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Head, Neck, & Spinal Trauma Pauline VanMeurs. Overview zAccounts for over 50% of the prehospital trauma deaths encountered by prehospital provider zEven.

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Presentation on theme: "Head, Neck, & Spinal Trauma Pauline VanMeurs. Overview zAccounts for over 50% of the prehospital trauma deaths encountered by prehospital provider zEven."— Presentation transcript:

1 Head, Neck, & Spinal Trauma Pauline VanMeurs

2 Overview zAccounts for over 50% of the prehospital trauma deaths encountered by prehospital provider zEven when not fatal, head injuries are devastating to the survivor and family zVictims of significant head injury seldom recover to the same physical and emotional state of pre-injury zMany victims suffer irreversible personality changes

3 Maxillo-facial Trauma zCauses - yMVA, home accidents, athletic injuries, animal bites, violence, industrial accidents zSoft tissue - ylacerations, abrasions, avulsions yvascular area supplied by internal and external carotids z Management - ySeldom life- threatening unless in the airway yconsider spinal precautions yhave suction available and in control of conscious patients ycontrol bleeding

4 Facial Fractures zFx to the mandible, maxilla, nasal bones, zygoma & rarely the frontal bone zS/S - ypain, swelling, malocclusion, deep lacerations, limited ocular movement, asymmetry, crepitus, deviated nasal septum, bleeding from orifice z Mandibular Fx - ymalocclusion, numbness, inability to open or close the mouth, excessive salivation z Anterior dislocation extensive dental work, yawning yCondylar heads move forward and muscles spasm

5 LaForte Fractures

6 Laforte

7 Description of LaForte FX zLaForte I - Maxillary fracture with “free- floating” maxilla zLaForte II - Maxilla, zygoma, floor of orbit and nose zLaForte III - Lower 2/3 of the face

8 Signs and Symptoms zTakes incredible forces especially to sustain a LaForte II or III zEdema, unstable maxilla, “donkey face” lengthening, epistaxis, numb upper teeth, nasal flattening, CSF rinorrhea (cribriform plate fracture) zII and II associated with orbital fractures yrisk of serious airway compromise from bleeding and edema ycontraindication to nasogastric tube or nasotracheal intubation

9 Blow-out Orbital Fracture zUsually result of a direct blow to the eye yS/S - flatness, numbness yepistaxis, altered vision yperiorbital swelling ydiplopia yinophthalmos yimpaired ocular movement

10 blowout

11 Management zSpinal motion restriction zControl Bleeding zControl epistaxis if possible unless CSF present zAirway is the most difficult part of these calls zSurgical Airway may be the only alternative but NEVER the first consideration

12 Ear Trauma zExternal injuries ylacerations, avulsions, amputations, frostbite yControl bleeding with direct pressure zInternal injuries ySpontaneous rupture of eardrum will usually heal spontaneously ypenetrating objects should be stabilized, not removed! xRemoval may cause deafness or facial paralysis xHearing loss may be result of otic nerve damage in basilar skull fracture

13 Barotitis zChanges in pressure cause pressure buildup and/or rupture of tympanic membrane zBoyle’s Law, at constant temperature, the volume of gas is inversely proportionate to the pressure zs/s - pain, blocked feeling in ears, severe pain zequalize pressure by yawning, chewing, moving mandible, swallowing (open Eustachian tubes allowing gas to release)

14 Eye Anatomy

15 Eye

16 Foreign Bodies zS/S - sensation of something in eye, excessive tearing, burning zInspect inner surface of upper lid as well as sclera zFlush with copious normal saline away from opposite eye

17 Corneal Abrasion zCaused by foreign body objects, eye rubbing, contact lenses zS/S - pain, feeling of something in eye, photophobia, tearing, decreased visual acuity zirrigate, patch both eyes zUsually heals in 24 to 48 hours if not infected or toxic from antibiotics

18 Other Globe Injuries zContusion, laceration, hyphema, globe or scleral rupture zS/S - Loss of visual acuity, blood in anterior chamber, dilation or constriction of pupil, pain, soft eye, pupil irregularity z Consider C-spine precautions due to forces required for injury z No pressure to globe for dressing, cover both eyes z Avoid activities that increase intra-ocular pressure

19 Dental Trauma z32 teeth in normal adult zAssociated with facial fractures zMay aspirate broken tooth zAvulsed teeth can be replaced so find them! zEarly hospital notification to find dentist z < 15 minutes, ask to replace the tooth in socket z do not rinse or scrub (removes periodontal membrane and ligament) z preserve in fresh whole milk z Saline OK for less than 1 hour

20 Trauma to Skull and Brain zScalp injuries zSkull fractures yLinear ybasilar yDepressed yOpen Vault

21 Linear Skull Fracture zAbout 70% of the skull fractures zMay occur without any overlying scalp laceration zAcross temporal-parietal sutures, midline, or occiput may lead to epidural bleed from vascular involvement of underlying structures

22 Basilar Skull Fracture zAssociated with major trauma zDoes not always show on x-ray zClinically diagnosed with following yEcchymosis over the mastoid (temporal bone) yEcchymosis over one or both orbits (sphenoid sinus fracture) yblood behind the tympanic membrane (temporal bone) yCSF leakage zComplications - infection, cranial nerve damage, hemorrhage from major artery

23 Depressed Skull Fracture zMost common to parietal and frontal area zhigh velocity small objects cause it z30% associated with cerebral hematoma or contusion zDural laceration likely zDefinitive tx includes craniotomy to remove fragments

24 Open Vault Fracture zHigh mortality due to forces required to cause injury zDirect contact between laceration and cerebral substance zUsually involves multiple system trauma

25 Cranial Nerve Hints yMay not be helpful in unconscious patients, but if they happen to wake up: yCranial nerve I - loss of smell, taste (basilar skull fracture hallmark) yCranial nerve II - blindness, visual defects yCranial nerve III - Ipsilateral, dilated fixed pupil yCranial nerve VII - immediate or delayed facial paralysis (basilar skull or LaForte) yCranial nerve VIII - deafness (basilarskull fx)

26 Cerebral Blood Flow z2% of the adult body weight, 20% of the oxygen consumption z25% of the total glucose consumption zOxygen and glucose delivery are controlled by cerebral blood flow

27 Cerebral Blood Flow… zFunction of cerebral perfusion pressure (CPP) and resistance of the cerebral vascular bed zCPP is determined by mean arterial pressure (MAP) zMAP = (diastolic pressure + 1/3 pulse pressure) - intracranial pressure(ICP) zNormal ICP = Torr zSo all this means what?.....

28 Bottom Line... zWhen ICP increases, CPP decreases and cerebral blood flow decreases zOut of all the fluid sources in the brain, vascular volume is the most mobile zSince the skull is rigid, the increase of CSF, edema, or hemorrhage, decreases vascular volume and therefore cerebral blood flow

29 The Role of CO 2 zVascular tone in the normal brain is controlled by CO 2 zP CO 2 has the greatest effect on intracerebral vascular diameter z Cerebral blood flow may be reduced by PO 2, neurohumeral (indirect hormone release), or autonomic control Reduced flow may lead to: z hypoxia z  CO 2 retention

30 Playing with the numbers zIncrease PCO 2 from 40 Torr to 80 Torr and cerebral blood flow doubles, resulting in increased brain blood volume and increased ICP zDecrease PCO 2 from 40 to 30 Torr and cerebral blood flow is reduced 25%, decreasing ICP

31 Intracranial Pressure zICP above 15 Torr compromises cerebral perfusion pressure and decreases perfusion zIf cranial vault continues to fill and ICP increases, the body attempts to compensate by increasing MAP (cushing’s reflex) zIncreased MAP increases, CPP, but as blood flow increases, so does ICP zUnchecked, the process leads to herniation of brain matter

32 Signs and Symptoms of ICP zEarly - yheadache, nausea, vomiting and altered level of consciouosness zLater - yincreased systolic pressure ywidened pulse pressure ydecrease in pulse and respiratory rate (Cushing’s Triad)

33 Very Late Signs zFixed and dilated pupils zCardiac arrhythmia zAtaxic respirations

34 Head Injury Spiral

35 Concussion zNo structural damage - mild to moderate impacts zreticular activating system or both cortices temporarily disturbed, resulting in LOC or altered consciousness ymay be followed by dizziness, drowsiness, confusion, retrograde amnesia yvomiting, combativeness, transient visual disturbances ychanges to vital signs are rare but possible

36 Cerebral Contusion zBruising of brain in area of cortex or deeper within frontal, temporal or occipital lobes ygreater neuro deficits than concussion due to structural change from bruising ySeizures, hemiparesis, aphasia, personality changes, LOC or coma of hours to days y75% of patients dying from head injuries have associated cerebral contusions

37 Cerebral Contusions, continues zCoup and contra coup injury may cause disruption of blood vessels within the pia mater as well as direct damage to the brain substance yContracoup is most commonly caused by deceleration of the head (fall, MVA) zUsually heal without surgical intervention/ Patients improve over time. Most important complication is increased ICP

38 Cerebral Edema zSwelling of the brain itself with or without associated bleeding yResults from humoral and metabolic responses to injury yleads to marked increases in ICP ydiffuse cerebral edema may also occur in hypoxic insult to the brain zIschemia ycaused by vascular injury or ICP, may lead to more focal or global infarcts

39 Brain Hemorrhage zClassified by location yepidural ysubdural ysubarachnoid yparenchymal yintraventricular

40 Epidural Bleed z Between Cranium and dura mater z rapidly developing lesion from lac or tear to meningeal artery z Associated with linear or depressed skull fx of the temporal bones z 50% patients have transient LOC with lucid interval of 6-18 hours

41 Epidural continued zIntial LOC is caused by concussion, followed by awakening and then loss of consciousness from pressure of blood clot z50% lose consciousness and never wake up due to rapid bleeding rate zLucid period may only be accompanied by headache yfollowed by nausea, vomiting, contralateral hemiparesis, altering states of consciousness, coma and death yCommon in low velocity blows y15-20% mortality

42 Subdural Hematoma z Blood between the dura and brain surface z blood from veins that bridge the subdural space z associated with lacerations or contusions to brain and skull fracture

43 Subdural Continued z50-80% mortality in acute injury (symptoms within 24 hours) z25% mortality in subacute injury (2-10 days) z20% mortality in chronic injury (> 2 weeks) z Signs and Symptoms similar to epidural z Absence of “lucid interval” z increased risk factors are: yadvanced age, clotting disorders, ETOH abuse, cortical atrophy yMay appear like a stroke! Rule out trauma.

44 Subarachnoid Bleed zMost common cause is a-traumatic zAssociated with congenital causes ymarfan’s syndrome ycoarctation of the aorta ypolycystic kidney disease ysickle cell disease zMortality - y10-15% die before reaching the hospital y40% within the first week y50% within 6 months

45 Subarachnoid Bleeding and site of aneurysm bleeding

46 Angiography of aneurysm

47 Assessment and Management zAirway - yassume spinal injury with significant head trauma yconsider intubation with GCS of less than 8 ysuction at ready yuse orogastric instead of nasogastric tube in facial injuries yventilate for adequate gas exchange and to decrease ICP xconsider breaths/min for ICP of 30

48 Circulation zControl bleeding zapply monitor (not highest priority) zhead injury does not produce hypovolemic shock, look for another cause if patient is hypotensive

49 Neurological Assessment zInterview for LOC on person, place, time, events, last clear recall ydo this early in conscious patients and be patient! If AVPU, check the best response. You must get a baseline zGet a history while you can. zCheck motor function (gross and fine) ycheck for drift zCheck pupils zCheck for extraocular movement y(nystagmus and bobbing)

50 Managment zIV - ynot a high priority yfluid restricted unless multisystem trauma zMannitol - diuretic to draw fluid directly away from brain and decrease edema zfurosemide - same idea z Dexamethasone - not as common but anti- inflammatory z Phenytoin, phenobarbital, valium yanti-convulsants z Versed, Narcuron ypatient sedation or paralysis as indicated by local protocol

51 Neck and Spine Trauma zNeck - 3 zones y1 = sternal notch to top of clavicles (highest mortality) y2 = clavicles or cricoid cartilage to angle of the mandible (contains major vasculature and airway) y3 = above angle of mandible (distal carotid, salivary, pharynx) z Management ystop bleeding as best as possible z See page 442 for assorted catastrophes z May need smaller tube z May need cricothyroidotomy z May only need a BVM

52 Esophageal Injury zEspecially common in penetrating trauma yS/S may include subcutaneous emphysema yneck hematoma, blood in the NG tube or posterior nasopharynx zhigh mortality rate from mediastinal infection secondary to gastric reflux through the perforation. Consider Semi- fowler’s vs. supine position unless contraindicated by MOI.

53 Spinal Trauma zMost common cause is spine being forced beyond its normal range of motion zc-spine is most vulnerable due to weight of head z27-33% of injuries occur in c1-c2 area zShould have 180 degrees rotation 60 degrees flexion and 70 extension z Compression - direct force, head to windshield, shallow dive, blow to top of head z Flexion, hyperextension, hyper- rotation ymay result in fx, ligamentous injury, muscle injury or subluxation yMay cause cord laceration/contusion

54 Spinal Trauma zLateral bending yhead stays in one place as the body continues in a lateral direction xside impact MVA, contact sports yrequires less movement to incur injury, lower velocities zDistraction ypulling force that typically tears structures of the spinal column

55 Guidelines for Immobilization zTrauma associated with ETOH zSeizures zPain in neck or arms with paraesthesia zNeck tenderness zUnconsciousness due to head injury z injury above the clavicles z fall 3 times the patient’s height, 1x the height of a child z fall with fracture to both heels z high speed MVA z Read 445 for types of fx, strains, and sprains

56 Cord Lesions zClassified as complete or incomplete zComplete usually associated with fx or dislocation zS/S of complete include absence of pain and sensation, paralysis below the level of the injury, autonomic dysfunction ybradycardia, hypotension, priapism, loss of sweating and shivering, poikilothermy yLoss of bowel and bladder control

57 Cord Anatomy

58 Central Cord Syndrome zHyperextension with flexion zgreater motor impairment in the upper than in the lower extremities zsacral sparing

59 Anterior Cord Syndrome z Flexion injuries z Caused by pressure to anterior spinal cord by ruptured disk or fragments z decreased sensation of pain and temp below the lesion z intact light touch and proprioception z paralysis

60 Brown Sequard zHemi-transection of the cord zcaused by ruptured disk or penetrating trauma zs/s - loss of function or weakness of upper and lower extremities of ipsilateral side and loss of pain and temperature on contralateral

61 Evaluation zAssumed but not evaluated until all life- threatening injuries are addressed zPrimary injury occurs on impact, prevent secondary by minimizing movement and providing anti- inflammatory therapy z High index of suspicion with LOC z LOC NOT A REQUIREMENT z Motor findings: yask the patient about pain and parasthesia ydo not ask them to move too much

62 Evaluation zStart with distal light touch zGENTLE pricking with sharp object zThen go head to toe with light touch zMark with a marker where sensation is demarcated

63 Landmarks zElbow flexion = C6 zExtension = C6 zfinger flexion = C8 zLoss of sensation to upper extremities indicates C-spine z Respiratory arrest = C3 z Paralysis of diaphragm = C4 z C5-6=diaphragmatic breathing with variable chest wall paralysis. z Hold up position=C6 z 50% of patients with c- spine injuries have normal motor, sensory, reflex exams

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