student notes chapter 25: face and neck injuries 1 chapter 25

Student Notes Chapter 25: Face and Neck Injuries 1

Chapter 25 Face and Neck Injuries

Unit Summary After students complete this chapter and the related course work, they will understand how to manage trauma-related issues with the face and neck. The student will learn how to recognize life threats associated with these injuries and the correlation with head and spinal trauma. The curriculum includes detailed anatomy and physiology of the head, neck, and eye, and discusses injuries including trauma to the mouth, penetrating neck trauma, laryngotracheal injuries, and facial fractures. The chapter also includes information on dental injuries and blast injuries to the eye. Management of common eye injuries such as foreign objects, puncture wounds, lacerated eyelids, burns, impaled objects, and complications from blunt trauma are included.

National EMS Education Standard Competencies Medicine Applies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely ill patient.

Diseases of the Eyes, Ears, Nose, and Throat Recognition and management of:

• Nosebleed (pp 869–870)

Trauma Applies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient.

Head, Facial, Neck, and Spine Trauma • Recognition and management of:

o Life threats (pp 856–857)

o Spine trauma (Chapter 26, “Head and Spine Injuries”)

• Pathophysiology, assessment, and management of: o Penetrating neck trauma (pp 874–875)

o Laryngotracheal injuries (p 875) o Spine trauma (Chapter 26, “Head and Spine Injuries”)

o Facial fractures (p 872) o Skull fractures (Chapter 26, “Head and Spine Injuries”)

o Foreign bodies in the eyes (pp 860–864) o Dental trauma (pp 855, 872–873)

Knowledge Objectives

Student Notes Chapter 25: Face and Neck Injuries 2 1. Discuss the anatomy and physiology of the head, face, and neck, including major structures and

specific important landmarks of which the EMT must be aware. (pp 851–854) 2. Describe the factors that may cause obstruction of the upper airway following a facial injury. (pp

859–860) 3. Discuss the different types of facial injuries and patient care considerations related to each one. (pp

859–860) 4. Describe the process of providing emergency care to a patient who has sustained face and neck

injuries, including assessment of the patient, review of signs and symptoms, and management of care. (pp 854–875)

5. List the steps in the emergency medical care of the patient with soft-tissue wounds of the face and neck. (pp 859–875)

6. List the steps in the emergency medical care of the patient with an eye injury based on the following scenarios: foreign object, impaled object, burns, lacerations, blunt trauma, closed head injuries, and blast injuries. (pp 860–869)

7. Describe the three different causes of a burn injury to the eye and patient management considerations related to each one. (pp 864–866)

8. List the steps in the emergency medical care of the patient with injuries of the nose. (pp 869–870)

9. List the steps in the emergency medical care of the patient with injuries of the ear, including lacerations and foreign body insertions. (pp 870–872)

10. Describe the physical findings of a patient with a facial fracture, and list the steps related to providing emergency medical care to these patients. (p 872)

11. List the steps in the emergency medical care of the patient with dental and cheek injuries, including how to deal with an avulsed tooth. (pp 872–873)

12. List the steps in the emergency medical care of patient with an upper airway injury caused by blunt trauma. (pp 873–874)

13. List the steps in the emergency medical care of the patient with a penetrating injury to the neck, including how to control regular and life-threatening bleeding. (pp 874–875)

Skills Objectives 1. Demonstrate the removal of a foreign object from under a patient’s upper eyelid. (pp 860–862, Skill

Drill 25-1)

2. Demonstrate the stabilization of a foreign object that has been impaled in a patient’s eye. (pp 862–864, Skill Drill 25-2)

3. Demonstrate irrigation of a patient’s eye using a nasal cannula, bottle, or basin. (pp 864–865) 4. Demonstrate the care of a patient who has a penetrating eye injury. (pp 863–864)

5. Demonstrate how to control bleeding from a neck injury. (pp 874–875, Skill Drill 25-3)

Lecture

I. Introduction

Student Notes Chapter 25: Face and Neck Injuries 3 A. The face and neck are particularly vulnerable to injury because of their relatively unprotected

positions on the body. 1. Soft-tissue injuries and fractures are common and vary in severity. 2. Some injuries are life threatening.

a. Penetrating trauma to the neck may cause severe bleeding. b. An open injury may allow an air embolism to enter the circulatory system.

i. If a hematoma forms in this area, it may stop or slow blood flow to the brain, causing a stroke. 3. With appropriate prehospital and hospital care, a patient with a seemingly devastating injury can have

a surprisingly good outcome.

II. Anatomy and Physiology A. The head is divided into the following:

1. Cranium a. Also referred to as the skull b. Contains the brain

i. The brain connects to the spinal cord through the foramen magnum, a large opening at the base of the skull.

c. The most posterior portion of the cranium is called the occiput. d. On each side of the cranium, the lateral portions are called the temples or temporal regions.

i. Between the temporal regions and the occiput lie the parietal regions. e. The forehead is called the frontal region. f. Anterior to the ear, in the temporal region, you can feel the pulse of the superficial temporal artery.

2. Face a. Composed of:

i. Eyes ii. Ears iii. Nose iv. Mouth v. Cheeks vi. Jowls

b. The six major bones of the face include: i. Nasal bone ii. Two zygomas iii. Two maxillae iv. Mandible

c. The orbit of the eye is composed of: i. Lower edge of the frontal bone of the skull ii. Zygoma iii. Maxilla iv. Nasal bone

d. The bony orbit protects the eye from injury. e. Only the proximal third of the nose is formed by bone.

i. The remaining two thirds are composed of cartilage.

Student Notes Chapter 25: Face and Neck Injuries 4 f. The exposed portion of the ear is composed entirely of cartilage covered by skin.

i. The external, visible part is called the pinna. ii. The tragus is a small, rounded, fleshy bulge immediately anterior to the ear canal. iii. The superficial temporal artery can be palpated just anterior to the tragus.

g. About 1″ posterior to the external opening of the ear is the mastoid process. i. Small, bony mass at the base of the skull

h. The mandible forms the jaw and chin. i. The jaw is the lower border of the mouth, where the tongue and 32 teeth are located. ii. Motion of the mandible occurs at the temporomandibular joint, which lies just in front of the ear on

either side of the face. iii. Below the ear and anterior to the mastoid process, the angle of the mandible is easily palpated.

B. Neck 1. Contains many important structures 2. Supported by the cervical spine

a. First seven vertebrae in the spinal column (C1 through C7) 3. The upper part of the esophagus and the trachea lie in the midline of the neck.

a. The carotid arteries are found on either side of the trachea, along with the jugular veins and several nerves. 4. The larynx

a. The Adam’s apple is located in the center of the anterior of the neck. i. The Adam’s apple is the upper part of the larynx. ii. It is formed by the thyroid cartilage. iii. More prominent in men than in women

b. The other portion of the larynx is the cricoid cartilage, a firm ridge of cartilage below the thyroid cartilage. c. Cricothyroid membrane

i. Lies between the thyroid cartilage and the cricoid cartilage ii. Soft depression in the midline of the neck iii. A thin sheet of connective tissue that joins the two cartilages

5. The trachea a. Below the larynx in the anterior midline of the neck b. The trachea connects the oropharynx and the larynx with the main passages of the lungs (the bronchi). c. On either side of the lower larynx and the upper trachea lies the thyroid gland.

6. Sternocleidomastoid muscles a. Originate from the mastoid process of the cranium and insert into the medial border of each collarbone and

the sternum at the base of the neck b. Allow movement of the head

C. The eye 1. Globe-shaped, approximately 1″ in diameter 2. Located within a bony socket in the skull called the orbit

a. The orbit is composed of adjacent bones of the face and skull. b. In adults, the orbit protects over 80% of the eyeball. c. Between and below the orbits are the nasal bone and the sinuses.

3. The eyeball, or globe, keeps its shape as a result of pressure from the fluid contained within its two chambers.

Student Notes Chapter 25: Face and Neck Injuries 5 a. Clear, jellylike fluid near the back of the eye is called the vitreous humor. b. In front of the lens is a clear fluid called the aqueous humor.

i. In penetrating injuries of the eye, aqueous humor can leak out. ii. With time and appropriate medical treatment, the body can make more.

4. The conjunctiva is a membrane that covers the eye. 5. The lacrimal glands, often called tear glands, produce fluid to keep the eyes moist.

a. When a person blinks, fluid is swept from the lacrimal glands over the surface of the eye, cleaning it. b. The tears drain on the inner side of the eye through two lacrimal ducts into the nasal cavity.

6. The sclera is the white, fibrous tissue that helps maintain the globular shape and protects the more delicate inner structures.

7. On the front of the eye, the sclera is replaced by a clear, transparent membrane called the cornea. a. Allows light to enter the eye b. The iris is a circular muscle behind the cornea.

i. The iris acts like a camera to adjust the size of the opening to regulate the amount of light that enters the eye.

ii. The iris is pigmented, giving the eye its color. 8. The pupil is the opening in the center of the iris.

a. Allows light to move to the back of the eye b. Anisocoria is a condition in which a person is born with different-sized pupils.

i. In unconscious patients, unequal pupil size may indicate serious injury or illness of the brain or eye. 9. The lens lies behind the iris.

a. The lens focuses images on the retina at the back of the globe. 10. The retina contains nerve endings, which respond to light by transmitting nerve impulses through the

optic nerve to the brain. a. The retina is nourished by a layer of blood vessels between it and the back of the globe.

i. Called the choroid b. Retinal detachment is when the retina detaches from the underlying choroid and sclera.

i. Causes blindness

III. Injuries of the Face and Neck A. Partial or complete obstruction of the upper airway may be the result of injuries.

1. Several factors may contribute to the obstruction. a. Blood clots in the upper airway from heavy facial bleeding

i. Can lead to complete obstruction, especially in unconscious patients b. Direct injuries to the nose and mouth, the larynx, and the trachea are often the source of significant

bleeding and/or respiratory compromise. i. May need to suction the airway

c. Injuries may cause teeth or dentures to become dislodged into the throat. d. Swelling that accompanies direct and indirect injury to the soft tissues can also contribute to airway

obstruction. e. The airway may also be affected when the patient’s head is turned to the side.

i. This is often the case with altered level of consciousness or unconscious patients. f. Possible injuries to the brain and/or cervical spine may interfere with normal respirations.

Student Notes Chapter 25: Face and Neck Injuries 6 i. If the great vessels in the neck are injured, significant bleeding and pressure on the upper airway are

common.

B. Soft-tissue injuries 1. Soft-tissue injuries of the face and neck are very common. 2. The face and neck are extremely vascular.

a. Swelling in this area may be more severe. b. Skin and tissues in these areas have a rich blood supply.

i. Bleeding from penetrating injuries may be heavy. ii. Even minor soft-tissue wounds of the face and neck may bleed profusely.

c. A blunt injury can cause a hematoma. i. Sometimes, a flap of skin is peeled back, or avulsed.

C. Dental injuries 1. Mandible injuries are common because of its prominence.

a. Secondly only to nasal fractures in frequency. 2. Most of these fractures are the result of vehicle collisions and assaults.

a. Signs of mandible fracture include: i. Misalignment of the teeth ii. Numbness of the chin iii. An inability to open the mouth

3. Maxillary fractures are usually found after blunt force high-energy impacts. a. The signs of maxillary fractures include:

i. Massive facial swelling ii. Instability of the facial bones iii. Misalignment of teeth

4. Fractured and avulsed teeth are common following facial trauma. a. Teeth fragments can become an airway obstruction and should be removed immediately.

IV. Patient Assessment A. Scene size-up

1. Scene safety a. Upon arrival, observe for hazards and threats to the safety of the crew, bystanders, and the patient. b. Assess for the potential of violence and environmental hazards. c. Standard precautions require eye protection and a face mask, because of the potential for projectile blood. d. Place several pairs of gloves in your pockets for easy replacement. e. Determine the number of patients and consider the need for additional assistance.

2. Mechanism of injury/nature of illness a. Assess the scene, looking for indicators of the mechanism of injury (MOI).

i. Consider how the MOI produced the injuries expected. b. Common MOI for face and neck injuries include:

i. Motor vehicle accidents ii. Sports iii. Falls

Student Notes Chapter 25: Face and Neck Injuries 7 iv. Penetrating trauma v. Blunt trauma

B. Primary assessment 1. Focuses on identifying and managing life-threatening concerns 2. Perform a rapid scan. 3. Form a general impression.

a. Look for important indicators about the seriousness of the patient’s condition. b. Injuries to the face and throat may be very obvious, but may also be hidden by collars or hats. c. Control blood loss with direct pressure. d. Consider the need for manual spinal stabilization. e. Check for responsiveness using the AVPU scale.

4. Airway and breathing a. Ensure a clear and patent airway. b. If the patient is unresponsive or has a significantly altered level of consciousness, consider a properly sized

oropharyngeal airway. i. The nasopharyngeal airway is contraindicated because of the possibility of insertion directly into the

cranial vault and brain tissue if the patient has a basilar skull fracture. c. Palpate the chest wall for DCAP-BTLS.

i. If penetrating trauma is discovered, place an occlusive dressing on the wound. ii. If a flail segment is discovered, stabilize the injury with a gloved hand or stabilize the injured chest

wall with a bulky dressing. iii. Check for clear and symmetric breath sounds. iv. Then provide high-flow oxygen or provide assisted ventilation using a bag-mask device.

d. Face and throat injuries increase the need for airway and breathing maintenance. i. Do not hesitate to place a nonrebreathing mask over facial injuries.

5. Circulation a. You must quickly:

i. Assess the pulse rate and quality. ii. Determine the skin condition, color, and temperature. iii. Check the capillary refill time.

b. Significant bleeding is an immediate life threat. 6. Transport decision

a. Patients with airway or breathing problems or with significant bleeding need to be transported immediately.

b. Stabilization and maintenance of an airway and breathing as well as control of bleeding can be very difficult in patients with facial or neck injuries.

c. A patient with internal bleeding must be transported quickly for treatment by a physician. d. Signs of hypoperfusion include:

i. Tachycardia ii. Tachypnea iii. Low blood pressure iv. Weak pulse v. Cool, moist, pale skin

e. The patient who has a significant MOI but whose condition appears stable should also be transported promptly.

Student Notes Chapter 25: Face and Neck Injuries 8 f. Remember that any significant blow to the face or throat should increase your suspicion of spinal or brain

injury. g. Even if the patient has no signs of hypoperfusion, there is the possibility of eye injuries.

i. Considered serious ii. The patient should be transported to the hospital as quickly as possible. iii. Surgery and/or restoration of circulation to the eye will need to be accomplished within 30 minutes or

permanent blindness may result.

C. History taking 1. Investigate the chief complaint.

a. Obtain a medical history. b. Be alert for injury-specific signs and symptoms. c. Be aware of any pertinent negatives such as no pain or no loss of sensation.

2. SAMPLE history a. Attempt to gather from friends or family if the patient is unresponsive b. In unresponsive patients, you will only be able to notice signs of injuries.

i. Information may have to be obtained by someone who knows the patient. ii. Information may or may not be accurate and may be incomplete.

D. Secondary assessment 1. More detailed, comprehensive examination of the patient that is used to uncover injuries that may

have been missed during the primary assessment. 2. You may not always have time to conduct a secondary assessment. 3. Physical examinations

a. If multiple systems are likely to have been affected, start with a full-body scan looking for DCAP-BTLS. b. Do not delay transport to complete a thorough physical examination. c. In a responsive patient who has an isolated injury with a limited MOI, focus your physical examination on:

i. The isolated injury ii. The patient’s complaint iii. The body region affected

d. Ensure that control of bleeding is maintained, and note the location of the injury. e. Inspect the open wound for any foreign matter or impaled object. f. During the physical examination, use both your eyes and your hands.

i. Your eyes will be looking for swelling, deformities of the bones, contusions, and discoloration. ii. Your hands will be gently palpating the face, looking and feeling for any abnormalities.

g. If your patient is responsive, you should explain exactly what you are doing and what you are looking for. i. Your discovery of an abnormality may be an old injury.

h. Assess all underlying systems, including: i. Brain and major nerves ii. Sensory organs, including the eyes and nose iii. Respiratory system, including mouth, nose, sinuses, and airway iv. Circulatory system, focusing on carotid arteries and jugular veins.

i. When evaluating the eyes, start with the outer aspect and work toward the pupils. i. In addition to discoloration, evaluate for clarity of the patient’s vision, bleeding in the iris area, or

redness. ii. Look for eye symmetry because asymmetry indicates a possible brain injury.

Student Notes Chapter 25: Face and Neck Injuries 9 iii. Look at each pupil for equal size and reaction to light. iv. If pupils are not symmetrical, inquire about previous surgeries or injuries. v. Determine whether unequal pupils are caused by physiologic or pathologic issues. vi. Brain injury, nerve disease, glaucoma, and meningitis are all possible causes of unequal pupils.

4. Vital signs a. Assess vital signs to obtain a baseline so that you can observe any changes during treatment. b. You must be concerned with visible bleeding and unseen bleeding inside a body cavity. c. With facial and throat injuries, baseline information about respirations and pulse is very important. d. Monitoring devices

i. Use appropriate monitoring devices to quantify your patient’s oxygenation and circulatory status. ii. You may also use noninvasive methods to monitor blood pressure.

E. Reassessment 1. Repeat the primary assessment. 2. Reassess vital signs and the chief complaint.

a. Continually reassess the adequacy of airway, breathing, and circulation. 3. Recheck patient interventions.

a. This is particularly important in patients with facial or neck injuries because the ease in which injuries can affect associated systems.

b. The patient’s condition should be reassessed at least every 5 minutes. 4. Interventions

a. Provide complete spinal immobilization to any patient with suspected spinal injuries. i. Spinal injuries should be suspected any time there is significant trauma to the face or neck.

b. Maintain an open airway, be prepared to suction the patient, and consider an oropharyngeal airway. c. Whenever you suspect significant bleeding, provide high-flow oxygen.

i. If needed, provide assisted ventilation using a bag-mask device with high-flow oxygen. d. Control any significant visible bleeding. e. If the patient has signs of hypoperfusion, treat the patient aggressively for shock and provide rapid

transport. f. Do not delay transport of a seriously injured patient to complete nonlifesaving treatments in the field.

5. Communication and documentation a. Communicate all relevant information to staff at the receiving hospital.

i. Include a description of the MOI and the position in which you found the patient. ii. Document the method used to remove the patient from the vehicle. iii. In patients with severe external bleeding, it is important to recognize, estimate, and report the amount

of blood loss that has occurred. iv. Inform the hospital about all injuries involving the head and neck. v. Specialists may be needed to manage injuries to the eyes, ears, teeth, mouth, sinuses, larynx,

esophagus, or large vessels.

V. Emergency Medical Care A. Treat soft-tissue injuries to the face and neck the same as soft-tissue injuries elsewhere on the

body. 1. Assess ABCs and life threats first.

Student Notes Chapter 25: Face and Neck Injuries 10 a. Follow standard precautions. b. The first step is to open and clear the airway.

i. The patient may need frequent suctioning of blood draining into the throat. c. Avoid moving the neck in patients with suspected cervical spine injuries.

i. Use the jaw-thrust maneuver to open the airway and then suction the mouth. ii. Once the patient is immobilized, you can turn the backboard to one side to allow blood or vomitus to

drain from the mouth.

B. Control bleeding by applying direct manual pressure with a dry, sterile dressing. 1. Use roller gauze, wrapped around the circumference of the head, to hold a pressure dressing in place. 2. Do not apply excessive pressure if there is a possibility of an underlying skull fracture. 3. When an injury exposes the brain, eye, or other structures, cover the exposed parts with a moist,

sterile dressing. 4. Apply ice locally to injuries that do not break the skin. 5. For soft-tissue injuries around the mouth, check for bleeding inside the mouth.

a. Broken teeth and lacerations to the tongue may cause profuse bleeding and obstruction of the upper airway.

b. Often, the patient will swallow the blood, so the hemorrhage may not be apparent. c. Patients who swallow blood are prone to vomiting.

6. Physicians can sometimes graft a piece of avulsed skin back into the appropriate position. a. If you find portions of avulsed skin, wrap them in a sterile dressing, place them in a plastic bag, and keep

them cool. i. Never place tissue on ice because freezing will destroy the tissue and make it unusable. ii. Deliver the bag labeled with the patient’s name to the emergency department.

b. If the skin is still attached in a loose flap, place the flap in a position that is as close to normal as possible. i. Hold it in place with a dry, sterile dressing.

VI. Emergency Medical Care for Specific Injuries A. Injuries of the eyes

1. Eye injuries are common, particularly in sports. a. Can produce lifelong complications, including blindness b. Proper emergency treatment will minimize pain and may prevent a permanent loss of vision.

2. In a normal, uninjured eye, the entire circle of the iris is visible. a. The pupils are round, usually equal in size, and react equally when exposed to light. b. Both eyes move together in the same direction when following your moving finger.

3. After an injury, pupil reaction or shape and eye movement are often disturbed. a. Abnormal pupil reactions sometimes are a sign of brain injury rather than an eye injury.

4. Treatment starts with a thorough examination. 5. Always use standard precautions.

a. Take care not to aggravate any problems. 6. Look for specific abnormalities or conditions that may suggest the nature of the injury.

a. A damaged cornea quickly loses its smooth, wet appearance. 7. Foreign objects

a. The orbit protects the eye from the penetration of large objects.

Student Notes Chapter 25: Face and Neck Injuries 11 b. Even a very small object can cause significant damage.

i. The conjunctiva becomes inflamed and red—a condition known as conjunctivitis—and the eye begins to produce tears in an attempt to flush out the object.

ii. Irritation of the cornea of conjunctiva causes intense pain. c. Irrigation with a sterile saline solution will frequently flush away loose, small particles.

i. Use a bulb syringe, or a nasal airway or cannula, to direct saline into the affected eye. ii. Always flush from the nose side of the eye toward the outside to avoid flushing material into the other

eye. d. A foreign body will leave a small abrasion on the surface of the eye.

i. The patient may still report irritation. e. Gentle irrigation may not wash out foreign bodies stuck to the cornea or lying under the upper eyelid.

i. If you see a foreign object on the surface of the eyelid, you may be able to remove it with a moist, sterile, cotton-tipped applicator.

ii. Follow the steps in Skill Drill 25-1. iii. Never attempt to remove an object that is stuck to the cornea.

f. Foreign bodies may be impaled in the eye. i. Must be removed by a physician

g. Your care involves stabilizing the object and preparing the patient for transport. i. Bandage the object in place to support it. ii. Cover the eye with a moist, sterile dressing. iii. Surround the object with a doughnut-shaped collar made from roller gauze or a small gauze pack. iv. Follow the steps in Skill Drill 25-2.

h. If multiple foreign bodies become completely imbedded in the eye, dress the eye closed without placing pressure on it. i. This type of injury must be handled by an ophthalmologist on an urgent basis.

8. Burns of the eye a. Your role is to stop the burn and prevent further damage. b. Chemical burns

i. Usually caused by acid or alkaline solutions ii. Flush the eye with water or saline. iii. Direct the greatest amount of irrigating solution or water into the eye as gently as possible. iv. You may have to force the lids open to irrigate. v. Use a bulb, irrigation syringe, nasal cannula, basin, or running faucet. vi. Irrigate the eye for at least 5 minutes. vii. Flush from the inner corner of the affected eye toward the outside corner. viii. If the burn was caused by an alkali or a strong acid, you should irrigate the eye for at least 20 minutes. ix. After irrigation, apply a clean, dry dressing to cover the eye, and transport the patient.

c. Thermal burns i. During a fire, the eyes will close to protect from heat. ii. May lead to burning of the eyelids, which requires very specialized care iii. Transport promptly without further examination. iv. Cover both eyes with a sterile dressing moistened with sterile saline. v. You may apply eye shields over the dressing.

d. Light burns

Student Notes Chapter 25: Face and Neck Injuries 12 i. Infrared rays, eclipse light, and laser beams all can cause significant damage to the sensory cells of the

eye. ii. Retinal injuries caused by exposure to extremely bright light are generally not painful but may result

in permanent damage. iii. Superficial burns of the eye can result from ultraviolet rays from an arc welding unit, light from

prolonged exposure to a sunlamp, or reflected light from a bright snow-covered area. iv. May not be painful at first, but may become so 3 to 5 hours later v. Severe conjunctivitis usually develops with redness, swelling, and excessive tear production. vi. You can ease the pain by covering each eye with a sterile, moist pad and an eye shield. vii. The patient should be examined by a physician as soon as possible.

9. Lacerations a. Lacerations of the eyelids require very careful repair to restore appearance and function.

i. Bleeding may be heavy, but it usually can be controlled with gentle, manual pressure. b. If there is a laceration of the globe itself, apply no pressure to the eye.

i. Compression can interfere with the blood supply and result in loss of vision. c. Follow these important guidelines in treating penetrating injuries of the eye:

i. Never exert pressure on the injured globe. ii. If part of the eyeball is exposed, gently apply a moist, sterile dressing to prevent drying. iii. Cover the injured eye with a protective metal eye shield, cup, or sterile dressing.

d. On rare occasions, the eyeball may be displaced from its socket. i. Do not attempt to reposition it. ii. Cover the eye and stabilize it with a moist sterile dressing. iii. Cover both eyes to prevent further injury because of sympathetic movement. iv. Have the patient lie supine to prevent loss of fluid from the eye.

10. Blunt trauma a. Injuries range from the ordinary black eye to a severely damaged globe. b. Hyphema (bleeding into the anterior chamber of the eye) obscures all or part of the iris.

i. Common in blunt trauma and may cause seriously impaired vision ii. Cover the eye to protect it from further injury, and provide transportation to the hospital.

c. Orbit fracture (blowout fracture) i. Fracture of bones that form the eye floor and support the globe ii. Cover the eye and transport immediately. iii. Protect the eye with a metal shield. iv. Cover the other eye to minimize eye movement.

d. Retinal detachment i. Often seen in sports, especially boxing ii. Painless but produces flashing lights, specks, or “floaters” iii. Requires prompt medical attention to preserve vision

11. Eye injuries following head injury a. Any of the following eye findings should alert you to the possibility of a head injury:

i. One pupil larger than the other ii. Eyes not moving together or pointing in different directions iii. Failure of the eyes to follow movement of your finger as instructed iv. Bleeding under the conjunctiva v. Protrusion or bulging of the eye

Student Notes Chapter 25: Face and Neck Injuries 13 b. For an unconscious patient, keep the eyelids closed.

i. Cover the lids with moist gauze, or hold them closed with clear tape. ii. Normal tears will then keep the tissues moist.

12. Blast injuries a. Signs and symptoms of blast injuries range from severe pain and loss of vision to foreign bodies within the

globe. i. Before responding to patients after the blast, ensure that the scene is safe.

b. Management of injuries to the eye depends on the severity of the injury. i. If there is a foreign body, do not attempt to remove it. ii. If only one eye is injured, follow local protocol. iii. Patients with a sudden loss or decrease of vision will have to be told what is going on around them. iv. If the patient has severe swelling or a hematoma to the eyelid, do not attempt to force the eyelid open

to examine. 13. Contact lenses and artificial eyes

a. In general, do not attempt to remove contact lenses. i. The only exception is for chemical burns.

b. To remove a hard contact lens, use a small suction cup, moistening the end with saline. c. To remove soft contact lenses, place one or two drops of saline in the eye, gently pinch it between your

gloved thumb and index finger, and lift it off the surface of the eye. d. Place the lens in a container with sterile saline solution. e. Alert the hospital staff if the patient is wearing contact lenses. f. Occasionally, you may find yourself caring for a patient wearing an eye prosthesis.

i. You should suspect an eye of being artificial when it does not respond to light, move in concert with the opposite eye, or appear quite the same as the opposite eye.

ii. If you are not sure, ask about it.

B. Injuries of the nose 1. Nosebleeds (epistaxis) are a common problem.

a. One of the most common causes is digital trauma. b. Nosebleeds are further categorized into anterior and posterior epistaxis. c. Anterior nosebleeds usually originate from the area of the septum and bleed fairly slowly.

i. Usually self-limiting and resolve quickly d. Posterior nosebleeds are usually more severe and often cause blood to drain into the patient’s throat.

i. Do not attempt to insert a nasopharyngeal airway in a patient with a suspected basilar skull fracture or with facial injuries.

2. The nose often takes the brunt of physical assaults and car crashes. a. Blunt injuries to the nose may be associated with fractures and soft-tissue injuries of the face, head

injuries, and/or injuries to the cervical spine. 3. Assess the nose structures for injury.

a. It is helpful to picture the inside of the nose itself. i. The nasal cavity is divided into two chambers by the nasal septum. ii. Contain layers of bone called turbinates iii. Directly above the nose are the frontal sinuses and, on either side, the orbit of the eye.

b. Cerebrospinal fluid (CSF) may escape down through the nose following a fracture at the base of the skull. i. Use a piece of gauze to absorb the blood. ii. If CSF is present, the blood will be surrounded by a lighter ring of fluid (halo test).

Student Notes Chapter 25: Face and Neck Injuries 14 4. Control bleeding by applying a sterile dressing.

a. If the patient is bleeding heavily, it could be the result of significant trauma. i. You should be concerned with cervical spine injury. ii. The patient should not be moved if the airway can be managed in the patient’s present position.

b. For a nontrauma patient who is bleeding from the nose, place the patient in a sitting position, leaning forward, and pinch the nostrils together. i. See Skill Drill 23-3 from Chapter 23, “Bleeding.”

C. Injuries of the ear 1. The ear is complex and associated with hearing and balance. 2. Divided into three parts:

a. Outer ear i. The pinna, or auricle, lies outside of the head. ii. The external auditory canal leads in toward the tympanic membrane (eardrum).

b. Middle ear i. Contains three small bones (hammer, anvil, and stirrup) that move in response to sound waves hitting

the eardrum. ii. The middle ear is connected to the nasal cavity by the eustachian tube, which is the internal auditory

canal. c. Inner ear

i. Composed of bony chambers filled with fluid ii. As the head moves, so does the fluid. iii. In response, fine nerve endings within the fluid send impulses to the brain about the position of the

head. 3. Ears are often injured, but they do not usually bleed very much.

a. If local pressure does not control bleeding, apply a roller dressing. 4. In case of an ear avulsion, wrap the avulsed part in a moist, sterile dressing and put it in a plastic bag. 5. Children place foreign bodies in the outer ear.

a. All foreign bodies should be removed by a physician. b. Do not try to manipulate the foreign body; you may push it further into the ear.

6. Clear fluid coming from the ear may indicate a skull fracture.

D. Facial fractures 1. Typically result from blunt trauma 2. You should assume that any patient who has sustained a direct blow to the mouth or nose has a facial

fracture. 3. Other clues include:

a. Bleeding in the mouth b. Inability to swallow or talk c. Absent or loose teeth d. Loose or movable bone fragments

4. Facial fractures alone are not acute emergencies unless there is serious bleeding. a. In addition to external hemorrhage, there is the danger of blood clots lodging in the upper airway and

causing an obstruction. 5. Plastic surgeons can repair the damage to the face and mouth if the injuries are treated within 7 to 10

days.

Student Notes Chapter 25: Face and Neck Injuries 15 a. Remove and save loose teeth or bone fragments from the mouth because it is often possible to replant

them. b. Remove any loose dentures or dental bridges to protect against airway obstruction.

6. Another source of airway obstruction is swelling, which can be extreme within the first 24 hours after injury.

E. Dental injuries 1. Dental injuries can be traumatic to the patient.

a. The injury may be traumatic and the patient’s permanent teeth may be lost. i. Can affect everything from eating to smiling

2. Bleeding will occur whenever a tooth is violently displaced from its socket. a. Apply direct pressure to stop the bleeding. b. Perform suctioning if needed. c. Cracked or loose teeth are possible airway obstructions.

3. Save and transport an avulsed tooth, handling it by the crown rather than by the root. a. Place the tooth in either cold milk or sterile saline. b. Notify the hospital of avulsed teeth.

i. Reimplantation is recommended within 20 minutes to 1 hour after the trauma.

F. Injuries of the cheek 1. You may encounter an object impaled in the patient’s cheek.

a. If you are unable to control the bleeding and it compromises the airway, consider removing the object. b. Then provide direct pressure both on the inside and outside of the cheek. c. The amount of bandaging should not be so overwhelming that it occludes the mouth and makes it difficult

to breathe.

G. Injuries of the neck 1. The neck contains many structures vulnerable to injury by blunt trauma, including:

a. Upper airway b. Esophagus c. Carotid arteries and jugular veins d. Thyroid cartilage (Adam’s apple) e. Cricoid cartilage f. Upper part of the trachea

2. Blunt injuries a. Any crushing injury of the upper part of the neck is likely to involve the larynx or trachea. b. Examples include:

i. Collision with a steering wheel ii. Attempted suicide by hanging iii. Clothesline injury sustained while riding a bicycle

c. Once the cartilages of the upper airway and larynx are fractured, they do not spring back to their normal position. i. Can lead to loss of voice, difficulty swallowing, severe and sometimes fatal airway obstruction, and

leakage of air into the soft tissues of the neck ii. Subcutaneous emphysema is a characteristic crackling sensation produced by the presence of air in the

soft tissues of the neck.

Student Notes Chapter 25: Face and Neck Injuries 16 iii. If you feel this when palpating the neck, maintain the airway as best you can and transport

immediately. iv. Complete airway obstruction can develop very rapidly.

d. It is possible that these incidents involving an injury to the throat may also have caused a cervical spine injury. i. Spinal stabilization may be needed.

3. Penetrating injuries a. Penetrating injuries to the neck can cause profuse bleeding from laceration of the great vessels in the neck. b. Injuries to the carotid and jugular veins in the neck can cause the body to bleed out, also known as

exsanguination. i. Can lead to a pulmonary embolism ii. The airway, the esophagus, and the spinal cord can be damaged by a penetrating injury. iii. Direct pressure over the bleeding site will control most neck bleeding. iv. Follow the steps in Skill Drill 25-3.

c. If a vein has been punctured, air may be sucked through it to the heart. i. This condition is called an air embolism. ii. A large amount of air in the right atrium and right ventricle of the heart can lead to cardiac arrest. iii. You may find it necessary to apply pressure above and below the penetrating wound to control life-

threatening bleeding. iv. Always maintain cervical spine stabilization.

H. Laryngeal injuries 1. Blunt force trauma to the larynx can occur when:

a. Unrestrained driver strikes the steering wheel b. Snowmobile rider or off-road biker strikes a clothesline or a fixed wire

2. The larynx becomes crushed against the cervical spine, resulting in soft-tissue injury, fractures, and/or separation of the fascia. a. These strangulation injuries can also be found in either intentional or unintentional hangings. b. Any time there is a suspected injury to the larynx, suspect possible cervical spine injury.

3. Penetrating or impaled objects in the larynx should not be removed unless they interfere with cardiopulmonary resuscitation. a. Stabilize all impaled objects if they are not obstructing the airway. b. See Skill Drill 24-2 from Chapter 24, “Soft-Tissue Injuries.”

4. Significant injuries to the larynx pose an immediate risk of airway compromise. a. Signs and symptoms of larynx injuries include:

i. Respiratory distress ii. Hoarseness iii. Pain iv. Difficulty swallowing (dysphagia) v. Cyanosis vi. Pale skin vii. Sputum in the wound viii. Subcutaneous emphysema ix. Bruising on the neck x. Hematoma xi. Bleeding

Student Notes Chapter 25: Face and Neck Injuries 17 b. To manage a laryngeal injury:

i. Provide oxygen and ventilation. ii. Apply cervical immobilization, but avoid the use of rigid collars.

VII. Summary A. Soft-tissue injuries and fractures of the bones of the face and neck are common and vary in

severity. B. In face and neck injuries, your priorities are to prevent further injury to the cervical spine,

manage the airway and ventilation of the patient, and control breathing. C. Airway compromise may be caused by heavy bleeding into the airway, swelling in and around the

structures of the airway located in the face and neck, and injuries to the central nervous system that interfere with normal respiration.

D. To control heavy bleeding from soft-tissue injuries to the face, use direct pressure with a dry, sterile dressing. If brain tissue is exposed, use a moist, sterile dressing.

E. Always check for bleeding inside the mouth because this may produce airway obstruction. F. Open the airway using the modified jaw-thrust maneuver (when indicated), and clear the airway in

all patients with facial injuries. G. Save avulsed pieces of skin and tissue, and transport them with the patient for possible

reattachment at the hospital. H. Maintain a high index of suspicion for patients with unequal pupils—this sign may indicate an

illness or an injury to the brain. I. Foreign bodies on the surface of the eye should be irrigated gently with normal saline solution.

Always flush from the region of the eye closest to the nose toward the outside, away from the midline.

J. If a foreign body is on the underside of the eyelid, remove it gently with a cotton-tipped applicator. Never remove foreign bodies stuck to the cornea.

K. Chemicals, heat, and light rays can all cause burn injury to the eyes, resulting in permanent damage.

L. Be alert to clear fluid draining from the ears or nose. This may indicate a basilar skull fracture. M. Blunt and penetrating trauma to the neck can produce life-threatening injuries. Palpate the neck

for signs of subcutaneous emphysema. In patients with this sign, complete airway obstruction may develop in minutes.

N. If bleeding is present from a penetrating injury, direct pressure over the site will usually control most forms of bleeding.

O. Be alert to the possibility of an air embolism from an open neck injury. Place an occlusive dressing over the site, and provide direct pressure.

Student Notes Chapter 25: Face and Neck Injuries 18

Post-Lecture

Unit Assessment 1. The opening at the base of the skull is called the ____________.

2. The bony socket that the eye sits in within the skull is called the ____________.

3. The clear membrane that allows light to enter the eye is called the ____________.

4. What method should be used to remove a foreign object on the surface of the eye?

5. How should an object impaled in the eye be managed?

6. How long should you flush an eye that has been burned by a strong acid?

7. Does a burn from ultraviolet light become immediately painful?

8. What findings should alert you to a possible head injury?

9. How should a patient with heavy bleeding from the nose be treated?

10. The presence of air in the soft tissues that causes a crackling sensation is called ____________.

Student Notes Chapter 25: Face and Neck Injuries 19 Knowledge Objectives

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student notes chapter 25: face and neck injuries 1 chapter 25

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