United States Department of Transportation

National Highway Traffic Safety Administration

Paramedic: National Standard Curriculum

(Reprinted with permission)

http://www.nhtsa.dot.gov/people/injury/ems/

Trauma: 4

Facial and Head Trauma: 5

UNIT TERMINAL OBJECTIVE

4-5 At the completion of this unit, the paramedic student will be able to integrate pathophysiological principles and the assessment findings to formulate a field impression and implement a treatment plan for the trauma patient with a suspected head injury.

COGNITIVE OBJECTIVES

At the completion of this unit, the paramedic student will be able to:

4-5.1 Describe the incidence, morbidity, and mortality of facial injures. (C-1)

4-5.2 Explain facial anatomy and relate physiology to facial injuries. (C-1)

4-5.3 Predict facial injuries based on mechanism of injury. (C-1)

4-5.4 Predict other injuries commonly associated with facial injuries based on mechanism of injury. (C-2)

4-5.5 Differentiate between the following types of facial injuries, highlighting the defining characteristics of each: (C-3)

a. Eye

1. Ear

2. Nose

3. Throat

4. Mouth

4-5.6 Integrate pathophysiological principles to the assessment of a patient with a facial injury. (C-3)

4-5.7 Differentiate between facial injuries based on the assessment and history. (C-3)

4-5.8 Formulate a field impression for a patient with a facial injury based on the assessment findings. (C-3)

4-5.9 Develop a patient management plan for a patient with a facial injury based on the field impression. (C-3)

4-5.10 Explain the pathophysiology of eye injuries. (C-1)

4-5.11 Relate assessment findings associated with eye injuries to pathophysiology. (C-3)

4-5.12 Integrate pathophysiological principles to the assessment of a patient with an eye injury. (C-3)

4-5.13 Formulate a field impression for a patient with an eye injury based on the assessment findings. (C-3)

4-5.14 Develop a patient management plan for a patient with an eye injury based on the field impression. (C-3)

4-5.15 Explain the pathophysiology of ear injuries. (C-1)

4-5.16 Relate assessment findings associated with ear injuries to pathophysiology. (C-3)

4-5.17 Integrate pathophysiological principles to the assessment of a patient with an ear injury. (C-3)

4-5.18 Formulate a field impression for a patient with an ear injury based on the assessment findings. (C-3)

4-5.19 Develop a patient management plan for a patient with an ear injury based on the field impression. (C-3)

4-5.20 Explain the pathophysiology of nose injuries. (C-1)

4-5.21 Relate assessment findings associated with nose injuries to pathophysiology. (C-3)

4-5.22 Integrate pathophysiological principles to the assessment of a patient with a nose injury. (C-3)

4-5.23 Formulate a field impression for a patient with a nose injury based on the assessment findings. (C-3)

4-5.24 Develop a patient management plan for a patient with a nose injury based on the field impression. (C-3)

4-5.25 Explain the pathophysiology of throat injuries. (C-1)

4-5.26 Relate assessment findings associated with throat injuries to pathophysiology. (C-3)

4-5.27 Integrate pathophysiological principles to the assessment of a patient with a throat injury. (C-3)

4-5.28 Formulate a field impression for a patient with a throat injury based on the assessment findings. (C-3)

4-5.29 Develop a patient management plan for a patient with a throat injury based on the field impression. (C-3)

4-5.30 Explain the pathophysiology of mouth injuries. (C-1)

4-5.31 Relate assessment findings associated with mouth injuries to pathophysiology. (C-3)

4-5.32 Integrate pathophysiological principles to the assessment of a patient with a mouth injury. (C-3)

4-5.33 Formulate a field impression for a patient with a mouth injury based on the assessment findings. (C-3)

4-5.34 Develop a patient management plan for a patient with a mouth injury based on the field impression. (C-3)

4-5.35 Describe the incidence, morbidity, and mortality of head injures. (C-1)

4-5.36 Explain anatomy and relate physiology of the CNS to head injuries. (C-1)

4-5.37 Predict head injuries based on mechanism of injury. (C-2)

4-5.38 Distinguish between head injury and brain injury. (C-3)

4-5.39 Explain the pathophysiology of head/ brain injuries. (C-1)

4-5.40 Explain the concept of increasing intracranial pressure (ICP). (C-1)

4-5.41 Explain the effect of increased and decreased carbon dioxide on ICP. (C-1)

4-5.42 Define and explain the process involved with each of the levels of increasing ICP. (C-1)

4-5.43 Relate assessment findings associated with head/ brain injuries to the pathophysiologic process. (C-3)

4-5.44 Classify head injuries (mild, moderate, severe) according to assessment findings. (C-2)

4-5.45 Identify the need for rapid intervention and transport of the patient with a head/ brain injury. (C-1)

4-5.46 Describe and explain the general management of the head/ brain injury patient, including pharmacological and non-pharmacological treatment. (C-1)

4-5.47 Analyze the relationship between carbon dioxide concentration in the blood and management of the airway in the head/ brain injured patient. (C-3)

4-5.48 Explain the pathophysiology of diffuse axonal injury. (C-1)

4-5.49 Relate assessment findings associated with concussion, moderate and severe diffuse axonal injury to pathophysiology. (C-3)

4-5.50 Develop a management plan for a patient with a moderate and severe diffuse axonal injury. (C-3)

4-5.51 Explain the pathophysiology of skull fracture. (C-1)

4-5.52 Relate assessment findings associated with skull fracture to pathophysiology. (C-3)

4-5.53 Develop a management plan for a patient with a skull fracture. (C-3)

4-5.54 Explain the pathophysiology of cerebral contusion. (C-1)

4-5.55 Relate assessment findings associated with cerebral contusion to pathophysiology. (C-3)

4-5.56 Develop a management plan for a patient with a cerebral contusion. (C-3)

4-5.57 Explain the pathophysiology of intracranial hemorrhage, including: (C-1)

a. Epidural

5. Subdural

6. Intracerebral

7. Subarachnoid

4-5.58 Relate assessment findings associated with intracranial hemorrhage to pathophysiology, including: (C-3)

a. Epidural

b. Subdural

8. Intracerebral

9. Subarachnoid

4-5.59 Develop a management plan for a patient with a intracranial hemorrhage, including: (C-1)

a. Epidural

10. Subdural

11. Intracerebral

12. Subarachnoid

4-5.60 Describe the various types of helmets and their purposes. (C-1)

4-5.61 Relate priorities of care to factors determining the need for helmet removal in various field situations including sports related incidents. (C-3)

4-5.62 Develop a management plan for the removal of a helmet for a head injured patient. (C-3)

4-5.63 Integrate the pathophysiological principles to the assessment of a patient with head/ brain injury. (C-3)

4-5.64 Differentiate between the types of head/ brain injuries based on the assessment and history. (C-3)

4-5.65 Formulate a field impression for a patient with a head/ brain injury based on the assessment findings. (C-3)

4-5.66 Develop a patient management plan for a patient with a head/ brain injury based on the field impression. (C-3)

DECLARATIVE

I. Facial Injury

A. Introduction

1. Incidence

2. Morbidity and mortality

3. Risk

B. Review of anatomy/ physiology of the face

1. Arteries and nerves

2. External carotid

a. Temporal artery

b. Mandibular artery

c. Maxillary artery

3. Nerves

a. 5th cranial nerve - trigeminal

b. 7th cranial nerve - facial

4. Bones

a. Nasal

b. Zygoma/ zygomatic arch

c. Maxilla

d. Mandible

C. Common mechanisms of injury

1. Blunt

a. Motor vehicular crashes

b. Falls

c. Body-to-body contact

d. Augmented force (i.e. sticks, clubs, etc.)

2. Penetrating

a. Gun shot wound, stabbing

b. Bites - dog, human, biting tongue

D. Other common associated injuries

1. Airway compromise

2. Cervical spine injury

3. Brain injury

4. Dental trauma or avulsion

E. Types of facial injuries

1. Bony injury

a. Mandible

(1) Fracture

(2) Dislocation

b. Maxillary fracture

(1) LeFort I, II and III

c. Zygomatic fracture

d. Orbital fracture

(1) Eye

(2) Ear

(3) Nose

(4) Throat

(5) Mouth

e. Nasal fracture

2. Soft tissue

a. Face

b. Mouth and oropharynx and tongue

c. Ear

d. Eye

F. Assessment

1. Airway patency and adequate ventilation

2. Cervical spine integrity

3. Adequate perfusion

4. Associated injury

a. Head injury

(1) Increased ICP

(2) Presence of CSF

b. Bony injury

(1) Malocclusion

(2) Depressed zygoma

(3) Facial asymmetry

(4) Diplopia/ blurred vision

c. Soft tissue injury

(1) Open wounds

(2) Hematomas

d. Broken or missing teeth

G. History

1. Mechanism of injury

2. Events leading up to the injury

3. Time it occurred

4. Associated medical problems

5. Allergies

6. Medications

7. Last intake

H. Management

1. Airway patency and adequate ventilations a priority

a. Suctioning

b. Intubating

c. Positioning

d. Ventilating

2. Assuring adequate circulation

3. Assuring cervical spine integrity

II. Throat injuries

A. Introduction

1. Incidence

2. Morbidity and mortality

3. Risk

B. Review of anatomy/ physiology of the throat

1. Critical structures

a. Airway

(1) Oropharynx

(2) Larynx

(3) Trachea

b. Cervical spine

(1) Cord

(2) Vertebra

c. Major vessels

(1) Internal and external jugular veins

(2) Carotid arteries

(3) Vertebral arteries

2. Associated structures

a. Vagus nerves

b. Thoracic duct

c. Pharynx and esophagus

d. Thyroid gland and parathyroid glands

e. Lower cranial nerves

f. Brachial plexus - responsible for lower arm and hand function

g. Muscles - platysma is major muscle

h. Soft tissue and fascia

C. Mechanism of injury

1. Blunt - motor vehicle crashes, blow to the neck, hanging

2. Penetrating - gun shot wound, stabbing, arrow

a. Lacerations or puncture

D. Pathophysiology

1. Transected trachea

a. Larynx separated from trachea or fractured

(1) Vocal cord swelling or contusion

(2) Disruption of normal airway landmarks

(3) Associated soft tissue swelling

b. Open wound to trachea

2. Vessel lacerated or torn

a. Arterial interruption

(1) Hypoxia to brain tissue and infarct

(2) Open wound may cause an air embolism

b. Rapid exsanguination

3. Cervical spine trauma

a. Vertebral instability

b. Cord interruption

(1) Paralysis or paresthesia

(2) Neurogenic shock

4. Impaled object

a. Do not remove unless obstructing airway

b. Consider emergency cricothyrotomy

E. Assessment

1. Signs - pale or cyanotic face, bruising of neck, redness of area, hematoma in neck, with open wound will see frothy blood or sputum in wound; subcutaneous air may be present

2. Symptoms - voice changes, tickle or feeling of fullness in throat, pain on palpation

3. Signs of stroke with air emboli or infarct

4. Signs of paralysis, paresthesia or neurogenic shock if spinal cord involved

5. Assess for other injury

F. Management

1. Airway patency and adequate ventilation a priority

a. If open wound to trachea

(1) ET tube can be inserted to maintain patency

b. If closed wound

(1) BVM with oxygen supplement

(2) Consider intubation - soft tissue swelling may be extreme, aim for bubbles

(3) Consider emergency cricothyrotomy

2. Maintenance of adequate tissue perfusion

a. If open wound to neck, lay patient on left side in Trendelenburg with occlusive dressing over neck wound

b. Direct pressure to bleeding site, avoid circumferential dressings, monitor pulse for reflex bardycardia

3. Maintain cervical immobilization, avoid cervical collars or other devices that obstruct your view of the neck

4. Stabilize impaled object if not obstructing airway

III. Nasal injuries

A. Review of anatomy and physiology

1. Nasal bone - between the eyes

2. Nasal cartilage - defines shape of nose

3. Internal structures - septum, turbinates and sinuses

B. Mechanism of injury

1. Blunt - motor vehicle crashes, body-to-body contact, falls

2. Penetrating - gun shot wounds, stabbing

3. Foreign bodies - beans, crayons, anything a child can pick up

C. Pathophysiology

1. Epistaxis - nose bleeds (may compromise airway)

a. Anterior bleeds - from septum, venous bleeding

b. Posterior bleeds - often drains down back of throat

c. Associated injury

(1) Sphenoid and/ or ethmoid bone fractures

(2) Basilar skull fracture

2. Foreign bodies

a. Common in young children

b. Leave alone and transport

c. Attempt to remove only if airway is compromised

D. Assessment

1. Airway patency

2. Cervical spine precautions

3. CSF drainage

4. Associated injuries

E. Management

1. Direct pressure

2. If bleeding severe, treatment similar to hemorrhagic shock

a. Sit upright, leaning forward or lying on side so blood is not swallowed

3. If CSF detected do not apply direct pressure, let drain freely

4. Elevate head of bed in reverse Trendelenburg

IV. Ear injuries

A. Review of anatomy and physiology

1. Outer ear - Pinna

a. Cartilage

b. Poor blood supply

2. External ear canal

a. Considered a mucous membrane but secretes wax for protection

3. Middle ear

a. Separated from external canal by ear drum

b. Delicate structures necessary for hearing

B. Mechanism of injury

1. Blunt - motor vehicle crashes, body-to-body contact, augmented force

2. Penetrating - gun shot wound, cutting, foreign body, puncture wound

3. Blast injuries-explosions

4. Pressure injuries-diving

C. Pathophysiology

1. Ruptured ear drum

2. Basilar skull fracture

3. Separation of ear cartilage

D. Assessment

1. Adequate assessment of external ear canal and middle ear cannot be done in the field

2. Airway patency and adequate ventilation a priority

3 Maintaining adequate tissue perfusion

4 Additional injuries

a0 If mechanism warrants, cervical spine precautions

E0 Management

1 Considerations

a0 Difficult for cartilage to heal

b0 Infection is prime influence for failure to heal

2 Realign ear into position and gently bandage with sufficient padding

3 Cover draining ear with loose dressing

V Eye injuries

A0 Review of anatomy and physiology

1 External parts

a0 Bony orbit

b0 Eyelids

c0 Lacrimal apparatus

2 Internal parts

a0 Sclera

b0 Cornea

c0 Conjunctiva

d0 Iris

e0 Pupil

f0 Lens

g0 Retina

h0 Optic nerve

i0 Muscle control

(1) Pairs

(2) Characteristics

3 Types of vision

a0 Central vision

b0 Peripheral vision

B0 Mechanism of injury

1 Penetrating - bullets, knives, glass, arrows, foreign bodies

2 Blunt- balls, falls, vehicle crashes, motorcycles

3 Burns- welding, sun, chemicals

C0 Pathophysiology

1 Penetrating

a0 Abrasions

b0 Foreign bodies

(1) Superficial

(2) Deep

c0 Lacerations

(1) Superficial

(2) Deep

2 Blunt

a0 Swelling

b0 Conjunctival hemorrhage

c0 Hyphema

d0 Ruptured globe

e0 Blow-out fracture of orbital rim

f0 Retinal detachment

3 Burns

a0 Flash burns

b0 Acid/ alkali

4 Other

a0 Lacerated eyelid

b0 Impaled object

c0 Avulsion

D0 Assessment

1 History

a0 When did the symptoms begin

b0 Mechanism of injury

c0 What did the patient first notice

d0 Were both eyes effected?

e0 Past history

(1) Visual acuity - glasses, contacts

(2) Diseases or conditions - glaucoma, etc.

f0 Any medications

2 Physical assessment

a0 Addressing priorities

(1) Maintaining open airway and assuring adequate ventilation

(2) Controlling bleeding and supporting cardiovascular system

(3) Potential for central nervous system injury

b0 Orbital rim

c0 Lids

d0 Cornea

e0 Conjunctiva

f0 Eye movement

(1) Dysconjugate gaze

(2) Paralysis of gaze

g0 Pupils

h0 Visual acuity

E0 Management

1 Blunt trauma treatment

a0 Positioning

b0 Bandaging eye(s)

(1) One versus both

(2) No pressure

2 Penetrating trauma treatment

a0 Positioning

b0 Removal of foreign bodies versus not

c0 Moist bandage versus dry

d0 Stabilize impaled object

3 Avulsion treatment

4 Burn

a0 Acid/ alkali

b0 Flash burn

5 Lacerated eyelid treatment

VI Mouth injuries

A0 Introduction

1 Incidence

2 Morbidity and mortality

3 Risk

B0 Review of anatomy/ physiology of the mouth

1 Muscles

a0 Tongue

b0 Orbicular oris - lips

c0 Masseter muscles - cheeks

2 Nerves

a0 Hypoglossal

b0 Glossopharyngeal

c0 Trigeminal (mandibular branch)

d0 Facial

3 Bones

a0 Hyoid

b0 Palate

c0 Mandible

d0 Maxilla

4 Teeth

5 Salivary glands

6 Lymphoid tissue

C0 Mechanisms of injury

1 Blunt

a0 Motor vehicle crash

b0 Blows to the mouth or chin

2 Penetrating

a0 Gun shot wounds

b0 Lacerations or punctures

D0 Pathophysiology

1 Lacerated tongue

a0 Airway compromise

(1) Blood and tissue

(2) Inability to communicate

b0 Broken or avulsed tooth

(1) Airway compromise

c0 Impaled object

(1) Airway compromise

d0 Lacerated mucous membranes

(1) Copious bleeding

(2) Airway compromise

2 Assessment

a0 Signs

(1) Copious bleeding

(2) Blood tinged mucous

b0 Symptoms

(1) Inability to talk unless leaning forward to allow for drainage

3 Management

a0 Airway patency and adequate ventilation is the first priority

b0 Impaled object

(1) If patient is able to breathe - stabilize

(2) Otherwise remove

c0 Collect tissue

(1) Tongue - manage as any other piece of tissue

(2) Tooth - rinse with normal saline and transport with patient

VII Head trauma

A0 Introduction

1 Incidence - approximately 4 million people sustain head injuries in the U.S. each year

2 Morbidity and mortality - approximately 450,000 require hospitalization

a0 Most are minor injuries (GCS 13-15)

b0 Major head injury (GCS <8) is the most common cause of death from trauma in trauma centers

c0 Over 50% of all trauma deaths involve head injury

3 Risk

a0 Highest in males 15-24 years of age

b0 Infants 6 months to 2 years

c0 Young school age children

d0 The elderly

B0 Review of anatomy/ physiology of head/ brain

1 Scalp

a0 Hair

b0 Subcutaneous tissue - contains major scalp veins which bleed profusely

c0 Muscle - attached just above the eyebrows and at the base of the occiput

d0 Galea - freely moveable sheet of connective tissue, helps deflect blows

e0 Loose connective tissue - contains emissary veins that drain intracranially (becomes important as a route for infection)

2 Skull - divided into two main groups of bones - face and cranium

a0 Cranial bones

(1) Composed of double layer of solid bone which surrounds a spongy middle layer gives greater strength

(2) Frontal, occipital, temporal, parietal, and mastoid

b0 Middle meningeal artery

(1) Lies under temporal bone, if fractured can tear artery

(2) Source of epidural hematoma

c0 Skull floor - many ridges

d0 Foramen magnum - opening at base of skull for spinal cord

3 Brain - occupies 80% of intracranial space

a0 Divisions

(1) Cerebrum - each lobe named after skull plates that lie immediately above

(a) Cortex controls

i Voluntary skeletal movement - interference with will result in extremity paresthesia, weakness and/ or paralysis

ii Level of awareness - part of consciousness

(b) Frontal lobe - personality, trauma here may result in placid reactions or seizures

(d) Temporal lobe - speech centers here, 85% of population has center on left, long term memory, taste and smell

(e) Occipital lobe - origin of optic nerve, trauma here may cause complaints of seeing "stars", blurred vision or other visual disturbances

(f) Hypothalamus - centers for vomiting, regulating body temperature and water

(2) Cerebellum - coordination of voluntary movement started by cerebral cortex

(3) Brain stem - connects the hemispheres of the brain, cerebellum and spinal cord responsible for vegetative functions and vital signs

(a) Parts - midbrain, pons and medulla oblongata

(b) Cranial nerves

i CN III - oculomotor, origin from midbrain - controls pupil size - pressure on nerve paralyzes nerve, pupil unreactive

ii CN X - vagal, origin from medulla - a bundle of nerves, primarily from parasympathetic system, that supply SA and AV node, stomach and GI tract - pressure on nerve stimulates bardycardia

iii Reticular activating system - level of arousal and responsible for specific motor movements

b0 Level of consciousness

(1) Reticular activating centers - level of arousal

(2) Intact cortical function - level of awareness

c0 Meninges - protective layers the surround and enfold entire CNS

(1) Dura mater - outer layer, tough and fibrous; literally two layers, inner layer serves to divide and separate various brain structures, forms the tentorium that surrounds the brain stem and separates the cerebellum below from the cerebral structures above, used as a landmark to describe intracranial lesions or when swelling is involved

(2) Arachnoid - middle layer, web-like with venous blood vessels that reabsorb cerebrospinal fluid

(3) Pia mater - inner layer, directly attached to brain tissue, provides form

d0 Cerebral spinal fluid (CSF) - clear, colorless fluid, circulates through entire brain and spinal cord

(1) Function - cushion and protect

(2) Ventricles - in center of brain, secretes CSF by filtering blood, forms blood-brain barrier

e0 Metabolism and perfusion

(1) High metabolic rate

(2) Nutrients

(a) Consumes 20% of body's oxygen

(b) Glucose

(d) Other nutrients

(e) Nutrients cannot be stored

(3) Blood supply

(a) Vertebral arteries

(b) Receives 15% cardiac output

(4) Perfusion

(a) Cerebral perfusion pressure (CPP)

(b) Mechanism called autoregulation regulates body's blood pressure to maintain CPP

(d) MAP of at least 60 mmHg required to perfuse brain

(e) Interference with CPP - edema, bleeding, hypotension

C0 Mechanisms of injury

1 Motor vehicle crashes

a0 Most common cause of head trauma

b0 Most common cause of subdural hematoma

2 Sports

3 Falls

a0 In elderly or in presence of alcohol abuse

b0 Associated with chronic subdural hematomas

4 Penetrating trauma

a0 Missiles (rifles, hand guns, shotguns) more common

b0 Sharp projectiles (knives, ice picks, axes and screwdrivers) not as common

D0 General categories of injury

1 Coup injuries

a0 Directly below point of impact

b0 More common when front of head struck because of irregularity of inner surface of frontal bones; occipital area is smooth

2 Contrecoup injuries

a0 On the pole opposite the site of impact

b0 More common when back of head struck because of irregularity of inner surface of frontal bones

3 Diffuse axonal injury (DAI)

a0 Shearing, tearing, stretching force of nerve fibers with axonal damage

b0 More common with vehicular occupants and pedestrians struck by vehicle

4 Focal injury

a0 An identifiable site of injury limited to a particular area or region of the brain

E0 Causes of brain injury

1 Direct or primary

a0 Caused by the impact

b0 Mechanical disruption of cells

c0 Vascular permeability

2 Indirect - secondary or tertiary

a0 Secondary - caused by edema, hemorrhage, infection and pressure inadequate perfusion (ischemia) tissue hypoxia

b0 Tertiary - caused by apnea, hypotension, pulmonary resistance and change in ECG

F0 Head injury - broad and inclusive

1 Defined - a traumatic insult to the head that may result in injury to soft tissue, bony structures and/ or brain injury

2 Categories - blunt (closed) trauma and open (penetrating trauma)

3 Blunt head trauma

a0 More common

b0 Dura remains intact

c0 Brain tissue not exposed to the environment

d0 May result in fractures, focal brain injuries and/ or diffuse axonal injuries (DAI)

4 Penetrating head trauma

a0 Less common, gun shot wound most frequent cause

b0 Dura and cranial contents penetrated

c0 Brain tissue exposed to the environment

d0 Results in fractures and focal brain injury

G0 Brain injury

1 Defined (by National Head Injury Foundation) - "a traumatic insult to the brain capable of producing physical, intellectual, emotional, social and vocational changes"

2 Categories - focal injury, subarachnoid hemorrhage or diffuse axonal injury

a0 Focal injury - specific, grossly observable brain lesions

(1) Cerebral contusion - related to severity of amount of energy transmitted

(2) Intracranial hemorrhage

(a) Penetrating

(b) Non-penetrating

(3) Epidural hemorrhage

b0 Diffuse axonal injury (DAI) - effect of acceleration/ deceleration

(1) Concussion - mild and classic

(2) DAI - moderate and severe

H0 Pathophysiology of head/ brain injury

1 Increased intracranial pressure (ICP)

a0 Direct or indirect injury

(1) Edema

(2) Bleeding

(3) Hypotension

(4) Hypercarbia

2 Mechanism

a0 As ICP approaches MAP the gradient for flow decreases, therefore cerebral blood flow is restricted

b0 This decreases cerebral perfusion pressure (CPP)

c0 As CPP decreases, cerebral vasodilation occurs which results in increased cerebral blood volume which leads to an increase in ICP which results in a decreased CPP which leads to further cerebral vasodilation and so on

d0 Hypercarbia causes cerebral vasodilation which results in increased cerebral blood volume, which leads to increased ICP, etc.

e0 Hypotension results in decreased CPP which leads to cerebral vasodilation, etc.

3 Assessment

a0 Pressure exerted downward

(1) Cerebral cortices and/ or reticular activating system effected

(a) Altered level of consciousness - amnesia of event, confusion, disorientation, lethargy or combativeness, focal deficit or weakness

(2) Hypothalamus - vomiting

(3) Brain stem

(a) Blood pressure elevates to maintain MAP and thus CPP

(b) Vagal nerve pressure - bardycardia

(d) Oculomotor nerve paralysis - unequal/ unreactive pupils

(e) Posturing - flexion/ extension

(4) Seizures - depending on location of injury

b0 Levels of increasing ICP

(1) Cerebral cortex and upper brain stem involved

(a) BP rising and pulse rate begins slowing

(b) Pupils still reactive

(d) Initially try to localize and remove painful stimuli

i Eventually withdraws then flexion occurs

(e) All effects reversible at this stage

(2) Middle brain stem involved

(a) Wide pulse pressure and bradycardia

(b) Pupils nonreactive or sluggish

(d) Extension

(e) Few patients function normally from this level

(3) Lower portion of brain stem involved/ medulla

(a) Pupil blown - same side as injury

(b) Respirations ataxic (erratic, no rhythm) or absent

(d) Labile pulse rate, irregular often great pulse swings in rate

(e) QRS, S-T and T wave changes

(f) Decreased BP, often labile BP

(g) Not considered survivable

c0 Glasgow coma scale - method to assess level of consciousness

(1) Three independent measurements

(a) Eye opening

(b) Verbal response

(2) Numerical score - 3 to 15

(3) Head injury classified according to score

(a) Mild - 13 to 15

(b) Moderate - 8 to 12

d0 Vital signs

e0 Pupil size and reaction

f0 Presence of focal deficit

g0 History of unconsciousness or amnesia of event

4 Management

a0 Suspect cervical spine injury

b0 Airway and ventilation - oxygenate to 95% -100% saturations

(1) Oxygenation does not always require hyperventilation

(2) Hyperventilate with signs and symptoms of increased ICP

(a) Do not exceed rate of 30 - does not allow for adequate exhalation and retains carbon dioxide further contributing to hypercarbia

(3) Avoid if possible nasal intubation - increases ICP

c0 Circulation - start IV of isotonic fluid (NS or LR) and titrate to BP

(1) Prevent hypotension to preserve CPP

(2) If hypotension present, look for internal bleeding

(3 Stop external bleeding

d. Disability - repeated assessment crucial to monitor presence of increased ICP, GCS and focal deficit

e. Pharmacology

(1 Osmotic diuretics

(a Mannitol and/ or furosemide

(2 Paralytics/ sedation

(3 Avoid glucose unless hypoglycemia confirmed

f. Non-pharmacological treatment

(1 Position - head end of the backboard elevated 30 degrees

(2 Decrease CNS stimulation

g. Transport considerations

(1 Trauma center candidate - follow system guidelines

(a Moderate to severe head injury (GCS < 12)

(2 Use of helicopter versus ground transport

(3 Use of lights/ sirens

h. Psychological support/ communication strategies

I. Specific Injuries - diffuse axonal injury and focal injuries

1. Diffuse axonal injury - shearing, stretching or tearing of nerve fibers with subsequent axonal damage

a. Concussion (mild DAI) - physiologic neurologic dysfunction without substantial anatomic disruption which results in transient episode of neuronal dysfunction with rapid return to normal neurologic activity

(1 Epidemiology - most common result of blunt trauma to the head

(2 Assessment - confusion, disorientation, amnesia of the event

(3 Management - quiet, calm atmosphere, constant orientation and reassessment, intact airway with adequate tidal volume a priority

2. Moderate DAI - shearing, stretching or tearing results in minute petechial bruising of brain tissue, brain stem and reticular activating system may be involved leading to unconsciousness

a. Epidemiology - occurs in 20% of all severe head injuries and 45% of all cases of DAI, commonly associated with basilar skull fracture, most survive but with neurologic impairment common

b. Assessment - may result in immediate unconsciousness or persistent confusion, disorientation and amnesia of the event extending to amnesia of moment-to-moment events; may have focal deficit; residual cognitive (inability to concentrate), psychologic (frequent periods of anxiety, uncharacteristic mood swings) and sensorimotor deficits (sense of smell altered) may persist

c. Management - quiet, calm atmosphere, avoid bright lights due to photophobia, constant orientation if conscious, frequent reassessment with loss of consciousness, intact airway with adequate tidal volume a priority

3. Severe DAI - formerly called brain stem injury, involves severe mechanical disruption of many axons in both cerebral hemispheres and extending to the brainstem

a. Epidemiology - represents 16% of all severe head injuries and 36% of all cases of DAI

b. Assessment - unconsciousness for prolonged period, posturing common, other signs of increased ICP occur depending on various degrees of damage

c. Management

4. Focal injury

a. Skull fracture - the significance is in the amount of force involved

(1 Epidemiology - intact galea protects skull by deflecting force more common with augmented blunt injury, such as vehicular crashes or falls from a height

(2 Types

(a Linear (80% of all skull fractures)

i) May have fluid leak out forming a bulge

ii) Fluid leak may not occur for 24 hours

iii) If no associated injuries there is no danger

(b Depressed

i) Bone fragments protrude into brain

ii) Neurologic signs and symptoms evident

(c Basilar

i) Extension of linear fracture to floor of skull, may not be seen on X-ray/ CT

ii) Signs and symptoms depend on amount of damage

iii) Most frequently blood vessels disrupted

a) CSF/ blood from ear(s) or nose - target sign

b) Bilateral black eyes - raccoon's sign

c) Bruising behind ear(s) - battle's sign

iv) May have seizures due to irritation of blood on brain tissue

(d Open skull fractures

i) Severe force involved, brain tissue may be exposed

ii) Neurologic signs and symptoms evident

(3 Assessment - linear fractures may be missed, depressed and open skull fractures usually found on palpation of head, use balls of fingers to palpate

(a Airway patency and breathing adequacy a priority

(b Vomiting and inadequate respirations are common

(c Assess for signs and symptoms of increased intracranial pressure

i) Altered LOC

ii) Glasgow coma scale

iii) Vomiting

iv) Pupil changes

v) Pulse, respiration and BP changes

(4 Management

(a Cervical spine precautions

(b Assuring clear airway and adequate ventilation with good tidal volume

(c Hypoxia must be prevented to prevent secondary injury to brain tissue

(d Cerebral perfusion pressure can be maintained with a systolic pressure of at least 70 mm Hg

b. Cerebral contusion - a focal brain injury in which brain tissue is bruised and damaged in a local area; may occur at both the area of direct impact (coup) and/ or on the opposite side (contrecoup) of impact

(1 Epidemiology

(a Relatively common in blunt head injury resulting in prolonged confusion

(b Most commonly found in frontal lobes

(c Often associated with a serious concussion

(d Patients may have multiple sites of contusion

(2 Assessment

(a Airway patency and breathing adequacy a priority

(b Alteration in level of consciousness

i) Confusion or unusual behavior common

(c May complain of progressive headache and/ or photophobia

(d May be unable to lay down memory - repetitive phrases common

(e Assess for signs and symptoms of increased intracranial pressure

i) Altered LOC

ii) Glasgow coma scale

iii) Vomiting

iv) Pupil changes

v) Pulse, respiration and BP changes

(3 Management

(a Cervical spine precautions

(b Assuring clear airway and adequate ventilation with good tidal volume

(c Hypoxia must be prevented to prevent secondary injury to brain tissue

(d Keep warm and comfortable

(e May need to repeat information

c. Intracranial hemorrhage

(1 Types

(a Epidural

(b Subdural

(c Intracerebral

(d Subarachnoid

(2 Epidemiology

(a Epidural hematomas almost always result from arterial tears, usually from the middle meningeal artery; they amount to about 0.5 to 1% of head injuries

(b Subdural hematomas are more common, result from rupture of bridging veins between cortex and dura; may be acute or chronic (chronic bleeds more common in the elderly and the alcoholic)

(c Subarachnoid hematoma results in bloody CSF and meningeal irritation

(d Intracerebral hematoma is within the brain substance; many small, deep intracerebral hemorrhages are associated with other brain injuries (especially DAI); neurologic deficits depend on the associated injuries and the region involved, the size of the hemorrhage and whether bleeding continues

(3 Assessment

(a May be impossible to tell which type of hematoma is present

i) History is important, what were they doing? What happened? What is wrong now? What doesn't seem right?

(b More important to recognize the presence of brain injury

(c Signs/ symptoms of increasing intracranial pressure

i) Headache that gets increasingly severe, vomiting, lethargy, confusion, changes in consciousness, comatose, pupil changes, pulse slows or becomes irregular, respirations become irregular, posturing, seizures

(d Signs/ symptoms of neurological deficit

(e Early signs and symptoms of alterations in level of consciousness

(f Signs of brain irritation - change in personality, irritability, lethargy, confusion, repeating words or phrases, changes in consciousness, paralysis of one side of the body, seizures

(g GCS

(4 Management

(a Cervical spine precautions

(b Maintaining airway and adequate ventilation

(c Elevating head of stretcher or backboard 30⁰

(d Establish IV, manage hypotension with fluid boluses, not to exceed a systolic of 90-100 mmHg in the adult male <40 (avoid shock)

(e Treat increased ICP first with assuring adequate tidal volume

(f Osmotic diuretics debatable for use by paramedics

5. Helmet issues

a. Purpose of helmet

(1 Protect head

(2 Protect the brain

(3 Cervical spine remains vulnerable

b. Various types

(1 Full face or open face (motorcycle, bicycle, roller-blade, etc.)

(2 Sports helmet (football, moto-cross, etc.)

c. Controversy regarding removal, at scene versus hospital

(1 Priorities

(a Airway management

(b Spinal immobilization

(2 Factors determining need for immediate removal

(a Access to airway

(b Patient’s condition