Title: Neuro/Craniofacial Trauma Lt. Joseph Meade RN
1Neuro/Craniofacial TraumaLt. Joseph Meade RN
2Types of Injuries
- Blunt Trauma
- Acceleration, deceleration
- Penetrating trauma
- Missiles , Shrapnel , Bladed weapons.
- High Mortality rate
3Penetrating 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.
4Types 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.
5Indications of Head Injury
6Principals of Treatment
Table 2-2 Glasgow Coma Scale
Parameter Response Score
Parameter Response Score
- \ 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 trauma - Hypotension 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, Battles
sign, raccoon eyes, hemotympanum), etc. - Consider C spine immobilization.
7Head 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.
8Neuro Exam
- Decrease 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.
9After 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.
10Intracranial pressure Symptoms
- vomitting
- headache
- changes in behavior
- progressive decreased consciousness lethargy
- neurological deficits
- Seizures (Late)
- Posturing (Late)
11Epidural Hematoma
- An 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 status - Symptoms occur in hours
- Requires immediate surgical intervention
12Epidural Hematoma
13Epidural Symptoms
- The most important symptoms of an Epidural
hemorrhage are - Headache, severe
- Drowsiness
- Confusion
- Nausea or vomiting may accompany the headache
- Dizziness
- Enlarged pupil in one eye
- Weakness of part of the body, usually on the
opposite side from the side with the enlarged
pupil - Head injury or trauma followed by loss of
consciousness, an alert period of time, then
rapid deterioration back to unconsciousness
14SDH CT
Subdural Hematoma
15SUBDURAL SYMTOMS
- Loss of consciousness after original injury
- Headache, steady or fluctuating
- Weakness, numbness or inability to speak
- Slurred speech
- Nausea and vomiting
- Lethargy
- Seizures
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17Surgical 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.
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19Burr 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 edges
-
- Cautery to coagulate bleeders
- The incision is extended to the periosteum and
the retractors or rakes are immediately placed
under the periosteum with tension on the wound - The skull is drilled with the penetrator
-
- The hematoma is evacuated using a soft suction
tip. - A Penrose drain is sutured in
20Burr Hole
21Craniotomy
Craniotomy
.
22Craniotomy
The hair on part of the
scalp is shaved. The scalp is
23Craniotomy Instrumentation
Craniotomy Instrumentation
24Facial Trauma
25Facial Trauma
- Facial 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
26Le Fort Fractures
- Fractures of mid portion of face have been
classified as - Le Fort 1 - Fracture detaching palate and
maxillary alveolus - Le Fort 2 - Pyramidal fracture through sinus wall
laterally and nasal bones medially - Le Fort 3 - Fracture through frontozygomatic
sutures and orbits detaching facial skeleton from
base of skull
27LeFort I
Lefort I
- Can 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.
28LeFort II
- Fracture of the maxilla in a pyramid shape,
extending into the nasal bones. - Characterized by mobility of the nose into the
dental arch
Le Fort II
Characterized by mobility of the nose into the
dental arch.
29LeFort III
Le Fort III
- Fracture that involves total craniofacial
separation in a tripod pattern with craniofacial
detachment.
Characterized by mobility of the nose and the The
dental arch.
30LaFort III with Orbital edemawith NG tube
placement
31NG tube in Brain
32Skull Fracture
-
- A 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 ears
- Unequal pupil size
- Bruises or discoloration around the eyes(Raccoon
eyes) or behind the ears(Battle signs) - Swelling or depression of the part of the head
33Skull Fracture
34Raccoon Eyes
35Battle Signs
36Treatment Principles
- Airway management
- Primary and secondary trauma survey
- Establish baseline mental status(GCS)
- Cervical spine immobilization
37References
- Emergency War Surgery NATO Handbook Part IV
Regional Wounds and Injuries Chapter XXII
Craniocerebral Injury
- United States Naval Flight Surgeon's Manual
Third Edition 1991 Chapter 7 Neurology
- FM 21-11 First Aid for Soldiers Chapter 3 First
Aid for Special Wounds
- Hospital Corpsman Sick call Screeners Handbook.
Neurologic System - General Medical Officer (GMO) Manual Clinical
Section Neurosurgical Emergencies - Central Nervous System Emergencies