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36 Cards in this Set
- Front
- Back
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Head Trauma Epi
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Young: 50% MVA
Old: 62% Falls Alcohol: 50% - Document Leading cause of Death in trauma in pts <25 Second peak at >65 |
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Classification
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Open vs Closed
Blunt vs Penetrating Mild GCS 14-15 Moderate 9-13 Severe 3-8 |
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Coma
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Inability to obey commands, utter words, open eyes
GCS <8 |
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Poor Outcome
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<18 good >60 poor
GCS Bilateral unreactive pupils Inracranial masslesions Multiple systemic injuries EtOH Unilateral non-reactive pupil Pupillary inequality |
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Primary HI
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Shear axonal injury
Laceration Hemmorhage Contusion Difuse axonal injury, worse in pts with mass lesions |
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Seconday Injury
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Intracranial -Increased ICP and hernaition
-SDH,EDH, SAH, ICH -stroke -hydrocephalus -meningitis -brain edema Extracranial -BP changes -hypoxia -lytes, fluids (SIADH) |
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Cushing Reflex
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Widening Pulse Pressure
Irregular breathing Bradycardia |
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Herniation
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Uncal
Central tentorial Cerebellotonsilar Upward transtentorial |
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Basilar Skull fracture findings
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Battle Sign
Raccoon Eyes Hemotympanum CSF leak - Otorrhea, Rhinorrhea (ring test), beta 2 transferrin vascular complications (ICA occlusion, cavernous fistula, Cranial Nerve Abnormalities (1,2,7,8 common) |
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Epidural Hematoma
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Uncommon, can expand into fatal lesion
Arterial (80%) fast, meningeal artery Venous (20%) slow most common traumatic lesion of posterior fossa, rare in elderly Lucid intervals CT - Cresentic, lens shaped hyperdensity under skull |
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Subdural Hematoma
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Path - tearing of bridging vessels from subarachnoid todural venous sinuses. more serious than EDH, because underlying brain damage more severe
more common in elderly and alcoholics Acute CT:Hyperdense cresentic shaped lesion extending across the entire hemisphere |
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Traumatic SAH
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Tearing of Subarachnoid vessels
33% of severe HI Most common CT abnormality Amount of blood ~ GCS level and outcome CT blood along the sulci and basal cistern |
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Severe HI Management
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Intubate regardless of GCS if there is cranial penetration
Neurosx for large bleeds, neurological findings |
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HI Respiratory Pattern
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Brady -ETOH, Narcotics, BZD, Barbituates
Tachy - Many causes Cheyne Stokes - bilateral cortical, diencephalon, unilateral pns/medulla, CHF, hypoxia, metabolic changes Apneustic Gasp Breathing - pontine lesion Ataxic - irregular rythm and depth, medullary lesion, impending arrest |
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HI Pupil
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Size and Reactivity important
Midbrain lesion interupts edinger westphalnucleus and CN 3, thus dilated pupil Pons lesion or below interupts sympathetic fibres constricted (miosis) Reactivity is a 2-3 reflex Early Compression of CN3 may cause dilated pupil w/o ptosis and laterally deviated eye (parasympathetic) Metabolic causes have reactive if poss sluggish pupils |
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HI EOM
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Nuclei close to RAS
ADducted -CN6 BS or peripheral lesion ABducted - CN3 BS or peripheral lesion Horizontal disconjugate gaze - drowsiness Vertical Disconjugate gaze - pons or CB Sustained downward conjugate gaze - variety disorders Sustained upward conjugate gaze - hypoxic encephalopaty |
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HI Brainstem reflexes
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Pupillary light reflexes CN2-3
Gag CN9-10 Corneal CN5-7 Occulocephalics CN 8, 3,4,6, Doll's sign - abnormal when eyes follow head movement |
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HI Intubation
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Pretreatment - lidocaine, fentanyl,
induction - etomidate, fentanyl and midaz paralysis - succ |
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Increased ICP
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Intubation
Hyperventilation Control hyertension No Steroids Elevate head of bed Mannitol 1 gram/kg Sz prophylaxis Metabolic Support Burr Hole if NSx not available |
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CT Head Rules
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High Risk
1. GCS <15 2 hrs after injury 2. Suspected open or depressed skull fracture 3. Any sign of Basal Skull fracture 4. Vomitting 2 or more episodes 5. Age > 65 years Medium Risk 6. Amnesia before impact >30min 7. Dangerous mechanism (pedestrian, occupant ejected, fall from elevation) |
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CT HEAD rules do not apply to
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Non-Traumatic causes
GCS <13 Age <16 Coumadin or bleeding disorder Obvious open skull # |
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Facial Injuries
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60% have associated injuries
Remember Child Abuse Sharp vs Blunt MOI |
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Facial Diag
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May not be obvious (orbital blow out)
Look for deformity, asymetry, bruising, abrasions, laceration, edema, ottorhea, rhinorrhea, malocclusion, dentition step-off, nasal septal hematoma, FB Enopthalmos a good indicator of blow out # Palpation of orbital rims, zygoma, maxilla, mandible, nasal, teeth Test all cranial nerves |
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Imaging
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Facial views - Water's, Caldwell, Lateral, submentovertex
Panorex -for mandibles CT face - Gold Standard for facial fractures MRI - limited use |
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Lip Injuries
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Mark boarders before local
Deep sutures in obicularis oris Electrical burns - risk of delayed massive bleeding from circumoral vessels |
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Tongue/oral cavity
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Small superficial - no closure
Refer for parotid or submandibular ducts lacerated (milk for saliva) Penicillin Rinse mouth QID |
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Nose
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Must look for septal hematoma (can lead to necrosis) incision, packing, atbx and refferral
Infraorbital + supratrochlear block Mucosal closure for w/ absorbable, subcuticular good for skin |
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Ear
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Lido (no epi) wheal around ear
Absorbable on backside of ear Staph atbx coverage Subperichondral hematoma will develope cauliflower ear. Aspirate and compressive dressing |
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Periorbital
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Optho referral for lid margin, orbital fat showing, loss of lid tissue, invovlement of medial canthus
Simple lacs repair with 6-0 |
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Facial Nerve/Parotid Gland
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Motor exam with CN7
Milk parotid for saliva, blood means disruption, refer for stenting |
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LeFort classification of Maxillary Fractures
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Midface mobility
I - maxilla at level of nsal fossa II - maxilla, nasal bones, medial aspect of orbits (pyramidal dysfunction) III - maxilla, zygoma, nasal bones, ethmoid, vomer, cranial base, (cranial facial dysfunction) |
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Zygomatic #'s
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Water's view
Malar eminence -flat cheek, nerve damage (anesthesia) diploplia, change in consensual gaze, step defect, subconjunctival hematoma -refer for ORIF Zygomatic Arch -depression of arch, bony deficit over arch and painful and limited mandibular movement - vertex view best - refer for ORIF |
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Orbital floor fractures
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Concern for combined and blow out #'s
hrniation into maxillary sinus Presentation - Diploplia due to muscle disturbance, enopthalmus and limited EOM, Tear Drop sign on water's view CT to r/o Refer |
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Orbital emphysema
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Visual acuity loss - central retinal occlusion
Emergent decompression with needle or canthotomy w/ cantholysis |
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Nasal fractures
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Pack bleeding
No xrays R/o septal hematoma If no edema can reduce, if edema refer for evaluation in 7/7. Peds refer in 4/7 Nasoethmoid # - if rhinorrhea -CT face, atbx, neurosurg consult |
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Mandibular #
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Mandibular pain/tenderness malocclusion - # until proven otherwise
Ecchymosis on floor of mouth very suggestive Panorex ORIF - referral Penicillin |
