TCRN REVIEW - HEAD AND NECK (NEUROLOGICAL TRAUMA AND MAXILLOFACIAL AND NECK TRAUMA) (29 QU, Exams of Nursing

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TCRN REVIEW - HEAD AND NECK (NEUROLOGICAL TRAUMA AND MAXILLOFACIAL AND NECK TRAUMA) (29 QUESTIONS ON EXAM) 2024 What are the three main constituents in the brain? - correct answer✔✔ CSF, Brain Tissue (mostly water), Blood The brain makes up approximately _____% of the volume of the skull and is _____% water. - correct answer✔✔ 80% 75% CSF makes up about _____% of the volume of the skull. - correct answer✔✔ 10% There is approximately _____ mL of CSF. - correct answer✔✔ 125-150 mL Blood makes up about _____% of the volume of the skull and _____% of the blood is venous. - correct answer✔✔ 10% 80% The pressure of water, CSF and blood against the skull is known as _____. - correct answer✔✔ ICP - Intracranial pressure What are the normal ICPs for children and adults? - correct answer✔✔ Child - 0-5 mmHg Adult - 5-12 mmHg ICP pressures above _____ mmHg in any age group is considered elevated. - correct answer✔✔ 20 mmHg ICP pressures above 20 mmHg do what? - correct answer✔✔ Compromise blood flow into the skull and contribute to cerebral hypoxia and hypoglycemia. What can happen if ICP pressures climb too high? - correct answer✔✔ The brain may be forced out of the skull through any opening (such as skull fractures, tentorial plate or foramen magnum). ICP above _____ mmHg is severe and life-threatening. - correct answer✔✔ 40 mmHg ICP between _____ and _____ mmHg is termed "moderate intracranial hypertension". - correct answer✔✔ 20 and 40 mmHg ICP above 20 mmHg is abnormally high and is known as _____. - correct answer✔✔ Early increased ICP What should resting ICP be? - correct answer✔✔ Less than 10 mmHg When ICP increases, pressure is exerted downwards on brain tissue, affecting the cerebral cortices _____ and _____. - correct answer✔✔ Reticular Activating System (RAS) and Cranial Nerves List 6 things caused by pressure on the RAS (Reticular Activating System). - correct answer✔✔ 1. Progressive restlessness 2. Confusion 3. Disorientation 4. Lethargy or combativeness 5. Changes in speech 6. Loss of judgement List 4 motor functions caused by increased ICP. - correct answer✔✔ 1. Monoplegia 2. Hemiplegia 3. Over-pronation or supination of the wrists 4. Pronator drift List 5 eye changes caused by increased ICP. - correct answer✔✔ Diplopia What are the risk factors with ICP monitoring? (2) - correct answer✔✔ Infection (8% of patients) Hemorrhage (2-10% of patients) What are the risk factors for infection related to ICP monitoring? - correct answer✔✔ Concurrent systemic infections Longer duration of monitoring (highest risk factor after 10 days of use) Presence of intraventricular hemorrhage or subarachnoid hemorrhage Open skull fracture Trauma Cerebrospinal fluid leakage at the site What are the signs of infection associated with ICP monitoring? - correct answer✔✔ Headache (if patient has headache from the injury, look for changes in the headache) Neck stiffness Fever AMS New-onset seizures Which patients are most likely to have hemorrhage related to ICP monitoring? - correct answer✔✔ More likely in patients who develop coagulopathies Discuss hemorrhages related to ICP monitoring? - correct answer✔✔ Most hemorrhages are small (less than 15 mL) and clinically insignificant. Clinically significant hemorrhage occurs in 1% of cases. What two things are perfusion to cerebral tissue dependent upon? - correct answer✔✔ An adequate MAP that is able to propel blood from the body into the skull A normal ICP Describe the relationship between MAP and ICP. - correct answer✔✔ ICP acts against MAP to reduce blood flow from the body into the skull. How do you determine CPP? - correct answer✔✔ CPP = MAP-ICP What is the average CPP (cerebral perfusion pressure)? - correct answer✔✔ 80-100 mmHg A CPP above _____ mmHg is ideal. - correct answer✔✔ 70 A CPP above _____ mmHg is required for consciousness. - correct answer✔✔ 60 A CPP less than _____ mmHg causes critical reduction in brain tissue oxygenation. - correct answer✔✔ 50 A CPP below _____ mmHg reduces cerebral blood flow to 25% of normal - correct answer✔✔ 40 A CPP below _____ mmHg equates to irreversible brain ischemia - correct answer✔✔ 30 If the MAP is lower than the CPP, the patient is _____. - correct answer✔✔ Dead What is the first step in performing a neurological assessment? - correct answer✔✔ Determine LOC What is the LOC of a patient who responds immediately to minimal external stimuli? - correct answer✔✔ Alert What is the LOC of a patient in a state of drowsiness or inactivity, in which the patient needs increased stimulus to be awakened, but is still easily arousable. - correct answer✔✔ Lethargic What is the LOC of a patient who is very drowsy when not stimulated, follows simple commands when stimulated, a duller indifference to external stimuli still exists, and response is minimally obtained? - correct answer✔✔ Obtunded What is the LOC of a patient who has minimal spontaneous movement, arousable only with vigorous and continuous external stimuli, motor responses to tactile stimuli are appropriate, verbal responses are minimal and incomprehensible? - correct answer✔✔ Stupurous What is the LOC of a patient in which vigorous stimulation fails to produce any voluntary neural response; both arousal and awareness are absent, no verbal responses, motor responses may be purposeful withdrawal to pain in light coma, non-purposeful or absent movement in deep coma? - correct answer✔✔ Comatose If the patient is awake enough to respond, determine the patient's degree of orientation based off of which 4 questions? - correct answer✔✔ What happened to you? (Event) What month and year is it? (Time) Can you tell me your home address? (Place) What is your name? (Person) What are usually the first signs of neurological deterioration? - correct answer✔✔ Changes in orientation Changes of orientation tend to occur in order. What is the order? - correct answer✔✔ The first sphere of orientation to decline is event, then time, then place. Person is almost always the last sphere to be lost. If the patient has deteriorated to the point where they cannot cooperate with determination of orientation, assess for arousal looking for what signs? - correct answer✔✔ Spontaneous eye opening Verbalization attempts Moaning Tossing Reaching Leg crossing Yawning Coughing Swallowing Pupils are usually equal in size and reactive to light in ICP of less than _____. - correct answer✔✔ 30 mmHg When ICP exceeds _____ mmHg, pupils tend to become pinpoint and less reactive to light. - correct answer✔✔ 30 mmHg With _____, one pupil tends to become fixed and dilated. - correct answer✔✔ Unilateral herniation With _____, both pupils tend to become fixed and dilated. - correct answer✔✔ Bilateral herniation What is the 4th step in a neurological assessment? - correct answer✔✔ Assess Vital Signs What is a eupnea respiratory pattern? - correct answer✔✔ moderately fast symmetrical breaths What is Cheyne-Stokes breathing? - correct answer✔✔ quick deep breaths with intermittent pauses What is central neurogenic hyperventilation? - correct answer✔✔ Very Rapid deep breaths What is Apneusis - correct answer✔✔ Virtually apneic breathing What is ataxic breathing? - correct answer✔✔ Very abnormal breathing with no specific pattern Discuss blood pressure in relation to the neurological assessment - correct answer✔✔ Hypotension is rare but detrimental Pulse pressure widens Pulse: bradycardia often develops, followed by dysrhythmias What are the BP and HR when the ICP is 10mmHg or less? - correct answer✔✔ BP is normal Pulse pressure is normal Pulse rate and rhythm is normal What are the BP, Pulse Pressure and Pulse when the ICP is 20 mmHg? - correct answer✔✔ BP, Pulse Pressure, Rate and Rhythm are all normal. Describe the BP and Pulse when the ICP is 30 mmHg. - correct answer✔✔ Widening pulse pressure Bradycardia palpated as a full and bounding pulse Describe the BP and Pulse with herniation. - correct answer✔✔ Wide pulse pressure Bradycardia with irregularities Mild temperature _____ are common with increased ICP - correct answer✔✔ elevations Temperature elevations due to brainstem lesions will lack _____. - correct answer✔✔ Sweating and Gooseflesh Rule out _____ rather than assuming temperature elevations are related to increases in ICP. - correct answer✔✔ infection Describe best eye opening in a Glasgow Coma Score. - correct answer✔✔ Spontaneous = 4 To verbal command = 3 To pain = 2 No response = 1 Describe best motor response in a GCS. - correct answer✔✔ Obeys commands = 6 Localizes pain = 5 Withdraws from pain = 4 Abnormal flexion = 3 Abnormal extension = 2 No response = 1 Describe best verbal response in a GCS. - correct answer✔✔ Oriented = 5 Confused = 4 Inappropriate words = 3 Incomprehensible sounds = 2 No response = 1 A GCS of 13-15 indicates _____. - correct answer✔✔ Normal function, or a mild brain injury A GCS of 9-12 indicates _____. - correct answer✔✔ A moderate brain injury A GCS of 3-8 indicates _____. - correct answer✔✔ Profound brain injury The goal of neurological treatment is to _____. - correct answer✔✔ Reduce the volume of the skull constituents in order to reduce the ICP. (reducing the volume of the brain) How quickly does Mannitol lower ICP? - correct answer✔✔ Within 1-5 minutes. What is the peak effect of Mannitol? - correct answer✔✔ 20-60 minutes How long does Mannitol last? - correct answer✔✔ 1.5-6 hours How is Mannitol given? - correct answer✔✔ As a bolus of 0.25g to 1g/kg (0.25g-0.5g/kg for long term reduction, 1 g/kg for urgent reduction) Is Mannitol preferred as a bolus or as a continuous infusion? - correct answer✔✔ bolus What should be done with mannitol in order to prevent rebound cerebral edema? - correct answer✔✔ Tapered down List 3 ways adequate blood pressure is accomplished. - correct answer✔✔ Administration of fluids Vasopressors (dopamine or phenylephrine) Inotropic agents Discuss early RSI to help reduce ICP. - correct answer✔✔ Pre-oxygenate with 100% oxygen for at least 5 minutes prior to intubation. Consider providing lidocaine 1.5 mg/kg bolus to reduce spikes in ICP associated with intubation. Administer a sedative/hypnotic agent and a rapid-acting neuro-blocking agent Titrate mechanical ventilation to establish a pCO2 of between 30-49 mmHg. End tidal capnography is strongly recommended. Suctioning can _____ ICP. - correct answer✔✔ Increase Discuss ways to manage suctioning in ICP. - correct answer✔✔ Consider medicating with lidocaine, opiates, or neuromuscular blocking agents prior to suctioning. Hyperoxygenate prior to suctioning Limit suctioning to two passes of the suction catheter, not to exceed 10-15 seconds duration per pass. What are some ways to ensure adequate oxygenation? - correct answer✔✔ Maintain adequate hemoglobin Ensure adequate arterial PO2 How can you maintain adequate hemoglobin? - correct answer✔✔ Ensure Hgb is at least 10 g/dL (may require transfusions) How could a Hgb too high be bad related to ICP? - correct answer✔✔ A Hgb too high is bad because increased blood viscosity can reduce tissue oxygenation How do you ensure adequate arterial PO2? - correct answer✔✔ Increased FiO2 on the ventilator Cautious use of PEEP (positive-end-expiratory-pressure) List 6 ways to reduce cerebral metabolism. - correct answer✔✔ 1. Maintain a darkened, quiet room 2. Limit visitors appropriately 3. Speak softly 4. Cluster nursing activities 5. Limit dialogue, keep topics light-hearted 6. Regular sedation/analgesia Describe the effect of Diazepam, Lorazepam and Midazolam on BP, ICP and CBP. - correct answer✔✔ BP decreases No effect on ICP CBP decreases Describe the effect of Morphine, Fentanyl, Alfentanil and Sufentanil on BP, ICP and CBF. - correct answer✔✔ BP decreases ICP increases No effect on CBF Describe the effect of Propofol and Etomidate on BP, ICP and CBF. - correct answer✔✔ BP decreases ICP decreases CBF decreases Describe glycemic maintenance to decrease ICF. - correct answer✔✔ Serum glucose should be maintained between 80-120 using titrated insulin drips. Avoid IV fluids and medications mixed with D5W Seizures are more likely in patients with: (5) - correct answer✔✔ GCS less than 10 Depressed skull fracture Subdural hematoma Epidural hematoma Intracranial hematoma Prophylactic _____ may prevent early-onset seizures but will have little effect on late-onset seizures. - correct answer✔✔ Dilantin What is the difference in early-onset seizures and late-onset seizures? - correct answer✔✔ Early onset seizures are within 7 days of injury Late onset seizures are more than 7 days after the injury What is the loading dose of prophylactic Dilantin? - correct answer✔✔ 20 mg/kg How fast is dilantin administered? Why? - correct answer✔✔ No faster than 50 mg/minute Faster administration may result in hypotension and circulatory collapse Dilantin can only be mixed with _____. - correct answer✔✔ Normal Saline What is the preferred route of dilantin? - correct answer✔✔ Central line Plasma levels should be maintained between _____&_____ while giving dilantin. - correct answer✔✔ 40-80 umol/L When administering dilantin, you should monitor closely for _____. - correct answer✔✔ Rashes Rashes during administration of dilantin may indicate _____. - correct answer✔✔ Steven Johnson Syndrome How is normothermia maintained in relation to ICP? - correct answer✔✔ Treat fevers with antipyretics Sponge baths Cooling blankets Avoid shivering How do you perform the Halo test? - correct answer✔✔ Allow blood to drip onto an absorbent material and look for a yellow ring to gather around the drop of blood. List 5 treatments for basilar skull fractures. - correct answer✔✔ 1. Monitor for and treat signs of increased ICP. 2. Do not pack ears or nose, allow free drainage 3. Do not place anything in the nose (nasal cannula, packing, NG tube, etc.) 4. Discourage the patient from blowing his or her nose 5. Antibiotics may be considered List the 3 meninges from the brain outwards. - correct answer✔✔ 1. Pia 2. Arachnoid 3. Dura What is the term for bleeding between the skull and the dura, usually associated with a blow to the temporal region, causing disruption of the middle meningeal artery? - correct answer✔✔ Epidural bleed What is the treatment for an Epidural bleed? - correct answer✔✔ Evacuation of blood (burr hole or surgery) What are the symptoms of an epidural bleed? - correct answer✔✔ Unconscious at time of incident Rapid recovery of consciousness with a lucid period; associated with an increasingly severe headache Rapid decline in LOC What is the term for bleeding between the dura and the arachnoid mater that is venus? - correct answer✔✔ Subdural bleed What is the treatment for a Subdural Bleed? - correct answer✔✔ Institute measures to reduce ICP Frequently needs surgical intervention Describe the symptoms of a subdural bleed. - correct answer✔✔ Similar to epidural bleed but have a slower onset of symptoms. Acute bleed - symptoms appear within 48 hours of the injury Subacute bleed - symptoms appear 48 hours to 2 weeks after the injury. Chronic bleed - symptoms appear more than 2 weeks after the injury What is the term for bleeding between the arachnoid and pia mater? - correct answer✔✔ Subarachnoid Bleed What are the symptoms of a subarachnoid bleed? - correct answer✔✔ Meningeal irritation (worst headache of life, nuchal rigidity, photophobia_ Decreased LOC Motor deficits Pupillary abnormalities What are the treatments for a subarachnoid bleed? - correct answer✔✔ Measures to reduce ICP Surgery frequently required Calcium channel blockers to reduce local vasospasms Describe the symptoms of a cerebral contusion/intercerebral hematoma - correct answer✔✔ Symptoms increase with time, may not be apparent for hours or days. Symptoms are dependent on location of lesion Where are cerebral contusions/intracerebral hematomas most common? - correct answer✔✔ Frontal and Temporal lobes Cerebral contusions/intracerebral hematomas rarely cause _____ initially. If a patient presents with decreased LOC, consider _____. - correct answer✔✔ unconsciousness diffuse axonal injury What are the physical symptoms of cerebral contusions / intracerebral hematomas? - correct answer✔✔ Personality changes Deficits in memory, executive function, behavior, language and motor function What are the specific signs of bleeding in the midbrain? - correct answer✔✔ Deep coma Midpoint fixed pupils Ophthalmoplegia What are the specific signs of bleeding in the pons? - correct answer✔✔ Coma Pinpoint pupils Ophthalmoplegia Abnormal extension in response to pain What are the specific symptoms of bleeding in the medulla? - correct answer✔✔ Bilaterally fixed and dilated pupils Death What is the treatment plan for cerebral contusions / intracerebral hematomas? - correct answer✔✔ Reduce increased ICP as it occurs What is the term for traumatic microscopic damage to cells in the white matter of the brain? - correct answer✔✔ Concussion A _____ causes reversible physiologic disturbance of neurological function that occurs at the instant of trauma. - correct answer✔✔ Concussion Describe a Grade 1 Concussion. - correct answer✔✔ No LOC Short-lived confusion Post-traumatic amnesia less than 30 minutes Central Cord Syndrome What is the second most common mechanism of injury for spinal cord injuries? - correct answer✔✔ Flexion (beyond 60%) A flexion injury puts the greatest stress at _____&_____. - correct answer✔✔ C5 & C6 What mechanism of injury causes posterior and lateral ligament damage in spinal cord injuries? - correct answer✔✔ Lateral bending Pathological fractures are often associated with _____ or _____. - correct answer✔✔ Osteoporosis Metastatic Disease This mechanism of injury occurs with the transmission of forces along the line of the axial skeleton (landing on feet or buttocks after a fall or diving injury). - correct answer✔✔ Vertical compression / axial loading Describe some complications of a vertical compression / axial loading injury. - correct answer✔✔ The vertebral body is compressed or shattered (burst) and fragments of bone may imbed in the cord (Anterior Cord Syndrome). Vertebrae may open up and cause severe instability. This mechanism of injury occurs when force applied to spinal axis to distract or pull it (hanging). - correct answer✔✔ Distraction What is the most common site of a distraction injury? - correct answer✔✔ Cervical spine A drop of _____ greater than the person's height causes irreversible CNS injury. - correct answer✔✔ 18 inches What is a Jeffersonian Ring Fracture? - correct answer✔✔ Rare fracture of C1 where the body splits into several parts. Usually leaves the patient neurologically intact, although fracture fragments may migrate causing fatality. A Jeffersonian Ring Fracture is frequently associated with what mechanism of injury? - correct answer✔✔ Axial loading What is an Atlanto-occipital dislocation? - correct answer✔✔ Rare avulsion oc C1 body from occipital bone Immediately fatal What is an Odontoid (dens) Fracture? - correct answer✔✔ Severe vertical compression at C2 May or may not involve the cord May be missed on plain films so consider Window CT, Cervial MRI, Open mouth view What is the term fr bilataral avulsion fracture through the arch of C2 with body of C2 separated from supporting. - correct answer✔✔ Hangman's Fracture What 2 factors are important to remember about a hangman's fracture? - correct answer✔✔ May be neurologically intact initially Treated with immobility (halo) and bedrest The posterior spinal cord transmits _____> - correct answer✔✔ Light touch Proprioception Vibration The Anterior spinal cord transmits _____. - correct answer✔✔ Motor functions The Lateral cspinal cord transmits _____. - correct answer✔✔ Pain Temperature Crude Touch _____ nerves cross over low where they enter the spinal cord. - correct answer✔✔ Lateral nerves Anterior and posterior nerves cross over _____, near the base of the brain. - correct answer✔✔ Bair Complete cord injury at C4 affects the _____ (innervated muscle) and the patient's response is _____. - correct answer✔✔ Diaphragm Ventilation Complete cord injury at C5 affects the _____ (innervated muscle) and the shrug shoulders, felx elbows. - correct answer✔✔ Deltoid, Biceps, Brachioradialis Complete cord injury at C6 affects the _____ and the patient response is to _____. - correct answer✔✔ Wrist Extensor Extend Wrist Complete cord injury at C7 affects what innervated muscle and elicits what patience response? - correct answer✔✔ Triceps Shrug shoulders, flex elbows Complete cord injury at C8 affects what innervated muscle and elicits what practice in reponsive. - correct answer✔✔ Flexor digitoum Complete cord injury at T1 affects what innervated muscle and elicits what practice responsive. What is the patient's repsonse to that phone? - correct answer✔✔ Hand intrinsic muscles Flex fingers Complete cord injury at T2-L1 are effected by what innervated muscle and what is the apatient's response? _____. - correct answer✔✔ Intercostals Viral Capacity Describe the sensory assessment for a patient with amnesia. - correct answer✔✔ May have radiclar pain at the point of injury that comes in "waves" of stabbing or sharp pain, or a band of burning pain at the point where normal feelings femind me. How are posterior cord sensory assessments made? - correct answer✔✔ Use a cotton wisp to test for light touch Use a tuning fork to test for vibration Use finger placement to test for proprioception. How are anterior cord sensory assessments made? - correct answer✔✔ Use a needle or the broken end of a stick to test for crude touch. Always start from areas of decreased sensation and move towards areas of increased, sensation when assessing sensation. What are the indications of partial cord syndrome? - correct answer✔✔ "Islands of sparing" within a dermatone Sacrao sparing (maintenance of perineal sensation, rectal sphincter and tone and flexor toe movement. How are anterior cord sensory assessments made? - correct answer✔✔ Use a needle or the broken end of a wooden stick to test for crude touch. When testing sensation, always start from areas of _____ and move towards areas of _____. - correct answer✔✔ Decreased sensation Increased sensation Upper cervical injuries may develop _____ which _____. - correct answer✔✔ Hematomas Impede the airway Cervical spinal injuries cause loss of the ability to _____. - correct answer✔✔ Cough and clear the airway In cervical injuries, if suctioned, limit pass to _____ seconds in order to _____. - correct answer✔✔ 10 seconds decrease vagal stimulation When intubating patients with cervical spine injuries, do not use succinylcholine without a _____. - correct answer✔✔ Defasciculating agent In cervical spine injuries, the _____ nerve innervates the diaphragm and will be negatively impacted with injuries between _____ and _____. - correct answer✔✔ Phrenic C3 and C5 Cervical injuries above C4 cause _____. - correct answer✔✔ diaphragmatic paralysis and respiratory arrest Cervical spine injuries below C4 _____. - correct answer✔✔ Diaphragm can support breathing A spinal injury between T1 and T8 results in _____. - correct answer✔✔ Loss of intercostal innervation (responsible for 35% of respiratory effort) A spinal injury above T7 results in _____. - correct answer✔✔ Decreased ability to cough/deep breathe A spinal injury above T12 results in _____. - correct answer✔✔ Loss of abdominal muscles, decreasing forceful expiration and coughing _____ after an injury causes swelling to rise up the spinal column in as little as _____ minutes, causing _____ - correct answer✔✔ Edema 30-60 minutes Increasing neurological deficits including a potential decline in respiratory function List the circulatory treatments for a patient with a spinal cord injury. - correct answer✔✔ Monitor and treat neurogenic shock as it occurs Patient may have limited or absent peripheral tone, avoid sudden patient movements. Fluid boluses or vasopressors Remember that hypovolemic shock may be masked and exacerbated by neurogenic shock A spinal lesion above S2/S3/S4 may have _____ and develop _____. Place a catheter. - correct answer✔✔ Areflexive bladder Autonomic Dysreflexia Why is a gastric tube necessary in a patient with a spinal cord injury? - correct answer✔✔ High cervical lesions have ileus for the first 24 hours with an increased risk of vomiting. What is the term for a temporary local neurological condition that occurs immediately after the spinal cord injury in which swelling and edema of the cord create the effect of a physiologic trans-section with disruption of nerve conduction? - correct answer✔✔ Spinal Shock What are the symptoms of spinal sock? - correct answer✔✔ Severe pain just above the injury Flaccid paralysis and absent reflexes Lack of sensory function Impaired thermoregulation Bowel distension/ileus Describe the outcomes of spinal shock. - correct answer✔✔ Usually subsides in hours to weeks Anal and bulbocavernous reflex will return Spasticity usually supersedes the flaccid state after several weeks in areas where no function has returned What is the bulbocavernosus reflex? - correct answer✔✔ When the glans penis or clitoris is squeezed, OR the urinary catheter is tugged on, anal sphincter contraction is noted What are common injuries associated with neck injuries? - correct answer✔✔ Pneumothorax Hemothorax Spinal Cord Injuries How do you insert an NPA? - correct answer✔✔ With the bevel toward the septum, advance the NPA gently, straight in, following the floor of the nose. In resistance is felt, do not force, try the other nostril. The phlange of the NPA should rest on the victim's nostril. Discuss an LMA (laryngeal mask airway). - correct answer✔✔ Can be placed quickly without direct visualization and minimal manipulation of the cervical spine. Cannot be used in awake or semiconscious patients. Does not prevent aspiration and may stimulate vomiting. Available in pediatric and adult sizes. Discuss a combitube. - correct answer✔✔ After insertion, fill the oropharyngeal balloon (with blue lumen) with 85 mL of air, then fill the distal balloon with 10 mL of air. Ventilate through blue tube first and check placement. If esophageal gurgling is noted, ventilate through white tube. NG tube and gastric suctioning can be done with esophageal placement. Do not use if patient is less than 48 inches tall (nor in pediatric patients). Discuss a king airway. - correct answer✔✔ Adult sizes only - greater than 48 inches tall. No pediatric sizes. Two balloons both inflated with single lumen. After insertion, ventilate and withdraw tube until placement is confirmed. What are the advantages of an endotracheal tube? - correct answer✔✔ Stable airway Provides protection from aspiration Permits mechanical ventilation Decreases gastric distention What are the disadvantages of an endotracheal tube? - correct answer✔✔ Esophageal or right mainstem bronchus intubation Vocal cord or pharyngeal injury Conversion of non-deficit to deficit spinal cord injury What are the advantages of a cricothyrotomy? - correct answer✔✔ More rapid, greater ease of accessibility and lower incidence of bleeding than tracheostomy. Contraindicated in children under 12 years of age. May be performed on conscious patient with local anesthesia. What are the risks of a cricothyrotomy? - correct answer✔✔ Vocal cord injury Aspiration Hemorrhage Tracheal or esophageal laceration What size tube is needed for a cricothyrotomy and how far is it placed? - correct answer✔✔ Insert a 6.0 ETT 2 cm beyond the cricothyroid membrane to maintain the airway. Discuss a needle cricothyrotomy. - correct answer✔✔ Ventilate with a jet insufflator If jet insufflator is not available, put a 3.0 ETT adaptor over the needle and use the BVM to oxygenate. Will not allow appropriate release of CO2 and causes hypercarbia Discuss a tracheostomy. - correct answer✔✔ Surgical technique with less blood loss than a cricothyrotomy. Bypasses upper airway and glottis, stable airway with low resistance to air flow, easily suctioned. Takes time to perform, used for long term airway control. _____ is frequently associated with spinal cord injuries. - correct answer✔✔ Maxillofacial trauma _____ is the most common site of spinal cord injury with maxillofacial trauma. - correct answer✔✔ C2 Describe closure times for facial lacerations. - correct answer✔✔ Ideally closed within 2 hours After 6 hours, bacterial invasion is usually significant Describe the important things to remember with lip lacerations and with cheek lacerations. - correct answer✔✔ Lips - maintain vermillion border for cosmetic reasons Cheek - Look for bloody discharge in the mouth or saliva in the wound, which could indicate separation of Stensen's duct. What should you remember about tongue lacerations? - correct answer✔✔ Typically heal well Teach good mouth care to prevent infection What should you remember about ear lacerations? - correct answer✔✔ Poor viability due to limited vascularity and cartilage construction What should you remember about eyebrow lacerations? - correct answer✔✔ Do not shave What should you remember about eyelid lacerations? - correct answer✔✔ Laceration to medial 1/3 poses a risk for disruption of lacrimal apparatus - require plastic surgery or opthalmology for closure. What is the strongest facial bone? - correct answer✔✔ Mandible What is the third most commonly injured bone? - correct answer✔✔ Mandible 50% of mandibular fractures are _____ or _____. - correct answer✔✔ Multiple or Bilateral When assessing a mandible fracture, always look to _____. - correct answer✔✔ Exclude a second fracture. What are the symptoms of a mandibular fracture? - correct answer✔✔ Malocclusion and facial asymmetry are the strongest predictors of mandibular fracture Drooling Malocclusion (teeth do not fit together) Hematoma to the floor of the mouth A displaced Le Fort I, II and III Fracture will require _____. - correct answer✔✔ Surgery and fixation What is a NOE fracture? - correct answer✔✔ nasal-ethmoid-orbital fracture What are the symptoms of a NOE fracture? - correct answer✔✔ CSF fluid leak Alteration in visual acuity Periorbital ecchymosis Epistaxis Traumatic telecanthus What is a telecanthus? - correct answer✔✔ Distance between the corner of the eyes (normally 33-34 mm). If edema or trauma makes measurement difficult, measure the interpupillary distance and divide in half. A _____ is usually associated with a blow to the side of the face and is often associated with _____ fractures. - correct answer✔✔ Zygomatic fracture Ocular fractures What are the symptoms of zygomatic fractures? - correct answer✔✔ Orbital floor displacement with limited eye movement. Periorbital ecchymosis Subcutaneous emphysema Difficulty opening and closing the mouth Diplopia / exopthalmos Numb lower lid, medial cheek, upper lid (infraorbital nerve) Flattening of the upper cheek What is the mnemonic to remember with a zygomatic fracture? - correct answer✔✔ TIDES T - Trismus I - Infraorbital anesthesia D - Diplopia E - Epistaxis S - Lack of symmetry What are the symptoms of an orbital fracture? - correct answer✔✔ Enopthalmos (eye sinks into the head) Exopthalmos (eye protrudes from the head) Ocular entrapment What are the signs of ocular entrapment? - correct answer✔✔ Decreased vertical ocular rotary movements Pain on upward gaze Eye cannot look above midline Eye often looks down and out What is important to remember in maxillofacial trauma? - correct answer✔✔ Allow the patient to assume a position to protect the airway (while protecting C-spine) Describe the airway treatments for patients who present with maxillofacial trauma - correct answer✔✔ Suction as needed Orogastric tube Jaw-thrust maneuver as required Early consideration of airway control: OPA/NPA Supraglottic airway Endotracheal Intubation Surgical airway What are the important teaching points for injuries involving the sinuses? - correct answer✔✔ Do not blow your nose Do not perform valsalva maneuver Precautions need to be taken to prevent vomiting What is the name of bleeding in the anterior chamber due to rupture of a vessel in the iris? - correct answer✔✔ Hyphema What are the 4 types of hyphemas? - correct answer✔✔ Small Moderate Severe Total (8 ball hyphema) Describe a Small hyphema. - correct answer✔✔ Blood in 33% or less of anterior chamber Describe a Moderate hyphema. - correct answer✔✔ Blood in 33-50% of anterior chamber Describe a severe hyphema. - correct answer✔✔ Blood in more than 50% of anterior chamber Describe a total or 8 ball hyphema - correct answer✔✔ Entire anterior chamber is filled with blood. What is the chief complaint of a patient who presents with a hyphema? - correct answer✔✔ Pain and decreased vision, reddish discoloration to vision, moving spots in the eyes A hyphema has _____ which may cause pain, nausea and vomiting. - correct answer✔✔ Increased intraocular pressure In a hyphema, red blood indicates _____ and brown blood is an _____. - correct answer✔✔ New Bleed Older Bleed Topical NSAIDs Tetanus Antibiotics or drops An intraocular foreign body is usually a _____. - correct answer✔✔ Metal object projected under high speed What is the clinical presentation for an intraocular foreign body? - correct answer✔✔ Pain and irritation Positive fluorescein stain at site of entry What diagnostics are ordered if an intraocular foreign body is suspected? - correct answer✔✔ Plain films if radiopague CT of the orbit What is the emergency management for an intraocular foreign body? - correct answer✔✔ Cover the eye with a protective shield (apply no pressure to the globe) Tetanus prophylaxis (as needed) Opthamology for removal IV antibiotics Anti-emetics if increased intraocular pressure causes nausea Describe the difference between a penetrating and perforating globe injury. - correct answer✔✔ Penetrating - entrance without exit (not through-and-through) Perforating - Complete disruption of the sclera an cornea (through-and-through) What are the symptoms of penetrating and perforating globe injuries? - correct answer✔✔ Change in the shape of the pupil (tear drop shaped pupil) Unequal pupils Decreased visual acuity Black/brown defect (caused by choroid/uveal prolapse into the defect) Pain Leakage of vitreous humor Enopthalmos with flat or shallow anterior chamber Hyphema What are the treatments for a penetrating or perforating globe injury? - correct answer✔✔ DO NOT remove an impaled foreign body DO NOT manipulate the eye DO NOT instill eye drops or apply antibiotic ointments DO NOT measure intraocular pressure Eye shield (should rest on the bone of the brow and the cheek and not exert pressure on the eye) Secure protruding objects with gauze rolls or a paper cup; patch the unaffected eye simultaneously Discourage the patient from bending, stooping, or moving the head suddenly What are the symptoms and treatment of a lens dislocation/subluxation? - correct answer✔✔ Symptoms: Pain and monocular diplopia Treatment: Opthamology consult What is the term for the iris being torn from the ciliary body? - correct answer✔✔ Irododialysis What are the symptoms of irododialysis? - correct answer✔✔ Patient appears to have a second pupil Hyphema Monocular diplopia What are the symptoms of a retinal detachment? - correct answer✔✔ painless darkening/haziness in the visual field or complaints of curtain or shadow in the visual field photopsia or floaters What is the term for a brilliant flash of light in the visual field? - correct answer✔✔ Photopsia What is the term for when the entire globe is found outside of the bony orbit? - correct answer✔✔ Globe luxation What is the treatment for a globe luxation? - correct answer✔✔ Cover with a cup or a cone Early reduction to minimize traction on the optic nerve List some examples of chemicals that can cause an alkali burn to the eye. - correct answer✔✔ Ammonia Sodium hydroxide Potassium hydroxide Calcium hydroxide Magnesium hydroxide What are some common sources of alkali burns to the eye? - correct answer✔✔ Fertilizers Drain cleaners, lye Lime, mortar, cement, whitewash Fireworks, sparklers, flares List some examples of chemicals that can cause an acidic burn to the eye. - correct answer✔✔ Sulfuric acid Sufurous acid Hydroflouric acid Chromic acid Hydrochloric acid What are some common sources of acidic burns to the eye? - correct answer✔✔ Battery acid Glass polish Bleach Vinegar