Head, Neck, and Facial Trauma.

Head, Neck, and Facial Trauma

Overview

  • Speaker: Emily Crowe, DNP, CRNP, FNP-BC

Traumatic Brain Injury: The Scale of the Problem

  • Over 69 million traumatic brain injuries (TBIs) occur worldwide annually.

  • The United States reports approximately 3 million TBIs per year.

  • 2021 Statistics: 69,000 deaths in the U.S. from TBI-related injuries.

  • The economic burden in the U.S. is estimated at $400 billion annually, accounting for both healthcare costs and economic impacts.

Leading Causes of Traumatic Brain Injury

  • Motor Vehicle Crashes:

    • Primary cause of TBIs.

    • Involve sudden deceleration forces and multiple impact injuries.

  • Violence & Firearms:

    • Includes suicide attempts and penetrating injuries.

    • Associated with significant mortality risk.

  • Falls:

    • Highest mortality rates observed in adults aged 65 and over.

    • Primarily result from blunt force trauma.

    • Increased rates of hospitalization reported.

Concussion vs. Contusion

  • Concussion:

    • Characterized by a brief loss of neurological function and consciousness.

    • Symptoms include confusion, disorientation, anterograde or retrograde amnesia, headache, dizziness, nausea, and impaired memory or concentration.

  • Contusion:

    • Refers to a "bruising" of the brain.

    • Typically caused by acceleration-deceleration injuries leading to bleeding into the brain parenchyma.

    • Coup Injury: Occurs at the direct point of impact.

    • Contrecoup Injury: Occurs on the opposite side of impact.

    • Most affected regions are the frontal and temporal lobes.

    • Contusions may evolve over 2-3 days as a result of edema.

Possible Interventions for Brain Trauma

  • Initial Assessment Tools: C-A,B,C,D,E,F,G

  • Intubation: As required based on condition.

  • Glasgow Coma Scale (GCS) and Respiratory Assessment: Critical for evaluating consciousness and airway.

  • CT Scans (without contrast): To assess for injuries.

  • Feeding Tubes: Assess indications and contraindications for orogastric (OGT) or nasogastric tubes (NGT).

  • Intracranial Pressure (ICP) Monitoring: Utilize bolt or ventriculostomy.

  • Medications such as Mannitol or Hypertonic Saline: To decrease cerebral edema.

  • Surgical Interventions: As indicated by OGT/NGT placements or ICP monitoring.

Intracranial Drain vs. Monitor

  • Types of Monitoring and Drains:

    • Ventriculostomy: For draining CSF.

    • Intraparenchymal Catheter: For monitoring pressures more directly within brain tissue.

    • Subdural Catheter / Bolt: For providing both monitoring and drainage options.

Critical Assessment: Types of Skull Fractures

  • Vault Fractures:

    • Most common in frontal and parietal regions.

    • Can be open (dura torn) or closed.

  • Basilar Skull Fractures:

    • Symptoms include:

    • Battle Sign: Ecchymosis over mastoid process.

    • Raccoon Eyes: Periorbital ecchymosis.

    • CSF Leak: Evidenced by rhinorrhea or otorrhea.

    • High risk of meningitis due to bacterial contamination.

    • Skull fractures indicate a high probability of intracranial hematoma, requiring substantial force to inflict a fracture.

Basilar Skull Fracture Assessment Signs

  • Raccoon Eyes: Periorbital ecchymosis indicative of trauma.

  • Battle's Sign: Mastoid ecchymosis.

  • Hemotympanum: Blood behind the tympanic membrane.

  • Halo Sign: Results from CSF leakage, presenting as blood-tinged fluid.

Facial Trauma

  • Mandibular Fractures:

    • Malocclusion: Misalignment of teeth when the mouth is closed.

    • Trismus: Spasms of jaw muscles causing difficulty in mouth opening.

    • Asymmetry: Visible facial deformity or unevenness.

  • Orbital Fractures:

    • Altered Extraocular Movements (EOMs): Difficulty moving the eye due to muscle entrapment.

    • Diplopia: Double vision from muscle involvement.

    • Enophthalmos: Sunken appearance of the eye due to orbital floor fracture.

Maxillary Fractures

  • LeFort Fractures:

    • LeFort I: Transverse fracture separating the maxilla from the rest of the facial skeleton.

    • LeFort II: Pyramidal fracture involving maxilla, nasal bones, and orbital floor.

    • LeFort III: Complete craniofacial separation, disconnecting midface from cranial base.

Penetrating Brain Injury & Diffuse Axonal Injury

  • Penetrating Brain Injury:

    • Most lethal form of TBI, with mortality rates as high as 90%.

    • Types include:

    • Depressed: Skull fractures into cerebral tissue.

    • Penetrating: Missiles (e.g., bullets) entering but not exiting the brain.

    • Perforating: Missiles entering and exiting the brain.

    • Major concerns include risk of infection and formation of cerebral abscesses.

  • Diffuse Axonal Injury (DAI):

    • Defined by prolonged coma not resulting from a mass lesion.

    • Mechanism involves acceleration-deceleration and rotational forces affecting brain axons.

    • Pathology includes stretching, shearing, and tearing of axons.

    • Mild Cases: Result in coma lasting 24 hours, potential for decorticate or decerebrate posturing.

    • Severe Cases: Prolonged deep coma, alongside hypertension and hyperthermia.

Primary vs. Secondary Brain Injury

  • Primary Injury:

    • Occurs immediately upon impact.

    • Involves direct mechanical forces damaging brain parenchyma resulting in:

    • Contusions

    • Lacerations

    • Shearing injuries

    • Hemorrhage

  • Secondary Injury:

    • Biochemical cascades that exacerbate the initial injury.

    • Factors contributing to secondary injury include:

    • Ischemia

    • Hypotension

    • Hypercapnia

    • Cerebral edema

    • Seizures

    • Metabolic derangements

    • Goal: Minimize secondary injury through timely critical care interventions, with hypoxia and hypotension as primary concerns.

Neck Trauma

  • Considerations Based on Anatomy:

    • Airway structures: trachea, pharynx.

    • Major vessels: carotids, jugulars.

    • Vertebral arteries and spinal cord.

    • Vagus nerve and esophagus.

    • Muscles/soft tissue factors.

    • Blunt Trauma: May seem benign but can be significant.

    • Penetrating Trauma: More likely to cause severe injury than superficial cuts or slashes.

Zones of Neck Trauma

  • Zone I: Extends from clavicles to cricoid cartilage.

  • Zone II: Lies above cricoid cartilage to the angle of the mandible.

  • Zone III: Extends from the angle of the mandible to the base of the skull.

Critical Considerations for Neck Wounds

  1. Airway & C-Spine Evaluation:

    • Always evaluate airway compromise or cervical spine injuries with any neck wound.

  2. Surgical Intervention:

    • Many neck wounds involve vital structures; timely surgical action may be necessary.

  3. Tracheobronchial Injury:

    • Observe for subcutaneous emphysema in the neck, face, or suprasternal area.

  4. Immediate Actions for Suspected Tracheobronchial Injury:

    • Secure the airway promptly.

    • Ensure breathing and oxygenation.

    • Prepare the patient for urgent surgical intervention.

Clinical Signs of Neck Trauma

  • Hoarseness: Indicates potential injury to the larynx, vocal cords, or recurrent laryngeal nerve.

  • Large, Expanding, or Pulsatile Hematoma: Suggests significant vascular trauma.

  • Dysphagia: May indicate esophageal or pharyngeal injury.

  • Platysma Penetration: Indicates risk of deeper vital structure injury.

  • Bruit or Thrill: Suggests turbulent blood flow consistent with arterial injury or pseudoaneurysm.

  • Oropharyngeal Bleeding: Indicates internal injury to the upper aerodigestive tract.

  • Bubbling from a Wound: Suggests tracheobronchial or lung injury (e.g., pneumothorax).