Head & EENT Trauma

Week 13

What is the periosteum

Fibrous membrane covering surface of skull

How about them skull bones | 4

• Skull has 28 bones

• Cranium/cranial vault - 8 bones that protect/encase brain

• Auditory ossicles - 6 bones that allow us to hear

• Face - 14 bones that DONT form part of cranial vault

What are the different bones in the auditory ossicles and what does it do | 4

• Malleus

• Incus

• Stapes

• Enable hearing by transmission of vibration from tympanic membrane

What is important to note about that brain | 3

• Takes 25% of body’s glucose n 20% of body’s O2

• No O2 or glucose storage capacity

• Brain attempts to maintain O2 n glucose supply (compensatory)

What is the frontal lobe responsible for | 4

• Voluntary motor action

• Problem-solving, decision-making, impulse control

• Memory n learning

• Personality traits

What is parietal lobe responsible for | 2

• Controls sensory n motor functions on opposite side of body

• Memory n emotions

What is occipital lobe responsible for

Processing visual info (colour, movement, etc)

What is temporal lobe responsible for | 2

• Speech, hearing, taste, smell

• Long-term memory

What does the subthalamus do

Controls motor functions

What is neurological vomiting

Pressure on the brainstem, without warning

What is ataxic breathing (biots) | 2

• Irregular rate, rhythm n volume 

• Damage to medulla oblongata

What is apneustic breathing | 3

• Regular, prolonged gasping inhale with short exhale

• Damage to pons

• Shark fin like breathing

What is cheyne stokes breathing | 3

• Rhythmic pattern 

• Crescendo-decrescendo-apnea

• Widespread damage (brain dying) 

What is important to note about them scalp injuries | 4

• Bleeding profusely - large # of BVs in subcutaneous/connective tissue

• Hypovolaemic shock in paeds

• Subgaleal haematoma

• Caused by blunt trauma

What is subgaleal haematoma

Collection of blood between skull n soft tissue of scalp

What are the different skull fractures | 4

Linear, depressed, basilar, open

What is a linear skull fracture | 4

• Non-displaced skull fracture

• 80% of skull fractures

• 50% in temporal/parietal region

• Sometimes no physical signs (if no ICP/major TBI - benign)

What is a cranial suture and how many | 2

• Joints in skull that are unmoveable

• 4 sutures

What is a depressed skull fracture | 3

• Soft, boggy area over injury

• Bone fragments can be driven into brain/meninges

• Frontal/parietal more susceptible (thinner bones)

What is a basilar (base of skull) fracture | 5

• Results from extension of linear fracture to base of skull

• CSF fluid drainage - halo sign

• Periorbital ecchymosis (raccoon eyes)

• Battle signs (ecchymosis over mastoid process behind ears)

• Develop rapidly or over 24hrs

What is an open skull fracture | 2

• High mortality rate

• High risk of bacterial meningitis

What are the common mechanisms of a TBI | 2

• Blunt trauma to head

• Deceleration injuries (coup-contrecoup)

What are the two types of TBI

Primary (direct) n secondary (indirect)

What is a primary (direct) TBI

Injury to brain/associated structures resulting instantaneously from impact to head

What is secondary (indirect) TBI | 2

• After-effects of primary injury can happen anytime after injury

• Cerebral oedema, intracranial haemorrhage, increased ICP, cerebral ischemia, hypoxic brain injury, infection

What is normal ICP

0-15mmHg

What does increasing ICP do | 4

• Oedema (swelling) or bleeding inside cranial vault

• Squeezes brain against skull

• Decreases CPP

• Decreased cerebral flow can be fatal

What CPP is required for brain to perfuse effectively | 3

• 60mmHg

• Drop in CPP = cerebral ischemia

• Potential for brain damage n death

What is important to note about CPP n ICP | 3

• CPP n ICP can’t be measured in field

• Focus on reducing/mitigating ICP rises

• Maintaining MAP

What can increased ICP result in

Cranial herniation - brain forced through foramen magnum

What are early signs of ICP | 7

• Vomiting (projectile, w/o warning, nausea)

• Headache (feel like head is going to fall off)

• Alerted LOC, low GCS (combative - taking off c-collar)

• Seizures

• Increased BP (to overcome ICP - MAP-ICP = CPP)

• Decreased HR

• Cheyne stokes breathing

What are late signs of ICP | 3

• Cushing triad

• Unilateral dilated/non-reactive/sluggish pupils

• Decorticate/decerebrate

What should you think about if pt becomes combative | 2

Asks for ACP (sedation) or restrain

What is cushing’s triad | 3

• Widening of pulse pressure (HTN)

• Bradycardia

• Irregular respirations (maybe apneic)

If a pt has decorticate n decerebrate what does that indicate

One side of brain has more pressure on it

What are focal brain injuries

Specific, clearly defined brain injury isolated to certain area

What are the 2 types of focal brain injuries

• Intracranial haemorrhage

• Cerebral contusion

What are diffuse brain injuries

Affect the entire brain

What are the 2 types of diffuse brain injuries

• Cerebral concussion

• Diffuse axonal injury (DAI)

What can intracranial haemorrhage (focal) cause

Increasing ICP

What are the 4 types of intracranial haemorrhage (focal)

• Epidural/extradural haemorrhage

• Subdural haemorrhage

• Subarachnoid haemorrhage

• Intracerebral haemorrhage

What is epidural/extradural haemorrhage (focal)

Bleeding between dura mater n skull

What causes epidural/extradural haemorrhage (focal)

Direct blow to head

What is epidural/extradural haemorrhage (focal) associated with

Linear skull fracture of temporal bone (middle meningeal artery runs along groove here - prone to disruption)

What are the S&S of epidural/extradural haemorrhage (focal) | 4

• Initial LOC followed by brief consciousness (lucid interval)

• Deterioration into unconsciousness

• Pupil on injured side becomes fixed n dilated (ICP puts pressure on oculomotor nerve)

• Signs of increased ICP

What is a subdural haemorrhage (focal) | 2

• Bleeding between arachnoid mater n dura mater (multiple pockets of bleeding - lower risk of ICP)

• More common than epidural bleeds

What causes subdural haemorrhage (focal) | 3

• Falls or strong deceleration forces

• Can occur w/or w/o skull fracture

• Results from ruptured vein (slower bleeding more contained)

Who is more likely to have subdural haemorrhage (focal) | 3

• Elderly pts

• Pts w/chronic alcohol dependance

• Pts on anticoagulant meds

What are S&S of subdural haemorrhage (focal) | 5

• Acute presentation (in 24hrs) or chronic (2 weeks)

• Fluctuating LOC

• Slurred speech

• Periods of confusion (answer you later)

• Unilateral hemiparesis (one-sideed weakness)

What is subarachnoid haemorrhage (focal)

Bleeding into subarachnoid space (where CSF is)

What causes subarachnoid haemorrhage (focal)

Traumatic/atraumatic mechanism (ruptured aneurysm)

What are the S&S of subarachnoid haemorrhage (focal) | 3

• Worst headache of their life (sudden, thunderclap)

• Meningeal irritation (pain radiates to neck, nuchal rigidity)

• Signs of increased ICP

What is nuchal rigidity

Stiff/painful neck that makes it hard to bend head forward)

What is intracerebral haemorrhage (focal)

Bleeding within brain tissue itself (S&S will vary, associated with other injuries)

What causes intracerebral haemorrhage (focal) | 3

• Penetrating head injuries

• Depressed skull fractures

• Rapid deceleration injuries

What is a cerebral contusion (focal)

Bruised, damaged brain tissue

What is important to note about cerebral contusion (focal)

Longer lasting neurological effects n deficits compared to concussion

What causes cerebral contusions (focal) | 2

Coup-contrecoup n direct blunt head trauma

What are the S&S of a cerebral contusion (focal) | 2

• Headache

• Swelling (watch for signs of increased ICP)

What is a cerebral concussion (diffuse)

Occurs when brain is jarred around inside skull

What causes a cerebral concussion (diffuse) | 3

• Coup-contrecoup

• Falls

• Mild blunt trauma

What are S&S of cerebral concussion (diffuse) | 4

• Confusion/disorientation

• Repetitive questioning (don’t be annoyed)

• Retrograde amnesia (work backwards until they remember)

• Anterograde amnesia

What is retrograde amnesia

Memory loss of event/events prior to this

What is anterograde amnesia

Difficulty forming new memories after event

What is a diffuse axonal injury (DAI) (diffuse) | 3

• Like a concussion but severe (permanent neurological impairment)

• Stretching/shearing of nerve fibres w/axonal damage

• Classified as mild, moderate n severe

What causes DAI (diffuse) | 2

Severe coup-contrecoup or falls

What are S&S of DAI (diffuse) | 4

• LOC (temporary/prolonged)

• Confusion/amnesia

• Cognitive impairment, mood swings, motor/sensory deficits

• Posturing n increased ICP

What is photophobia

Sensitivity to light

What is dialopia

Double vision

What is important to note about H-test | 3

• Less distractible - not focusing on finger

• Peripheral vision gone

• Nystagmus

What is nystagmus

Ticking at extreme ends of h-test

What is post-ictal

Period following a seizure w/pt being confused/altered GCS

How to airway management head injuries | 4

• Jaw thrust if unconscious

• OPA if below GCS 6 (trismus)

• iGel can be used but can raise ICP

• Get suction ready (sudden vomiting)

How to ventilatory support | 2

• Provide O2 if signs of hypoxia

• May use BVM

How to BVM w/o cerebral herniation

Maintain ETCO2 at 35-45mmHg (10bpm)

How to BVM w/cerebral herniation 

Hyperventilate pt to maintain ETCO2 at 30-35mmHg (20bpm)

When do you hyperventilate pt | 4

• Signs of cerebral herniation

• GCS <9

• Dilated/unreactive/asymmetrical pupils AND/OR

• Unilateral/bilateral posturing

Why we hyperventilate | 5

• Causes cerebral vasoconstriction

• Shunts blood away from brain - lowers ICP

• Shunts O2 n glucose from brain

• Creates space for bleeding n swelling

• Never allow ETCO2 <30mmHg - cerebral anoxia

What should we considering doing for head injured pts

Raising pts head to 30 degrees to reduce swelling n ICP

How to hyperventilate w/ETCO2 monitoring | 3

• Adult - 20bpm - 1 breath every 3 secs

• Child - 25bpm - 1 breath every 2.5 secs

• Infant - 30bpm - 1 breath every 2 secs

What about circulatory support | 2

• If MAP drops CPP drops

• Maintain MAP w/IV fluids (only if haemorrhaging n hypotensive)

How to control scalp lacerations

Direct pressure

How to control depressed/open skull fractures

Flat palm pressure

When can you use haemostatic dressing on head?

When brain tissue is not exposed

What about when brain tissue is exposed?

Cover with moist, sterile dressing

Can you have hypovolaemic shock from head injury?

No, not enough space (look somewhere else!)

What is 90-90-9 rule | 3

• 1 drop <90% in SPO2 ×2 mortality

• 1 drop <90 SBP x2 mortality

• GCS <9 ×2 mortality

What to do with leaking CSF?

Cover w/loose sterile dressing

What does EENT stand for | 4

Ears, eyes, nose, throat

What is orbital fossa

Eye socket

What is a sclera

White around eye

What is the iris

Pigmented ring

What is the pupil

Black hole centre of iris (lets light through)

What is the lens

Behind pupil

What is the retina

Extension of optic nerve at back of globe

What is cornea

Transparent film covering iris n pupil

What is conjuctiva

Mucous membrane covering sclera

What are the 3 parts of the ear

External, middle, internal ear

What is external ear

Pinna/auricle (visible part of ear), external auditory canal n tympanic membrane

What is middle ear

Tympanic membrane n ossicles