Head and Face Trauma

 

History:

 

  • Time of injury
  • Mechanism (blunt vs. penetrating)
  • Loss of consciousness
  • Bleeding
  • Past medical history
  • Medications
  • Evidence for multi-trauma

 

Significant Findings:

 

  • Pain
  • Swelling/bleeding
  • Altered mental status
  • Unconscious
  • Respiratory distress/failure
  • Vomiting
  • Major traumatic mechanism of injury

 

Differential:

 

  • Skull fracture
  • Brain injury
  • Concussion
  • Contusion
  • Hemorrhage
  • Laceration
  • Epidural/subdural hematoma
  • Subarachnoid hemorrhage

 

Treatment:

 

 

 

  • Oxygen; maintain O2 sat > 90% and EtCO2 between 35 and 45
  • Consider Spinal Immobilization
  • Obtain and record GCS every 5 min

 

 

 

  • Obtain BGL
  • 12-Lead EKG

 

 

 

  • Initiate IV

 

Glucose < 60 with signs of hypoglycemia ?

 

  • Yes

 

 

 

 

  • No

 

GCS < 8 ?

 

  • Yes

 

 

 

    • Consider Intubation

 

  • No

 

    • Notify receiving facility or contact Medical Control

 

PEARLS:

 

  • If GCS is less than 12 consider air/rapid transport.
  • In the absence of capnography, hyperventilate the patient
    • adult: 20 breaths/min
    • child: 30 breaths/min
    • infant: 35 breaths/min

 

  • only if ongoing evidence of brain herniation

 

    • blown pupil
    • decorticate posturing
    • decerebrate posturing
    • bradycardia
  • Increased intracranial pressure (ICP) may cause hypertension and bradycardia (Cushing's Response).
  • Hypotension usually indicates injury or shock unrelated to the head injury and should be aggressively treated.
  • The most important item to monitor and document is a change in the level of consciousness.
  • Consider restraints if necessary for patient’s and/or personnel’s protection per the Behavioral Emergencies/Chemical Restraint Protocol.
  • Limit IV fluids unless patient is hypotensive.
  • Concussions are periods of confusion or LOC associated with trauma which may have resolved by the time EMS arrives. Any prolonged confusion or mental status abnormality which does not return to normal within 15 minutes or any documented loss of consciousness should be evaluated by a physician as soon as possible.
  • In areas with short transport times, RSI/drug-assisted intubation is not recommended for patients who are spontaneously breathing and who have oxygen saturations greater than 90% with supplemental oxygen.

 

Significant Findings:

 

Le Fort I

  • Slight swelling
  • Maxilla moves independently of the rest of the face
  • Possible malocclusion

 

Le Fort II

  • Massive edema, malocclusion
  • Nose is obviously fractured
  • Cerebrospinal fluid leak possible

 

Le Fort III

  • Massive edema
  • Mobility of zygoma, orbital rim
  • Anesthesia of cheek possible
  • Diplopia (without blowout fx of orbit)
  • Depression of cheek bone
  • Open bite
  • Cerebrospinal leak possible

NREMR

National Registry Emergency Medical Responder

NREMT

National Registry Emergency Medical Technician

NREMT-I

National Registry EMT-Intermediate

NREMT-I

National Registry EMT-Intermediate

NRP

National Registry Paramedic