Neuro/Craniofacial TraumaLt. Joseph Meade RN

Types of InjuriesTypes of Injuries

Blunt Trauma Acceleration, deceleration

Penetrating traumaMissiles , Shrapnel , Bladed weapons.High Mortality rate

If the skull is fractured, bone fragments may be driven into the brain. Any object that penetrates the skull may implant foreign material and dirt into the brain, leading to an infection.Penetrating head trauma is associated with a high mortality rate.

Penetrating Head TraumaPenetrating Head Trauma

Types of injuriesTypes of injuriesClosed head injury

Closed head injury refers to brain injury without any penetrating injury to the brain. It may be the result of a direct blow to the head; of the moving head being rapidly stopped, such as when a person's head hits a windshield in a car accident; or by the sudden deceleration of the head without its striking another object.

Indications of Head InjuryIndications of Head Injury

Principals of Treatment

\ Frequently associated with other severe trauma. ABCs take priority. Saving only the head will not save the patient.

Primary and secondary survey should be performed. Aggressive airway management is often required in craniofacial trauma

1. Hypotension in adults is never caused by an isolated head injury except near death. Look for other injuries including cord injuries.

2. Physical exam includes complete neurological exam(GCS) as well as inspection for evidence of basilar skull fracture (CSF rhinorrhea, Battle’s sign, raccoon eyes, hemotympanum), etc.

3. Consider C – spine immobilization.

Head trauma AssessmentHead trauma Assessment

Disability (D). The goal of assessing disability is to determine neurological injury. Key components of this evaluation are as follows:

•Mental status (GCS).

•Pupil exam.

•Motor/sensory exam of the extremities.

Neuro ExamNeuro Exam

•Decrease in level of consciousness. A patient who was previously talking to you but now has to be shaken gently or have a painful stimulus applied before he or she talks to you, or other decline along the lines of the GCS.

•A pupil which becomes less responsive to light and larger than the opposite one. Pupils are best examined in a darkened room; otherwise the ambient light causes stimulation and rest/response sizes are misgauged.

After the airway is protected, shock is treated or prevented by placing two large-bore venous catheters and infusing plasma, normal saline, or lactated Ringer's solution. The stomach should be emptied(OG tube) and the bladder catheterized. NaHC03, 1meq/kg is given for metabolic

acidosis, and should be administered empirically when respiration has been compromised.

•vomitting

•headache

•changes in behavior

•progressive decreased consciousness lethargy

•neurological deficits

•Seizures (Late)

•Posturing (Late)  

Intracranial pressure SymptomsIntracranial pressure Symptoms

Epidural HematomaEpidural Hematoma

An epidural hematoma occurs when there is a tear in a vascular structure, usually arterial, in the potential space between the dura and the skull.

A “Fast Bleed” Blood accumulates rapidly leading to increased ICP,decreased neuro status

Symptoms occur in hours

Requires immediate surgical intervention

Epidural Hematoma

Epidural SymptomsEpidural Symptoms

The most important symptoms of an Epidural hemorrhage are:•Headache, severe•DrowsinessDrowsiness •Confusion •Nausea or vomiting may accompany the headache•Dizziness •Enlarged pupil in one eye•Weakness of part of the body, usually on the opposite side from the side with the enlarged pupil•Head injury or trauma followed by loss of consciousness, an alert period of time, then rapid deterioration back to unconsciousness

SDH CTSDH CTSubdural HematomaSubdural Hematoma

SUBDURAL SYMTOMSSUBDURAL SYMTOMS

•Loss of consciousness after original injury

•Headache, steady or fluctuating

•Weakness, numbness or inability to speak

•Slurred speech

•Nausea and vomiting

•Lethargy

•Seizures

Surgical InterventionSurgical Intervention

The definitive treatment for closed head injury is Burr hole or decompressive craniotomy.

Because of limited resources in the FST, the Burr hole is the most effective way to stabilize the closed head injury patient for evacuation.

Burr HoleBurr Hole•Shave and "prep" the side of the skull.

•A vertical incision approximately 3 cm long is made centered over the entry point.

•Haemostatic clips are placed in scalp edges • Cautery to coagulate bleeders

•The incision is extended to the periosteum and the retractors or rakes are immediately placed under the periosteum with tension on the wound

•The skull is drilled with the penetrator • •The hematoma is evacuated using a soft suction tip.

•A Penrose drain is sutured in

Burr HoleBurr Hole

CraniotomyCraniotomy

.

Craniotomy

The hair on part of the

CraniotomyCraniotomy

Craniotomy InstrumentationCraniotomy Instrumentation

Craniotomy Instrumentation

Facial TraumaFacial Trauma

Facial TraumaFacial Trauma

Facial fractures common with high speed deceleration and blunt trauma. Definitive treatment is beyond the scope of the FST.

The primary focus is on aggressive airway management and rapid evacuation. Due to massive edema often found with these injuries, surgical airway should be anticipated

Le Fort Fractures

•Fractures of mid portion of face have been classified as

•Le Fort 1 - Fracture detaching palate and maxillary alveolus

•Le Fort 2 - Pyramidal fracture through sinus wall laterally and nasal bones medially

•Le Fort 3 - Fracture through frontozygomatic sutures and orbits detaching facial skeleton from base of skull

LeFort ILeFort II

          

 

             

  

•.

          

 

             

  

•Can be identified by grasping the top teeth and attempting to move them; with Le Fort I, the teeth and maxilla will move, but the nose and upper face will stay fixed.

Lefort I

LeFort IILeFort II•Fracture of the maxilla in a pyramid shape, extending into the nasal bones.  

•Characterized by mobility of the nose into the dental arch

Characterized by mobility of the nose into the dental arch .

Le Fort II

LeFort IIILeFort III  •Fracture that involves total craniofacial

separation in a tripod pattern with craniofacial detachment.  

Le Fort III

Characterized by mobility of the nose and theThe dental arch.

LaFort III with Orbital edemawith NG tube placement

NG tube in Brain

Skull FractureA skull fracture is a medical emergency that must be treated promptly to prevent possible brain damage. Such an injury may be obvious if blood or bone fragments are visible, but it's possible for a fracture to have occurred without any apparent damage. A skull fracture should be suspected if there is:

•Blood or clear fluid leaking from nose or ears

•Unequal pupil size

•Bruises or discoloration around the eyes(Raccoon eyes) or behind the ears(Battle signs)

Swelling or depression of the part of the head

Skull FractureSkull Fracture

Raccoon Eyes

Battle Signs

Treatment PrinciplesTreatment Principles

Airway managementPrimary and secondary trauma surveyEstablish baseline mental status(GCS)Cervical spine immobilization

ReferencesReferences

•Emergency War Surgery NATO Handbook: Part IV: Regional Wounds and Injuries: Chapter XXII: Craniocerebral Injury

•United States Naval Flight Surgeon's Manual: Third Edition 1991: Chapter 7: Neurology

•FM 21-11 First Aid for Soldiers: Chapter 3; First Aid for Special Wounds

•Hospital Corpsman Sick call Screeners Handbook. Neurologic System

•General Medical Officer (GMO) Manual: Clinical Section: Neurosurgical Emergencies Central Nervous System Emergencies