chapter 6 brain, craniofacial trauma

BRAIN ANDCRANIOFACIAL TRAUMA

Epidemiology

• Brain and craniofacial injuries account for 40 to 50% of all trauma deaths

• Transportation-related to vehicle use is the leading risk factor

• Primary mechanism of injuries are motor vehicle crashes

Epidemiology

• Behavior that increases risk

Alcohol Drugs Incorrect or nonuse of safety restraints

Participation in sports without protection

Mechanism of injury and Biomechanics

• Most common mechanisms

Motor vehicle crashes Fall Intentional assaults

Recreational and sports injuries

Firearm use

Mechanism of injury and Biomechanics

• Energy forces result in cranial injury

• Forces are : Shearing Tensile

• Coup injury (same side)

Compressive

• Contracoup injury (opposite side)

Types of Injuries

Blunt injuries areassociated with :

Acceleration forces

Deceleration forces

Combination

Penetrating injuries areassociated with :

Missile type wound

High mortality rate

Concurrent Injuries

• 30% of patients with brain or craniofacial injuries have at least one additional injury to another body system

Pathophysiology

• Injury to the brain may result in :

Primary injury (skull fracture, epidural hematoma)

Secondary injury (cerebral ischemia)

Airway Obstruction

• Occlusion by tongue

• Oral debris

• Accumulation of secretions

• Bleeding

• Facial edema

• Facial fractures

Cerebral Perfusion

Adequate cerebral perfusion is dependent on Adequacy of cerebral perfusion pressure (CCP)Which is the difference between the mean arterial Pressure (MAP) and the intracranial pressure (ICP) CCP=MAP minus ICP

Cerebral Perfusion

• Close relationship between cerebral blood flowand cerebral perfusion pressure.

• Cerebral blood flow is a function of: Cerebral perfusion pressure The brain’s ability to autoregulate cerebral

blood vessels• Altered autoregulation

Increased intracranial pressure Decreased cerebral perfusion pressure

Intracranial Pressure

• Intracranial pressure reflects Brain Cerebrospinal fluid Blood

• As intracranial pressure increases, cerebralperfusion pressure decreases

• Leads to cerebral ischemia and hypoxia

• In a hypotensive patient, even a marginallyelevated ICP can be harmful

• Adequacy of cerebral perfusion pressure is most important

Intracranial Pressure

• EARLY signs and symptoms of increasedintracranial pressure Headache Nausea and vomiting Amnesia for events Altered level of consciousness Restlessness, drowsiness, change in speech,

loss of judgement

Intracranial Pressure

• LATE signs and symptoms of increasedintracranial pressure

Dilated, nonreactive pupil Unresponsive to verbal or painful stimuli Abnormal motor posturing patterns Change in respiratory rate and pattern

Intracranial Pressure

• Cushing Response ( Late Signs )

Increased systolic blood pressure Widening pulse pressure Decreased pulse rate

Hypotension and hypoxia

• Need to maintain adequate cerebal perfusionpressure

• Early post injury episodes which increasemorbidity and mortality include: Hypotension (blood pressure <90 mm Hg)

with increased ICP Hypoxia

As apnea/cyanosis in the field PaO2 <60 mm Hg

Herniation Syndromes

Symptoms

• Unilateral or bilateral pupillary dilation

• Asymmetric pupillary reactivity

• Abnormal posturing

• Other evidence of neurologic deterioration

Herniation Syndromes

Types

• Uncal: Uncus (medial aspect of the temporal lobe)is displaced over the tentorium into posteriorfossa (most common type)

• Central or transtentorial : downward movement ofcerebral hemispheres with herniation of diencephalon and midbrain through gaps oftentorium

Cerebrospinal Fluid Leakage

• Displaced or nondisplaced fractures or fracturesof the basilar skull or craniofacial area may lacerate the dura mater creating a passage forcerebrospinal fluid from the nose or ear

• Potential entrance of bacteria Meningitis Encephalitis Brain abscess

Scalp and Facial Abscess

Concussion

Classifications

Mild : Diffuse brain injury with no identifiablelesion

Classic : Diffuse brain injury associated with (no longer than 6 hours) loss of consciousnesswith no identifiable lesion

Concussion - Mild

Signs and Symptoms:

• No loss of consciousness

• Headache

• Confusion and disorientation

• Possible memory loss

Concussion - Classic

Signs and Symptoms:

• Transient loss of consciousness

• Nausea and vomiting

• Confusion and disorientation

• Dizziness

• Memory loss

Diffuse Axona Injury

• Diffuse brain injury resulting from accelerationand deceleration forces that produce shearing or tensile stresses and damage to axons

• Brain stem and reticular activating system (RES)may be involved leading to prolonged coma

Diffuse Axona Injury

Signs and Symptoms:

• Immediate unconsciousness (may last a few weeksto 3 months)

• Hypertension : Systolic blood pressure between140 and 160 mm Hg

• Hyperthermia : 40 to 40.5 • Excessive sweating

• Abnormal motor posturing

Contusion and Intracerebral Hematoma

• Contusion : Common focal brain injury in which tissueis bruised and damaged in a local area (associated with subdural bleed)

Frontal Temporal

• Intracerebral Hematoma : Caused by delayed hemorrhage or evolution of hematoma

Contusion and Intracerebral Hematoma

Signs and Symptoms:

• Altered level of consciousness

• Unusual behavior

• Abnormal posturing

Epidural Hematoma

• A focal brain injury results in collection of bloodbetween the skull and dura

• Associated with fractures of the temporal or parietal area that lacerate the middle meningealartery

Epidural Hematoma

• Bleeding usually arterial

• Immediate surgical intervention required

• Prognosis excellent if treated early

Epidural Hematoma

Signs and Symptoms:

• Decreased level of consciousness may follow a pattern Initial decrease in the level of consciousness

may followed by return of consciousness(lucid interval) followed by a rapid unconsciousness OR

Persistent decreased level of consciousness

Epidural Hematoma

Signs and Symptoms: (continued)

• Hemiparesis or hemiplegia on the opposite sideof the hematoma

• Unilateral and fixed dilated pupil on the same sideas the hematoma

Subdural Hematoma

• Focal brain injury beneath the dura resulting from acceleration, deceleration, or combinationforces

• More common than epidural hematomas

Subdural Hematoma

Causes:

• Usually venous in origin; tearing of the bridging veins

• Also from injuries to tissue or vessels of cerebralcortex

• Direct injury to brain tissue

Subdural Hematoma

• Onset may be acute (within 48 hours) orchronic (up to 2 weeks after even)

• Patient types Elderly Those on anticoagulants Chronic alcohol users

• More lethal than most brain lesions

Subdural Hematoma

Signs and Symptoms:

• Steady decline in level of consciousness

• Hemiparesis or hehiplegia on opposite sideof the hematoma

• Unilateral fixed or dilated pupil on sameside as hematoma

Skull Fractures

Types:

• Linear : Nondisplaced fracture of cranium;underlying vessels may be lacerated

• Depressed : Extends below the surface of the skullcan cause compression and dural laceration

• Basilar : Fractures of bones of the base of theskull

Skull Fracture - Linear

Signs and Symptoms:

• Headache

• Possible decreased level of consciousness

Skull Fracture - Depressed

Signs and Symptoms:

• Headache• Decreased level of consciousness

• Open fracture

• Palpable depression of the skull overfracture site

Skull Fracture - Basilar

Signs and Symptoms:

• Headache

• Altered level of consciousness

• Raccoon’s eyes : Periorbital ecchymosis• Battle’s sign : Mastoid ecchymosis

Skull Fracture - Basilar

Signs and Symptoms: (continued)

• Hemotympanun : Blood behind tympanicmembrane

• Facial nerve palsy (cranial nerve VII)

• Cerebrospinal fluid rhinorrhea or otrrhea

Mandibular Fractures

Common fracture sites : Canine and 3rd molar areaAngle of the mandible, and condyles

Mandibular Fractures

Signs and Symptoms:

• Maloccusion

• Trismus (inability to open the mouth)

• Pain (especially on movement)

• Facial asymmetry

• Edema or hematoma at the fracture site

• Bloody or ruptured tympanic membrane

• Anesthesia of the lower lip

Mandibular Fractures

Types:

• Le Fort I : Transverse maxillary fracture

• Le Fort II : Pyramidal fracture involving themidface

• Le Fort III : Complete craniofacial separation

Mandibular Fractures – Le Fort I

Signs and Symptoms:

• Slightly maxillary area swelling

• Lip laceration or fractures of the teeth

• Independent movement of maxilla• Malocclusion

Mandibular Fractures – Le Fort II

Signs and Symptoms:

• Massive facial edema• Nasal swelling

• Malocclusion

• Cerebrospinal fluid rhinorrhea

Mandibular Fractures – Le Fort III

Signs and Symptoms:

• Massive facial edema

• Mobility / depression of the zygomatic bones• Ecchymosis• Anesthesia of the cheek• Diplosia• Open bite or malocclusion

• Cerebrospinal fluid rhinorrhea

Orbital Fracture

• Orbital fracture is composed of: Frontal bone Zygoma Maxilla Ethmoid bone

• Entrapment of cranial nerve may occur

Orbital Fracture

Signs and Symptoms:

• Diplopia

• Loss of vision• Altered extraocular eye movements• Enopthalmos• Subconjunctival hemorrhage• Infraorbital pain or sensation loss

• Orbital bony deformity

Nursing Care - Assessment

History

• If conscious, what are the complaints?• If altered consciousness, does the history

suggest brain and craniofacial trauma?• Any loss of consciousness following injury?

If so, how long?

Nursing Care - Assessment

History (continued)

• Does the patient have any amnesia

• Any drugs or alcohol used?

• Does the patient have any previousneurologic deficits or seizure history?

Nursing Care – Physical Assessment

Inspection

• Assess airway

• Observe respiratory rate, pattern, and effort

• Determine level of consciousness

• Assess pupillary size and light response

Nursing Care – Physical Assessment

Inspection (continued)

• Assess for abnormal posturing patterns

• Inspect craniofacial area for ecchymosis orcontusions, nose and ears for drainage

• Assess extraocular movements and for occlusion of mandible and maxilla

Nursing Care – Physical Assessment

Palpation

• Palpate craniofacial area

• Assess facial sensory function

• Assess all extremities Motor Sensory

Diagnostic Procedures

• Radiographic Studies Computerized tomography scan (CT SCAN) Skull series Facial radiographs Magnetic Resonance Imaging (MRI)

• Laboratory Studies Arterial blood gases

Nursing Diagnoses

• Ineffective airway clearance

• Impaired gas exchange• Altered tissue perfusion

• Aspiration risk

• Injury risk

• Hyperthermia risk

• Infection risk

Planning and Implementation

• Open and clear the airway

• Administer oxygen via a nonrebreather maskat 12 to 15 L/min

• Assist with early endotracheal intubation

• Chronic prolonged hyperventilation or prophylactic hyperventilation : Only withclinical evidence of increased intracranialpressure refractory to sedation, paralysiscerebrospinal fluid drainage and osmoticdiuretics

Planning and Implementation

• Apply direct pressure to bleeding sites (except depressed skull fractures)

• Cannulate two veins with large bore cathertersand infuse lactated Ringer’s solution

• Insert an oro or nasogastric tube

• Position the patient as guided by protocols

• Prepare for intracranial pressure monitoringaccording to protocols

Planning and Implementation

• Administer as prescribed Mannitol Anticonvulsants Antipyretics Antibiotics Tetanus prophylaxis

Planning and Implementation

• Do not pack the nose and ears if cerebrospinalfluid leaks

• Assist with wound repair

• Prepare the patient for operativeintervention, admission, or transfer

Nursing Intervention for a Facial Injury

• Position the patient in a high-Fowler’s positionif no spinal injury

• Prepare for endotracheal intubation

• Apply cold compress to the face

• Assist with wound repair

• Administer antibiotics as prescribed

Evaluation and Ongoing Assessment

• Changes in level of consciousness, computeGlasgow Coma Sclae (GCS)

• Pupillary changes

• Blood pressure trends, pulse SpO2, respiratoryrate, patterns for signs of increased intra cranialpressure, hypotension, hypoxia

Evaluation and Ongoing Assessment

• Increasing craniofacial edema

• Nausea, vomiting, seizure, severe headache

• Changes in motor and sensory function

• Response to fluid administration and diuretics by monitoring urinary output

Summary