Hearing  Tympanic membrane  Ossicle bones  Cochlea  Auditory Nerve  Structures for Proprioception  Semicircular canals Sense position & motion  Present when eyes are closed  Vertigo Continuous movement sensation Anatomy & Physiology of the Face

50  Eye  Structures  Sclera  Cornea  Conjunctiva  Anterior Chamber Aqueous humor Iris  Pupil  Lens  Posterior Chamber Vitreous humor  Retina  Lacrimal Fluid  Bathes, protects, and nourishes cornea  Eye  Structures  Sclera  Cornea  Conjunctiva  Anterior Chamber Aqueous humor Iris  Pupil  Lens  Posterior Chamber Vitreous humor  Retina  Lacrimal Fluid  Bathes, protects, and nourishes cornea Anatomy & Physiology of the Face

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52  Eye  Innervation  CN-III (Oculomotor) Pupil dilation Conjugate movement  Movement of eyes together Normal range of motion  CN-IV (Trochlear) Downward & inward movement  CN-VI (Abducens) Abduction (outward) gaze  Eye  Innervation  CN-III (Oculomotor) Pupil dilation Conjugate movement  Movement of eyes together Normal range of motion  CN-IV (Trochlear) Downward & inward movement  CN-VI (Abducens) Abduction (outward) gaze Anatomy & Physiology of the Face

53  Vasculature of the Neck  Carotid Arteries  Arise from RIGHT: Brachiocephalic Artery LEFT: Aorta Artery  Split Internal & External Carotid Arteries Upper border of the Larynx Carotid Bodies & Sinuses located  Bodies: Monitor CO 2 and O 2 levels  Sinuses: Monitor Blood Pressure  Vasculature of the Neck  Carotid Arteries  Arise from RIGHT: Brachiocephalic Artery LEFT: Aorta Artery  Split Internal & External Carotid Arteries Upper border of the Larynx Carotid Bodies & Sinuses located  Bodies: Monitor CO 2 and O 2 levels  Sinuses: Monitor Blood Pressure Anatomy & Physiology of the Neck (continued)

54  Jugular Veins  External Superficial, lateral to the trachea  Internal Sheath with the carotid artery and vagus nerve  Jugular Veins  External Superficial, lateral to the trachea  Internal Sheath with the carotid artery and vagus nerve Anatomy & Physiology of the Neck

55  Airway Structures  Larynx  Epiglottis  Thyroid & Cricoid Cartilage  Trachea  Posterior border is anterior border of esophagus  Airway Structures  Larynx  Epiglottis  Thyroid & Cricoid Cartilage  Trachea  Posterior border is anterior border of esophagus Anatomy & Physiology of the Neck

56  Other Structures  Cervical Spine  Musculoskeletal Function External Skeletal support of the head and neck Attachment point for spinal column ligaments Attachment point for tendons to move head and shoulders  Nervous Function Spinal Cord contained within Peripheral Nerve  Exit between vertebrae  Other Structures  Cervical Spine  Musculoskeletal Function External Skeletal support of the head and neck Attachment point for spinal column ligaments Attachment point for tendons to move head and shoulders  Nervous Function Spinal Cord contained within Peripheral Nerve  Exit between vertebrae Anatomy & Physiology of the Neck

57  Other Structures  Esophagus  Cranial Nerves  CN-IX (Glossopharyngeal) Carotid Bodies & Carotid Sinuses  CN-X Speech, swallowing, cardiac, respiratory & visceral function  Thoracic Duct  Delivers lymph to the venous system  Other Structures  Esophagus  Cranial Nerves  CN-IX (Glossopharyngeal) Carotid Bodies & Carotid Sinuses  CN-X Speech, swallowing, cardiac, respiratory & visceral function  Thoracic Duct  Delivers lymph to the venous system Anatomy & Physiology of the Neck (continued)

58  Glands  Thyroid Rate of cellular metabolism Systemic levels of calcium  Brachial Plexus  Network of nerves in lower neck and should that control arm and hand function  Glands  Thyroid Rate of cellular metabolism Systemic levels of calcium  Brachial Plexus  Network of nerves in lower neck and should that control arm and hand function Anatomy & Physiology of the Neck

59  Mechanism of Injury  Blunt Injury  Motor vehicle collisions  Assaults  Falls  Penetrating Injury  Gunshot wounds  Stabbing  Explosions  “Clothesline”  Mechanism of Injury  Blunt Injury  Motor vehicle collisions  Assaults  Falls  Penetrating Injury  Gunshot wounds  Stabbing  Explosions  “Clothesline” Pathophysiology of Head, Facial, & Neck Injury

60 Scalp Injury  Contusions  Lacerations  Avulsions  Significant Hemorrhage ALWAYS Reconsider MOI for severe underlying problems  Contusions  Lacerations  Avulsions  Significant Hemorrhage ALWAYS Reconsider MOI for severe underlying problems

61 Cranial Injury  Trauma must be extreme to fracture  Linear  Depressed  Open  Impaled Object  Basal Skull  Unprotected  Spaces weaken structure  Relatively easier to fracture  Trauma must be extreme to fracture  Linear  Depressed  Open  Impaled Object  Basal Skull  Unprotected  Spaces weaken structure  Relatively easier to fracture

62 Cranial Injury  Basal Skull Fracture Signs  Battle’s Signs  Retroauricular Ecchymosis  Associated with fracture of auditory canal and lower areas of skull  Raccoon Eyes  Bilateral Periorbital Ecchymosis  Associated with orbital fractures  Basal Skull Fracture Signs  Battle’s Signs  Retroauricular Ecchymosis  Associated with fracture of auditory canal and lower areas of skull  Raccoon Eyes  Bilateral Periorbital Ecchymosis  Associated with orbital fractures

63 Cranial Injury  Basilar Skull Fracture  May tear dura  Permit CSF to drain through an external passageway May mediate rise of ICP Evaluate for “Target” or “Halo” sign  Basilar Skull Fracture  May tear dura  Permit CSF to drain through an external passageway May mediate rise of ICP Evaluate for “Target” or “Halo” sign

64 Brain Injury  As defined by the National Head Injury Foundation  “a traumatic insult to the brain capable of producing physical, intellectual, emotional, social and vocational changes.”  Classification  Direct Primary injury caused by forces of trauma  Indirect Secondary injury caused by factors resulting from the primary injury  As defined by the National Head Injury Foundation  “a traumatic insult to the brain capable of producing physical, intellectual, emotional, social and vocational changes.”  Classification  Direct Primary injury caused by forces of trauma  Indirect Secondary injury caused by factors resulting from the primary injury

65 Direct Brain Injury Types  Coup  Injury at site of impact  Contrecoup  Injury on opposite side from impact  Coup  Injury at site of impact  Contrecoup  Injury on opposite side from impact

66 Direct Brain Injury Categories  Focal  Occur at a specific location in brain  Differentials  Cerebral Contusion  Intracranial Hemorrhage Epidural hematoma Subdural hematoma  Intracerebral Hemorrhage  Diffuse  Concussion  Moderate Diffuse Axonal Injury  Severe Diffuse Axonal Injury  Focal  Occur at a specific location in brain  Differentials  Cerebral Contusion  Intracranial Hemorrhage Epidural hematoma Subdural hematoma  Intracerebral Hemorrhage  Diffuse  Concussion  Moderate Diffuse Axonal Injury  Severe Diffuse Axonal Injury

67 Focal Brain Injury  Cerebral Contusion  Blunt trauma to local brain tissue  Capillary bleeding into brain tissue  Common with blunt head trauma  Confusion  Neurologic deficit Personality changes Vision changes Speech changes  Results from  Coup-contrecoup injury  Cerebral Contusion  Blunt trauma to local brain tissue  Capillary bleeding into brain tissue  Common with blunt head trauma  Confusion  Neurologic deficit Personality changes Vision changes Speech changes  Results from  Coup-contrecoup injury

68  Epidural Hematoma  Bleeding between dura mater and skull  Involves arteries  Middle meningeal artery most common  Rapid bleeding & reduction of oxygen to tissues  Herniates brain toward foramen magnum  Epidural Hematoma  Bleeding between dura mater and skull  Involves arteries  Middle meningeal artery most common  Rapid bleeding & reduction of oxygen to tissues  Herniates brain toward foramen magnum Focal Brain Injury Intracranial Hemorrhage

69  Subdural Hematoma  Bleeding within meninges  Beneath dura mater & within subarachnoid space  Above pia mater  Slow bleeding  Superior sagital sinus  Signs progress over several days  Slow deterioration of mentation  Subdural Hematoma  Bleeding within meninges  Beneath dura mater & within subarachnoid space  Above pia mater  Slow bleeding  Superior sagital sinus  Signs progress over several days  Slow deterioration of mentation Focal Brain Injury Intracranial Hemorrhage

70  Intracerebral Hemorrhage  Rupture blood vessel within the brain  Presentation similar to stroke symptoms  Signs and symptoms worsen over time  Intracerebral Hemorrhage  Rupture blood vessel within the brain  Presentation similar to stroke symptoms  Signs and symptoms worsen over time Focal Brain Injury Intracranial Hemorrhage

71 Diffuse Brain Injury  Due to stretching forces placed on axons  Pathology distributed throughout brain  Types  Concussion  Moderate Diffuse Axonal Injury  Severe Diffuse Axonal Injury  Due to stretching forces placed on axons  Pathology distributed throughout brain  Types  Concussion  Moderate Diffuse Axonal Injury  Severe Diffuse Axonal Injury

72  Mild to moderate form of Diffuse Axonal Injury (DAI)  Nerve dysfunction without anatomic damage  Transient episode of  Confusion, Disorientation, Event amnesia  Suspect if patient has a momentary loss of consciousness  Management  Frequent reassessment of mentation  ABC’s  Mild to moderate form of Diffuse Axonal Injury (DAI)  Nerve dysfunction without anatomic damage  Transient episode of  Confusion, Disorientation, Event amnesia  Suspect if patient has a momentary loss of consciousness  Management  Frequent reassessment of mentation  ABC’s Diffuse Brain Injury Concussion

73  “Classic Concussion”  Same mechanism as concussion  Additional: Minute bruising of brain tissue  Unconsciousness  If cerebral cortex and RAS involved  May exist with a basilar skull fracture  Signs & Symptoms  Unconsciousness or Persistent confusion  Loss of concentration, disorientation  Retrograde & Antegrade amnesia  Visual and sensory disturbances  Mood or Personality changes  “Classic Concussion”  Same mechanism as concussion  Additional: Minute bruising of brain tissue  Unconsciousness  If cerebral cortex and RAS involved  May exist with a basilar skull fracture  Signs & Symptoms  Unconsciousness or Persistent confusion  Loss of concentration, disorientation  Retrograde & Antegrade amnesia  Visual and sensory disturbances  Mood or Personality changes Diffuse Brain Injury Moderate Diffuse Axonal Injury

74  Brainstem Injury  Significant mechanical disruption of axons  Cerebral hemispheres and brainstem  High mortality rate  Signs & Symptoms  Prolonged unconsciousness  Cushing’s reflex  Decorticate or Decerebrate posturing  Brainstem Injury  Significant mechanical disruption of axons  Cerebral hemispheres and brainstem  High mortality rate  Signs & Symptoms  Prolonged unconsciousness  Cushing’s reflex  Decorticate or Decerebrate posturing Diffuse Brain Injury Severe Diffuse Axonal Injury

75 Intracranial Perfusion  Review  Cranial volume fixed  80% = Cerebrum, cerebellum & brainstem  12% = Blood vessels & blood  8% = CSF  Increase in size of one component diminishes size of another  Inability to adjust = increased ICP  Review  Cranial volume fixed  80% = Cerebrum, cerebellum & brainstem  12% = Blood vessels & blood  8% = CSF  Increase in size of one component diminishes size of another  Inability to adjust = increased ICP

76 Intracranial Perfusion  Compensating for Pressure  Compress venous blood vessels  Reduction in free CSF  Pushed into spinal cord  Decompensating for Pressure  Increase in ICP  Rise in systemic BP to perfuse brain  Further increase of ICP Dangerous cycle  Compensating for Pressure  Compress venous blood vessels  Reduction in free CSF  Pushed into spinal cord  Decompensating for Pressure  Increase in ICP  Rise in systemic BP to perfuse brain  Further increase of ICP Dangerous cycle ICPBP

77 Intracranial Pressure  Role of Carbon Dioxide  Increase of CO 2 in CSF  Cerebral Vasodilation Encourage blood flow Reduce hypercarbia Reduce hypoxia  Contributes to  ICP  Causes classic  Hyperventilation & Hypertension  Reduced levels of CO 2 in CSF  Cerebral vasoconstriction Results in cerebral anoxia  Role of Carbon Dioxide  Increase of CO 2 in CSF  Cerebral Vasodilation Encourage blood flow Reduce hypercarbia Reduce hypoxia  Contributes to  ICP  Causes classic  Hyperventilation & Hypertension  Reduced levels of CO 2 in CSF  Cerebral vasoconstriction Results in cerebral anoxia

78 Factors Affecting ICP  Vasculature Constriction  Cerebral Edema  Systolic Blood Pressure  Low BP = Poor Cerebral Perfusion  High BP = Increased ICP  Carbon Dioxide  Reduced respiratory efficiency  Vasculature Constriction  Cerebral Edema  Systolic Blood Pressure  Low BP = Poor Cerebral Perfusion  High BP = Increased ICP  Carbon Dioxide  Reduced respiratory efficiency

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80  Increased pressure  Compresses brain tissue  Against & around Falx Cerebri Tentorium Cerebelli  Herniates brainstem  Compromises blood supply  Signs & Symptoms Upper Brainstem  Vomiting  Altered mental status  Pupillary dilation Medulla Oblongata  Respiratory  Cardiovascular  Blood Pressure disturbances  Increased pressure  Compresses brain tissue  Against & around Falx Cerebri Tentorium Cerebelli  Herniates brainstem  Compromises blood supply  Signs & Symptoms Upper Brainstem  Vomiting  Altered mental status  Pupillary dilation Medulla Oblongata  Respiratory  Cardiovascular  Blood Pressure disturbances Pressure & Structural Displacement

81  Altered Mental Status  Altered orientation  Alteration in personality  Amnesia  Retrograde  Antegrade  Cushing’s Reflex  Increased BP  Bradycardia  Erratic respirations  Altered Mental Status  Altered orientation  Alteration in personality  Amnesia  Retrograde  Antegrade  Cushing’s Reflex  Increased BP  Bradycardia  Erratic respirations Signs & Symptoms of Brain Injury  Vomiting  Without nausea  Projectile  Body temperature changes  Changes in pupil reactivity  Decorticate posturing  Vomiting  Without nausea  Projectile  Body temperature changes  Changes in pupil reactivity  Decorticate posturing

82  Pathophysiology of Changes  Frontal Lobe Injury  Alterations in personality  Occipital Lobe Injury  Visual disturbances  Cortical Disruption  Reduce mental status or Amnesia Retrograde  Unable to recall events before injury Antegrade  Unable to recall events after trauma  “Repetitive Questioning”  Focal Deficits  Hemiplegia, Weakness or Seizures  Pathophysiology of Changes  Frontal Lobe Injury  Alterations in personality  Occipital Lobe Injury  Visual disturbances  Cortical Disruption  Reduce mental status or Amnesia Retrograde  Unable to recall events before injury Antegrade  Unable to recall events after trauma  “Repetitive Questioning”  Focal Deficits  Hemiplegia, Weakness or Seizures Signs & Symptoms of Brain Injury

83  Upper Brainstem Compression  Increasing blood pressure  Reflex bradycardia  Vagus nerve stimulation  Cheyne-Stokes respirations  Pupils become small and reactive  Decorticate posturing  Neural pathway disruption  Upper Brainstem Compression  Increasing blood pressure  Reflex bradycardia  Vagus nerve stimulation  Cheyne-Stokes respirations  Pupils become small and reactive  Decorticate posturing  Neural pathway disruption Signs & Symptoms of Brain Injury Physiological Changes

84  Middle Brainstem Compression  Widening pulse pressure  Increasing bradycardia  CNS Hyperventilation  Deep and Rapid  Bilateral pupil sluggishness or inactivity  Decerebrate posturing  Middle Brainstem Compression  Widening pulse pressure  Increasing bradycardia  CNS Hyperventilation  Deep and Rapid  Bilateral pupil sluggishness or inactivity  Decerebrate posturing Signs & Symptoms of Brain Injury Physiological Changes

85  Lower Brainstem Injury  Pupils dilated and unreactive  Ataxic respirations  Erratic with no pattern  Irregular and erratic pulse rate  ECG Changes  Hypotension  Loss of response to painful stimuli  Lower Brainstem Injury  Pupils dilated and unreactive  Ataxic respirations  Erratic with no pattern  Irregular and erratic pulse rate  ECG Changes  Hypotension  Loss of response to painful stimuli Signs & Symptoms of Brain Injury Physiological Changes

86  Different pathology than older patients  Skull can distort due to anterior and posterior fontanelles  Bulging  Slows progression of increasing ICP  Intracranial hemorrhage contributes to hypovolemia  Decreased blood volume in ped’s  General Management  Avoid hyperextension of head  Tongue pushes soft pallet closed  Ventilate through mouth and nose  Different pathology than older patients  Skull can distort due to anterior and posterior fontanelles  Bulging  Slows progression of increasing ICP  Intracranial hemorrhage contributes to hypovolemia  Decreased blood volume in ped’s  General Management  Avoid hyperextension of head  Tongue pushes soft pallet closed  Ventilate through mouth and nose Signs & Symptoms of Brain Injury Pediatric Head Trauma

87 Signs & Symptoms of Brain Injury Glasgow Coma Scale

88  Physiological Issues  Indicate pressure on  CN-II, CN-III, CN-IV, & CN-VI CN-III (Oculomotor Nerve)  Pressure on nerve causes eyes to be sluggish, then dilated, and finally fixed  Reduced peripheral blood flow  Pupil Size & Reactivity  Reduced Pupillary Responsiveness  Depressant drugs or Cerebral Hypoxia  Fixed & Dilated  Extreme Hypoxia  Physiological Issues  Indicate pressure on  CN-II, CN-III, CN-IV, & CN-VI CN-III (Oculomotor Nerve)  Pressure on nerve causes eyes to be sluggish, then dilated, and finally fixed  Reduced peripheral blood flow  Pupil Size & Reactivity  Reduced Pupillary Responsiveness  Depressant drugs or Cerebral Hypoxia  Fixed & Dilated  Extreme Hypoxia Signs & Symptoms of Brain Injury Eye Signs

89 Facial Injury  Facial Soft Tissue Injury  Highly vascular tissue  Contribute to hypovolemia  Superficial injuries rarely life threatening and rarely involve the airway  Deep Injuries can result in blood being swallowed and endanger the airway  Soft tissue swelling reduces airflow  Consider likelihood of basilar skull fracture or spinal injury  Facial Soft Tissue Injury  Highly vascular tissue  Contribute to hypovolemia  Superficial injuries rarely life threatening and rarely involve the airway  Deep Injuries can result in blood being swallowed and endanger the airway  Soft tissue swelling reduces airflow  Consider likelihood of basilar skull fracture or spinal injury

90 Facial Injury  Facial Dislocations & Fractures  Common Fractures  Mandibular Deformity along jaw & loss of teeth Possible airway compromise if patient placed supine Evaluate for multiple fracture sites  Maxillary & Nasal Le Fort I, II and III Criteria  Orbit Involve Zygoma, Maxilla, and/or interior shelf Reduction of eye movement  Possible Diplopia Limitation of jaw movement  Facial Dislocations & Fractures  Common Fractures  Mandibular Deformity along jaw & loss of teeth Possible airway compromise if patient placed supine Evaluate for multiple fracture sites  Maxillary & Nasal Le Fort I, II and III Criteria  Orbit Involve Zygoma, Maxilla, and/or interior shelf Reduction of eye movement  Possible Diplopia Limitation of jaw movement

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92 Facial Injury  Nasal Injury  Rarely life threatening  Swelling & Hemorrhage interfere with breathing  Epistaxis  Most common problem  AVOID NASOTRACHEAL INTUBATION  Passage of ET tube into the cerebral cavity  Nasal Injury  Rarely life threatening  Swelling & Hemorrhage interfere with breathing  Epistaxis  Most common problem  AVOID NASOTRACHEAL INTUBATION  Passage of ET tube into the cerebral cavity

93 Facial Injury  Ear Injury  External Ear  Pinna is frequently injured due to trauma  Poor blood supply  Poor healing  Internal Ear  Well protected from trauma  My be injured due to rapid pressure changes Diving, Blast, or Explosions Temporary or permanent hearing loss Tinnitus may occur  Ear Injury  External Ear  Pinna is frequently injured due to trauma  Poor blood supply  Poor healing  Internal Ear  Well protected from trauma  My be injured due to rapid pressure changes Diving, Blast, or Explosions Temporary or permanent hearing loss Tinnitus may occur

94 Facial Injury  Eye Injury  Penetrating trauma  can result in long term damage  Suspect small foreign body if patient complains of sudden eye pain and sensation of something on the eye  DO NOT REMOVE ANY FOREIGN OBJECT  Corneal Abrasions & Lacerations  Common & usually superficial  Hyphema  Blunt trauma to the anterior chamber of the eye  Blood in front of iris or pupil  Sub-conjunctival Hemorrhage  Less serious condition  May occur after strong sneeze, severe vomiting or direct trauma  Eye Injury  Penetrating trauma  can result in long term damage  Suspect small foreign body if patient complains of sudden eye pain and sensation of something on the eye  DO NOT REMOVE ANY FOREIGN OBJECT  Corneal Abrasions & Lacerations  Common & usually superficial  Hyphema  Blunt trauma to the anterior chamber of the eye  Blood in front of iris or pupil  Sub-conjunctival Hemorrhage  Less serious condition  May occur after strong sneeze, severe vomiting or direct trauma

95 Facial Injury  Eye Injury  Acute Retinal Artery Occlusion  Non-traumatic origin  Painless loss of vision in one eye  Occlusion of retinal artery  Retinal Detachment  Traumatic origin  Complaint of dark curtain/obstruction in the field of view  Possibly painful depending on type of trauma  Soft Tissue Lacerations  Eye Injury  Acute Retinal Artery Occlusion  Non-traumatic origin  Painless loss of vision in one eye  Occlusion of retinal artery  Retinal Detachment  Traumatic origin  Complaint of dark curtain/obstruction in the field of view  Possibly painful depending on type of trauma  Soft Tissue Lacerations

96 Neck Injury  Blood Vessel Trauma  Blunt trauma  Serious hematoma  Laceration  Serious exsanguination  Entraining of air embolism Cover with occlusive dressing  Airway Trauma  Tracheal rupture or dissection from larynx  Airway swelling & compromise  Blood Vessel Trauma  Blunt trauma  Serious hematoma  Laceration  Serious exsanguination  Entraining of air embolism Cover with occlusive dressing  Airway Trauma  Tracheal rupture or dissection from larynx  Airway swelling & compromise

97 Neck Injury  Cervical Spine Trauma  Vertebral fracture  Paresthesia, anaesthesia, paresis or paralysis beneath the level of the injury  Neurogenic shock may occur  Other Neck Trauma  Subcutaneous emphysema  Tension pneumothorax  Traumatic asphyxia  Penetrating Trauma  Esophagus or Trachea  Vagus nerve disruption Tachycardia & GI disturbances  Thyroid & Parathyroid glands High vascular  Cervical Spine Trauma  Vertebral fracture  Paresthesia, anaesthesia, paresis or paralysis beneath the level of the injury  Neurogenic shock may occur  Other Neck Trauma  Subcutaneous emphysema  Tension pneumothorax  Traumatic asphyxia  Penetrating Trauma  Esophagus or Trachea  Vagus nerve disruption Tachycardia & GI disturbances  Thyroid & Parathyroid glands High vascular

98  Scene Size-up  Initial Assessment  Airway, Breathing, Circulation  Rapid Trauma Assessment  Head, Face, Neck  Glasgow Coma Scale Score  Vital Signs  Focused History & Physical Exam  Detailed Assessment  Ongoing Assessment  Scene Size-up  Initial Assessment  Airway, Breathing, Circulation  Rapid Trauma Assessment  Head, Face, Neck  Glasgow Coma Scale Score  Vital Signs  Focused History & Physical Exam  Detailed Assessment  Ongoing Assessment Assessment of Head, Facial & Neck Injuries

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100  Airway  Suctioning  Patient Positioning  OPA & NPA Use  Endotracheal Intubation  Orotracheal  Digital  Nasotracheal  Retrograde  Direct  RSI  Cricothyrotomy  Airway  Suctioning  Patient Positioning  OPA & NPA Use  Endotracheal Intubation  Orotracheal  Digital  Nasotracheal  Retrograde  Direct  RSI  Cricothyrotomy Head, Facial, & Neck Injury Management  Breathing  Oxygen  15 LPM/NRB  Ventilations  12-20/min  Hyperoxygenate  Circulation  Hemorrhage Control  Blood Pressure Maintenance  Fluid resuscitation  Consider PASG  Breathing  Oxygen  15 LPM/NRB  Ventilations  12-20/min  Hyperoxygenate  Circulation  Hemorrhage Control  Blood Pressure Maintenance  Fluid resuscitation  Consider PASG

101 Needle Cricothyrostomy  Locate Site  Cricothyroid Membrane  Cleanse upper anterior neck  Aseptic Technique  Iodine & Alcohol  Prepare Equipment  14 ga IV catheter  Syringe  Transtracheal jet insufflation device  6.0 ET Hub  Locate Site  Cricothyroid Membrane  Cleanse upper anterior neck  Aseptic Technique  Iodine & Alcohol  Prepare Equipment  14 ga IV catheter  Syringe  Transtracheal jet insufflation device  6.0 ET Hub  Insert Catheter into membrane  Downward Angle  Feel “pop”  Advance Catheter  Attach BVM or jet ventilator  Evaluate breath sounds  Secure Catheter Similar to impaled object  Consider 2nd catheter for exhalation  Insert Catheter into membrane  Downward Angle  Feel “pop”  Advance Catheter  Attach BVM or jet ventilator  Evaluate breath sounds  Secure Catheter Similar to impaled object  Consider 2nd catheter for exhalation

102 Surgical Cricothyrotomy  Locate Site  Cricothyroid Membrane  Cleanse upper anterior neck  Aseptic Technique  Iodine & Alcohol  Prepare Equipment  Commercial device  Scalpel  4” ET Tube  Locate Site  Cricothyroid Membrane  Cleanse upper anterior neck  Aseptic Technique  Iodine & Alcohol  Prepare Equipment  Commercial device  Scalpel  4” ET Tube  Insert scalpel into membrane  Downward Angle  Feel “pop”  Enlarge opening  Place short ET tube  Evaluate breath sounds  Secure device  Insert scalpel into membrane  Downward Angle  Feel “pop”  Enlarge opening  Place short ET tube  Evaluate breath sounds  Secure device

103  Hypoxia  Prevent/Reduce  Hyperoxygenation with BVM  Hypovolemia  Reduces cerebral perfusion & hypoxia  Consider early management with 2 large bore IV’s and isotonic fluids  Prevents slower compensatory mechanism  Maintain SBP mmHg  Consider PASG  Hypoxia  Prevent/Reduce  Hyperoxygenation with BVM  Hypovolemia  Reduces cerebral perfusion & hypoxia  Consider early management with 2 large bore IV’s and isotonic fluids  Prevents slower compensatory mechanism  Maintain SBP mmHg  Consider PASG Head, Facial, & Neck Injury Management

104 Medications: Oxygen  Primary 1 st line drug  Administer high flow  Hyperventilation is contraindicated  Reduces circulating CO 2 levels  NRB: 15 LPM  BVM: times per minute  Keep SaO 2 > 95%  Primary 1 st line drug  Administer high flow  Hyperventilation is contraindicated  Reduces circulating CO 2 levels  NRB: 15 LPM  BVM: times per minute  Keep SaO 2 > 95%

105 Medications: Diuretics  Mannitol (osmotrol)  MOA  Large glucose molecule Does not leave blood stream Osmotic Diuretic  Effective in drawing fluid from brain  Contraindication  Hypovolemia & Hypotension  CHF  Dose  1gm/kg  CAUTION  Forms crystals at low temperatures  Reconstitute with rewarming & gentle agitation  USE IN-LINE filter & PREFLUSH line  Mannitol (osmotrol)  MOA  Large glucose molecule Does not leave blood stream Osmotic Diuretic  Effective in drawing fluid from brain  Contraindication  Hypovolemia & Hypotension  CHF  Dose  1gm/kg  CAUTION  Forms crystals at low temperatures  Reconstitute with rewarming & gentle agitation  USE IN-LINE filter & PREFLUSH line

106 Medications: Diuretics  Furosemide (Lasix)  MOA  Loop Diuretic  Inhibits reabsorption of Na + in Kidneys Increased secretion of water and electrolytes  Na +, Cl –, Mg ++, Ca ++.  Venous dilation & Reduces cardiac preload  May be given in combination with Mannitol  Contraindication  Pregnancy: fetal abnormalities  Dose  Slow IVP or IM over 1-2 minutes  mg/kg: Commonly 40 or 80 mg  Furosemide (Lasix)  MOA  Loop Diuretic  Inhibits reabsorption of Na + in Kidneys Increased secretion of water and electrolytes  Na +, Cl –, Mg ++, Ca ++.  Venous dilation & Reduces cardiac preload  May be given in combination with Mannitol  Contraindication  Pregnancy: fetal abnormalities  Dose  Slow IVP or IM over 1-2 minutes  mg/kg: Commonly 40 or 80 mg

107 Medications: Paralytics  Succinylcholine (Anectine)  MOA  Depolarizing Medication Causes Fasciculations  Onset & Duration  Onset: seconds  Duration: 2-3 minutes  Precaution  Paralyzes ALL muscles including those of respiration  Increases intraoccular eye pressure  Contraindication  Penetrating eye injury & Digitalis  Dose  mg/kg IV  Consider administration of 0.5 mg of Atropine to reduce fasciculations  Succinylcholine (Anectine)  MOA  Depolarizing Medication Causes Fasciculations  Onset & Duration  Onset: seconds  Duration: 2-3 minutes  Precaution  Paralyzes ALL muscles including those of respiration  Increases intraoccular eye pressure  Contraindication  Penetrating eye injury & Digitalis  Dose  mg/kg IV  Consider administration of 0.5 mg of Atropine to reduce fasciculations

108 Medications: Paralytics Pancuronium (Pavulon)  MOA  Non-depolarizing agent  Does not affect LOC  Onset & Duration  Onset: 3-5 min  Duration: min  Dose  Must premed with sedative  mg/kg Pancuronium (Pavulon)  MOA  Non-depolarizing agent  Does not affect LOC  Onset & Duration  Onset: 3-5 min  Duration: min  Dose  Must premed with sedative  mg/kg Vecuronium (Norcuron)  MOA  Non-depolarizing agent  Does not affect LOC  Onset & Duration  Onset: < 1 min  Duration: min  Dose  Consider premed with sedative  mg/kg Vecuronium (Norcuron)  MOA  Non-depolarizing agent  Does not affect LOC  Onset & Duration  Onset: < 1 min  Duration: min  Dose  Consider premed with sedative  mg/kg

109 Medications: Sedatives  Diazepam (Valium)  MOA  Benzodiazepine  Anti-anxiety  Muscle relaxant  Onset & Duration  Onset: 1-15 min  Duration: min  Dose  5-10 mg  Diazepam (Valium)  MOA  Benzodiazepine  Anti-anxiety  Muscle relaxant  Onset & Duration  Onset: 1-15 min  Duration: min  Dose  5-10 mg  Midazolam (Versed)  MOA  Benzodiazepine  3-4x potent than valium  Dose  SLOW IVP 1 mg/min  mg titrated  Midazolam (Versed)  MOA  Benzodiazepine  3-4x potent than valium  Dose  SLOW IVP 1 mg/min  mg titrated

110 Medications: Sedative  Morphine  MOA  Opium alkaloid Analgesic Sedation Anti-anxiety  Reduces vascular volume & cardiac preload Increases venous capacitance  Side Effects  Respiratory depression  Hypovolemia  Dose  5-10 mg IVP  Consider using promethezine with to reduce nausea  Naloxone (Narcan) is antagonist  Morphine  MOA  Opium alkaloid Analgesic Sedation Anti-anxiety  Reduces vascular volume & cardiac preload Increases venous capacitance  Side Effects  Respiratory depression  Hypovolemia  Dose  5-10 mg IVP  Consider using promethezine with to reduce nausea  Naloxone (Narcan) is antagonist

111 Medications: Atropine  MOA  Anticholinergic  Parasympathetic  Reduces parasympatholyic stimulation  Reduce oral and airway secretions  Reduce fasciculations  Pupillary dilation  Dose  mg rapid IVP  MOA  Anticholinergic  Parasympathetic  Reduces parasympatholyic stimulation  Reduce oral and airway secretions  Reduce fasciculations  Pupillary dilation  Dose  mg rapid IVP

112 Medications: Dextrose  Consider if patient is hypoglycemic  Only if VERIFIED by GLUCOMETER  Dose  25 gm IVP  Consider Thiamine if known alcoholic  100 mg Thiamine  Consider if patient is hypoglycemic  Only if VERIFIED by GLUCOMETER  Dose  25 gm IVP  Consider Thiamine if known alcoholic  100 mg Thiamine

113 Medications: Thiamine  Vitamin B1  Essential for the processing of glucose through Kreb’s cycle  Chronic alcoholics can have B1 depletion  Dose  100 mg IV or IM  Vitamin B1  Essential for the processing of glucose through Kreb’s cycle  Chronic alcoholics can have B1 depletion  Dose  100 mg IV or IM

114  Medications  Xylocaine or Benzocaine  Anesthetize oral and pharyngeal mucosa Reduces gag reflex Reduces likelihood of ICP associated with vomiting  Inhibits nerve sensation  Onset & Duration Onset: 15 seconds Duration: 15 minutes  PRECAUTION Patient has reduced ability to remove oral fluids ASPIRATION can occur  Medications  Xylocaine or Benzocaine  Anesthetize oral and pharyngeal mucosa Reduces gag reflex Reduces likelihood of ICP associated with vomiting  Inhibits nerve sensation  Onset & Duration Onset: 15 seconds Duration: 15 minutes  PRECAUTION Patient has reduced ability to remove oral fluids ASPIRATION can occur Medications: Topical Anesthetic Spray

115 Transport Considerations  Limit external stimulation  Can increase ICP  Can induce seizures  Cautious about Air Transport  Seizures  Limit external stimulation  Can increase ICP  Can induce seizures  Cautious about Air Transport  Seizures

116 Emotional Support  Have friend or family provide constant reassurance  Provided constant reorientation to environment if required  Keeps patient calm  Reduces anxiety  Have friend or family provide constant reassurance  Provided constant reorientation to environment if required  Keeps patient calm  Reduces anxiety

117 Special Injury Care  Scalp Avulsion  Cover the open wound with bulky dressing  Pad under the fold of the scalp  Irrigate with NS to remove gross contamination  Pinna Injury  Place in close anatomic position as possible  Dress and cover with sterile dressing  Scalp Avulsion  Cover the open wound with bulky dressing  Pad under the fold of the scalp  Irrigate with NS to remove gross contamination  Pinna Injury  Place in close anatomic position as possible  Dress and cover with sterile dressing

118 Special Injury Care  Eye Injury  General Injury  Cover injured and uninjured eye Prevents sympathetic motion  Consider sterile dressing soaked in NS  Corneal Abrasion  Invert eyelid and examine eye for foreign body  Remove with NS moistened gauze or Morgan’s Lens  Avulsed or Impaled Eye  Cover and Protect from injury  General Care  Calm & reassure patient  Eye Injury  General Injury  Cover injured and uninjured eye Prevents sympathetic motion  Consider sterile dressing soaked in NS  Corneal Abrasion  Invert eyelid and examine eye for foreign body  Remove with NS moistened gauze or Morgan’s Lens  Avulsed or Impaled Eye  Cover and Protect from injury  General Care  Calm & reassure patient

119 Special Injury Care  Dislodged Teeth  Rinse in NS  Wrap in NS soaked gauze  Impaled Objects  Secure with bulky dressing  Stabilize object to prevent movement  Indirect pressure around wound  Dislodged Teeth  Rinse in NS  Wrap in NS soaked gauze  Impaled Objects  Secure with bulky dressing  Stabilize object to prevent movement  Indirect pressure around wound


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