Neuro/Craniofacial Trauma Lt. Joseph Meade RN

1
Neuro/Craniofacial TraumaLt. Joseph Meade RN
2
Types of Injuries

• Blunt Trauma
• Acceleration, deceleration
• Penetrating trauma
• Missiles , Shrapnel , Bladed weapons.
• High Mortality rate

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.
5
Indications of Head Injury
6
Principals 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.

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 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.

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.
10
Intracranial pressure Symptoms

• vomitting
• headache
• changes in behavior
• progressive decreased consciousness lethargy
• neurological deficits
• Seizures (Late)
• Posturing (Late)  

11
Epidural 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

12
Epidural Hematoma
13
Epidural 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

14
SDH CT
Subdural Hematoma
15
SUBDURAL SYMTOMS

• Loss of consciousness after original injury
• Headache, steady or fluctuating
• Weakness, numbness or inability to speak
• Slurred speech
• Nausea and vomiting
• Lethargy
• Seizures

16
(No Transcript)
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.

18
(No Transcript)
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 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

20
Burr Hole
21
Craniotomy

Craniotomy

.
22
Craniotomy
The hair on part of the

scalp is shaved. The scalp is
23
Craniotomy Instrumentation
Craniotomy Instrumentation
24
Facial Trauma
25
Facial 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

26
Le 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

27
LeFort 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.

28
LeFort 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.
29
LeFort 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.
30
LaFort III with Orbital edemawith NG tube
placement
31
NG tube in Brain
32
Skull 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

33
Skull Fracture
34
Raccoon Eyes
35
Battle Signs
36
Treatment Principles

• Airway management
• Primary and secondary trauma survey
• Establish baseline mental status(GCS)
• Cervical spine immobilization

37
References

• 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