Regional Assessment and Special Diagnostic Tests

 Based on mechanism, location of injuries identified on physical examination, screening radiographs, and
the patient’s overall condition, additional diagnostic studies often are indicated.
Head
 Evaluation of the head includes examination for injuries to the scalp, eyes, ears, nose, mouth, facial bones,
and intracranial structures.
 Palpation of the head is done to identify scalp lacerations, which should be evaluated for depth, and
presence of associated depressed or open skull fractures.
 The eye examination includes not only pupillary size and reactivity, but also examination for visual acuity
and for hemorrhage within the globe.
 Ocular entrapment, caused by orbital fractures with impingement of the ocular muscles, is evident when
the patient cannot move his or her eyes through an entire range of motion.
 It is important to perform the eye examination early because significant orbital swelling may prevent later
evaluation. A lateral canthotomy may be needed to relieve periorbital pressure.
 The tympanic membrane is examined to identify hemotympanum, otorrhea, or rupture, which may signal
an underlying head injury.
 Otorrhea, rhinorrhea, raccoon eyes, and Battle’s sign (ecchymosis behind the ear) suggest a basilar skull
fracture. Although such fractures may not require treatment, there is an association with blunt
cerebrovascular injuries, cranial nerve injuries, and risk of meningitis.
 Anterior facial structures should be examined to rule out fractures. This entails palpating for bony step-off
of the facial bones and instability of the midface (by grasping the upper palate and seeing if this moves
separately from the patient’s head).
 A good question to ask awake patients is whether their bite feels normal to them; abnormal dental closure
suggests malalignment of facial bones and the possibility for a mandible or maxillary fracture.
 Nasal fractures, which may be evident on direct inspection or palpation, typically bleed vigorously. This
may result in the patient having airway compromise due to blood running down the posterior pharynx, or
there may be vomiting provoked by swallowed blood. Nasal packing or balloon tamponade may be
necessary to control bleeding.
 Examination of the oral cavity includes inspection for open fractures, loose or fractured teeth, and
sublingual hematomas.
 All patients with a significant closed head injury (GCS score <14) should undergo CT scanning of the head.
Additionally,
 elderly patients or those patients on antiplatelet agents or anticoagulation should be imaged despite a GCS
of 15.
 For penetrating injuries, plain skull films may be helpful in the trauma bay to determine the trajectory of
the bullet.
 The presence of lateralizing findings (e.g., a unilateral dilated pupil unreactive to light, asymmetric
movement of the extremities either spontaneously or in response to noxious stimuli, or unilateral
Babinski’s reflex) suggests an intracranial mass lesion or major structural damage. Such intracranial
lesions following trauma include hematomas, contusions, hemorrhage into ventricular and subarachnoid
spaces, and diffuse axonal injury (DAI).
 Epidural hematomas occur when blood accumulates between the skull and dura, and are caused by
skull fracture(Fig. 7-16).
 Subdural hematomas occur between the dura and cortex and are caused by venous disruption or
laceration of the parenchyma of the brain. Due to associated parenchymal injury, subdural hematomas
have a much worse prognosis than epidural collections.
 Hemorrhage into the subarachnoid space may cause vasospasm and further reduce cerebral blood flow.
 Intraparenchymal hematomas and contusions can occur anywhere within the brain. DAI results from high-
speed deceleration injury and represents direct axonal damage from shear effects. CT scan may
demonstrate blurring of the gray and white matter interface and multiple small punctate hemorrhages, but
magnetic resonance imaging is a more accurate test. Although prognosis for these injuries is extremely
variable, early evidence of DAI is associated with a poor outcome.
 Stroke syndromes should prompt a search for carotid or vertebral artery injury using multislice CTA (Fig.
7-17).
  Significant intracranial penetrating injuries usually are produced by bullets from handguns, but an array of
other weapons or instruments can injure the cerebrum via the orbit or through the thinner temporal
region of the skull. Although the diagnosis usually is obvious, in some instances wounds in the auditory
canal, mouth, and nose can be elusive. Prognosis is variable, but virtually all supratentorial wounds that
injure both hemispheres are fatal.
Maxillofacial Injuries.
 Maxillofacial injuries are common with multisystem trauma and require coordinated management by the
trauma surgeon and the specialists in otolaryngology, plastic surgery, ophthalmology, and oral and
maxillofacial surgery. Delay in addressing these systems that control vision, hearing, smelling, breathing,
eating, and phonation may produce dysfunction and disfigurement with serious psychological impact. The
maxillofacial complex is divided into three regions; the upper face containing the frontal sinus and brain;
the midface containing the orbits, nose, and zygomaticomaxillary complex; and the lower face containing
the mandible. High-impact kinetic energy is required to fracture the frontal sinus, orbital rims, and
mandible, whereas low-impact forces will injure the nasal bones and zygoma. The most common scenario,
which at times may be lifethreatening, is bleeding from facial fractures. 87 Temporizing measures include
nasal packing, Foley catheter tamponade of posterior nasal bleeding, and oropharyngeal packing. Prompt
angioembolization will halt exsanguinating hemorrhage. Fractures of tooth-bearing bone are considered
open fractures and require antibiotic therapy and semiurgent repair to preserve the airway as well as the
functional integrity of the occlusion (bite) and the aesthetics of the face. Orbital fractures may compromise
vision, produce muscle injury causing diplopia, or change orbital volume to produce a sunken appearance
to the orbit. Nose and nasoethmoidal fractures should be assessed carefully to identify damage to the
lacrimal drainage system or to the cribriform plate producing cerebrospinal fluid rhinorrhea. After initial
stabilization, a systematic physical examination of the head and neck should be performed that also
includes cranial nerve examination and three-dimensional CT scanning of the maxillofacial complex (Fig.
7-53).