Ernst / Herzog / Seidl Head and Neck Trauma

An Interdisciplinary Approach
1. Auflage 2006
ISBN: 978-3-13-257842-5
Verlag: Thieme
Format: EPUB
Kopierschutz: 6 - ePub Watermark

E-Book, Englisch, 240 Seiten, ePub

Reihe: Thieme

Written by an interdisciplinary team of experts in ear, nose, and throat trauma; oral and maxillofacial surgery; neurosurgery; and accident surgery, this book is a state-of-the-art manual on the diagnostic, treatment, and therapeutic techniques available to manage trauma injuries to the head and neck. This book features more than 240 illustrations, most in color, and step-by-step discussions of the initial management, evaluation, and examination of the patient, followed by a thorough collection of flow-charts and checklists. In each chapter the authors present the surgical anatomy, pathomechanism and classification, clinical signs and symptoms, functional tests, diagnostic imaging, as well as other appropriate diagnostic measures. Head and Neck Trauma covers everything from wound management to the latest surgical techniques and their complications. The authors also discuss the medical and technical aspects of trauma management, including antibiotic therapy, grafting and osteosynthesis materials, and the assessment of posttraumatic functional disorders. This beautifully illustrated reference belongs in every emergency room and trauma center library and is an essential tool for any medical professional treating patients with head and neck injuries.

Ernst

Zielgruppe

Ärzte

Autoren/Hrsg.

Ernst, Arneborg

Herzog, Michael

Seidl, Rainer Ottis

Fachgebiete

• Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Chirurgie

Inhaltsverzeichnis

I Evaluation of Head and Neck Trauma
1 Initial Management
2 Examining the Patient
3 Flow Charts and Checklists
4 General Principles of Trauma
II Diagnostic of Head and Neck Trauma
5 Injuries of the Neurocranium and Craniocervical Junction
6 Diagnosing Injuries of the Skull Base
7 Diagnosing Injuries of the Ear and Lateral Skull Base
8 Diagnosing Injuries of the Facial Nerve
9 Diagnosing Injuries of the Midface
10 Diagnosing Injuries of the Orbit
11 Diagnosing Injuries of the Mandible
12 Diagnosing Dental Injuries
13 Diagnosing Injuries of the Pharynx, Salivary Glands, and Soft Tissues of the Neck
14 Diagnosing Injuries of the Larynx and Trachea
III Therapy of Head and Neck Trauma
15 Principles of Wound Management
16 Treatment of Injuries of the Neurocranium and Craniocervical Junction
17 Treatment of Injuries of the Skull Base
18 Treatment of Injuries of the Ear and Lateral Skull Base
19 Treatment of Injuries of the Midface
20 Treatment of Orbital Injuries
21 Treatment of Injuries of the Mandible
22 Treatment of Dental Injuries
23 Treatment of Injuries of the Larynx, Pharynx, Trachea, Esophagus, and Soft Tissues of the Neck
IV Appendix
24 Antibiotic Therapy
25 Grafting and Osteosynthesis Materials

Leseproben

1 Initial Management

Checklist Initial Evaluation, Chapter 3, p. 15

Checklist Initial Management, Chapter 3, p. 15

First Aid at the Scene

In areas where rapid access to medical care is ensured, persons arriving at the scene normally need only to call the paramedics and wait for their arrival. Securing the scene of the accident has absolute priority over further measures in order to protect the injured individual, motorists, and other persons administering aid.

Evaluation of Vital Functions

Vital signs should always be determined first as a means of initial assessment:

is evaluated on the basis of the patient's response when spoken to and to pain.

The (GCS; Table 5.1, p. 39) is necessary for further clinical assessment.

is evaluated based on observation of breathing pattern and respiratory rate.

can be evaluated by palpating the carotid pulse.

Stabilizing Vital Functions

Obstruction of the upper airways is the greatest threat in patients with head and neck injuries. The jaw-thrust and chin-lift maneuvers (Fig. 1.1) are the simplest means of stabilizing the airways.

Foreign bodies (dentures, mucus, and vomitus) must be removed from the oral cavity using a finger. More proximal airways should be cleaned by suction if possible.

Intubation with pharyngeal tubes is another possibility for securing the airways (Guedel tube, Wendel tube; Fig. 1.1c). For complex injuries, transport to a regional trauma center is essential. If associated injury of the neurocranium is suspected, early orotracheal intubation should be performed.

Stabilizing Circulation

It is imperative that treatment of shock begin at the scene. Initial management includes:

elevation of the patient's legs (autotransfusion);

intravenous administration of a colloidal volume substitute;

adequate pain management;

protection from hypothermia.

Massive hemorrhage should be managed with direct compression. Ligation of the extremities should be avoided, however, and the exact time that compression began must be noted. Cardiopulmonary resuscitation should be performed if necessary.

Emergency Care

Soft tissue injuries should be covered with a sterile bandage to help control bleeding and protect the wound from additional contamination. Penetrating foreign bodies should be removed only after the patient is in a clinical setting.

If cervical spine injury is suspected, rotation or hyperextension of the patient's neck must be avoided. If removal of a motorcycle helmet at the scene is necessary in order to control the airways, a second person must stabilize the cervical spine using traction. Then, a rigid cervical collar must be applied until cervical spine injury has been excluded.

After emergent care procedures are complete, further treatment should take place in a specialized properly equipped trauma center. This is especially important for complex injuries. The patient should only be moved after stabilization of vital functions.

Fig. 1.1 Obstruction of the upper airways caused by fall-back of the tongue and epiglottis (modified from Eisele and McQuone 2000).

a Laxity of the tongue musculature causing it to obstruct the upper airways.

b Tilting the head to dorsal and applying pressure to the chin assures the patency of the airways.

c Positioning a Guedel tube to secure the upper airways.

Emergency Measures

Airways

Establishment and maintenance of the airways is of the utmost urgency in treating any multiply injured patient with craniofacial trauma. It is important to remember that following an accident, even airways with adequate ventilation can quickly become obstructed by blood or swelling.

Fall-Back of the Tongue

A particular problem of craniofacial injury is the fall-back of the tongue in segmental fractures of the mandible, especially those involving the midface. The continuity of the horseshoe-shaped mandible, to which the tongue is attached, is disrupted and the injured individual is no longer able to maintain the position of the tongue to keep the airways open (Fig. 1.2).

In an emergency, one can attempt to place the patient in the lateral position or to advance the fractured mandibular arch manually. If the patient is unconscious, a suture can be placed through the posterior of the tongue, lifting the tongue and pulling it forward (Fig. 1.2c).

Oral intubation follows. Successfully positioning the larynx is usually unproblematic, despite hemorrhage and swelling, as the tongue base loses its supporting buttress as a result of mandibular injury.

Fig. 1.2 Obstruction of the upper airways in a mandibular fracture.

a Dorsal displacement of the mandibular arch and tearing of the musculature of the floor of the mouth and tongue.

b Fall-back of the tongue due to loss of fixation on the mandible.

c Emergency procedure for advancing the tongue using a suture to establish the airways.

Injuries of the Larynx and Trachea

Specific problems related to injury of the larynx and trachea can arise and should be expected:

of the larynx often renders oral intubation impossible; intubation should never be forced under such circumstances as manipulation can permanently obstruct any remaining space in the larynx. In rare cases, intubation can be attempted using a stiff tube.

.

Cricothyrotomy is not advisable due to possible existing concomitant injury of the cricoid cartilage or cricoid lamina.

In of the trachea or larynx, the injury site should be used for intubation (Fig. 23.2a, p. 208).

If , intubation should be accomplished using a flexible endoscope or by means of primary tracheotomy. The endoscope is advanced under visualization past the tracheal injury and the tube is positioned inferior to the injury site. The tube should not be too large as this can result in further displacement of the ruptured trachea (Fig. 14.5, p. 126).

Cricothyrotomy involves creating an opening in the cricothyroid membrane, which covers the area between the thyroid lamina and the cricoid cartilage. The available today belong to standard paramedic equipment:

The cricoid cartilage is palpated and the slight indentation above it is punctured with a needle.

If the needle comes into contact with the thyroid cartilage, it can be used to guide the needle to the cricothyroid membrane. The needle tip then points in the direction of the jugular and is directed downward to the palpable gap and then advanced through the cricothyroid membrane (Fig. 1.3).

If an emergency kit is not available, a horizontal incision is made over the cricothyroid membrane. A blade with suitable dimensions is advanced directly into the trachea. The blade is not removed, but instead is rotated, thus serving to guide a speculum or catheter for placing the tube.

Fig. 1.3 Cricothyrotomy (modified from Eisele and McQuone 2000).

a Palpation of the cricoid cartilage; an incision is made at its superior border.

b A suitably sized blade is used to penetrate the cricothyroid membrane and is advanced in the trachea, where it is then rotated.

c Intubation occurs through the opening created into the trachea.

Following cardiopulmonary resuscitation, a cricothyrotomy should be transformed into a tracheotomy as it will otherwise result in permanent damage to the larynx after a few days.

Procedures for tracheostomy are similar to those used in cricothyrotomy. Emergency kits are also available for urgent tracheostomy.

If possible, a local anesthetic (e. g., lidocaine with epinephrine to control bleeding) should be applied prior to beginning the procedure.

An incision is then made in the skin vertically (minimizing the risk of damage to the thyroid gland), directly into the trachea.

The blade remains in situ, and a speculum is inserted over it; the opening is enlarged and a tube is advanced (Fig. 1.4). If necessary, a suction catheter can also be inserted in order to advance the tube using the Seldinger technique.

Given the consequences of respiratory insufficiency, concerns about heavy bleeding are misplaced. In most cases, hemorrhage can be controlled using a clip or by means of compression, for example, damp packing in the tube until definitive treatment (tracheostomy).

.

Fig. 1.4 Tracheotomy (modified from Eisele and McQuone 2000).

a One hand stabilizes the larynx while a vertical incision is made in the skin beneath the cricoid cartilage.

b The tissue is forced apart using the fingers...

Über Autor(innen)

Ernst