6.0 Management of Head Injuries for Maxillofacial SHOs

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1 6.0 Management of Head Injuries for Maxillofacial SHOs As a Maxillofacial SHO you are not required to manage established head injury, however an awareness of the process is essential when dealing with facial trauma. Learning objectives: At the end of this session the learner should be able to: Specify the prioritisation of head injury in respect of the ATLS doctrine Describe the use of the Glasgow coma scale in assessing and monitoring head injured patients Explain the importance of pupillary examination Describe the relevant anatomy Describe and explain the basic management of head injury Explain basic terminology ATLS (Advanced Trauma Life Support) This is a system that has been established to allow a safe and reliable method for the immediate management of the trauma patients. It is dealt with elsewhere more fully in this course. The basic initial management is outlined below for re-enforcement: A B C D E Airway maintenance (with cervical spine control) Breathing and Ventilation Circulation and haemorrhage control Disability; Neurological status Exposure / Environmental Control In the acute management the priority is to preserve life by establishing or preserving breathing and circulation to provide adequate oxygenation of the patient. A baseline assessment of neurological status is also very important at this stage in order to assess the severity of head injury at that moment and to monitor any neurological deterioration (or improvement).

2 Cervical Spine This should be suspected and excluded in all patients with facial injury. All movement of the neck (i.e. hyperextension, hyperflexion and rotation) should be avoided until the status of the patient's cervical spine is known. The responsibility for this usually lies with orthopaedic or neurosurgical colleagues. Cervical spine control is achieved by maintaining in-line immobilisation, firstly with your hands and then by application of the cervical spine trinity (collar, sandbags & tape). Glasgow Coma Scale This is a system that allows uniformity of monitoring by different individuals. Glasgow Coma Scale Assessment Area Eye opening Spontaneous To speech To pain Best Motor Response Obeys commands Localises pain Normal flexion Abnormal flexion Extension (decorticate) Verbal Response Orientated Confused conversation Inappropriate words Incomprehensible Sounds Score A GCS score is given according to the following evaluation Severe Head Injury (Coma) = <8 Moderate Head Injury = 9 - Mild Head injury = - 5 Mini-Neurological exam

3 This should include an examination of the pupillary response as well as a GCS score. Dilated or non-reactive pupils are indicative of intracranial bleeding and raised intra-cranial pressure (ICP) until proved otherwise. Interpretation of pupillary findings. Pupil size Light response Interpretation Unilaterally dilated Sluggish or fixed Consensual reflex in other eye present. IIIrd Nerve compression secondary to tentorial herniation (increased ICP) Traumatic mydriasis Bilaterally dilated Sluggish or fixed Inadequate brain perfusion. Bilateral IIIrd nerve palsy Unilaterally dilated or Cross reactive Optic nerve injury equal (Consensual response present i.e reacts to light shone in other eye) Bilaterally constricted May be difficult to Drugs (opiates) determine Unilaterally constricted Preserved Sympathetic Nerve injury Management of Mild Head Injury (GCS -5) These patients are usually fully awake and orientated but may give a history of loss of consciousness, amnesia or severe headache. All penetrating head injuries require admission. They should be admitted and observed for - hours. Neurosurgical advice should be sought and a brain CT scan may be indicated. % of patients will deteriorate. A head injury card is given on discharge. (You should familiarise yourself with the card used in your particular unit or trust). 5

4 Management of Moderate Head injury (GCS 9-) These patients require admission on a trauma or neurosurgical ward. A brain CT scan is usually obtained. Establishment of cardiopulmonary stability is essential to prevent secondary neurological damage. Management of Severe Head injury (GCS 8 and below) These patients are transferred to the care of a Neurosurgical team following resuscitation and cardiopulmonary stabilisation. Endotracheal intubation is indicated. In some instances neurosurgical intervention may be required and combined maxillofacial repair may be possible. Anatomy It is important to have a basic understanding of the relevant anatomy. You are encouraged to refer to a textbook. Know the layers of the scalp S Skin C Connective tissue A Aponeurosis L Loose areaolar tissue P Pericranium Skull Comprises the calvarium and base of skull. The base of skull defines an anterior, middle and posterior cranial fossa. The facial bones are attached to it. Meninges These are the coverings of the brain, they are composed of: Dura Subdural space Arachnoid Pia 6

5 Brain Composed of main parts Cerebrum,cerebellum & brainstem CSF Cerebrospinal fluid Tentorium This is a membrane that divides the contents of the anterior and middle cranial fossae from the posterior cranial fossa. Terminology of Modality Blunt high or low velocity Penetrating Gunshot or other Terminology of Morphology Skull fractures Vault Linear or stellate Depressed Non-depressed Open or closed Base of skull +/_ CSF leak +/_ VII palsy Intracranial Lesions Focal Epidural Subdural Intracerebral Diffuse Mild concussion Classic Concussion Diffuse axonal injury 7

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