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58
CHAP TER2 The injured patient
• Retraction sign***
•
When looking from the side of the patient, as they look upward
the globe is seen to move posteriorly. This is a good sign for a
blowout frac ture. Entrapment of the fat and restriction of the
infer ior rectus muscle results in a shift of the axis of rotation of the
globe from its centre to the point of entrapment. Thus the pull of
the superior rectus result s in a back ward rotation of theglobe.
• Hypoglobus*
•
Inferior displacement of the globe seen in cheek complex fractures,
where the bone and Lockwood’s ligament drop down. May also be
seen in large blowout fractures.
• Enophthalmos*
•
Posterior displacement of the globe due to increased orbital
volume. Seen in blowout fractures of the orbit and cheek fractures.
Globe appears ‘sunken in’ with a deep supra tarsal groove.
• Third nerve palsy***
•
Dilated pupil, the eye look s down and out, and ptosis. In severe
head injuries this represents third nerve compression from
an expanding intracranial lesion. The patient has a reduced
GCSscore.
• Aqueous leakage***
•
Apenetrating injury of the cornea .
• Superior orbital ssure (SOF) syndrome**
•
(Lazy French Tart s Sit Naked In Anticipation!) Ophthalmoplegia,
xed dilated pupil, and ipsilateral forehead numbness— fracture
extending into the SOF, or possible carotid aneur ysm. This is
usually part of a signicant injury.
• Orbital apex syndrome**
•
As in the SOF but here the patient has reduced visual acuity.
• Periorbital oedema*
•
When infective in origin represents signicant spread of infection.
If the eye is closing the patient may probably need admission.
Theears
• Haemotympanum**
•
Blood visualized behind the ear drum. Indicative of a fracture of the
middle cranialfossa.
• Battles sign***
•
Bruising around the mastoid region— fr actured base of skull
(middle cranial fossa).
• CSF rhinorrhoea/ otorrhoea***
•
‘Tramlining’— fractured base of skull. B lood mixes with CSF and
leaks out. Along the edges the blood clots while centrally the CSF
leak washes it away to form two parallel lines (like tr amlines).
• Bleeding from theear**
•
May indicate a fractured base of skull or mandibular condyle. If the
tympanic membrane is intact, the bleeding is local to the meatus,
usually the anter ior wall. This is often secondary to an associated
condylar fracture. If the tympanic membrane is perforated the
blood may be from a middle cranial fossa fracture.
SOME U SEFU L CLINICA L SIGN S AND THEIR SIGNI FICA NCE
Further reading
Amer ican C olle ge of Sur geon s Commi tte e on Trauma . ATLS Adv anced Trau ma Life S uppor t for
Doctors. 8th e d. Chi cago, I L: Amer ican C olle ge of Sur geon s; 200 8. https:// www.facs.org/
quality- programs/ trauma/ atls
Amer ican S ociet y of An esth esiol ogis ts. Pr act ice gui delin es for t he man agem ent of th e dic ult
air way:a repor t by the Amer ican Socie ty of An esthesio logists Task F orce on Mana gemen t of
the Di cult A irway. Anesthesiology. 1993;78:597– 6 02.
Natio nal Au dit O ce. Maj or Trauma C are in En gland. 20 10. ht tp:// ww w.na o.or g.uk / wp -
content/ uploads/ 2010/ 02/ 0910213.pdf
Nott ingh am Uni vers ity Ho spit als NH S Trust. M ajor Trauma Clinical Guidelines. 2011. h tt ps ://
www.nuh.nhs.uk/ media/ 12076/ MTguidelinesOct2011.pdf
Perr y M. Ad vance d Trauma L ife Sup por t (ATLS) an d facia l trau ma: can on e size t a ll? Par t 1.
Dile mmas in the m anage ment of the m ultip ly injure d patie nt with coex isting fac ial injuri es. Int
J Oral Ma xillofa c Surg. 2008;37:209– 14.
Perr y M, Mo rris C . Advanced t raum a life su ppor t (AT LS) an d faci al tra uma: can one s ize t a ll?
Par t2 : ATLS, ma xill ofaci al inj urie s and air way m anage ment d ilem mas. I nt J Oral M axillo fac
Surg. 20 08;37:309– 20.
Perr y M, Mo utray T. Ad vance d Trauma L ife Sup por t (ATLS) and f acia l trau ma:c an one s ize t
all? Pa rt4:‘can the pat ient see? ’ Timely d iagnosis , dilemma s and pitf alls in th e multipl y injured ,
poorly responsive/ unresponsive patient. Int J Ora l Maxill ofac Sur g. 20 08;37:505– 14.
Perr y M, O’Hare J , Port er G. Advanc ed Traum a Life Suppo rt (ATLS) and fa cial tr auma:can on e
size t a ll? Pa rt 3:H ypovol aemi a and fa cial in juri es in th e mult iply i njure d pati ent. I nt J Oral
Maxillofac Surg. 2 00 8;37: 40 5– 14 .
59
Chapter3
61
Thehead
Common presentations 62
Common problems and their causes 62
Useful questions and what to look for 64
Examination of the head 66
Useful investigations 71
Head trauma:introduction 72
Head injuries:pathophysiology 73
Assessment of head injur ies 75
Classication and common types of head (brain) injuries 76
Head injuries:initial management 79
Headache 80
Classication of headaches 81
Assessing a patient with a headache 82
Headaches:associated symptoms 83
Intracranial infections 84
Intracranial bleeding (non- traumatic) 87
Hydrocephalus and raised intracranial pressure 90
Shunts and shunt complications 91
Intracranial thrombosis 92
Cerebral tumours 93
Extracranial causes of headache 94
Primary headaches 97
62
CHAP TER3 Thehead
Common presentations
• Blackouts/ ts (seizures)/ faints
• Headaches (bilateral/ generalized)
• Headaches (unilateral/focal)
• Trau m a
• Loss of smell (see E Chapter 7)
• Ver tigo/ loss of balance (see also E Chapter 6)
• Visual disturbance.
Common problems and theircauses
Blackouts/ ts (seizures)/ faints
Common
• Vasovagal
• Epilepsy/non-epileptic attacks
• Medical conditions (hypoglycaemia, cardiac disease, stroke,
hypotension,etc.)
Uncommon
• Carotid disease
• Cervical spine disease in elderly.
Headaches (bilateral/ generalized)
Common
• Tension headache
• Sinusitis
• Migraine
• Cervicogenic headache
• Analgesic misuse.
Uncommon
• Intracranial haemorrhage(ICH/SAH)
• Hydrocephalus
• Raised ICP (tumours/ trauma)
• Intracranial infections (meningitis, encephalitis)
• Dural venous thrombosis (cavernous sinus/ sagittal sinus).
Headaches (unilateral)
Common
• Trauma/ post- concussion headache
• Infections (sinusitis/otitis media)
• Glaucoma
• Temporal (giant cell) arteritis
• Migraine
• Cluster headaches
• Tension headache/ TMJ symptoms.
COMMON PROBLEMS AND THEIRCAUSES
Uncommon
• Post- traumatic haematomas (extradural, subdural)
• Intracranial infections (meningitis can be localized, brain abscess,
subdural empyema)
• Mastoiditis
• Brain tumours
• Referred dental pain
• Trigeminal autonomic cephalalgias
• ICH (may initially be localized).
Injuries
Common
• Blunt trauma
• Scalp lacerations.
Uncommon
• Impalement injuries
• Penetrating injuries
• Blast injuries.
Loss ofsmell
(See E Chapter 7.)
Common
• Upper respirator y tract infection/ rhinitis/ sinusitis
• Nasal polyps/ hayfever/ allergies
• Head/ nasal/ naso-orbito-ethmoidal (NOE) trauma (anterior
cranialfossa).
Uncommon
• Tumours of the frontal lobe/ esthesioneuroblastoma
• Multiple sclerosis
• Cushing’s syndrome/ diabetes
• Epilepsy
• Cranial radiotherapy
• Liver or kidney disease
• Parkinson’s disease
• Alzheimer’s disease
• Primar y ciliary dyskinesia
• Meningioma
• Paget’s disease ofbone
• Primar y amoebic meningoencephalitis
• Long- term alcoholism
• Kallmann syndrome — a genetic condition
• Sarcoidosis.
Vertigo/loss of balance
(See also E Chapter 6.)
Common
• Middle/inner ear conditions (see E Chapter 6).
63
64
CHAP TER3 Thehead
Uncommon
• Meningitis
• Subarachnoid haemorrhage.
Useful questions and what tolookfor
Blackouts/ ts (seizures)/ faints
Askabout
• Onset
• Duration and frequency
• Exacerbating factors
• Nausea and vomiting
• Preceding or associated symptoms (aura/change in vision/ jaw
claudication)
• Detailed PMH (consider non-neurological causes).
Lookfor
• Reduced level of consciousness
• Visual disturbance
• Photophobia/ papilloedema
• Heart murmurs/ cardiacsigns
• Autonomic symptoms
• Neck stiness/ dizziness onmoving
• Focal neurological decit/ signs ofinjury
• Systemic symptoms (including BP and rash)
• Tongue biting
• Incontinence.
Headaches (alltypes)
Askabout
• Location/ character
• Timing
• Onset
• Duration and frequency
• Exacerbating/ relieving factors
• Nausea and vomiting
• Visual disturbance
• Preceding or associated symptoms (aura/ jaw claudication/ seizures)
• PMH (hyper tension/diabetes)
• Diet (especially caeine) and medication/drug intake.
Lookfor
• Reduced level of consciousness
• Photophobia/ papilloedema
• Autonomic symptoms
• Neck stiness
• Focal neurological decit (especially abnormal/asymmetric pupils
or CN IIIpalsy)
USEF UL QU ESTI ONS AND WHAT TO LOOKFOR
• Systemic signs (includingBP)
• Tenderness (frontal sinus/ temporal artery/ globe)
• Rash (meningitis/herpes zoster).
Injuries
Ask about
• When it occurred
• Mechanism of injury (blunt/penetrating)
• Loss of consciousness
• Other injuries (especially the neck)
• Progression of symptoms since injury
• Alcohol or drug use
• Medications (especially anticoagulants)
• Seizures
• Preceding headache.
Look for
• ATLS (as required)
• GCS
• Pupil responses
• Other injuries (notably neck/scalp/facial/ocular).
Loss ofsmell
(See E Chapter 7.)
Askabout
• Histor y of head/ nasalinjury
• Constant or intermittent
• Obstructed breathing through thenose
• Nasal discharge
• Headaches/ visual problems
• PMH (many medical causes).
Lookfor
• Examinenose
• Cranial nerve examination
• Frontal sinus tenderness to percussion
• Vision and ocular movements.
Vertigo/loss of balance
(See also E Chapter 6.)
Ask about
• Describe symptoms
• Duration: seconds, minutes, hours, days
• Associated symptoms (neurological or aural)
• PMH.
Look for
• General exam
• Otoscopy
• Neurological exam/eye movements.
65
66
CHAP TER3 Thehead
Examination ofthehead
This is tailored according to the suspected pathology (injuries, infections,
neurological). Various elements make up a comprehensive examination.
Neurological examination cannot be considered in total isolation from the rest
of the body. The following should all be considered.
Conscious level:theGlasgow ComaScale
The GCS has three components ( Table 3.1). Afully alert and orientated person has a GCS score of 15. Adead body has a GCS score of 3 (notzero).
Paediatric variation of the Glasgow ComaScale
• Motor and eye opening same asadult.
• Verbal depends on age/ ability— 5- pointscale:
•
Babbles/ coos/ words as perusual (5)
•
Less than usual abilit y or spontaneous irritablecry (4)
•
Inappropriatecrying (3)
•
Occasionally whimpers/ moans (2)
•
No response (1).
Cranial nerve examination
This should be undertaken routinely. With practice, a ‘quick cranial
nerve sur vey’ can be undertaken in just a few minutes (see Table3.2).
Table3.1 Components ofthe Glasgow Coma Scale (corresponding score
inbra ckets)
Eye open ing (EO)
EO spontaneously (4)
EO to spe ech (3)
EO to pai n* (2)
EO none (1)
* Do not te st with supr aorbita l pres sure a s patient will instinc tive ly clos e thei r eyes.
Verbal response
Orientate d (5)
Confused (4)
Inappropriate words (3)
Incomprehensible sounds (2)
None (1)
Best motor response
Obeys commands (6)
Localizes pain (5)
Flex ion to pa in (4)
Abnormal (spastic) exion* (3)
Ext ensi on to pai n (2)
None (1)
Adapt ed fro m The Lan cet, Volume 304, Issue 7872, Graham Teasdale and Bryan
Jenn ett , Asse ssme nt of coma a nd impaire d consc iousn ess:a pr actical s cale, p p. 81– 84,
Copyr ight(1974), with per mission fr om Else vier.
EXAMIN ATION OF THEHEAD
Table3.2 Cranial nerve functions and their examination
Number Ner ve Function Test Palsy
I Olfactory Smell Vario us sme ll bott les,
II Optic Vision Visual acuity, visual
III Oculo motor Eye
IV Trochlear Eye
V Tri gem ina l Facia l
VI Abducens Eye movements E ye movem ent
VII Facial Facial
VIII Vestibulo-
cochlear
IX Glosso -
pharyngeal
X Vagu s Visceral
XI Accessor y Trapezius &
XII Hypo glossal Ton gue
movements
movements
sensation
Muscl es of
mastication
movements
Taste to
anterior tongue
Hearing
Equilibrium
Pharyngeal
& post erio r
tongue
sensation
&tas te
Motor to upper
pharynx
parasympathetic supply
(extensive)
Lar ynx &
phar ynx motor
function
sternoma stoid
motor function
movements
e.g. co ee, le mon
(test e ach nos tril
sepa rate ly)
elds, pupillary
responses, fundoscopy, colour vision
Eye move ment in all
directions, pupillary
responses
Eye move ment down
when looking medially
Sens ation i n 3
trigeminal divisions,
corn eal re ex, j aw
movement
laterally
Facial movements
Sweet , bitter, salt
taste substances
Hear ing, Weber’s &
Rinne’s tests, balance
& equilibrium
Phar yngeal se nsati on,
gag reex
Pharyngeal
movement,
gag reex
Lary ngoscopy
Trapezius & sternomastoid power
Ton gue
movements
Loss of s mall
(anosmia)
Blin d eye, vi sual eld
defe ct or los s of
acuity
Ptosis, eye deviated
down and outwards,
unreactive dilated
pupil
Inability to look
down wh en lookin g
medially
Loss of f acial
sensation, loss of
cornealreex
Jaw wea k & deviates
to side o f lesion on
opening, wasting of
mastication muscles
(chr oni c)
Inability to look
laterally
Loss of f acial
movement
UMN: forehead
spared
LMN:fo rehe ad
aected
Loss of t aste
Deafness
Nyst agmus, los s of
equili brium
Loss of g ag re ex &
pharyngeal sensation
Deviation o f the
uvula.
Loss of g ag re ex
& phar yngeal
movement
Hoar se voice , vocal
cord paralysis
Weakn ess of
trapezius &
sternomastoid
Tongue de viate s to
side of lesion
67