Head and Face Trauma: Assessment and Management
1. Introduction to Head and Face Injuries
Head and face injuries encompass a wide range of trauma, including:
• Maxillofacial injuries
• Eye and ear injuries
• Oral and dental injuries
• Injuries to the anterior neck
• Head and traumatic brain injuries
The brain is highlighted as "the most important organ in the body," requiring "maximum protection from injury."
Initial Assessment and Care for Head/Face Trauma
A key scenario presented involves a patient ejected from a motorcycle, not wearing a helmet, lying supine with eyes closed and no movement. Initial concerns and care revolve around:
• Airway Compromise: This is an immediate and critical concern, especially with massive soft-tissue trauma to the face and unstable facial bones. Blood from facial injuries can irritate the gastric lining, causing vomiting and aspiration, further complicating airway management.
• Spinal Motion Restriction: Protecting the cervical spine is the initial step in managing facial injuries.
• Rapid Assessment and Prompt Transport: Distinguishing specific maxillofacial fractures in the prehospital setting is not as important as rapid assessment, managing life-threatening conditions, airway management, spinal motion restriction, and prompt transport to an emergency department for radiographic evaluation.
2. Anatomy of the Head and Face
2.1. The Skull and Facial Bones
• The skull consists of 28 bones in three groups: 6 auditory ossicles (three on each side) and 22 bones making up the cranium and face.
• Cranial Vault: Composed of eight bones (parietal (2), temporal (2), frontal, occipital, sphenoid, ethmoid). The foramen magnum is a crucial opening at the base.
• Skull Joints (Sutures): Include sagittal, coronal, and lambdoid sutures, along with structures like fontanelles and the mastoid process.
• Floor of Cranial Vault: Divided into anterior, middle, and posterior fossae, containing structures like the crista galli, cribriform plate, olfactory nerves, and nasal cavity.
• Base of the Skull: Features occipital condyles, hard palate, and zygomatic arch.
• Facial Bones: 14 bones form the face's structure, including maxilla, vomer, inferior nasal concha, zygomatic, palatine, nasal, and lacrimal bones. The zygomatic arch is also mentioned.
2.2. Major Nerves and Blood Supply
• Nerves:
◦ Trigeminal nerve (fifth cranial nerve): Sensory (ophthalmic, maxillary) and sensory/motor (mandibular) branches.
◦ Facial nerve (seventh cranial nerve): Controls motor activity of facial expression muscles and taste to the anterior two-thirds of the tongue.
• Blood Supply of the Face: Primarily through the external carotid artery and its branches (temporal, mandibular, maxillary arteries).
2.3. The Orbits
• Protect the eye and its structures (eyeball, muscles, blood vessels, nerves, fat).
• The orbital floor is thin and "easily fractured," leading to potential "blowout fractures."
2.4. The Nose
• Features a nasal septum and paranasal sinuses (frontal, maxillary, ethmoid, sphenoid).
• The external nose is "mostly cartilage."
2.5. Other Facial Structures
• Mandible (jawbone).
• Temporomandibular joint (TMJ).
• Hyoid bone: Not part of the skull, supports the tongue, and provides attachment for neck and tongue muscles.
2.6. The Eye Structures
• Globe (eyeball): Contains the sclera, cornea, conjunctiva, iris, pupil, lens, retina, and anterior/posterior chambers (filled with aqueous and vitreous humour, respectively).
• Nerves: Oculomotor nerve (third cranial nerve) and Optic nerve (second cranial nerve).
• Vision: Light passes through the lens to the retina, then via the optic nerve to the brain's visual cortex for conscious image formation.
◦ Central vision: Processed by the macula (central retina).
◦ Peripheral vision: Processed by the remainder of the retina.
• Lacrimal apparatus: Secretes and drains tears, which "moisten conjunctivae."
2.7. The Ear
• External ear: Pinna, external auditory canal, eardrum.
• Middle ear: Tympanic membrane, ossicles (three small bones).
• Inner ear: Cochlea, semicircular canals.
• Sound Perception: Sound waves enter through the pinna, travel through the auditory canal to the tympanic membrane, cause vibration of ossicles, transmit to the cochlear duct, stimulate hairs in the fluid-filled cochlea, and send nerve impulses to the brain via the auditory nerve.
2.8. The Teeth
• Adults have 32 teeth in four quadrants, each containing central/lateral incisors, canines, premolars, and molars.
• Structure: Crown (external to gum) and root. The root contains the pulp cavity (blood vessels, nerves, connective tissue), surrounded by dentin and enamel.
• Bony Sockets: Teeth are housed in alveoli within the mandible and maxilla, covered by gingiva (gums) on alveolar ridges.
2.9. The Mouth
• Digestion begins with mastication and mixing food with salivary gland secretions.
• The Tongue: Organ of taste, used for chewing, swallowing, speaking; attached to the hyoid bone and mandible.
• Nerves of the Mouth: Hypoglossal (motor function of tongue), Glossopharyngeal (taste, salivary gland function), Trigeminal (motor chewing), Facial (facial expression, taste, cutaneous sensations).
2.10. Anterior Neck
• Contains critical airway structures (thyroid and cricoid cartilage, trachea), major blood vessels (internal/external carotid arteries, internal/external jugular veins, vertebral arteries), spinal cord, nerves, muscles, and glands (thyroid and parathyroid), and the esophagus.
• Major arteries in the neck "supply oxygenated blood directly to the brain."
3. Specific Head and Face Injuries
3.1. Face Injuries: Soft Tissue
• Mechanism of injury and forces involved are important.
• Be alert to "airway compromise."
• "Impaled objects can be present," with risk of "cheek or airway penetration."
• "Blood is a gastric irritant, which can cause vomiting."
3.2. Maxillofacial Fractures
• Facial bones "absorb energy of impact."
• Signs/Symptoms: Deep lacerations, ecchymosis, bony pain/crepitus/instability, dental malocclusions, facial asymmetry, impaired eye movement, visual disturbances.
• Nasal Fractures: Most common facial fracture, structurally unsound nasal bones. May cause severe nosebleed (epistaxis) and "airway issues."
• Mandibular Fractures and Dislocations: Second most common. Result from blunt force trauma to lower third of face (common in assaults). Suspect with dental malocclusion, chin numbness, inability to open mouth.
• Maxillary Fractures: Massive blunt facial trauma (e.g., MVCs). Signs include massive facial swelling, midfacial instability, malocclusion, elongated face. Classified by Le Fort I, II, and III fractures.
• Orbital Fractures: Patients may report "double vision (diplopia)" or "loss of sensation" around the eyebrow/cheek. Inferior orbit fractures (blowout fractures) are common and "can cause paralysis of upward gaze."
• Zygomatic Fractures: Fractures of the cheek bone, commonly from blunt trauma. Signs include flattened face, paraesthesia/loss of sensation over cheek/nose/upper lip, and "paralysis of upward gaze."
3.3. Eye Injuries
• High incidence (over 700 Canadian workers daily). Caused by blunt trauma, penetrating trauma, or burns.
• Lacerations, Foreign Bodies, Impaled Objects: Lacerations of eyelids require meticulous repair. Do not apply pressure if the globe is lacerated. Orbit prevents large objects. Moderate/smaller foreign objects can cause conjunctivitis. "Impaled objects must be removed by a physician," and "cover both eyes to limit unnecessary movement."
• Blunt Eye Injuries: Range from swelling/ecchymosis to globe rupture. Includes hyphema (blood in anterior chamber), orbital blowout fractures, and retinal detachment.
• Eye Burns:
◦ Chemical burns: "Immediate emergency care" with irrigation (5 min for sterile water/saline, 20 min for strong acid/alkali). "Never use any chemical antidotes." Irrigate gently, forcing eyelids open if necessary, from nose side to outer eye.
◦ Thermal burns: Eyelids often burned.
◦ Infrared rays/Laser burns: Cause retinal injuries.
◦ Ultraviolet rays: Superficial burns.
• Signs/Symptoms of Ocular Injury: Vision loss, double vision, severe eye pain, foreign body sensation, obvious ocular damage.
• Assessment: Evaluate orbital rim, eyelids, corneas (for foreign bodies), conjunctivae (redness, pus, inflammation, foreign bodies), globes (redness, abnormal pigmentation, lacerations), and pupils (size, shape, equality, reaction to light).
• Ocular Function: Assess eye movements (paralysis of gaze, discoordination) and visual acuity (testing each eye separately).
• Treatment Guidelines: Best treated in ED. "Never exert pressure on globe." If globe exposed, apply moist, sterile dressing and protective shield. For hyphema/globe rupture, restrict spinal motion, elevate head 30-40 degrees, decrease IOP, discourage coughing/sneezing.
• Avulsion of Globe: "Do not manipulate or reposition." Stabilize with moist, sterile dressing, cover uninjured eye, supine position, immediate transport.
• Impaled Object in Eye: "Do not remove an object impaled in the globe."
3.4. Ear Injuries
• Can lead to sensory impairment and permanent disfigurement.
• Soft-tissue injuries: Lacerations, avulsions, contusions. Pinna has poor blood supply, and cartilaginous pinna healing can be complicated by infection.
• Eardrum Rupture (Tympanic Membrane Perforation): Caused by foreign bodies, blast injury, barotrauma. Signs include hearing loss and blood drainage from ear. "Extremely painful, heals spontaneously."
• Assessment/Management: Ensure airway patency and breathing adequacy, consider MOI, possible spinal stabilization. "Assessment difficult in field." Padded dressing recommended.
• Avulsion of Pinna: Gently realign and bandage. For complete avulsion, retrieve and treat as amputated part. Note blood or CSF leakage (do not stop flow, look for skull fracture signs).
• Impaled Object in Ear: "Do not remove an impaled object." Stabilize and cover ear. "Isolated ear injuries typically are not life threatening."
3.5. Oral and Dental Injuries
• Caused by blunt or penetrating mechanisms.
• Biggest danger: airway compromise. Assess teeth in any facial trauma.
• Soft-Tissue Mouth Injuries: Risk of hemorrhages. For responsive patients without spinal concerns, lean forward to drain blood. "Swallowed blood irritates gastric lining," leading to "vomiting and aspiration."
• Dental Injury: Fractured and avulsed anterior teeth common after facial trauma. Assess the striking individual in assault cases (bacteria risk). "Tooth fragments in wound."
• Assessment/Management: ABCs (airway patency, adequate breathing). Suction as needed, may intubate. Remove fractured teeth fragments. Spinal motion restriction precautions.
• Impaled Objects in Mouth: Leave in place and stabilize unless interfering with airway (then remove from entry direction). Control bleeding with direct pressure.
• Care for an Avulsed Tooth: Can be successfully reimplanted up to 1 hour post-injury. Handle by crown only, rinse gently with sterile saline/water (no soaps/chemicals/scrubbing), "Don’t allow it to dry out."
3.6. Injuries to Anterior Part of Neck
• Involve critical airway portions (larynx, trachea), major blood vessels, spinal cord, nerves, muscles, glands, esophagus. "Divide the neck into zones to assist in classification."
• Soft-Tissue Injuries: Blunt (MVC, hangings) or penetrating. Direct traumas cause swelling/edema. Injuries to trachea, larynx, esophagus, cervical spine. Blunt injuries can affect neck vasculature.
• Penetrating Injuries: Common from gunshot wounds, stabbings, impaled objects. Risk of "massive hemorrhage" and "airway compromise" due to direct damage. "Do not remove unless obstructing airway."
• Open Neck Injury Damage: Risk of air embolism (jugular veins entrain air, occluding blood flow to lungs). "Seal with occlusive dressing immediately."
• Life Threats: Larynx fracture, tracheal transection, perforated esophagus (leading to mediastinitis from gastric contents).
• Airway Concerns: Maxillofacial fractures complicate bag-mask ventilation. Upper airway distortion makes tracheal intubation difficult, potentially requiring cricothyrotomy.
• Assessment/Management: Note MOI, maintain high suspicion, stabilize head in neutral in-line position, open airway with jaw-thrust, suction as needed. Monitor breathing (rate, regularity, depth). Apply nonrebreathing mask if adequate; assist with bag-mask ventilation and 100% oxygen if inadequate.
• Treatment Focus: "What will be most rapidly fatal first?" Open neck wounds need immediate treatment to prevent air embolism by covering with occlusive dressing and direct pressure. "Do not wrap bandage circumferentially around neck" as it can be fatal by impairing cerebral perfusion or occluding carotid arteries/interfering with breathing. Treat for shock.
• Serious Laryngeal Trauma: Often requires surgical airway. Tracheal intubation can be hazardous (passing through defect, complete transection). "Always confirm correct tube placement."
4. Head Injuries (Traumatic Brain Injury - TBI)
• Prevalence: 160,000 people in Canada annually, 8% fatal admissions.
• Mechanisms: Most common are MVCs, assaults, falls (elderly), sports, incidents involving children.
• Types:
◦ Closed Head Injury: Most common (blunt trauma). Dura mater intact, brain tissue not exposed. Includes skull fractures, focal or diffuse brain injuries. "Often complicated by increased ICP."
◦ Open Head Injury: Dura mater and cranial contents penetrated, brain tissue exposed. Most common from gunshot wounds. "High mortality rate," survivors often have neurologic deficits.
• Scalp Lacerations: Can cause significant blood loss (rich blood supply), leading to "hypovolemic shock" (more common in children). Often associated with deeper injuries.
• Skull Fractures: Four types: Linear, Depressed, Basilar, Open. Significance depends on fracture type, force, and area.
◦ Linear: Nondisplaced (80% of all skull fractures, 50% in temporal-parietal). Radiographic evaluation needed; benign if brain uninjured/scalp intact. Infection risk with laceration.
◦ Depressed: High-energy, direct trauma (small surface area). Frontal/parietal most susceptible. Bony fragments driven into skull. Neurologic signs (LOC) often present.
◦ Basilar: High-energy, diffuse impact (falls). Extension of linear fracture to skull base. Difficult to diagnose. Signs include "CSF drainage from ears," "Raccoon or panda eyes," and "Battle sign."
◦ Open: Severe forces. Often associated with multitrauma. Brain tissue may be exposed, high infection/mortality rates.
• Traumatic Brain Injury (TBI): "An insult to the brain that can produce Physical, intellectual, emotional, social, and vocational changes."
◦ Primary Injury: Instantaneous from impact.
◦ Secondary Injury: Consequence of primary injury (cerebral edema, intracranial hemorrhage, increased ICP, ischemia, hypoxia, hypoglycemia, hypotension, infection).
• Injury to Brain: Penetration or indirectly by external force. Includes "Coup–contrecoup injury" (front-and-rear). Can lead to cerebral edema and vasodilation.
• Intracranial Pressure (ICP): Normal adult ICP is 5-15 mm Hg. "No room for expansion in cranium." Increased ICP "decreases brain perfusion." Brain requires constant oxygen supply.
• Cerebral Perfusion Pressure (CPP): Pressure of blood flow through brain. CPP = MAP – ICP. Critical minimum threshold is 60 mm Hg; below this, "cerebral ischemia occurs."
◦ Body responds to decreased CPP by increasing MAP and cerebral vasodilation (autoregulation). This "increases blood flow" which in turn "increases ICP." Increased ICP forces CSF out. Autoregulation can lead to fatal ICP increase and brain ischemia.
• Prehospital Goal: "Maintain cerebral blood flow. Mitigate ICP as much as possible."
• Cerebral Herniation: Brain forced from cranial vault through foramen magnum or over tentorium.
4.1. Brain Injuries: Signs and Symptoms
• Dependent on pressure and brainstem involvement.
• Early Signs: Vomiting, headache, altered level of consciousness, seizures.
• Later Signs: "Hypertension, bradycardia, and irregular respirations (Cushing triad)," pupil changes, coma, posturing (decorticate/flexor, decerebrate/extensor).
4.2. Types of Brain Injury
• Diffuse Brain Injury:
◦ Cerebral concussion: Rapid acceleration-deceleration forces causing transient cerebral cortex dysfunction. Signs: transient confusion, disorientation, LOC, retrograde/anterograde amnesia.
◦ Diffuse axonal injury (DAI): More severe than concussion, poor prognosis. Stretching, shearing, tearing of nerve fibers (axonal damage). Classified as mild, moderate, or severe.
• Focal Brain Injury: Specific, clearly defined, visible on CT scan.
◦ Cerebral Contusions: Bruised/damaged brain tissue in a specific area (often frontal lobe). Leads to greater neurologic deficits and ICP problems.
◦ Intracranial Hemorrhage: Bleeding within the skull (no room for accumulation). Increases ICP. Epidural Hemorrhage: Between skull and dura mater (0.5-1.0% of head injuries). Usually blow to head with linear fracture (common at temporal bones due to middle meningeal artery involvement). Signs: LOC, lucid interval, unresponsiveness, fixed/dilated pupil on hematoma side. "Death if pressure not relieved surgically." Subdural Hematoma: Beneath dura mater, outside brain (5% of head injuries). Rupture of bridging veins; venous bleeding is slower. Signs: fluctuating LOC, focal neurologic signs (hemiparesis), slurred speech. Intracerebral Hemorrhage: Within brain tissue (penetration injury, rapid deceleration). Can occur with DAI. Frontal/temporal lobes most affected. Rapid deterioration once symptoms appear. High mortality rate. Subarachnoid Hemorrhage: Bleeding into CSF circulation (bloody CSF). Sudden, severe headache (later diffuse). Increased ICP, decreased LOC, pupil changes, posturing, vomiting, seizures. "Sudden, severe subarachnoid hemorrhage usually results in death."
4.3. Assessment of Head and Brain Injuries
• Guided by severity and LOC. "Level of consciousness changes are very significant." Use AVPU scale and Glasgow Coma Scale (GCS). Reassess every 5 minutes, documenting accurate times.
• Pupil assessment: Monitor size, equality, reactivity. Sluggish reaction indicates "cerebral hypoxia or increased ICP" or "pressure on oculomotor nerves."
• Assessing ICP: Estimated in the field by clinical presentation: posturing, hypotension/hypertension, abnormal pupil signs.
4.4. Management of Head and Brain Injuries
• Assume cervical spine injuries (stabilize, jaw thrust).
• ABCs are critical. Maintain patent airway. Be prepared for vomiting (roll patient, suction); "Mortality increases if aspiration occurs." Use airway adjuncts, 100% oxygen.
• Respiration: Monitor depth, rate, regularity. Use bag-mask ventilation if unconscious or inadequate. "Avoid routine hyperventilation."
◦ "Hyperventilate only if signs of herniation" (20 breaths/min for adults). Monitor ETCO2 (maintain between 35 and 40 mm Hg). Below 30 mm Hg can cause "brain death due to anoxia."
• Tracheal Intubation: Precautions to "avoid any increase in ICP." Preoxygenate with 100% O2. Lidocaine IV push (1-1.5 mg/kg) "can blunt acute ICP increase." Maintain neutral in-line head position with two providers. For combativeness/clenched teeth, consider sedative-hypnotic and neuromuscular blocking drugs. Maintain oxygen saturation "95% or higher."
• Managing Circulation: Secure airway first, then support circulation.
◦ Control major bleeding with direct pressure (not excessive if skull fracture suspected). Active bleeding causes/worsens hypoxia and decreases CPP.
◦ Hypovolemic Shock: "Isolated closed head injury won’t cause in an adult." Watch for signs of shock (persistent hypotension, tachycardia, diaphoresis) and assess for occult injuries.
◦ Establish one large-bore IV with normal saline or lactated Ringer solution (no dextrose solutions).
◦ For severe closed head injury, patients are "often hypertensive." Restrict IV fluids (30-50 mL/h) to minimize ICP and cerebral edema. If hypotension develops, bolus 20 mL/kg, maintaining systolic BP at 90 mm Hg.
◦ Be aware of cardiac rhythm disturbances/pulseless arrest (follow ACLS).
• 90-90-9 Rule: Single drop in oxygen saturation < 90%, systolic BP < 90 mm Hg, or GCS score < 9 (or drop of 2 points) increases chance of death exponentially, especially if hypoxemia and hypotension occur together.
• Other Management:
◦ Thermal management: Do not allow overheating (hyperpyrexia). Do not cover with blankets if ambient temperature is 21°C or higher.
◦ Associated injuries: For open fracture with brain exposed, cover lightly with sterile, moist dressing. For CSF leakage from nose/ears, apply loose, sterile dressings. Stabilize impaled objects.
• Pharmacologic Therapy: Only for intubation or seizures. Not indicated for brain injury itself. Medical control may advise mannitol (Osmitrol) for cerebral edema/ICP reduction if transport is prolonged, or benzodiazepines (diazepam, lorazepam) for seizures.
• Transport Considerations: Prompt transport is critical, consider air transport. For ground transport, be quick but cautious. Transport to trauma center with neurosurgical capabilities, bypassing nearest hospital if necessary.
5. Case Study Considerations
The document includes a running case study of a motorcycle collision patient with severe head and facial trauma. Key questions raised for this scenario are:
• Initial concern: Airway management due to ejection and closed eyes.
• How to direct initial care: Manual stabilization of head, jaw-thrust maneuver, rapid trauma assessment.
• Complications of facial trauma on airway management: Massive soft-tissue trauma and unstable facial bones.
• Hypovolemic shock: The patient has bilateral angulated femurs, which could indicate significant blood loss and lead to hypovolemic shock. An isolated closed head injury alone typically won't cause shock in an adult because the skull cannot accommodate enough blood volume.
• IV fluid boluses: Not routinely indicated for head injury patients unless hypotension develops, then bolus 20 mL/kg to maintain systolic BP >= 90 mm Hg.
• Hyperventilation: Indicated only if signs of herniation (e.g., dilating pupils, posturing), at 20 breaths/min for adults.
• Concern with exact etiology of head injury: In prehospital setting, the exact etiology of head injury (e.g., epidural vs. subdural) is less important than managing the life-threatening conditions (airway, breathing, circulation, and signs of increased ICP).
• Most important interventions to maintain cerebral perfusion: Securing airway, ensuring adequate oxygenation and ventilation, maintaining systolic BP >= 90 mm Hg, and mitigating ICP.
This briefing summarizes the essential information for understanding and managing head and face injuries in emergency medical settings.