LO5 Head and Facial Injuries (Chapter 12)

Question 1

meninges

Answer 1

Fibrous coverings of the brain

Dura mater, arachnoid mater and pia mater

Question 2

The intercranial volume is composed of

Answer 2

the brain,

the CSF

blood in the blood vessels which completely fill the cranial cavity

Any increase in one of the components is at the expense of the other two

Question 3

Monro-kellie doctrine

Answer 3

because of the fix space within the rigid skull as a brain tissue swells it takes up more volume

initially with brain swelling, blood and CSF volumes inside the skull decrease and compensate for the rise and pressure

as brain swelling continues compensation fails and intercranial pressure begins to rise

As the ICP increases the amount of blood they can enter the skull and perfused brain decreases leading to further brain injury

Question 4

what happens when something obstructing the outflow a spinal fluid

Answer 4

Trumatic blood in the vesicles or subarachnoid space will cause an accumulation of spinal fluid within the brain and an increase in ICP

Question 5

Primary brain injury

Answer 5

is the immediate damage to the brain tissue that is direct result of the mechanical force and is essentially fixed at the time of injury

Most primary brain injuries occur either as a result of external force is applied against the skull or from movement of the brain inside the skull

Question 6

deceleration head injuries

Answer 6

the head usually strikes in object which causes a sudden discolouration of the skull

the brain continues to move forward impacting first against the skull in the original direction of the motion third collision and then rebounding to hit the opposite side of the inner surface of the skull a fourth collision

Question 7

Coup

contracoup

Answer 7

Coup: injuries that occur to the brain in the area of the original impact

Contracoup: injuries that occur to the brain on the opposite side

Question 8

Secondary brain injury

Answer 8

is the result of hypoxia and or decreased perfusion of the brain tissue

In response to the primary insult swelling can cause a decrease in perfusion

result in Vasodilation with increased blood flow to the injured area

No extra space inside the skull swelling of the injured area or newly formed intracerebral haematoma increases intracerebral pressure leading to a decrease cerebral blood flow that causes secondary brain injury

Question 9

hypoventilation vs hyperventilation

Answer 9

An increase in the level of CO2 hypoventilation promotes vasodilation of vessel supplying the brain whereas lowering the level of CO2 hyperventilation causes vasoconstriction and decreases blood flow to the brain

Question 10

Intracranial pressure

Answer 10

The pressure within the

skull

Question 11

increased ICP

Answer 11

Blood supply will be decreased by the increased ICP and because the brain requires a constant supply of blood to survive brain swelling can be rapidly catastrophic

ICP is considered dangerous when it rises above 15 mmHg cerebral herniation may occur at pressures above 25 mmHg

Question 12

Cerebral perfusion pressure (CPP):

Answer 12

The net pressure gradient causing blood flow through the brain

It’s value is obtained by subtracting the ICP from the MAP

Question 13

what happens when ICP increases

Answer 13

the system blood pressure increases to try to preserve blood flow to the brain

the body senses the rising systemic blood pressure and this triggers a drop in pulse rate

Question 14

why does heart rate drop when ICP increases

Answer 14

the body tries to lower the systemic blood pressure by lowering cardiac output

Question 15

Cerebral perfusion

Answer 15

Pressure required to perfuse brain

You must maintain a CPP of 60 to 70 mmHg which requires maintaining a map of greater than 70 mmHg in the patient with severe TBI

CPP= MAP-ICP

Map constant + ICP increase = CPP Decrease

Map increases + ICP constant = CPP Increase

MAP decrease + ICP increase =CPP critical

Question 16

map in normal brain vs ICP brain

Answer 16

Map- normal brain 65+= 90/p

Map- increase ICP = 85 110/p

Question 17

Cerebral Herniation Syndrome

Answer 17

When the brain swelling or intercranial haemorrhage occurs particularly after a blow to the head a sudden rise in ICP may occur and force portions of the brain downward through the tentorium cerebelli

This leads to obstruction of the flow of CSF in the herniated brain apply significant pressure to the brain stem resulting in cerebral herniation syndrome

Question 18

Cerebral Herniation Syndrome signs and symptoms

Answer 18

a decreasing LOC that rapidly progresses to coma

dilation of the pupils in an outward downward deviation of the eye on the side of injury

paralysis of the arm and leg on the side opposite the injury or dcerebrate positioning,

vital signs revealed increased blood pressure and bradycardia

Question 19

signs of Increasing ICP

Answer 19

Respirations- increase, decrease, irregular

Pulse- decrease

Blood pressure- increase, widening pulse

Question 20

Cushings reflex

Answer 20

increase BP

decrease heart rate

irregular resp: Heyne stroke

Question 21

Hyperventilation

Answer 21

Hyperventilation will decrease the size of the blood vessels in the brain and briefly decrease ICP

Cerebral herniation syndrome is the only situation in which hyperventilation is still indicated

you must ventilate every three seconds and attempt to keep ET CO2 at 30 to 35 mmHg

Question 22

When to hyperventilate:

Answer 22

after fixing hypoxia and hypotension

1. TBI patient with a GCS score less than 9 with extensor posturing (decerebrate)
2. TBI patient with a GCS score less than 9 with asymmetric, dilated, or non-reactive pupils
   - -Remember hypoxemia, orbital trauma, substances, lightning strike, and hypothermia also affect people every reaction
3. TBI patient with an initial GCS score less than 9 that then drops his or her GCS by more than two points

Question 23

treatment of facial injuries

Answer 23

gentle irrigation with normal Celine if needed an application of Eyeshield

Elevate the head of a stretcher if possible

Question 24

open skull fracture treatment

Answer 24

Open skull fracture should have the wound dressed but avoid excess pressure when controlling bleeding penetrating objects in the skull should be secured patient transported immediately

Question 25

Concussion

Answer 25

There is a history of trauma to the head with a variable period of unconsciousness or confusion and then a return to normal consciousness There may be amnesia following the injury which usually extends to some point before the injury rendering the patient unable to remember events leading up Patient may report dizxiness, heacdache, ringing in the ears, or nausea

Question 26

Cerebral contusion

Answer 26

A patient with a cerebral contusion bruised brain tissue will usually have a history of prolonged and consciousness or serious alteration in LOC The patient may have focal neurologic signs and appear to have suffered a cerebrovascular accident May have personality changes

Question 27

Diffuse axonal injury

Answer 27

Result of severe blunt head trauma Generalized edema The patient presents unconscious, due to disruption of nerve fibers between the cortex and brain stem with no focal motor deficits

Question 28

Anoxic brain injury

Answer 28

Perfusion of the cortex is interrupted due to spasm that develops in the small cerebral arteries after 4 to 6 minutes of anoxia restoring oxygenation and blood pressure will not restore perfusion of the cortex and they will be irreversible damage Hypothermia seems to protect against this phenomenon

Question 29

Intracranial hemorrhage

Answer 29

hemmorhage can occur between: the skull in the Dura, between the Dura and the arachnoid, beneath the subarachnoid or directly in the brain tissue

Question 30

Acute epidural haematoma

Answer 30

bleeding between dura mater and skull Because the bleeding is usually arterial bleeding and rise in ICP can occur rapidly and death may occur quickly

Question 31

symptoms of Acute epidural haematoma

Answer 31

a history of head trauma with initial LOC, often followed by a lucid period A few minutes to several hours the patient will develop signs of increasing ICP Lapse into unconsciousness, and develop body paralysis on the side opposite the head injury pupils Often dilated and fixed people on the side of the head injury

Question 32

Acute subdural hematoma

Answer 32

bleeding between dura and arachnoid layers ICP increases slowly and the diagnosis is often not apparent until hours or days after injury Use of anticoagulants increases the risk of subdural bleeding Those with alcoholism and older adults are at high risk for this injury after a deceleration injury

Question 33

Acute subdural hematoma signs and symptoms

Answer 33

headache, fluctuations in LOC, focal neurological signs

Question 34

Subarachnoid hemorrhage

Answer 34

bleeding between brain and subarachnoid layer Rarely occurs alone most commonly associated with subdural haematoma or cerebral contusion The massive amount of subarachnoid blood causes irritation that result in intravascular fluid leaking into the brain causing more Edema

Question 35

signs and symptoms of subarachnoid hemorrhage

Answer 35

headache, coma, and vomiting

Question 36

intracranial pressure

Answer 36

Is bleeding within the brain tissue that may result from blunt or penetrating injury so the head

Question 37

signs and symptoms of intracranial pressure

Answer 37

depend on the regions involved in the degree of the injury They occur in anatomical pattern similar to those from a stroke in the same area of the brain alteration in LOC is commonly seen Awake patient complains of headache and vomiting

Question 38

A basilar skull facture may indicate any of the following

Answer 38

bleeding from the ear or nose, clear fluid from nose or ear, battle signs and raccoon eyes

Question 39

pupils

Answer 39

are controlled by the third cranial nerve which is affected by the increasing ICP if both pupils are dilated and do not react to light the patient probably has a brainstem injury if pupils are dilated but still reactive to light the injury is often reversible a uni laterally dilated pupil remains reactive to light may be the earliest sign of cerebral herniation the development of a unilaterally dilated nonreactive pupil (blown pupil) is an extreme emergency and requires hyperventilation

Question 40

Management of patient with a TBI

Answer 40

1. ) Provide good oxygenation 1. 1) Maintain goo ventilation 1. 2)Endotracheal tubes recommened 2. Apply SMR based on MOI/status of spine 2. 1) When possible elevate head of stretcher 30degrees to decrease ICP 3. Agitated and combative patients fighting against restraints or ventikation will increase ICP 4. Record vital signs every 5 mins 5. Finger stick glucose 6. 2 large bore IV 7. Hyperventilation is recommended for cerebral herniation after correcting hypoxia and hypotension 8. If the a patient develops hypotension, assume it is due to hemorrhage or rarely spinal cord

Question 41

Conjunctivas

Answer 41

almost immediately and the eyes begin to predict tears in an attempt to flush out the object Irritation of the cornea or conjunctiva cause intense pain Prehospital care involves stabilizing the object and preparing the patient for transport The greater the length of the foreign object sticking out of the eye the more important stabilization becomes

Question 42

Hyphemia

Answer 42

is bleeding into the anterior chamber of the eye that scares vision partially or completely

Question 43

blowout fracture

Answer 43

is the fragments of a fractured bone can entrap some of the muscles that control movement causing double vision especially with upward gaze Any patient who reports pain, double vision or decreased vision following a blunt injury about the eye should be assumed to have a blowout fracture

Question 44

Retinal detachment

Answer 44

separation of the inner layers of the retina from the underlined membrane it is often seen in sports injuries Painless condition produces flashing lights, specs or floaters in the field of vision and a cloud or shade over the patient’s vision

Question 45

Visual loss that does not improve on the patient blinks

Answer 45

is the most important symptom of an eye injury it may indicate damage to the globe or to the optic nerve

Question 46

Double vision

Answer 46

usually points to trauma involving the extraocular muscles such as a fracture of the orbit

Question 47

Foreign body sensation

Answer 47

usually indicates superficial injury to the cornea or the presence of a foreign object trapped behind the eyelids

Question 48

Injuries to eyelids Dash lacerations, abrasions and contusions

Answer 48

require a little in the way of prehospital care other than bleeding control and gentle patching

Question 49

Anisocoria

Answer 49

condition in which the pupils are not of equal size

Question 50

Follow these three important guidelines in treating penetrating injuries of the eye:

Answer 50

Never exert pressure on or manipulate the injured globe in anyway If part of the globe is exposed gently apply a moist sterile dressing to prevent drying Cover the injured eye with a protective rigid a shield cup or sterile dressing apply soft dressings to both eyes

Question 51

If rupture of the globe is suspected

Answer 51

take spinal motion restriction precautions Elevate the head of the stretcher approximately 30° to 40° and ensure the cervical collar is not too tight

Question 52

globe may be displaced out of its socket

Answer 52

do not attempt to manipulate it or reposition it Cover the protruding I with a moist sterile dressing and stabilize it along with uninjured eye to prevent further injury due to sympathetic eye movement Place the patient in supine to prevent further loss of fluid from the eye

Question 53

Burns the eye that are caused by ultraviolet light

Answer 53

covering the eye with a sterile moist pad and an eye shield. Place the patient in a supine position during transport and protect the patient from further exposure to bright light

Question 54

Chemical burns to the eye

Answer 54

immediate irrigation with sterile water or saline solution If only one is affected take care to avoid contaminated water is getting into the other eye Irrigate the eye for at least five minutes if the burn was caused by an alkali or strong acid irrigate continuously for 20 minutes Always flush from the nose side of the eye towards the outside to avoid flashing material into the other eye

Question 55

Ruptured ear drum

Answer 55

Perforation of the tympanic membrane can result from foreign bodies in the ear or from pressure related injuries such as blast injuries or diving related injuries Signs and symptoms of perforated tympanic membrane include loss of hearing and blood drainage from ear

Question 56

pinna avulsed

Answer 56

carefully realign the ear into position and gently bandage If it has been completely avulsed attempt to retrieve the part for reimplantation If detached part is retrieved a treat as an amputation If blood or CSF drainage is noted apply loose dressing over the ear without stopping the flow and assess the patient for other signs of basillar skull fracture

Question 57

anterior part of the neck injury zone 1 2 and 3

Answer 57

zone I: can extend into the chest and may not be easily recognized on physical examination Injuries in this area are associated with the highest mortality rate Zone II: most common are usually the most obvious and have a lower mortality rate than zone one injuries Zone III: often are difficult for surgeon to access and repair because many of the structures enter the base of the skull