3 Penetrating Head Trauma If the skull is fractured, bone fragments may be driven into the brain. Any object that penetrates the skull may implant foreign material and dirt into the brain, leading to an infection.Penetrating head trauma is associated with a high mortality rate.
4 Types of injuries Closed head injury Closed head injury refers to brain injury without any penetrating injury to the brain. It may be the result of a direct blow to the head; of the moving head being rapidly stopped, such as when a person's head hits a windshield in a car accident; or by the sudden deceleration of the head without its striking another object.
6 Principals of Treatment Table 2-2: Glasgow Coma ScaleParameter Response ScoreParameter Response ScorePrincipals of Treatment\ Frequently associated with other severe trauma.ABCs take priority. Saving only the head will not save the patient. Primary and secondary survey should be performed. Aggressive airway management is often required in craniofacial traumaHypotension in adults is never caused by an isolated head injury except near death. Look for other injuries including cord injuries.Physical exam includes complete neurological exam(GCS) as well as inspection for evidence of basilar skull fracture (CSF rhinorrhea, Battle’s sign, raccoon eyes, hemotympanum), etc.Consider C – spine immobilization.
7 Head trauma Assessment Disability (D). The goal of assessing disability is to determine neurological injury. Key components of this evaluation are as follows:Mental status (GCS).Pupil exam.Motor/sensory exam of the extremities.
8 Neuro ExamDecrease in level of consciousness. A patient who was previously talking to you but now has to be shaken gently or have a painful stimulus applied before he or she talks to you, or other decline along the lines of the GCS.A pupil which becomes less responsive to light and larger than the opposite one. Pupils are best examined in a darkened room; otherwise the ambient light causes stimulation and rest/response sizes are misgauged.
9 After the airway is protected, shock is treated or prevented by placing two large-bore venous catheters and infusing plasma, normal saline, or lactated Ringer's solution. The stomach should be emptied(OG tube) and the bladder catheterized. NaHC03, 1meq/kg is given for metabolic acidosis, and should be administered empirically when respiration has been compromised.
11 Epidural HematomaAn epidural hematoma occurs when there is a tear in a vascular structure, usually arterial, in the potential space between the dura and the skull.A “Fast Bleed” Blood accumulates rapidly leading to increased ICP,decreased neuro statusSymptoms occur in hoursRequires immediate surgical intervention
13 Epidural SymptomsThe most important symptoms of an Epidural hemorrhage are:Headache, severeDrowsinessConfusionNausea or vomiting may accompany the headacheDizzinessEnlarged pupil in one eyeWeakness of part of the body, usually on the opposite side from the side with the enlarged pupilHead injury or trauma followed by loss of consciousness, an alert period of time, then rapid deterioration back to unconsciousness
17 Surgical Intervention The definitive treatment for closed head injury is Burr hole or decompressive craniotomy.Because of limited resources in the FST, the Burr hole is the most effective way to stabilize the closed head injury patient for evacuation.
19 Burr Hole Shave and "prep" the side of the skull. A vertical incision approximately 3 cm long is made centered over the entry point.Haemostatic clips are placed in scalp edgesCautery to coagulate bleedersThe incision is extended to the periosteum and the retractors or rakes are immediately placed under the periosteum with tension on the woundThe skull is drilled with the penetratorThe hematoma is evacuated using a soft suction tip.A Penrose drain is sutured in
25 Facial TraumaFacial fractures common with high speed deceleration and blunt trauma. Definitive treatment is beyond the scope of the FST.The primary focus is on aggressive airway management and rapid evacuation. Due to massive edema often found with these injuries, surgical airway should be anticipated
26 Le Fort FracturesFractures of mid portion of face have been classified asLe Fort 1 - Fracture detaching palate and maxillary alveolusLe Fort 2 - Pyramidal fracture through sinus wall laterally and nasal bones mediallyLe Fort 3 - Fracture through frontozygomatic sutures and orbits detaching facial skeleton from base of skull
27 Lefort II.LeFort ICan be identified by grasping the top teeth and attempting to move them; with Le Fort I, the teeth and maxilla will move, but the nose and upper face will stay fixed.
28 Characterized by mobility of the nose into the dental arch Fracture of the maxilla in a pyramid shape, extending into the nasal bones. Le Fort IILeFort IICharacterized by mobility of the nose into the dental arch.
29 Le Fort IIILeFort IIIFracture that involves total craniofacial separation in a tripod pattern with craniofacial detachment. Characterized by mobility of the nose and theThe dental arch.
30 LaFort III with Orbital edema with NG tube placement
32 Skull FractureA skull fracture is a medical emergency that must be treated promptly to prevent possible brain damage. Such an injury may be obvious if blood or bone fragments are visible, but it's possible for a fracture to have occurred without any apparent damage. A skull fracture should be suspected if there is:Blood or clear fluid leaking from nose or earsUnequal pupil sizeBruises or discoloration around the eyes(Raccoon eyes) or behind the ears(Battle signs)Swelling or depression of the part of the head
37 ReferencesEmergency War Surgery NATO Handbook: Part IV: Regional Wounds and Injuries: Chapter XXII: Craniocerebral InjuryUnited States Naval Flight Surgeon's Manual: Third Edition 1991: Chapter 7: NeurologyFM First Aid for Soldiers: Chapter 3; First Aid for Special WoundsHospital Corpsman Sick call Screeners Handbook. Neurologic SystemGeneral Medical Officer (GMO) Manual: Clinical Section: Neurosurgical EmergenciesCentral Nervous System Emergencies