Alexander ch37 lecture

Copyright © 2017, 2012 Pearson Education, Inc. All Rights Reserved.
Advanced EMT
A Clinical-Reasoning Approach, 2nd Edition
Chapter 37
Head, Brain, Face,
and Neck Trauma

• Applies fundamental knowledge to provide basic
and selected advanced emergency care and
transportation based on assessment findings for
an acutely injured patient.
Advanced EMT
Education Standard

1. Define key terms introduced in the chapter.
2. Describe the anatomy and function of the brain,
skull, meninges, intracranial blood vessels, eye,
facial structures, and structures of the neck.
3. Discuss special considerations in the assessment
and management of patients with injuries to the head,
face, and neck, including airway compromise, profuse
bleeding, potential that injuries may be self-inflicted
or the result of violence, and patient fears associated
with the injuries.
Objectives (1 of 4)

4. Given a variety of scenarios, demonstrate the
assessment-based management of patients
with injuries to the brain, skull, scalp, face, eye,
and neck.
5. Demonstrate the assessment and management
of specific injuries of the eye, scalp, face, and neck.
6. Explain the indications and procedure for removing
contact lenses from an injured eye.
Objectives (2 of 4)

7. Explain the pathophysiology and significance of the
following with respect to traumatic brain injury: scalp
lacerations and avulsions, open and closed skull
fractures, cerebral concussion and diffuse axonal injury,
cerebral contusion, coup–contrecoup injury, cerebral and
intracranial hematomas, and cerebral hemorrhage.
8. Explain the compensatory mechanisms, and the resulting
symptoms, for increased intracranial pressure.
9. Explain the limitations of the compensatory mechanisms
for increased intracranial pressure.
Objectives (3 of 4)

10.Describe the pathophysiology and key signs of increased
intracranial pressure and brain herniation.
11.Identify and, where possible, manage factors that can
worsen traumatic brain injuries, including hyperglycemia,
hypoglycemia, hyperthermia, hypotension, hypoxia,
hypercarbia, and hypocarbia.
12.Document information relevant to the assessment and
management of patients with injuries to the head.
Objectives (4 of 4)

Introduction (1 of 2)
• As an Advanced EMT, identify traumatic brain
injury (TBI) by evaluating MOI and assessing
patient for signs and symptoms of injury.
• Significant trauma to face can occlude airway or
cause profuse bleeding into airway, compromising
patency.
• Be sensitive to patients.

Introduction (2 of 2)
• Do not lie to patient if asked about potential for
scarring or disfigurement; be tactful and
supportive.
• Injury to neck, especially to trachea or larynx, can
be life threatening due to airway obstruction.

Think About It
• What does this information tell Chuck and Matt
about the MOI?
• How would the MOI assist Chuck and Matt in
determining the potential for injury to this patient?
• What additional information should Chuck and
Matt obtain?

Anatomy and Physiology Review (1 of 9)
• The skull
– Part of skeletal system; protection for brain
– Cranium
 Large plates of bone fused together
 Frontal, temporal, parietal, sphenoid, occipital
– Facial bones
 Orbits and nose, maxillae, zygomatic bones, mandible

• The skull (continued)
– Basilar skull
 Floor of the skull
– Brain occupies 85% of total space within skull.
– Remainder of space
 Cerebrospinal fluid and volume of blood

Figure 37-1
The brain.

• The brain
– Cerebrospinal fluid (CSF) serves as a cushion for
brain.
– Surrounded by three layers of meninges
– Three parts: cerebrum, cerebellum, brainstem.
– Cerebrum:
 Cognitive function, sensory functions, motor functions, emotion

• The brain (continued)
– Cerebellum
 Coordination and equilibrium
– Brainstem (pons, midbrain, medulla oblongota)
 Autonomic body functions (blood pressure, heart rate,
respiratory rate)
 Injury to brainstem can lead to circulatory and respiratory
failure and death of patient.

• The neck
– Structures that are vital to sustaining life
– Trachea and larynx
 Vital to air exchange
– Major blood vessels
 Transporting blood to and from brain
– Injury that results in significant bleeding may lead to
rapid deterioration, death of patient.

Figure 37-2
The facial bones.

• The face
– 14 facial bones
 Orbits around eyes, nasal bones, zygomatic bones, maxilla
– Most facial bones are immovable.
– Provide protection for eyes
 Form framework of airway and face.
– Significant trauma that causes fractures of the face
may also cause brain injury.

Figure 37-3
Anatomy of the eye.

• The eye
– Globe spherical shape
 1 inch in diameter
– Outer layer
 Sclera
– Cornea
 Clear covering over front
 Covers pupil

• The eye (continued)
– Iris
 Colored portion
 Eye color
 Iris dilates and constricts to change size of pupil to let in
more or less light.
– Lens
 Focuses light entering eye onto retina

• The eye (continued)
– Retina
 Light-sensitive; optic nerve receives impulses, sends to brain
 Within brain, impulses interpreted as image
– Two fluid-filled cavities
 Aqueous humor and viscous vitreous humor
– Surrounded by cup-shaped orbits formed by facial
bones
– Muscles attach eye to orbit and allow movement.

General Assessment and Management
(1 of 5)
• Signs:
– Altered mental status, bleeding, substantial edema or
discoloration
• Complaints:
– Pain and swelling of affected area, loss of function of
affected area, dizziness, headache, nausea, vomiting
• Perform scene size-up to determine scene safety
and MOI.

(2 of 5)
• Do not let dramatic appearance of head and facial
injuries distract you.
• Ensure patient has open airway and ventilation,
and that oxygenation and circulation are
adequate.
• Concern for airway obstruction or aspiration
– Significant facial or oral bleeding, vomiting, altered
mental status, and complaints of swelling can lead to
airway obstruction or aspiration.

(3 of 5)
• Severe cases, endotracheal intubation or
cricothyrotomy necessary
• Consider need for paramedic transport or closest
emergency department.

(4 of 5)
• Open wounds
– Use direct pressure to control bleeding; keep blood
from entering airway.
• If patient is critical or has substantial MOI:
– Expose patient and perform rapid trauma exam and
head-to-toe exam.
• Focused exam for patients with isolated injuries

(5 of 5)
• Obtain vital signs and SAMPLE history.
• Establish baseline for patient’s condition.
• Reassess critical patients every 5 minutes.
• Reassess noncritical patients every 15 minutes.
• Remain alert for signs and symptoms of shock.

Injuries to the Head (1 of 6)
• Scalp injuries
– Highly vascular; minor laceration can bleed profusely
– Can cause or contribute to hypovolemia
– Indication of potential skull fracture and TBI
– Carefully assess and control bleeding.
– Scalping injuries
 Large flap of scalp (hair, skin, underlying soft tissues) avulsed
from skull

• Scalp injuries (continued)
– Closed scalp injuries occur from blunt trauma.
– May result in formation of hematoma
– Consider underlying injury to skull and brain.
– Application of cold pack may reduce bleeding.

Figure 37-4
Types of skull fractures.

• Skull injuries
– Skull
 Thick plates of fused bone; provide protection to brain
– Can fracture as result of forceful impact
 Can injure brain
– Maintain airway, breathing, and circulation.
– Assess for TBI and cervical-spine injury.

• Skull injuries (continued)
– Linear skull fracture
 Thin line fracture across bone on X-ray; no obvious deformity
of skull
 Does not result in displaced segments of bone
– Depressed skull fracture
 Impact results in multiple cracks.
 Pushed/depressed into skull

– Closed skull fracture
 Scalp remains intact.
– Open skull fracture
 Open injury to scalp present
– Immobilize impaled object in skull; do not remove.

– Basilar skull fracture
 Fracture to base or floor of skull
– Clear or bloody fluid draining from ears, nose, mouth
in patient with trauma to head, suspect cerebrospinal
fluid (CSF)
– “Raccoon eyes” (ecchymosis around eyes) and
“Battle’s sign” (ecchymosis behind ears)

Traumatic Brain Injuries (1 of 17)
• Skull does not expand
– Swelling of injured brain or accumulation of blood
within skull will increase intracranial pressure (ICP)
• Primary brain injury
– Time of impact with skull
• Secondary brain injury
– Cerebral edema, ischemia, hypoxia

• Cerebral edema and increased intracranial
pressure (ICP)
– Brain tissue compressed by increasing ICP
– Progressive brain dysfunction
– Projectile vomiting
– Headaches

pressure (ICP) (continued)
– Altered mental status
– Unequal pupils
– Cushing’s reflex:
 Increasing blood pressure, decreasing heart rate
– Cushing’s triad:
 Cushing’s reflex and irregular breathing pattern

Figure 37-5
(A)
(B)
(A) Flexion (decorticate) posturing and (B) extension (decerebrate) posturing.

– Increase in blood pressure worsens intracranial
bleeding and cerebral edema.
– Corrected by decreasing intracranial pressure with
surgical interventions and medications
– Herniation
 Tissue forced through structures within the cranium
– Signs of herniation
 Cushing’s triad, pupillary changes, altered respirations,
trismus, posturing in response to painful stimuli

– Decerebrate posturing
 Rigid extension of extremities in response to painful stimuli
– Decorticate posturing
 Rigid flexion of upper extremities in response to pain
• What are the factors that worsen cerebral edema
and ischemia?

– Maintaining mean arterial pressure (MAP) with cerebral
edema critical
– Patients with TBI should receive IV fluids to maintain
systolic blood pressure of 90 mmHg.
– Ventilate patient to remove excess carbon dioxide.
– High PaCO2 causes vasodilation.
– Low PaCO2 causes vasoconstriction.
– Increased perfusion of brain accompanied by adequate
blood glucose level

• Key components of neurologic exam
– Determine if history of altered mental status or loss
of consciousness after injury.
– Assess level of responsiveness and mental status.
– Check pupils for size, equality, reactivity to light.
– Look for neurologic deficits.

• Consider restricting motion of cervical spine.
• Open and maintain airway.
• Ensure normal ventilation.
• Administer oxygen, if needed.
• Control bleeding.

• Start IVs, if needed.
• Maintain normal body temperature.
• Check blood glucose level; treat hypoglycemia.
• Transport patient without delay.

• Specific brain injuries—concussion
– Brain injury caused by blunt force trauma
– No structural damage
– Postconcussive syndrome
 Patient experiences headaches, memory problems,
depression.
– Can occur in conjunction with other TBIs

Figure 37-6
Coup and contrecoup injury to the brain.

• Specific brain injuries—cerebral contusion
– Bruising of brain with prolonged loss of consciousness
or confusion
– Edema to brain is a concern.
– Coup–contrecoup injuries
 Brain “bounces” back and forth in skull

• Specific brain injuries—cerebral contusion
(continued)
– Signs and symptoms of TBI
 Altered mental status
 Weakness
 Seizures
 Altered respiratory rate or pattern
 Bradycardia, hypertension
 Impaired speech, unusual behavior, unequal pupils
 Nausea, vomiting, posturing, trismus

• Specific brain injuries—diffuse axonal injury
– Caused by shearing or tearing forces associated with
acceleration/deceleration injuries
– Prognosis for such injuries is generally poor.
– Shaken baby syndrome

Figure 37-7
Epidural hematoma. Linear fractures can cause laceration of the middle meningeal artery, which leads to
the accumulation of blood between the skull and dura mater.

Figure 37-8
Subdural hematoma. Venous bleeding between the dura mater and arachnoid mater usually leads to the
formation of a hematoma.

Figure 37-9
Intracerebral hemorrhage.

• Specific brain injuries—intracranial hemorrhage
– Bleeding within cranial vault, resulting hematoma
– Epidural
 Between skull and dura mater
– Subdural
 Between dura mater and arachnoid mater
– Subarachnoid
 Between arachnoid and pia mater
– Intracerebral
 Within brain tissue itself

• Injuries to the face
– Can be very frightening for patient
– Temporary or permanent loss of vision
– Permanent disfigurement.
– Do your best to calm and comfort patient.
– Primary concern:
 Maintaining patent airway
– Both open and closed injuries

Figure 37-10
Le Fort facial fracture classification.

• Injuries to the face
– Fractures of mandible are painful; may result in airway
compromise.
– Le Fort I fractures
 Maxilla only; may result in slight instability and deformity
– Le Fort II fractures
 Maxilla and nasal bones

• Injuries to the face (continued)
– Le Fort III fractures
 Entire midfacial region
– Le Fort II and III fractures usually result in leakage
of cerebrospinal fluid.
– Fractures to nasal bone are not life threatening.
– Ensure airway remains patent through suctioning
or directing patient to spit blood from mouth.
– Orbital fractures involve zygoma and maxilla.

Think About It
• What are the pertinent pieces of information
gathered from the mechanism of injury?
• How does the mechanism of injury and the clinical
presentation of the patient assist in making a
transport decision?
• What are Matt and Chuck’s major concerns at this
point?

Eye Injuries (1 of 4)
• Result of blunt trauma, penetrating trauma,
chemical exposure
• Detached retina
– Force applied to eye is great enough to cause
separation of retina from wall of eye
– True emergency
– Patients complain of dark areas within their vision.

• Penetrating trauma
– Places patient at risk for blindness
• Extent of injury is directly related to the MOI.
• Stabilize impaled objects in eye in place.
– Removal can cause additional injury.
• Never attempt to replace eyeball in its socket.

• Hold cup and dressing in place while you apply
bandage that encircles head and covers both
eyes.
• Important to cover uninjured eye.
• Transport patient immediately.

• Chemical burns to eyes are true emergencies.
– Cause blindness within seconds of exposure
• Signs and symptoms
– Redness or cloudiness of eyes
– Swelling
– Blurred or diminished vision
– Pain
– Redness or burns around eyes
– Flush chemical from affected eye with water.
– If contact lenses are in eyes, remove them.

Ear Injuries
• Bleeding minor:
– Does not pose a life threat
• Internal structures are well protected by skull.
• Injury results from penetrating trauma or rapid
changes in pressure.

Teeth Injuries
• Avulsed teeth
– Consider teeth to be potential airway obstructions.
– Transport teeth with patient:
 Doctors may be able to reimplant them.

Injuries to the Neck (1 of 3)
• Cervical spine
– Protection to spinal cord
– Blunt or penetrating trauma:
 Patient is at risk for paralysis, shock, respiratory compromise,
or death.

• Obvious penetrating trauma to the neck
– Injury to carotid arteries may result in life-threatening
bleeding in matter of minutes.
– Hematomas from closed injuries can obstruct airway
or impair blood flow.
– Air embolism:
 Air enters vessels of neck.
 Prevent this by immediately covering open neck wound
with gloved hand then an occlusive dressing.

• Injuries to the airway
– Injury to trachea or larynx
 Affects airway patency
– Frequently assess adequacy of airway and breathing
status.

Chapter Summary (1 of 3)
• Identify life threats related to specific injuries.
• Consider potential for associated trauma to other
parts of body.
• Internal injuries may produce internal bleeding,
causing hypotension.
• Caring for patient with head injury challenging due
to altered level of responsiveness and patient
possibly being combative.

• Vital that you have additional help on scene
and en route.
• TBI patients very susceptible to deterioration
in condition as result of hypotension, hypoxia,
hypercapnia, hypocapnia.
• Ensure adequate ventilation.
• Provide positive pressure ventilations with high-
flow oxygen, if needed.

• Be prepared to use suction when a patient
experiences bleeding into airway and/or vomiting
present.
• Failure to do so can lead to loss of airway patency.

Alexander ch37 lecture

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Alexander ch37 lecture