hello and welcome to chapter 28 face and neck emergencies of the emergency care and transportation of the sick and injured 12th edition after you complete this chapter and the related coursework you will understand how to manage trauma related issues with face and neck you will also learn to recognize life threats associated with these emergencies and injuries and the correlation with the head and spinal trauma the curriculum includes detailed Anatomy physiology of the head neck and eye and discusses injuries including trauma to the mouth penetrating neck trauma lenot tracheal 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 okay so let's get started the face and neck are particularly vulnerable to injury because of their relatively unprotected position on the body soft tissue injuries and fractures are common and vary in severity some injuries are life-threatening such as p uh penetrating trauma to the neck may cause severe bleeding and an open injury may allow an air embolism to enter the circulatory system so let's talk about the anatomy and physiology of this area the head is divided into the following first it's the cranium and it's also referred to as the skull it contains the brain posterior portion of the cranium is called the ocit on each side of the cranium the lateral portions are called the temples or temporal regions the forehead is called The frontal region anterior to the ear in the temporal region you can feel the pulse of the super icial temporal artery the six major bones of the face include first you have the nasal bone then you have two zagas two maxil and the mandible the Bony orbit protects the eye from injury composed of lower edge of the frontal bone and the zagmail and the nasal bones only the proximal third of the nose is formed by bone the exposed portion of the ear is composed entirely of cartilage covered by skin the external visible part is called the penina the tragus is a small rounded fleshy bulge immediately anterior to the ear canal the superficial temporal artery can be palpated just anterior to the tragus about 1 in posterior to the external opening of the ear is the mastoid process the mandible forms the jaw and Chin okay so let's move down from the head into the neck and the neck contains many important structures supported by the cervical spine the first seven vertebrae in the cervical spine uh is C1 through C7 the spinal cord exits from The Forum mag and lies within the spinal canal formed by vertebrae the upper part of the esophagus and trachea lying in the midline of the neck the coted arteries are found on either side of the trachea along with the jugular veins and several nerves the LX which is the atoms apple is located in the center of the anterior of the neck the other portion of the LX is the cry cartilage and it's a form Ridge of cartilage below the thyroid cartilage the CID thyroid membrane lies between the thyroid cartilage and the CID cartilage the trachea is below the Linex the trachea connects the oral ferx and the Linex with the main passages to the lungs on either side of the lower Linex and the upper tra lies the thyroid gland sternomastoid muscles originate from the mastoid process of the cranium and insert into the medial border of each collar bone and the sternum at the base of the neck this allows for movement of the head the eye and that's a globe shape approximately 1 inch in diameter is located within a bony socket in the skull called the orbit if it's composed of adjacent bones of the face and skull in adults the orbit protects over 80% of the eyeball between and below the orbits are the nasal bones and sinuses the figure on this slide illustrates the major components of the eye the eye ball or Globe keeps its shape as it result of pressure from the fluid contained within the two Chambers it's clear jelly-like fluid fluid near the back of the eye is called the vitous humor in the front of the lens the clear fluid is called the aquous humor the conjunctiva is a membrane that covers the eye the lacal glands often are called Tear glands produce fluid to keep the eyes moist the tear drains in the inner side of the eye through two lacrimal ducts into the nasal cavity the Scara is white fibrous tissues that helps maintain the global shape and protects the more delicate inner structures on the front of the eye the Scara is replaced by clear transparent membrane called the cornea this allows light to enter the eye the iris is a circular muscle behind the cornea the pupil is the opening in the center of the iris it allows light to move to the back of the eye um a condition in which a person is born with two different Siz pupils is called aniso cor an escora the lens behind the iris um the lens focuses images on the retina at the back of the globe the retina contains nerve endings which respond to light by transmitting nerve impulses through the optic nerve to the brain the retina is nourished by a layer of blood vessels between it and and the back of the globe retinal detachment is when the retina detaches from the underlying um choid and can cause blindness injuries to the face and neck so let's talk about these now injuries about the face and neck can often lead to partial or complete obstruction of the upper Airway several factors May contribute to the obstruction you could have blood clots in the upper Airway from heavy facial bleeding or direct injuries to the nose and mouth and Linex and the trachea are often the source of significant bleeding or respiratory compromise injuries may cause teeth or dentures to become dislodged into the throat swelling that accompanies direct or indirect injury to those soft tissues can also contribute to an airway obstruction the airway may also be affected when the patient's head is turned to the side Poss injuries to the brain and the cervical spine May interfere with normal respirations so soft tissue injuries the face and neck are extremely vascular swelling in the area may be more severe skin and tissues in these areas have a rich blood supply and a blunt injury can cause a hematoma and then there's Dental injuries Okay so mandible injuries are common because of its prominence second only two nasal fractures in frequency most of these fractures are the result of vehicle collisions or assaults signs of mandible fractures include misalign teeth numbness to the chin or the inability to open the mouth maxillary fractures are usually found after blunt force high energy impacts the sign of a maxillary fracture includes facial swelling inab instability of facial bones and misalignment of the teeth fractured and Evol teeth are common following facial trauma teeth fragments can become an airway obstruction and should be removed immediately okay so now we're going to start talking about the patient assessment of the face and neck injuries and just like every patient assessment seen safety is highest priority then we're going to assess for any par potential violence or environmental hazards standard precautions require eye protection and face mask because of the potential for projectile blood now determine the number of patients and consider the need for additional resources so the mechanism of injury is going to be very important um you want to assess the scene looking for indicators of that mechanism of injury common mois for face and neck injuries include motor vehicle collisions Sports Falls penetrating trauma blunt trauma next let's talk about the primary assessment and this let you want to focus on identifying and managing lifethreatening concerns threats to X ABC's must be treated immediately when there is life-threatening external Hemorrhage it should be addressed before the airway and breathing okay you want to form that general impression so look for important indicators of the seriousness of the patient condition injuries to the face and throat may be very obvious but may also be hidden by collars or hats control blood loss with direct pressure consider the need for spinal immobilization and check the responsiveness using your avpo scale Airway and breathing so ensure clear and patent Airway if the patient is unresponsive or has significantly altered level of Consciousness consider a properly sized oral faren gal quickly ass assess for adequacy of bleeding splinting or otherwise restricting the chest well motion is contraindicated you do not want to attempt this now is the C so assess the pulse and quality and significant bleeding is an immediate life threat of course and then the D the transport decision so consider quickly transporting patients with an airway or breathing problem or with a significant bleeding stabilization and maintenance of the airway and breathing as well as control of bleeding may be very difficult in patients with face and neck injuries consider Advanced life support um backup if the transport is too long patient with internal bleeding must be transported quickly for treatment by a physician signs of hypo profusion imply the need for Rapid transport the patient who has a sign significant mechanism of injury but whose condition appears stable should also be transported promptly remember that any significant blow to the face or throat should increase your suspicion of spinal or brain injury even if the patient has no signs of hyper profusion or hypoperfusion or other life-threatening injuries there is a possibility of eye injuries history taking so investigate the chief complaint obtain medical history be alert for injury specific signs and symptoms be aware of the pertinent negatives such as no pain or any loss of sensation next get that sample history and attempt to gather from friends or family if the patient's unresponsive if unresponsive patient you will only be able to notice signs of injuries and then is your secondary assessment so if multiple symptoms are likely to be affected start with assessment of the entire body looking for that Decap btls do not delay transport to complete a thorough physical exam in a responsive patient who has an isolated injury with limited mechanism of injury consider focusing your physical examination ensure the control of bleeding is maintained and note the location of that injury inspect the wound for any foreign matter and stabilize the objects during the physical exam use both your eyes and your hands if your patient is responsive you should explain exactly what you're going to do and what you're looking for and assess all underlying systems when evaluating the eyes start with the outer aspects and work towards the pupils visual Acuity is considered the Vital sign of the eye when it comes to vital signs you want to assess an main those baselines so that you can observe for any changes during treatment you must be concerned with visible bleeding and unseen bleeding inside the body cavity with facial and throat fractures Baseline information about respirations and pulse are very important in used monitoring devices and your reassessment you want to repeat that primary reassess vital signs in the chief complaint and continually reassess the adequacy of Airway breathing and circulation recheck patient interventions this is particularly important in patients with facial or neck injuries because the ease in which the injuries can affect the associated symptom systems the patient's condition should be reassessed at least every 5 minutes as for interventions you must provide complete spinal immobilization to any patient with suspected spinal injuries you want to maintain an open Airway be prepared to suction the patient and consider an oral fenal whenever you suspect significant bleeding profi provide high flow oxygen and control any significant visual bleeding if the patient has any signs of hypo profusion treat the patient aggress aggressively for shock and provide rapid transport do not delay transport of a seriously injured patient to complete non-li saving treatments in the field documentation and communication in your documentation include a description of the mechanism of injury and the position in which you found the patient emergency medical care so treat soft tissue injuries to the face and neck the same as soft tissue injuries Elsewhere on the body assess the X ABC's and life threats first follow standard precautions in the absence of life-threatening bleeding the first step is to open and clear the airway avoid moving the neck in the patients with suspected cervical injury control bleeding by applying direct pressure with a sterile dry dressing use roller guys unwrapped around the circumference of the head and to hold the pressure dressing in place do not apply excessive pressure If there is a possibility of underlying skull fracture and when an injury uh exposes the brain eye or other structures cover the exposed Parts with a moist stero dressing apply ice locally to injuries that do not break the skin enforce soft tissue injuries around the mouth check for bleeding inside the mouth Physicians can sometimes graft a piece of an Evol skin back into the appropriate position if you find portions of a v skin wrap them in sterile dressing place them in a plastic bag and keep them cool if the skin is still attached in a loose flap place the flap in the position that it as close to normal as possible all right so then we're going to talk about emergency care for specific injuries and first we're going to talk about injuries to the eyes okay and so eye injuries are common particularly in sports and they can produce lifelong complications including blindness so proper emergency treatment will minimalize pain and may prevent a permanent loss of vision after an injury pupil reaction or shape of the eye movement are often Disturbed abnormal pupil reactions sometimes are a sign of a brain injury rather than an eye injury treatment starts with a thorough exam so look for specific specific abnormalities or conditions that may suggest the nature of the injury foreign objects the orbit protects the eye from penetration of large objects even a very small object May produce severe irritation so irrigate with a sterile saline solution and it will and frequently flush away loose small particles gentle irrigation usually will not wash out foreign objects which are stuck to the cornea or underlying upper eyelid under the upper eyelid if you spot a foreign object on the surface of the eyelid you may be able to remove it with a moist cotton tipped applicator and so you could uh follow the skill drill in 28-1 okay so foreign bodies they may be impelled in the eye and those must be removed by The Physician your care involves stabilizing the object and preparing the patient for transport and you could follow the steps in skill drill 28-2 when you see or suspect an impaled object in the eye bandage both eyes with soft soft bulky dressing to prevent further damage or injury Burns of the eye so first of course we need to stop the burn and prevent for further damage when it comes to chemical burns usually caused by acid or alkaline Solutions flush the eye with water or sterile solution to irrigation Solution Direct the amount of irrigation solution or water into the eye as gently as possible the figure on this slide demonstrates four ways to irrigate the eye you could use a nasal canula you could do the shower a bottle or a basin okay so chemical burns you may have to force the lids open flush from the inner to the outside corner if the burn was caused by a an alkaloid or a strong acid irrigate continuously for at least 20 minutes after irrigation apply clean dry dressing and cover the eye and transport when it comes to Thermal burs during a fire the eyes will close to protect them from heat however eyelids are frequently burned and require Specialized Care cover both eyes with a sterile dressing U moistened with sterile saline then you could have light burns so infrared Rays uh Eclipse light and laser beams can cause significant damage to the sensory cells of the eye retinal injuries caused by exposure to extreme bright light are generally not painful but may result in permanent damage superficial Burns of the eye can result in Al from ultraviolet Rays from an arc welding light light from prolonged exposure to a sunlamp or reflected light from a bright snow covered area it may be painful at first but they may become painful within 3 or 4 hours later so severe conju titis usually develops with red swelling and excessive tear production cover each eye with a sterile moist pad and an Eye shield lacerations and these require very careful repair to restore appearance and function if there is a laceration of the globe itself apply no pressure to the eye gently apply a moist sterile dressing to prevent drying and cover the injure with a protective metal shield cup or sterile dressing to prevent drying and apply a soft dressing to both eyes on rare occasions the eyeball may be dislodged from the socket do not attempt to reposition it cover the eye and stabilize it with moist sterile dressing cover both eyes to prevent further injury because of sympathetic movement have the patient lipine to prevent loss of fluid from the eye and then there's blunt trauma to the eye okay so you could have an orbit fracture or a blowout fracture bone fragments can entrap some of the muscles that control the eye movement causing double vision protect the injured eye with a metal shield and cover the eye to minimize movement with a um on another on the other injured side okay so eye injuries following a head injury so there's signs and symptoms of a possible head injury and these could be when one pupil is larger than the other or the eyes are not moving together or pointing in different directions failure of the eyes to follow movement of your fingers is um if it's if you instruct them to do that and they cannot do that so bleeding under the conjunctiva protrusion or bulging of an eye management what you want to do is keep the eyelids closed and cover the lids with moist gauze or hold them closed with clear tape then you could have blast injuries and so signs and symptoms of blast injuries rain from Rage from severe pain and loss of vision to worn objects within the globe management of injuries to the eye depends on the severity of the injury and then there's contact lenses or artificial eyes in general do not attempt to remove them except for chemical um Burns um to remove hard contact lenses use a small cup um suction cup and these are specially made for those contact lenses okay to remove soft ones place one or two drops of Sal in the eye you could gently pinch the lens between your glove thumb and index finger okay place the lens in a container with some steril saline solution and advise the hospital if the patient is wearing contact lenses care for the an artificial eye as you would for a normal one the figure on this slide it'll show you how to remove hard contact lenses and soft contact lenses okay next we're going to talk about injuries to the nose and nose bleeds which are um epistases are a common problem okay and one of the most common causes is digital trauma it's characterized into anterior and posterior epistasis and anterior nose bleed usually originally from the area of the septum and bleed fairly slowly posterior nose bleeds are usually more severe and often cause blood to drain into the back of the patient's throat blunt trauma to the nose may be associated with fractures and soft tissue injuries of the face head injuries and injuries to the cervical spine so you want to assess the nose structures for injury this slide shows um the two Chambers which are divided by that septum patients with severe nasal injury may also have that cervical spine injury and cerebral spinal fluid so CSF May Escape down through the nose following the fracture to the base of the skull control bleeding by applying sterile dressing if the patient is bleeding heavily it can be a result of significant trauma so for a non-trauma patient who's bleeding from the nose Pace the patient place the patient in the sitting position leaning forward and pinch the nostrils together now we're going to talk about injuries to the ear okay so these are divided into three parts external middle and inner and the figure on the slide shows the structures of the inner ear ears are often injured but they do not usually bleed very much so if local pressure does not control the bleeding apply a roller dressing in case of a severe um ear evulsion wrap the evulse part in a moist sterile dressing and place it in the plastic bag labeled with the patient's name a tanic membrane rupture sudden changes in pressure create a blast wave can cause a rupture impatients will report severe pain difficulty hearing or ringing in that affected ear it may be caused by insertion of objects too far into the ear so Children Place foreign objects into that auditory canal all foreign objects or bodies should not be removed um by you they need to be removed by a physician so do not try to manipulate the foreign body because you could put push it back further into the ear clear fluid coming from the ear May indicate a skull fracture and next we're going to talk about facial fractures and so in addition to external Hemorrhage there's a danger of blood clots lodging in that upper Airway and causing obstruction plastic surgeons can repair the damage to the face and mouth if the injuries are treated within 7 to 10 days so remove and save loose teeth or bone fragments from the mouth because it is often possible to replant them remove any loose dentures and dental bridges to protect against an aoy obstruction another source of aoy obstruction is swelling and which can be extreme within the first 24 hours after injury then there's Dental injuries it can be traumatic to the patient the injury may be traumatic and the patient's permanent teeth may be lost bleeding will occur within a two and when it's violently displaced from the socket so apply direct pressure to stop the bleeding perform suctioning if needed and cracked or loose teeth are possible Airway obstructions so save and transport that tooth um handling it by the crown rather than the root and place the tooth in a tooth storage solution hold milk or a sterile saline then injuries to the cheek so if you're unable to control bleeding and it compromises the airway consider removing the object provide direct pressure on both sides inside and out okay of the cheek the amount of bandaging should not be so overwhelming though that it udes the mouth and makes it difficult to breathe and then with injuries to the neck the neck contains many structures and it's very vulnerable to injury by Blood trauma any crushing injury of the upper part of the neck is likely to involve the Linex or trachea fractures of the upper Airway and Lal cartilage so signs and symptoms include include loss of voice difficulty swallowing severe and sometimes fatal Airway obstruction and leakage of air into soft tissues of the neck this is called subcutaneous osma management of this so maintain the airway and immediately transport you want to consider Advanced life support early and also consider spinal motion restriction when it comes to penetrating trauma in that area you can uh it can cause profuse bleeding from lacerations of great vessels in the neck injuries to the crowded and jugular veins in the neck cause the body to bleed out if a vein has been punctured an air embolism may result the air the esophagus and the spinal cord can be damaged by a penetrating injury direct pressure over the bleeding sight will control most of the neck bleeding follow the steps and skild 28-3 and assess for signs of shock immediate spinal motion restriction if indicated and apply high flow oxygen when it comes to laryngeal injuries and this is blunt force trauma it can cause the Linex to be injured um it's usually an unrestrained driver who strikes the steering wheel or possibly maybe a snowmobile Rider or an off Bo off-road bike rider that strikes a closed line or a fixed wire the LX can become crushed against the cervical spine resulting in soft tissue injury fractures or separation of the fascia these strangulation injuries can also be found in either intentional or unintentional hangings anytime there is suspected injury to the Linex suspect possible cervical spine injury penetrating or impelled objects in leics should not be removed unless they interfere with CPR stabilize all impaled objects if they are not obstructing the airway significant injuries to the LX pose an immediate risk of Airway compromise and of course signs and symptoms of aaronic injury include respiratory distress hor horseness pain difficulty swallowing cyanosis pale skin sputum in the wound um subcutaneous empyema bruising on the neck hematoma and bleeding so you want to provide oxygen and ventilate and then sepine but avoid the use of a rigid collar okay okay so that includes chapter 28 the face and neck injuries lecture next we're just going to go through the review questions to see what we've learned okay so which of the following statements regarding the app Adam's apple is false which one is it inferior to the CID is it formed by the thyroid is it the uppermost part of the lonex or is it more prominent in men and women all right and so it is a it is inferior to the CID cartilage that is incorrect okay the ey is also called do you guys remember and that's the eyeball D so it's D when a person is looking at an object of close the pupil should do you guys remember so the pupil should allow the light to move to the back of the eye and it is going to constrict when caring for a chemical burn to the eye the empty should right so when we're when we're um doing flushing the eye we need to flush it away from the uninjured eye and so that's what it was it was to prevent contamination of the opposite eye okay so number five which of the following signs is least indicative of a head injury or indicative of a head injury and we know it is pupilary constriction to the bright light because that's what it's supposed to do right pupils are supposed to constrict okay and what do we think is the purpose of the station tube what is it supposed to do and it's the middle air and it is supposed to equalize pressure in the middle layer when external pressure changes when caring for a patient with facial trauma the EMT should be most concerned with well I'm going to say Airway compromise that is big big deal no Airway no patient the presence of subcutaneous empyema following trauma to the face and throat is most Su suggested of so crushing injuries of that uh Linex okay so tracheal injuries and that is because air is escaping just right underneath this right under the skin right so subcutaneous EMP AA formed number nine a 21-year-old male has a large laceration to his neck when you assess him you knowe bright red blood is spurting so we know that that is an arterial bleed from the left side of the neck what should you do with an arterial bleed all right so here we go you're going to place your GL hand over it first and I'm sure you're going to put some type of dressing bandage on it which of the following mechanisms of injury would most likely cause a crushing injury to the lonx or trachea all right so GSW car crash patient whose head hits the windshield and right away you could see the attempted suicide by a hanging okay okay so thank you for joining us today for chapter 28 face and neck injuries and if you like this uh lecture go ahead and subscribe to the channel because we're going to complete the whole book thank you