Head and Neck Trauma PowerPoint Presentation

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Head and Neck Trauma Jeffrey Coughenour, MD Assistant Professor Medical Director, Surgical Critical Care

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Objectives Review the appropriate anatomy, injury pathology, clinical assessment findings, and management of maxillofacial and neck injuries Discuss surgical management of neck injuries Neck exploration Surgical Airway Special situation: BCVI

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Head and Face Highly vascular and innervated tissue overlying facial musculature

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Face

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Face Glands, bones, foramens, fissures, canals, nasal complex, sinuses, ear, eye, cranial nerves, oral cavity, dentation Comprise 35 slides of educational detail good for holiday party conversation

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Pharynx

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Pathophysiology Soft tissue injuries Due to the position and anatomy of the face, are perhaps most common injuries the critical care paramedic can expect to encounter Of facial trauma presenting in emergency departments, >50 percent result from motor vehicle collisions Assaults and sports-related injuries make up most of remaining cases

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Pathophysiology Rich vascular supply of the facial soft tissue and scalp can result in significant bleeding Rich vascular supply also allows for rapid wound healing and reduces the incidence of infection Insult to a major vessel (e.g., the facial or temporal artery) can result in shock if bleeding is controlled inadequately Facial lacerations, avulsions, incisions, and contusions can damage underlying structures (e.g., cranial nerves, salivary glands, and lacrimal glands)

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Mechanism of Injury Blunt trauma Shearing, torsional, frictional, and compressive forces can lacerate soft tissue Ensure that a more serious underlying internal injury does not exist In particular, contusions, abrasions, and hematomas should alert the provider that blunt forces were involved and injury assessment must occur Common underlying injuries include fractures and internal hemorrhage

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Mechanism of Injury Penetrating trauma May result in a seemingly benign facial insult and must always be considered when evaluating soft-tissue injuries Low-velocity (2,000 ft/sec) gunshot wounds to the face can have a minimal superficial presentation but extensive internal tissue destruction Stab wounds typically do not result in the extensive internal tissue destruction typical of gunshot wounds

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Mechanism of Injury Penetrating trauma Penetrating trauma to the face is associated with a higher incidence of life-threatening airway compromise than is blunt force trauma Penetrating trauma to the inferior tissue of the face may extend internally into Zone III of the neck and include structures like the internal carotid, external carotid, and vertebral arteries

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Nasal Bone Fractures Nasal bone most common May require reduction or splinting Usually minimal hemorrhage Fractured cribiform plate of ethmoid bone only true contraindication to nasally placed gastric decompression tube

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Mandibular Fracture Most common sites of fractures are the body, condyle, angle, symphysis, ramus, and coronoid process Patients commonly present with malocclusion and limited mandibular mobility Oral cavity should be carefully inspected, if possible, to rule out compound fracture

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Zygoma Fractures Blunt force trauma, arch most common Tripod fracture involves the disarticulation of the zygomatic-frontal suture, fracture of the arch, and fracture of the infraorbital rim Present with: Trismus, subconjunctival hemorrhage, infraorbital anesthesia, difficulty opening the mouth, flattening of midface over fracture site

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Maxillary Fractures

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Head & Face Dental injuries, miscellaneous facial fracture complications, auditory, and ocular injuries Comprise 29 additional slides of educational detail good for holiday party conversation (assuming you have 2 in the same weekend)

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Examination of the Head and Face Inspect Palpate Careful exam of: Eyes, nares, mouth (including dentation), ears (external and internal), scalp Don’t let cervical collars hide life-threatening hemorrhage

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Neck Contains many vital structures in a small space Cardiovascular Carotid arteries Internal External Carotid bodies Jugular veins Internal External Carotid sheath

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Neck Musculoskeletal Cervical vertebrae Clavicles Platysma Sternoclidomastoid muscle Trapezius Central nervous Cranial nerves Cervical and brachial plexus From Fig. 7-12, p. 189, from Essentials of Anatomy & Physiology, 2nd ed., by Frederic H. Martini, Ph.D. and Edwin F. Bartholomew, M.S. Copyright 2000 by Frederic H. Martini, Inc. Published by Pearson Education, Inc. Reprinted by permission.

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Neck Respiratory Larynx Trachea Digestive Esophagus Endocrine Thyroid gland Parathyroid glands

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Zones of the Neck Anterior neck divided into three zones to help evaluate and manage penetrating neck injuries Zone I: Clavicle to the cricoid cartilage Zone II: Cricoid cartilage to angle of mandible Zone III: Angle of mandible to skull base

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Zones of the Neck

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Examination of the Neck Inspection Palpation Note swelling, pulsating masses, subcutaneous emphysema Areas of particular attention Zone III under the mandible Posterior triangle Inferior aspect of Zone I Penetrating injuries to Zone I can result in thoracic injury Chest film can be useful to rule out pneumothorax, hemothorax, and pneumomediastinum

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Examination of the Neck Auscultate Carotid bruit or thrill Signs concerning for impending respiratory failure or airway obstruction Progressive respiratory distress Stridor Hoarseness Dysphonia

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Neck Injuries General information Useful to classify neck injuries according to the anatomical zones affected Aids in: Providing a clear, comprehensible verbal and written report to the receiving facility Anticipating injuries based on known anatomy in the zones Early mobilization of diagnostic/treatment assets

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Neck Injuries Zone I Injuries here are associated with high mortality Great vessels chest, inferior larynx, trachea, thorax Zone II Carotid sheath vasculature, airway Zone III ICA, ECA, vertebral arteries, cranial nerves

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Laryngeotracheal Injury Edema and swelling of the soft tissue Thyroid and cricoid cartilage fracture Hyoid bone fracture Laryngotracheal disruption “Clothesline” injuries

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Laryngeotracheal Injury Clinical findings include dysphonia, horseness, dysphagia, dyspnea, pain, and hemoptysis Injuries can be overlooked due to their unimpressive initial presentations High risk for developing total airway occlusion secondary to swelling and edema of the surrounding tissues Hoarseness is an ominous sign of impending airway occlusion

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Laryngeotracheal Injury Deformity of the normal anatomical landmarks can make oral intubation difficult even for the most experienced provider Often requires use of a surgical airway Tracheostomy versus cricothyrotomy

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Neurologic Injury Lower cranial nerves Brachial plexus Phrenic nerve Spinal cord

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Neurologic Injury Detailed physical exam Penetrating injuries to the neck do not require spinal immobilization Stab and GSW rarely associated with spinal instability Cervical nerve roots and brachial plexus most commonly injured Nerves run with major vascular structures, neurologic deficit mandates angiogram

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Esophageal Injury Pharyngeal and esophageal injuries are rare More common penetrating mechanism Esophageal injuries are often difficult to identify clinically and are often overlooked during initial assessment Mortality approaches 100% if treatment delayed >24 hours

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Esophageal Injury Presence of SQ air without pneumothorax mandates evaluation Esophagoscopy 80-90% sensitivity Gastrograffin swallow 80-90% sensitivity Combined 95% sensitivity Patients without physical or radiographic evidence of injury may be observed

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Management of Neck Injury

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Hemorrhage Control Inspect wounds, look under cervical collars Direct pressure Hemostatic dressings Consider slight HOB elevation with direct pressure if venous bleeding Simple suture ligation if obvious exposed vessels

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Management of Neck Injury Management Airway The most common cause of death from maxillofacial trauma is obstruction of the upper airway secondary to posterior displacement of the tongue into the hypopharynx Also arguably the most preventable

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Management of Neck Injury Management Airway Manual BLS airway maneuvers should always precede the initiation of ALS mechanical procedures Modified jaw thrust Suctioning of the oropharyngeal cavity Cervical spine precautions if cervical injury is suspected Use of OPA/NPA

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Management of Neck Injury Management Airway Signs/symptoms of developing airway compromise include: Worsening dyspnea Tachypnea Cyanosis Agitation, altered mental status, loss of consciousness Accessory muscle use, nasal flaring Subcutaneous emphysema Hoarseness

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Drug-Assisted Intubation Controversial topic Improved success—improved outcomes? Large systems with short transport times or small systems with inadequate call volume? County of San Diego Health and Human Services Agency Emergency Medical Services The Use of Neuromuscular Blocking Agents and Advanced Sedation by Field EMT-Paramedics for More Effective Airway Management in Adult Trauma Patients with Glasgow Coma Score of 8 or Less Presented to the California EMS Commission, August 28, 2002

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Surgical Airway Inability to control or establish airway with standard means If patient already in extremis, don’t delay! Other examples: Airway compromise with ETT already in place Complex facial injury Open neck wounds that communicate with trachea

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Cricothyroidotomy Pre-hospital setting or ED Procedure of choice in emergent situation Membrane is subcutaneous Anatomy usually easily identifiable Procedure fairly easy to perform Literature to substantiate high incidence of subglottic stenosis lacking

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Cricothyroidotomy in Peds Avoid in children < 12 years of age Dependence on cricoid ring and softer, less developed cartilage raises risk of stenosis Needle cricothyroidotomy preferred Assumes advanced methods to achieve endotracheal intubation soon available (Bronchoscopy assist)

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Cricothyroidotomy Equipment Scalpel (prefer #11 blade) Appropriate sized endotracheal tube (6.0-6.5) Finger Large, chaotic crowd

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Cricothyroidotomy Procedure Chlorhexidine prep, local anesthetic a luxury Vertical midline incision over cricothyroid membrane Palpate to confirm appropriate landmarks

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Cricothyroidotomy Procedure Transverse incision through membrane Insert finger into the airway Advance 6.0 ETT Secure with suture after placement confirmed

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Cricothyroidotomy Pitfalls: Failure to act, retrograde tube position No urgency to convert to formal tracheostomy Use standard methods to assure correct tube placement Chest radiograph

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Cricothyroidotomy Commercial kits are available Familiarize yourself with institution’s equipment Knife, finger, tube method most reproducible

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Bougie-Assist Cricothyroidotomy

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Blunt Cerebrovascular Injury High index of suspicion with specific injury patterns Heparin of benefit if associated injuries allow anticoagulation ASA of questionable benefit Angiography currently diagnostic modality of choice Screening algorithm varies

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Summary Points The critical care paramedic will encounter few situations that are as potentially gruesome, disturbing, and clinically challenging as a patient with severe maxillofacial and neck trauma A sound understanding and appreciation of anatomy, physiology, pertinent medical equipment, and treatment modalities will ensure the best chance at reduced morbidity and mortality

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Summary Points Most maxillofacial and neck trauma is not life threatening, but it commonly intimidates the conscious patient Fear of long-term disability and disfigurement is justified, high potential for physical and psychological impairment > 25% of patients with maxillofacial injury experience PTSD This reality should not be lost on the critical care paramedic, who is likely to be in a position to provide emotional support and reassurance, as well as advanced procedures

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Summary Points Understand hemorrhage control, advanced airway management, and indications for surgical management of neck injuries