Lecture 17: Head and Face Injuries

What are the causes of facial lacerations?

May be a penetrating (sharp object) or blunt trauma causing direct or indirect compressive force

What are the signs of injury for facial lacerations?

Pain

Substantial bleeding

What is the care for facial laceration ?

• Facial lacerations should be cleaned with sterile saline and assessed for the presence of debris or damage to underlying structures.

• Apply pressure to control bleeding

• Rule out skull/ brain traumas per the rest of this lecture

• Referral to a physician may be necessary for stitches

What are scalp injuries?

Highly vascular area

What are the causes of injury for scalp injuries?

• Blunt trauma or penetrating trauma tends to be the cause

• Can occur in conjunction with serious head trauma

What are the signs of a scalp injury?

• Athlete complains of blow to the head

• Bleeding is often extensive (difficult to pinpoint exact site)b

What is the car for scalp injuries?

• Clean w/ antiseptic soap and water (remove debris)

• Cut away hair, if necessary, to expose area

• Apply firm pressure to reduce bleeding

• Wounds larger than 1/2 inch in length should be referred

• Smaller wounds can be covered w/ protective covering and gauze (use extra adherent)

When is tissue adhesive generally recommended?

for closure of simple lacerations less than 4 cm in length, that are not at points of high skin tension.

• If tissue adhesive is used for a laceration anywhere near the eye, be sure to place a drape to prevent dripping of the adhesive into the eye.

When is Closure with sutures instead of tissue adhesive may be preferable?

• for wounds over 4 cm in length or at points of high skin tension

• if it is through all skin layers and/or showing exposed fat, tendons, bones or vessels.

• Place a non-medicated gauze pad over the lesion if patient is to be sent for sutures

• Within 8-12 hours maximum

What are other options other that stitches?

▪Steri-strips ▪butterfly bandage

Brain injuries occur as a result of direct blow causing?

• Compressive force • Tensile (negative pressure) force

• Shearing

What is Cerebrospinal Fluid (CSF)?

• acts to convert focal force into compressive stress dissipated over the brain's full surface

• Has minimal impact on shearing force, especially when combined with rotation.

What is battle's Signs?

Periauricular ecchymosis Periauricular - around the external ear

Ecchymosis - bleeding under the skin

Late finding- 24-48 hours!

What is Periorbital Ecchymosis (Raccoon Eyes)?

Periorbital - around the eye Ecchymosis - bleeding under the skin

Late finding- 24-48 hours!

What is the halo sign?

Clear drainage that separates from bloody drainage suggests the presence of cerebrospinal fluid

What is PEARL?

Pupils Equal And Reactive to Light - Normal

Equal but Dilated / Unresponsive

Cardiac arrest, CNS injury

Equal but Constricted / Unresponsive

CNS injury or disease

Unequal, One Dilated / Unresponsive

Cerebrovascular accident (CVA), head injury, direct trauma to the eye

What is the cause of injury for Epidural Hematoma?

• Blow to head or a skull fracture which tears meningeal arteries

• Blood accumulation and creation of hematoma and pressure occur rapidly (minutes to hours)

What are the signs of injury for Epidural Hematoma?

• May or may not have brief LOC followed by period of lucidity. During this period, they may not display clear signs and symptoms of serious head injury

• Gradual progression of S&S

• Severe head pain, dizziness, nausea, dilation of one pupil (anisocoria), occurring on same side as injury, deterioration of consciousness, depression of pulse and respiration, and convulsion

What is the care for Epidural Hematoma?

Requires urgent neurosurgical care

• Must relieve pressure to avoid disability or death

What is the causes of a Subdural Hematoma?

- Result of acceleration/deceleration forces that tear vessels that bridge Dura matter and brain

- Venous bleeding (simple hematoma may result in little to no damage to cerebellum while more complicated bleed can damage cortex)

What are the signs of a Subdural Hematoma?

• Athlete may experience LOC in seconds to minutes,

• Pupillary asymmetry

• Signs of headache, dizziness, nausea or sleepiness if not unconscious

What is the care of a Subdural Hematoma?

Immediate Emergency medical attention

• CT or MRI is necessary to determine extent of injury

How many hours should you monitor an athlete after a head injury?

4-6 hours!

Don't send them home alone!

What is the Recognition and Management of Specific Facial Injuries?

1. Assess :

• Airway and breathing

• Mental status

2. Manage significant bleeding

• can better assess all structures

3. Check nose and ears for CSF

4. Take a top-down approach to assess

• Get an idea of facial asymmetry ASAP as these injuries will swell quickly

• Forehead and orbits

• Maxilla and nose

• Cheekbones (zygoma)

• Oral cavity and mandible

5. Evaluation criteria Symptoms - Asymmetry, bony steps, bruising and mobility

What are the causes of injury for forehead fractures?

- most common cause is blunt trauma

- usually fairly resistant to fractures

- Most superior portions of the weaker orbital structures reside withith the bounds fof the forehead

What are the signs for Forehead Fracture?

- Severe headache and nausea

- Palpation may reveal defect in skull

- May be blood in the middle ear, ear canal, nose, ecchymosis around the eyes (raccoon eyes) or behind the ear (battles sign)

- Cerebrospinal fluid may also appear in ear and nose (halo sign seen on gauze)

What are the causes of an orbital fracture?

Direct trauma to the eyeball

What are the signs of injury of an orbital fracture?

Possible posterior displacement of the eye (enophthalmos)

• Diplopia

• Restricted upward gaze

• Downward displacement of the eye

• Soft-tissue swelling and hemorrhaging

• Subconjunctival hemor rhaging

• Periorbital ecchymosis (r accoon eyes)

• Unilateral epistaxis

• Numbness

What is the numbness of orbital fracture?

due to injury to infra orbital nervecheek, side of nose, upper lip and ipsilateral teeth

What care orbital fracture?

• Ice, no blowing nose and Valsalva maneuver

• Risk of infection (due to proximity of maxillary sinus and bacteria)

• X-ray/CT will be necessary to confirm fracture

• Treated surgically or allow to resolve spontaneously

what are the signs of a Midface (Maxillary) Fracture?

• Must also assess airway and eyes

• Lengthening and flattening of face

• Mobile maxilla (see below)

• Nasal bleeding

• Ecchymosis of cheek

• Malocclusion (alteration of bite)

Palpation of facial bones Midface (Maxillary)Fracture

• palpation along maxilla for major deformities

• Identify by forehead stabilization with one hand, while gently pulling maxillary incisors

What is a Zygomatic Complex Fracture cause of injury?

Direct blow to the cheek

What are the signs of Zygomatic Complex Fracture?

• Deformity, or bony discrepancy

• Palpable step-offs in the upper lateral orbital rim and inferior orbital rim

• Cheek numbness- • due to injury to infra orbital nervecheek, side of nose, upper lip and ipsilateral teeth)

• Nosebleed (on injured side due to sinus filling with blood)

• Diplopia and possible restricted eye movements

• Subconjunctival hemorrhage and periorbital ecchymosis are seen in as many as 50% of patients

What is the care of Midface (Maxillary) and Zygomatic Complex?

• Secure airway

• If conscious, keep in upright sitting position to aid blood and saliva drainage.

•Transport to emergency for definitive diagnosis/imaging.

What are mandible fractures cause of injury?

Direct blow

•Often occur at the angle or the condyle

What are Signs of Injury Mandible Fractures?

• Pain with biting

• +ve Tongue blade test

What is the deformity with Mandible Fractures?

• Palpate inferior border & mandibular condyle

• Loss of occlusion

• Bleeding around teeth

• Lower lip anesthesia

What is the tongue blade bite test?>

Insert a wooden tongue depressor (TD) into both sides of the patient's mouth Have patient bite down while you attempt to pull the TD out. If the you cannot pull it out, the test is considered negative.

What is the care for mandible fractures?

• Secure airway

• Temporary immobilization w/ elastic wrap followed by reduction and fixation

• Emergency medical referral

What is the prevention of dental injuries?

• When engaged in contact/collision sports, mouth guards should be worn

• Greatly reduces the incidence of oral injuries- Strength of evidence A

- three basic types of mouth guards: Stock mouthpieces, "boil and bite" mouth guards, and custom guard

What are the causes of tooth fractures?

• Impact to the jaw

• Direct dental trauma

What are the signs of a Uncomplicated fracture?

produce fragments w/out bleeding

What are the signs of a complicated fracture?

produce bleeding, w/ the tooth chamber being exposed w/ a great deal of pain and sensitivity to thermal changes , air exposure and touch

What are the signs of a root fracture?

are difficult to determine and require follow-up w/ X-ray

What is the care for tooth fractures?

• Uncomplicated and complicated crown fractures do not require immediate attention

• Fractured pieces can be placed in a bag, milk, or save-a-tooth solution.

• DO NOT place the avulsed tooth portion in ice

• If not sensitive to air or cold, follow-up can be within 24 hours

• Bleeding can be controlled via gauze • In instances of root fractures, the athlete can continue to play but must follow-up immediately following competition

What is the cause of injury for Tooth Subluxation, Luxation, Avulsion & Intrusion?

Direct blow

What are the signs of injury for a subluxed ?

tooth may be loose w/in socket

What are the signs of a luxations?

no fracture has occurred, however, there is displacement

What is an intrusion?

the tooth is driven back into the socket • Do not try to reposition. Refer to dentist immediately

What is an extrusion?

it is partially outwardly dislodged • Attempt repositioning and hold in place by biting-down

What is laterally displaced tooth?

(forward, back, or side to side) • Do not attempt to reposition. Refer to dentist immediately

What is an avlusion?

the tooth is completely r emoved fr om the oral cavity

What is the important thing to remember about avulsion injuries?

• Prognosis is 90% with replacement within 30 minutes

• After 2 hours, results in a 95% failure rate.

What is the management of alusion?

• Locate and protect tooth

• If soiled, rinse lightly with milk or saline

• Do not rub, use tap or drinking water, as this may injure the periodontal ligament cells and compromise implantation.

Reposition tooth if athlete is conscious, ASAP • Minutes matter! Try to get it in within 5-10 minutes • Don't worry about getting it in perfectly, it can be repositioned by the dentist

• Splint with hand or wad of paper towel to hold in place

• Refer for immediate dental evaluation If unable to replace

• Stored in "Save-A-Tooth," cold milk, cold saline, saline gauze on ice or athlete's cheek

What is the cause of injury for nasal fractures?

Direct trauma

What is the examination of nasal fractures?

• Observe for and palpate gently for crepitus, or bony asymmetries

• Depression of the nasal dorsum

• Deviation of the septum

• Examine for septal hematoma

• Breathe through each nostril?

What is the care for nasal fractures?

• Secure airway if needed

• Control bleeding by external pressure or if needed, internal packing

• Protect and transport for X-ray, examination and reduction Uncomplicated and simple fractures will pose little problem for the athlete 's quick return

What is the cause of a Septal Hematoma?

Hemorrhage between the two layers of mucosa covering the septum

What are the signs of injury for a Septal Hematoma?

• Blueish or dull red bulge on the septum • Athlete will complain of nasal pain and may have difficulty breathing out of one nostril

What is the care for a septal Hematoma?

This may complicate a trivial nosebleed.

• A neglected hematoma will result in formation of an abscess along with bone and cartilage loss and deformity

• At the site of the hematoma, compression will be required (and if MD present, drained immediately)

• Following drainage, a wick is inserted to allow for further drainage

• Packing will be necessary to prevent a return of the hematoma

What are the cause of injury for a nose bleed (epistaxis)?

• Result of a direct blow in sport situations • A foreign body or some other serious facial injury

What are the signs of injury for a nose bleed?

• Generally bleeding from the anterior aspect of the septum (Little's/Kiesselbach's area) • Usually presents with minimal bleeding and resolves spontaneously • More severe bleeding may require more medical attention

What is the care for a nose bleed?

• Have athlete blow each nostril to clear clots. • Sit upright in the head-forward position to avoid blood from pooling in the posterior pharynx. • Using a cold compress over the nose, compress vessels of the nasal septum. • If bleeding does not cease in 5 minutes, an astringent or styptic may need to be applied along with a gauze/cotton nose plug to encourage clotting • Ice to back of head/neck can also help decrease vagal tone, thereby allowing bleeding to slow and help the clotting process. • After bleeding has ceased, the athlete can return to play but should be reminded not to blow the nose under any circumstances for at least 2 hours after the initial insult

What are Aspects associated with sport-related ocular injuries?

• High likelihood of being a severe injury • Treatment often limited to salvaging the remaining vision • Most can be prevented • 26% decrease in the incidence of pediatric ocular injuries from 2006 to 2014 • High-risk sports include basketball, baseball, soccer, lacrosse, tennis, racquetball, hockey. • Basketball was the leading cause of sports-related ocular injuries attending the emergency department between 2010 and 2013 • Very high-risk sports include boxing, martial arts, and wrestling.

What is the cause of a Subconjunctival Hemorrhage?

Appears as a bright red area in the white conjunctiva

• Can occur spontaneously • Due to Minor eye trauma or a orbital/zygomatic fracture • Valsalva maneuvers, such as coughing, sneezing, or straining are the usual causes.

What do you need to assess for with Subconjunctival Hemorrhage?

If this covers the entire sclera ,it may be obscuring a perforation in the eye. Patient should be referred immediate. Otherwise, usually resolves in 2-3 weeks

What is the cause of Corneal Abrasions?

An injury that occurs to the most anteri or layer of t he eye Cause of Injury • Poke to t he eye • Attempt t o remove foreign object from eye by r ubbing

What are the signs of injury for Corneal Abrasions?

• Mild t o sever e pain • Watering of the eye • Photophobia • Pain with bli nking • Decreased focusing abi lity • Spasm of the orbicular muscle of the eyeli d

What is the care for Corneal Abrasions?

• Ref er to a physician (May need to patch unti l assessed) • U su a lly he a l w ithin 24 to 7 2 h o urs • A rec e nt rev ie w(2 01 6 ) d id n o t s h ow an y im pro v em en t in p ain , sy mp to ms , o r h ea ling with pa tch in g, wh e n c o mp are d w ith n on -p atc h ed ind ivid u als • A pa tc h m ay be n ec e ss a ry with yo u ng e r p a tie n ts to a v oid ru b bin g . • R etu rn to p la y is g u ide d b y a d ec re as e in sy m pto ms an d ma y re qu ire s h ort -te rm e ye p ro te ctio n.

What is the cause injury Hyphema?

This is a serious injury that leads to serious problems with the lens or retina

- • Anterior chamber injured due to blunt trauma • High force injury so you must rule out penetrating trauma, orbital fracture, abrasion, and/or retinal injury

What are the signs of injury for hyphema?

• Visible reddish tinge (occasionally pea green) in the anterior chamber of the eye • Vision is partially or completely blocked

What is the care for a hyphema?

▪ IMMEDIATE referral to an ophthalmologist

▪ Bed rest (4 days)and elevation (30-40 degrees); both eyes patched

▪ Discontinue use of NSAIDs

▪ Irreversible vision damage if not managed properly!

What is the cause of injury for a Periorbital ecchymosis (black eye)

Blow to the area surrounding the eye

What are the signs of injury for a Periorbital Ecchymosis (Black Eye)?

Swelling and discoloration Signs of a more serious condition if accompanied by a subconjunctival hemorrhage

What is the care for a Periorbital Ecchymosis (Black Eye)?

Cold application for at least 30 minutes,

• Do not blow nose after acute eye injury - may increase hemorrhaging

What is the basic eye assessment?

1. History-determine force and direction of force

2. Check vision- before any manipulation

• Chart or newspaper 16" away

• Diplopia suggests serious injury

3. Pupil/ Cornea/conjunctiva

• Penlight exam (PEARL)

• Foreign bodies

• Hyphema or Subconjunctival hemorrhaging

4. Eye movements

• Full mobility....Up, down, all around

If there is a chemical injury to the eye how long do you flush it for?

flush immediately for 30 mins

What is the most dangerous injury?

maxillofacial injuries

What is the second most cause of death?

Airway compromise secondary to laryngotracheal trauma

What are air way injuries?

Any blow to the anterior neck can cause significant airway obstruction.

What can happen with minor injuries to the larynx?

can worsen due to laryngospasm

- Closure of the larynx caused by spasm.

- Athlete becomes agitated and panic stricken

- To treat, move chin forward and place strong anterior pressure behind the angle of the jaw. Hold for 45-60 seconds until you can hear inspiration.

What is an larynx injury?

Cartilaginous fracture to the Thyroid/Cricoid car tilages

What are the signs and symptoms of Larynx injuries?

1.Athlete initially may be speechless or have hoarse (muffled, breathy, changed) voice 2.Loss of prominence in anterior neck (fractured thyroid/cricoid cartilage)

3.Difficulty breathing • Feeling of impending doom 4.Pain/tenderness with swallowing,

5.Cr epitation on palpation of the anterior neck • Subcutaneous emphysema- cr itical! 6.Hematoma/hemoptysis

◼This is a medical emergency- Load and go!