Understanding Face and Neck Injuries

Chapter 28. Face and Neck Injuries. Introduction. The face and neck are particularly vulnerable to injury because of their relatively unprotected positions on the body. Soft tissue injuries and fractures to the bones of the face are common and vary greatly in severity. Some are potentially life-threatening, and many leave disfiguring scars if not treated properly. Penetrating trauma to the neck may cause severe bleeding. An open injury may allow an air embolism to enter the circulatory system. If a hematoma forms in this area, it may stop or slow blood flow to the brain, causing a stroke. Appropriate pre-hospital and hospital care can sometimes allow a seemingly devastating injury to result in a surprisingly good outcome. As an emergency medical technician, your objectives when treating a patient with face and neck injuries include preventing further injury, particularly to the cervical spine. managing any acute airway problems and controlling bleeding this chapter first reviews the anatomy of the head and neck and then examines the factors that can produce upper airway obstruction a discussion follows that includes emergency medical care of soft tissue wounds of the face nose and ear facial fractures penetrating injuries of the neck and dental injuries anatomy and physiology the head is divided into two parts the cranium and the face. The cranium, or skull, contains the brain, which connects to the spinal cord through the forearm and magnum, a large opening at the base of the skull. The most posterior portion of the cranium is called the occiput. On each side of the cranium, the lateral portions are called the temples or temporal regions. Between the temporal regions and the occiput lie the parietal regions. The forehead is called the frontal region. just anterior to the ear in the temporal region you can feel the pulse of the superficial temporal artery the face is composed of the eyes ears nose mouth and cheeks six bones the nasal bone the two maxillae upper jaw bones the two zygomas cheekbones and the mandible jawbone are the major bones of the face the orbit of the eye is composed of the lower edge of the frontal bone of the skull The Zygoma the maxilla and the nasal bone the bony orbit protects the eye from injury by viewing the face from the side you can see the eyeball recessed in the orbit only the proximal third of the nose the bridge is formed by bone the remaining two-thirds are composed of cartilage the exposed portion of the ear is composed entirely of cartilage that is covered by skin the external visible part of the ear is called the pinna The ear lobes are the fleshy portions at the bottom of each ear. 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 inch, 2.5 centimeters, posterior to the external opening of the ear is a prominent bony mass at the base of the skull called the mastoid process. The mandible forms the jaw and chin. The jaw is the lower border of the mouth, where the tongue and 32 teeth are located. Motion of the mandible occurs at the temporomandibular joint, which lies just in front of the ear on either side of the face. Below the ear, and anterior to the mastoid process, the angle of the mandible is easily palpated. The neck also contains many important structures. It is supported by the cervical spine, or the first seven vertebrae in the spinal column. C1 through C7. The spinal cord exits from the foramen magnum, and lies within the spinal canal formed by the vertebrae. The upper part of the esophagus, and the trachea lie in the midline of the neck. The carotid arteries are found on either side of the trachea, along with the jugular veins, and several nerves. Several useful landmarks can be palpated and seen in the neck. The most obvious is the firm prominence in the center of the anterior surface. commonly known as the Adam's apple. Specifically, this prominence is the upper part of the larynx, formed by the thyroid cartilage. It is more prominent in men than in women. The other portion of the larynx is the cricoid cartilage, a firm ridge of cartilage, the only complete circular cartilage structure of the trachea, below the thyroid cartilage, which is somewhat more difficult to palpate. Between the thyroid cartilage, and the cricoid cartilage in the midline of the neck is a soft depression, the cricothyroid membrane. This is a thin sheet of connective tissue, fascia, that joins the two cartilages. The cricothyroid membrane is covered at this point only by skin. Below the larynx, several additional firm ridges are palpable in the anterior midline. These ridges are the cartilage rings of the trachea. The trachea connects the oropharynx and the larynx with the main air passages of the lungs, the bronchi. On either side of the lower larynx, and the upper trachea lies the thyroid gland. Unless it is enlarged, this gland is usually not palpable. Pulsations of the carotid arteries are easily palpable in a groove approximately 0.5 inch, 13 millimeters, lateral to the larynx. Lying immediately adjacent to these arteries, but not palpable, are the internal jugular veins, and several important nerves. Lateral to these vessels and nerves lie the sternocleidomastoid muscles. These muscles 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 they allow movement of the head a series of bony prominences like posteriorly in the midline at the neck they are the spines of the cervical vertebrae the lower cervical spines are more prominent than the upper ones they are more easily palpable when the neck is inflection at the base of the neck posteriorly the most prominent spine is the seventh cervical vertebra The eye. The eye is globe shaped. approximately 1 inch 2.5 centimeters in diameter and located within a bony socket in the skull called the orbit figure 28-5 the orbit is composed of the adjacent bones of the face and skull the orbit forms the base of the floor of the cranial cavity and directly above it are the frontal lobes of the brain in the adult more than 80% of the eyeball is protected within this bony orbit between and below the orbits of the nasal bone. and the sinuses, respectively. Therefore, any severe injury to the face or head can potentially damage the eyeball or the muscles attached to the eyeball that cause the eye to move. The eyeball, or globe, keeps its global shape as a result of the pressure of the fluid contained within its two chambers. The clear, jelly-like fluid near the back of the eye is called the vitreous humor. In front of the lens is a clear fluid called the aqueous humor, named for its watery appearance. In Latin, aqua means water. In penetrating injuries of the eye, aqueous humor can leak out, but with time, and appropriate medical treatment, the body can make more. The inner surface of the eyelids, and the exposed surface of the eye itself, which are covered by a delicate membrane, the conjunctiva, are kept moist by fluid produced by the lacrimal glands, often called tear glands. Humans blink unconsciously many times per minute. This action sweeps fluid from the lacrimal glands over the surface of the eye, cleaning it. The tears drain on the inner side of the eye through to lacrimal tear, ducts into the nasal cavity. This is why people sometimes need to blow their nose when they cry. The white of the eye, called the sclera, extends over the surface of the globe. This extremely tough, fibrous tissue helps maintain the eye's globular shape, and protects the more delicate inner structures. On the front of the eye, the sclera is replaced by a clear, transparent membrane called the cornea, which allows light to enter the eye. A circular muscle lies behind the cornea with an opening in its center. Like the shutter in a camera, this muscle adjusts the size of the opening to regulate the amount of light that enters the eye. This circular muscle, and surrounding tissue are called the iris. The iris is pigmented, giving the eye its characteristic brown, green. or blue color. The opening in the center of the iris, which allows light to move to the back of the eye, is called the pupil. Normally, the pupil appears black. Like the opening in a camera, the pupil becomes smaller in bright light and larger in dim light. The pupil also becomes smaller and larger when the person is looking at objects near at hand and farther away. These adjustments occur almost instantaneously. Normally, the pupils in both eyes are equal in size. Some people are born with pupils that are not equal, an isochoria, however, particularly in unconscious patients, an equal pupil size may indicate serious injury or illness of the brain or eye. Behind the iris is the lens. Like the lens of a camera, this lens focuses images on the light-sensitive area at the back of the globe, called the retina. Within the retina are numerous nerve endings that respond to light. by transmitting nerve impulses through the optic nerve to the brain. In the brain, the impulses are interpreted as vision. The retina is nourished by a layer of blood vessels between it and the sclera at the back of the globe. This layer is called the choroid. If, as sometimes happens, the retina detaches from the underlying choroid and sclera, the nerve endings are not nourished, and the patient experiences blindness. This may be partial blindness, depending on how much of the retina is separated. This condition is called retinal detachment. Injuries of the face and neck. 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. Bleeding from facial injuries can be heavy, producing large blood clots in the upper airway. These clots can lead to complete obstruction, particularly in a patient who is not fully conscious. In particular, Direct injuries to the nose and mouth, the larynx, or the trachea are often the source of significant bleeding and or respiratory compromise. You may need to suction the airway if you are unable to control the bleeding. In addition, the injuries may cause loosened teeth or dentures to become dislodged into the throat, where they may be swallowed or aspirated. The swelling that often accompanies direct and indirect injury to the soft tissues in these areas can also contribute to airway obstruction. the airway may also be affected when the patient's head is turned to the side as often is done when the patient has an altered level of consciousness or is unconscious other factors that interfere with normal respirations include possible injuries to the brain and or cervical spine that may be associated with facial injuries if the great vessels in the neck are injured significant bleeding and pressure on the upper airway are common these can result in airway obstruction as well Depending on the mechanism of injury, there may be a cervical spine injury. If there is significant impact to the face, suspect accompanying cervical spine injury, and follow your agency's protocol for spinal motion restriction. Soft tissue injuries. Soft tissue injuries of the face and neck are common. Because the face and neck are extremely vascular, swelling from soft tissue injuries in this area may be more severe than in other injured parts of the body. The skin and underlying tissues in these areas have a rich blood supply, so bleeding from penetrating injuries may be heavy. Even minor soft tissue wounds of the face and neck may bleed profusely. A blunt injury that does not break the skin may cause a break in a blood vessel wall, causing blood to collect under the skin. This is called a hematoma. In some situations, a flap of skin is peeled back, or avulsed, from the underlying muscle and fascia. dental injuries mandible lower jaw fractures are relatively common because of the prominence of the mandible itself these fractures are second only to nasal fractures in frequency most of these fractures are the result of vehicle collisions and assaults if your patient has a mandibular fracture then consider the major force necessary to cause that fracture there is a strong probability your patient will have additional facial trauma and or cervical injuries Signs of a mandibular fracture include a misalignment of the teeth, numbness of the chin, and an inability to open the mouth. The patient will most likely have swelling, bruising, and loosened or missing teeth. Maxillary fractures are predominantly found after blunt force, high energy impacts such as an unrestrained driver striking the steering wheel, a fall, or a direct blow from an object such as a pipe. The signs include massive facial swelling. instability of the facial bones, and misalignment of the teeth. Fractured and avulsed teeth are common following facial trauma. Dental injuries may be associated with motor vehicle crashes or an assault. Always assess the patient's mouth following a facial injury, especially if your examination reveals fractured or avulsed teeth. Teeth fragments, or even whole teeth, can become an airway obstruction, and should be removed from the patient's mouth immediately. Patient Assessment Scene Size Up As you arrive on the scene, observe for hazards and threats to the safety of the crew, bystanders, and the patient. Assess the effect of hazards on patient care, and address those hazards. Assess for the potential for violence, and for environmental hazards. Patients who are conscious and supine and have oral or facial bleeding may protect their airway by coughing, projecting the blood at you. Therefore, Standard precautions require eye protection and a face mask. Also, put several pairs of gloves in your pocket for easy access in the event your gloves tear or there are multiple patients with bleeding. If your response is to a motor vehicle crash, you may be confronted with more than one patient in a vehicle. Determine the number of patients, and consider whether you will need additional or specialized resources on the scene. As you observe the scene, look for indicators of the mechanism of injury. This assessment helps you develop an early index of suspicion for underlying injuries in the patient who has sustained a significant mechanism of injury. As you put together information from dispatch and your observations of the scene, consider how the mechanism of injury produced the injuries expected. Common mechanism of injuries for face and neck injuries include motor vehicle collisions, sports participation, falls, penetrating trauma, and blunt trauma. In motor vehicle collisions, the probability of injury increases if the vehicle rolled over or came to an abrupt stop when striking an immovable object, such as a tree. During sports participation, injuries can occur in a player without a helmet who was struck by a baseball or two players who sustained a helmet-to-helmet collision in football. Primary Assessment The primary assessment focuses on identifying and managing life-threatening concerns. Threats to Airway breathing or circulation must be treated immediately when there is obvious active life-threatening external hemorrhage it should be addressed before airway and breathing as you approach the patient look for important indicators to alert you to the seriousness of the patient's condition is the patient interacting with the environment or lying still making no sounds does the patient have any apparent life threats such as significant bleeding How is the patient's skin color? The general impression will help you develop an index of suspicion for serious injuries and determine your sense of urgency for medical intervention. Injuries to the face and throat, such as bleeding and significant swelling, may be obvious but may also be hidden under collars and hats. Because of the likelihood of respiratory distress with these injuries, they should be recognized as early as possible. As with any injury with life-threatening bleeding, Control the blood loss with direct pressure. Always consider the need for manual spinal stabilization and check for responsiveness using the awake and alert verbal stimuli pain unresponsive scale. Ensure that the patient has a clear and patent airway. If the patient is unresponsive or has a significantly altered level of consciousness, consider inserting a proper size oropharyngeal airway. The use of a nasopharyngeal airway is controversial. many believe that inserting a nasopharyngeal airway into the nares of a patient with facial or head trauma carries the risk of introducing the device into the cranial vault and brain tissue however recent research suggests this risk is extremely small as always be aware of and follow your local protocols quickly assess the pulse rate and quality determine the skin condition color and temperature and check the capillary refill time Significant bleeding is an immediate life threat. If the patient has obvious life-threatening bleeding, you must control it quickly. If the patient you are treating has an airway or a breathing problem or significant bleeding, you must consider quickly transporting the patient to the hospital for treatment or requesting advanced life support if that will result in faster access to someone who will be able to intubate the patient. stabilization and maintenance of airway and breathing and controlling bleeding can be difficult in patients with facial or neck injuries avoid delays in transport and consider advanced life support backup if the transport time is long a patient with signs and symptoms of internal bleeding must be transported quickly to the appropriate hospital for treatment by a physician internal bleeding in face and throat injuries may compromise blood flow to the brain Bleeding from major vessels of the throat can have a serious effect on the patient's airway. The condition of a patient with visible significant bleeding or signs of significant internal bleeding may quickly become unstable. Treatment is directed at quickly addressing life threats and providing rapid transport to the closest appropriate hospital. Signs such as tachycardia, tachypnea, low blood pressure, weak pulse, and cool, moist Pale skin are signs of hypoperfusion and imply the need for rapid transport. Note that because skin paleness can be difficult to detect in patients with dark skin, you may need to check for pale mucous membranes inside the inner lower eyelid or slow capillary refill. The patient who has a significant mechanism of injury but whose condition appears stable should also be transported promptly to the closest appropriate hospital. Remember that any significant blow to the face or throat should increase your suspicion of spinal or brain injury. Be alert to these signs, and reconsider your priority, and transport decision if they develop, even if the patient has no signs of hypoperfusion or other life-threatening injuries. If the patient has an injury involving the eye it should be considered potentially serious. Consider transporting a patient with serious, isolated eye injuries to an eye care specialty center depending on local protocol. Do not delay transport of a seriously injured patient, particularly one with significant bleeding, even if it is controlled, to take a patient's history or perform a secondary assessment. Further assessment can continue during transport. History taking. After the life threats have been managed during the primary assessment, investigate the chief complaint or history of present illness. Obtain a medical history, and be alert for injury-specific signs and symptoms, as well as any pertinent negatives such as no pain or no loss of sensation. Next, obtain a sample history from your patient. If the patient is not responsive. Attempt to obtain the sample history from friends or family members who may be present. In an unresponsive patient you will only be able to notice the signs of the patient's injuries. Any other information will need to be obtained by someone who is knowledgeable about the patient. Keep in mind that the information you obtain may or may not be accurate and may be incomplete. The person providing the information may not be able to give you the actual names of the patient's medications but might be able to provide some pertinent medical history and possibly known allergies. Secondary Assessment The secondary assessment is a comprehensive examination of the patient that is used to uncover injuries that may have been missed during the primary assessment. In some instances, such as when a patient is critically injured or a short transport time, you may not have time to conduct a secondary assessment. If there is significant trauma that likely affects multiple systems, start with an assessment of the entire body looking for DCAP-BTLS to be sure that you have found all life threats and injuries. When this is completed, perform a detailed examination of specific areas. However, do not delay transport to complete a thorough physical examination. In the responsive patient who has an isolated injury with a limited mechanism of injury, consider focusing your physical examination on the isolated injury, the patient's chief complaint, and the body region affected, which, in this case, is the face and throat. Ensure that control of bleeding is maintained and note the location of the injury. Inspect open wounds for any foreign matter, and stabilize impaled objects if they do not obstruct the airway. During the physical examination, use your eyes, and your hands. Your eyes will be looking for swelling, deformities of the bones, contusions, and discoloration, whereas your hands will be gently palpating the face, looking and feeling for any abnormalities such as deformity or tenderness. Ask yourself the following questions. 1. Do the facial bones seem to be in alignment? 2. Does the nasal bone seem to deviate from the midline? 3. Note any variations from the normal facial examination. Is there any facial drooping? 4. Does one eye appear to be lower than the other? If so, this is an indication of an orbital fracture. 5. Does the mandible appear to deviate toward one side or the other? If your patient is responsive, explain exactly what you are doing. and what you are looking for. Your discovery of what you consider to be an abnormality may actually be an old injury that the patient can tell you more about. Assess all underlying systems. This should include the neurologic system, including the brain, and major nerves, sensory organs, including the eyes and nose, the respiratory system, including the mouth, nose, sinuses, and airway, and the circulatory system. particularly focusing on the carotid arteries and jugular veins. When you are evaluating the eyes, start at the outer aspect of the eye and work your way in toward the pupils. Examine the eye for any obvious foreign matter. Your patient may relay this information to you, I have something in my eye. Visual acuity, or the clarity of the patient's vision in each eye, is considered the vital sign of the eye. Quickly assess the patient's visual acuity by gently covering one eye, and holding fingers up at arm's length in front of the open eye. Test for the ability to see fingers in both the injured and uninjured eyes and document your findings. Note any discoloration of the eye, bleeding in the iris area, or redness. Look for eye symmetry because asymmetry is a possible indication of a brain injury. Look at each pupil for equal size and reaction to light. If the pupils are not symmetric, ask the patient if he or she has undergone any previous eye surgeries or sustained any injuries. Previous surgery or injury, rather than brain injury, may be the root cause of the pupils not appearing the same. Cataract surgery can cause unequal pupils, but when you have a patient with a suspected head injury or ocular injury, anisocoria, unequal pupils in dim light, may be present. Determine whether the unequal pupils are caused by physiologic or pathologic issues. Use of over-the-counter eye drops can change pupil size, and certain asthma inhalers can have the same effect if inadvertently sprayed into the eye. Brain injury, nerve disease, glaucoma, and meningitis are all possible causes of unequal pupils. Does the patient have the ability to follow your finger from side to side as well as up and down? Can the patient read normal print? Does the patient report blurry vision in either eye? Is there a new sensitivity to light? Assess vital signs to obtain a baseline so that you can observe any changes a patient may display during treatment. A systolic blood pressure reading of less than 100 millimeters of mercury with a weak, rapid pulse and cool, moist skin that is pale or gray should alert you to the presence of hypoperfusion in a patient who may have significant bleeding. Remember, you must be concerned with visible bleeding, and unseen bleeding inside a body cavity. With facial and throat injuries, baseline information about the rate and quality of respirations and pulse is very important, as is monitoring throughout patient care. In addition to hands-on assessment, use monitoring devices to quantify your patient's oxygenation and circulatory status. Reassessment Repeat the primary assessment. Reassess vital signs, and the chief complaint. Continually reassess the adequacy of the patient's airway, breathing, and circulation. Recheck patient interventions. Are the treatments you provided for problems with airway, breathing, and circulation still effective? This is particularly important in patients with facial or neck injuries because of the ease with which injuries can affect associated systems, such as the respiratory, airway and breathing. circulatory and nervous systems the patient's condition should be reassessed at least every five minutes if you suspect possible spinal injury follow local protocols regarding spinal motion restriction precautions spinal injuries should be suspected any time there is significant trauma to the face or neck maintain an open airway be prepared to suction the patient and consider an or opharyngeal airway if the patient becomes unresponsive. Whenever you suspect significant bleeding, provide high-flow oxygen. Adequate oxygenation and airway maintenance are important for all patients with face and neck injuries. If needed, provide assisted ventilation using a bag-mask device with high-flow oxygen. Control any significant visible bleeding. If the patient has signs of hypoperfusion, treat the patient aggressively for shock, and provide rapid transport to the appropriate hospital. Do not delay transport of a seriously injured trauma patient to complete non-life-saving treatments in the field, such as splinting extremity fractures. Instead, complete these treatments en route to the hospital. If there is no cervical spine injury suspected, the patient may be more comfortable in the sitting position during transport. In your documentation, describe the mechanism of injury and the position in which you found the patient when you arrived at the scene. Document difficulties that occurred when removing the patient from the vehicle, for example, prolonged extrication. In patients with severe external bleeding, it is important to recognize, estimate, and report the amount of blood loss that has occurred, and how rapidly or how much time has passed since the bleeding started. This can be a challenge for you, especially if the patient is on a surface that is wet or absorbs fluids or if the environment is dark. Inform the hospital personnel about all injuries involving the patient's head and neck. Emergency Medical Care The emergency care of soft tissue injuries to the face and neck is the same as treatment of soft tissue injuries elsewhere on the body. You should assess the X-airway, breathing, and circulations and care for any life threats first. Remember also to follow standard precautions in all cases. In the absence of life-threatening bleeding, your first step is to open and clear the airway. Securing and maintaining a patent airway is paramount. Remember that blood draining into the throat can produce vomiting and airway obstruction, therefore, the patient may need frequent suctioning. Avoid moving the neck if you suspect that the patient may have sustained a cervical spine injury. Use the jaw thrust maneuver to open the patient's airway, and then suction the mouth. Once spinal motion restriction is achieved, you can tilt the patient or backboard to one side to allow any blood or vomitus to drain out of the mouth rather than pool in the pharynx. and obstruct the airway control bleeding by applying direct manual pressure with a dry sterile dressing use roller gauze wrapped around the circumference of the head to hold a pressure dressing in place do not apply excessive pressure if there is a possibility of an underlying skull fracture when an injury exposes the brain I or other structures cover the exposed parts with a moist sterile dressing to protect them from further damage For injuries in which the skin is not broken, apply ice or a cold pack locally to help control the swelling of bruised tissues. For soft tissue injuries around the mouth, always check for bleeding inside the mouth. Broken teeth and lacerations to the tongue may cause profuse bleeding and obstruction of the upper airway. Often, the patient will swallow the blood from lacerations inside the mouth, so the hemorrhage may not be apparent. You should also inspect the inside of the mouth for bleeding, and it and injuries in patients who have sustained facial trauma. Remember that patients who swallow significant amounts of blood are prone to vomiting. Often, physicians will be able to graft a piece of a vulva's skin back into the appropriate position. For this reason, if you find portions of a vulva's skin that have become separated, wrap them in a sterile dressing, place them in a plastic bag, and keep them cool. Never place tissue directly on ice because freezing will cause further injury to the tissue and make it unusable. Deliver the bag labeled with the patient's name to the emergency department along with the patient. In many avulsion injuries, the skin will still be attached in a loose flap. Place the flap in a position that is as close to normal as possible and hold it in place with a dry, sterile dressing. These steps will help to increase the patient's chances of having his or her normal appearance restored. Emergency medical care for specific injuries. Injuries of the eyes. Eye injuries are common, particularly in sports. An eye injury can produce severe, lifelong complications, including blindness. Proper emergency treatment will minimize pain, and may very well help to prevent a permanent loss of vision. In a normal, uninjured eye. the entire circle of the iris is visible the pupils are round usually equal in size and react equally when exposed to light both eyes move together in the same direction when following your moving finger after an injury pupil reaction or shape and eye movement are often disturbed any of these conditions should cause you to suspect an injury of the globe or its associated tissues Remember, though, In patients who are unconscious or who have a significantly altered mental status, abnormal pupil reactions sometimes are a sign of brain injury rather than eye injury. Treatment starts with a thorough examination to determine the extent and nature of any damage. Perform your examination using standard precautions, taking care to avoid aggravating any problems. You are looking for specific abnormalities or conditions that may suggest the nature of the injury. For example, blunt or penetrating injuries can produce swollen or lacerated eyelids. Bleeding soon after irritation or injury can result in a bright red conjunctiva. A damaged cornea quickly loses its smooth, wet appearance. Foreign objects. Large objects are prevented from penetrating the eye by the protective orbit that surrounds it. However, Moderately sized and smaller foreign objects of many different types can enter the eye and cause significant damage. Even a tiny foreign object, such as a grain of sand lying on the surface of the conjunctiva, may produce severe irritation. The conjunctiva becomes inflamed and red, a condition known as conjunctivitis, almost immediately, and the eye begins to produce tears to flush out the object. Irritation of the cornea or conjunctiva causes intense pain. The patient may have difficulty keeping the eyelids open, because the irritation is further aggravated by bright light. If a small foreign object is lying on the surface of the patient's eye, you should use a normal saline solution to gently irrigate the eye irrigation with a sterile saline solution will frequently flush away loose small particles if a small bulb syringe is available you can use this or nasal airway or cannula to direct the saline into the affected eye always flush from the nose side of the eye toward the outside to avoid flushing material into the other eye After it has been flushed away. foreign body will often leave a small abrasion on the surface of the conjunctiva for this reason the patient will report irritation even when the particle itself is gone it is always a good idea to transport the patient to the hospital for further assessment to ensure appropriate medical care to the affected eye gentle irrigation usually will not wash out foreign bodies that are stuck to the cornea or lying under the upper eyelid to examine the undersurface of the upper eyelid. pull the lid upward and forward if you spot a foreign object on the surface of the eyelid you may be able to remove it with a moist sterile cotton tipped applicator skill drill 28 dash one never attempt to remove a foreign body that is stuck to the cornea one tell the patient to look down while you grasp the lashes of the upper eyelid with your thumb and index finger gently pull the eyelid away from the eyeball step 1 2. Gently place a cotton tipped applicator horizontally along the center of the outer surface of the upper eyelid step 2 3 Pull the eyelid forward and up which causes it to roll or fold back over the applicator Exposing the under surface of the eyelid step 3 4 if you see a foreign object on the surface of the eyelid Gently remove it with a moistened sterile cotton tipped applicator step 4 Skill Drill 28-1 Removing a Foreign Object from Under the Upper Eyelid. Step 1. Have the patient look down, grasp the upper lashes, and gently pull the lid away from the eye. Step 2. Place a cotton-tipped applicator on the outer surface of the upper lid. Step 3. Pull the lid forward and up, folding it back over the applicator. Step 4. Gently remove the foreign object from the eyelid with a moistened, sterile cotton-tipped applicator. Foreign bodies ranging in size from a pencil to a sliver of metal may be impaled in the eye. These objects must be removed by a physician. Your care involves stabilizing the object and preparing the patient for transport to definitive care. The greater the length of the foreign object you can see sticking out of the eye, the more important stabilization becomes in avoiding further damage. Bandage the object in place to support it. Cover the eye with a moist, sterile dressing, and then surround the object with an eye shield or donut-shaped collar made from roller gauze or a small gauze pack. Follow the steps in skill drill 28-2. 1. Begin to prepare the donut ring by wrapping a 2-inch, 5-centimeter, gauze roll circumferentially around your fingers and thumb enough times to make a thick dressing layer. You can adjust the inner diameter of what will become the ring by spreading your fingers or squeezing them together. Step 1. 2. Remove the gauze from your hand and wrap the remainder of the gauze roll radially around the ring that you have created. Step 2. 3. Work your way around the ring until you have wrapped all the way around it and finish the donut. Step 3. 4. Carefully place the ring over the eye and impaled object without bumping the object. you can then stabilize the object with a cup or other protective barrier over the object and secure the object with the roller bandage surrounding their head bandage both the injured and uninjured eyes to minimize eye movement and prevent further damage to the globe because when one eye moves so does the other transport to an appropriate medical facility for treatment step 4 skill drill 28 dash to stabilizing a foreign object impaled in the I Step 1. To prepare a donut ring, wrap a 2 inch, 5 centimeter, gauze roll around your fingers and thumb 7 or 8 times. Adjust the diameter by spreading your fingers or squeezing them together. Step 2. Remove the gauze from your hand, and wrap the remainder of the gauze roll radially around the ring that you have created. Step 3. Work around the entire ring to form a donut. Step 4. Place the dressing over the eye with a protective barrier to hold the impaled object in place, and then secure it with a roller bandage. Sometimes, a variety of types of large and small foreign bodies, particularly small metal fragments, become completely embedded within the eye itself. The patient may not even be aware of the cause of the problem. Suspect such an injury when the history includes metal work, such as hammering, exposure to splinters, grinding, vigorous filing, and when there are other signs of ocular injury. When you see or suspect an impaled object in the eye, place an eye shield over the affected eye, and then bandage both eyes with soft bulky dressings to prevent further injury to the affected I your bandage should be loose enough to hold the eyelid closed but not cause pressure on the I itself using this technique prevents sympathetic motion the movement of one eye causing both eyes to move which may cause additional damage to the injured I this type of injury must be handled by an ophthalmologist on an urgent basis radiographs and special equipment may be required to find the foreign body Burns of the eye. Chemicals, heat, and light rays all can burn the delicate tissues, such as the cornea, often causing permanent damage. Your role is to stop the burn and prevent further damage. Chemical burns. Chemical burns, usually caused by acid or alkaline solutions, require immediate emergency care. This consists of flushing the eye with water or a sterile saline irrigation solution. If sterile saline is not available, you can use any clean water. The idea is to direct the greatest amount of irrigating solution or water into the eye as gently as possible. Because opening the eye spontaneously may cause the patient pain, you may have to force the lids open to irrigate the eye adequately. Ideally, you will use a bulb or irrigation syringe, a nasal cannula, or some other device that will allow you to control the flow. In some circumstances, You may have to resort to pouring water into the eye by holding the patient's head under a gently running faucet. You can even have the patient immerse his or her face in a large pan or basin of water, and rapidly blink the affected eyelid. If only one eye is affected, care must be taken to avoid contaminated water from getting into the unaffected eye. Be sure to flush from the inner corner of the affected eye toward the outside corner. never flush from the outside corner as this may cause the substance to contaminate the unaffected I if the burn was caused by an alkali or a strong acid irrigate the I continuously for 20 minutes follow local protocols or consult with medical control as to whether to try to irrigate while transporting or to stay unseen until flushing is complete strong acids and all alkaline solutions can penetrate deeply requiring a prolonged flush Again. Always take care to protect the uninjured eye and prevent irrigation fluid from running into it. After you have completed irrigation, apply a clean, dry dressing to cover the eye and transport the patient promptly to the hospital for further care. If the irrigation can be carried out satisfactorily in the ambulance, it should be done during transport to save time. Thermal burns. When a patient is burned on the face during a fire, the eyes usually close rapidly because of the heat this reaction is a natural reflex to protect the eye from further injury however the eyelids remain exposed and are frequently burned burns of the eyelids require highly specialized care it is best to provide prompt transport for these patients without further examination first however you should cover both eyes with a sterile dressing moistened with sterile saline you may apply shields over the dressing consider transporting these patients to a designated burn center depending on local protocol or medical control recommendations light burns infrared rays the light from a solar eclipse if the patient has looked directly at the Sun and laser burns all can cause significant damage to the sensory cells of the eye when rays of light become focused on the retina Retinal injuries that are caused by exposure to extremely bright light are generally not painful but may result in permanent damage to vision. Superficial burns of the eye can result from ultraviolet rays from an arc welding unit, light from prolonged exposure to a sun lamp, or reflected light from a bright, snow-covered area, snow blindness. this kind of burn often is not painful at first but may become so three to five hours later when the damage cornea responds to the injury severe conjunctivitis usually develops with redness swelling and excessive tear production you can ease the pain from these corneal burns by covering each eye with a sterile moist pad and an eye shield have the patient lie down during transport to the hospital and protect him or her from further exposure to bright light the patient should be examined by a physician as soon as possible lacerations lacerations of the eyelids require careful repair to restore appearance and function bleeding may be heavy but it usually can be controlled by gentle manual pressure if there is a laceration of the globe itself apply no pressure to the I compression can interfere with the blood supply to the back of the eye and result in loss of vision from damage to the retina Furthermore, pressure may squeeze the vitreous humor, iris, lens, or even the retina out of the eye and cause irreparable damage or blindness. Follow these three important guidelines in treating penetrating injuries of the eye. 1. Never exert pressure on or manipulate the injured eye, globe, in any way. 2. If part of the eyeball is exposed, gently apply a moist, sterile dressing to prevent drying. 3. Cover the injured eye with a protective metal eye shield, cup, or sterile dressing. Apply soft dressings to both eyes, and provide prompt transport to the hospital. On rare occasions following a serious injury, the eyeball may be displaced out of its socket. Do not attempt to reposition it. Simply cover the eye, and stabilize it with a moist, sterile dressing. remember to cover both eyes to prevent further injury because of sympathetic movement have the patient lie in a supine position en route to the hospital to prevent further loss of fluid from the eye blunt trauma blunt trauma can cause many serious eye injuries these range from the ordinary black eye a result of bleeding into the tissue around the orbit to a severely damaged globe you may see an injury called hyphema or bleeding into the anterior chamber of the eye that obscures part or all of the iris. This injury is common in blunt trauma and may seriously impair vision. 25% of hyphemas are associated with underlying globe injuries, a serious injury to the eye. Cover the eye to protect it from further injury, and provide transportation to the hospital for further medical evaluation. Blunt trauma can also cause a fracture of the orbit. specifically of the bones that form its floor and support the globe. When associated with displacement, this injury is sometimes referred to as a blowout fracture. The fragments of fractured bone can entrap some of the muscles that control eye movement, causing double vision. Any patient who reports pain, double vision, or decreased vision following a blunt injury about the eye should be placed on a stretcher, and promptly transported to the emergency department. Protect the eye from further injury with a metal shield cover the other eye to minimize movement on the injured side Another possible result of blunt eye injury is retinal detachment This injury is often seen in sports especially boxing It is painless but produces flashing lights Specs or floaters in the field of vision and a cloud or shade over the patient's vision Because the retina is separated from the nourishing choroid This injury requires prompt medical attention to preserve vision in the eye. Eye injuries following head injury. Abnormalities in the appearance or function of the eyes often occur following a brain injury. Any of the following eye findings should alert you to the possibility of a head injury. One pupil larger than the other in an unconscious patient. The eyes not moving together or pointing in different directions. failure of the eyes to follow the movement of your finger as instructed bleeding under the conjunctiva which obscures the sclera white portion of the eye protrusion or bulging of one eye record any of these observations along with the time that you make them for an unconscious patient remember to keep the eyelids closed drying of the ocular tissue can cause permanent injury and may result in blindness cover the lids with moist gauze or hold them closed with clear tape normal tears will then keep the tissues moist blast injuries the signs and symptoms a blast injuries range from severe pain and loss of vision to foreign bodies within the globe Before responding to patients after the blast, first ensure that the scene is safe. Management of blast injuries to the eye depends on the severity of the injury. If there is a foreign body within the globe, do not attempt to remove it. Use a clean cup or similar item to protect the area. If only one eye is injured, follow local protocols, which may include covering the other eye to eliminate sympathetic motion. Patients with a sudden loss or decrease of vision will need to be verbally instructed on what actions are taking place around them. If the patient has severe swelling or a hematoma to the eyelid, do not attempt to force the eyelid open to examine the eye because this increases the pressure already present within the globe. Contact lenses and artificial eyes. Small, hard contact lenses usually are tinted, making them relatively easy to see. Large Soft contact lenses are clear and can be very difficult to see. In general, you should not attempt to remove either type of lens from a patient's eye. You should never attempt to remove a lens from an eye that has been, or may have been, injured because manipulating the lens can aggravate the problem. The only time that contact lenses should be removed immediately in the field is in the case of a chemical burn of the eye. In this situation, the lens can trap the chemical and make irrigation difficult. If it is necessary to remove a hard contact lens, use a small suction cup, moistening the end with saline. To remove soft lenses, place one to two drops of saline in the eye. Gently pinch the lens between your gloved thumb and index finger, and lift it off the surface of the eye. Place the contact lens in a container filled with sterile saline solution to prevent damage to the contact lens. Always advise the emergency department staff if a patient is wearing contact lenses. Occasionally, you may find yourself caring for a patient who is wearing an eye prosthesis, an artificial eye. Many people are surprised to find that it can be difficult to distinguish a prosthesis from a natural eye. You should suspect that an eye is artificial when it does not respond to light, move in concert with the opposite eye, or appear quite the same as the opposite eye. If you think that a patient may have an artificial eye but you are not sure, go ahead and ask about it. Although no harm will be done if you care for an artificial eye as you would a normal one, you need to clearly understand the patient's eye function. Injuries of the nose, nosebleeds, epistaxis, are a common problem that can occur spontaneously or from trauma. One of the most common causes of nosebleeds is digital trauma, picking the nose with a finger. Nosebleeds are further classified in anterior and posterior epistaxis. Anterior nosebleeds usually originate from the area of the septum and bleed slowly. They are usually self-limited and resolve quickly. Posterior nosebleeds are usually more severe and often cause the patient to swallow blood, which can lead to nausea and vomiting. Trauma to the face and skull that results in a basilar skull fracture can cause the posterior wall of the nasal cavity to become unstable. Due to this risk, attempting to place a nasopharyngeal airway in a patient with significant facial trauma, or a suspected basilar skull fracture, is controversial. Follow local protocols regarding insertion of a nasopharyngeal airway in a patient with head or facial trauma. When you are assessing injuries involving the nose, it helps to picture the inside of the nose itself the nasal cavity is divided into two sections or chambers by the nasal septum which is made of cartilage within each nasal chamber there are layers of bone called the turbinates which are covered with a moist lining both chambers have a superior turbinate a middle turbinate and an inferior turbinate as a person breathes air moves through the nasal chambers and is humidified as it passes over the turbanets Directly above the nose are the frontal sinuses and, on either side, the orbit of the eye. In patients with severe nasal injury, there may also be injury to the cervical spine. Keep in mind that cerebral spinal fluid may escape down through the nose, or ears, following a fracture at the base of the skull. If blood or drainage contains cerebral spinal fluid, a characteristic staining of the dressing will occur. This can be seen by using a piece of gauze to absorb blood that is flowing from the nose or ears. If cerebrospinal fluid is present, the blood will be surrounded by a lighter ring of fluid. This is often called the halo test. Do not delay care or transportation of a priority patient to perform the halo test. You can control bleeding from abrasions and lacerations to the nose by applying a sterile dressing. If the patient is bleeding heavily from the nose, this is most likely caused by significant trauma, and you must consider cervical spine injury. The patient should not be moved if the airway can be managed in the patient's current position. For a non-trauma patient who is bleeding from the nose, one effective way to control bleeding is to place the patient in a sitting position, leaning forward. and pinch his or her nostrils together for 10 to 15 minutes. For a detailed discussion of the care for epistaxis, see Chapter 26, Bleeding. Injuries of the ear. The ear is a complex organ that is associated with hearing and balance. The ear is divided into three parts. The external ear is composed of the pinna, or auricle, which is the part lying outside of the head, and the external auditory canal. which leads in toward the tympanic membrane or air drum. The middle ear contains three small bones, the hammer, anvil, and stirrup, that move in response to sound waves hitting the tympanic membrane. This is the mechanism by which sounds are heard and differentiated. The middle ear is connected to the nasopharynx by the eustachian tube. This connection permits equalization of pressure in the middle ear when external atmospheric pressure changes. The inner ear is composed of bony chambers filled with fluid. As the head moves, so does the fluid. In response, fine nerve endings within the fluid send impulses to the brain indicating the position of the head, and the rate of change of position. Ears are often injured, but they usually do not bleed very much. If local pressure does not control the bleeding, you can apply a roller dressing. First, however, you should place a soft Pattern dressing between the back of the ear and the scalp because bandaging the ear against the tender underlying scalp can be extremely painful for the patient. In the case of an ear avulsion, you should wrap the avulsed part in a dry sterile dressing and put it in a plastic bag labeled with the patient's name. Keep the avulsed part cool and transported to the hospital with the patient. Often, avulsed tissue from the ear can be reattached. Sudden changes in pressure created by a blast wave may rupture one or both tympanic membranes. Patients with a ruptured tympanic membrane will often report severe ear pain, difficulty hearing, or ringing in the affected ear. The tympanic membrane may also be perforated by insertion of objects, such as a cotton swab, too far into the ear. Any patient with a suspected tympanic membrane injury should be transported to the hospital for a more detailed evaluation. The external auditory canal is a favorite place for children to place foreign bodies such as crayons or food. All such items should be removed by a physician in the emergency department. Never try to manipulate the foreign body because you may press it further into the auditory canal and cause permanent damage to the tympanic membrane. Again, note any clear fluid coming from the ear of a severely injured patient because this may indicate a fracture at the base of the skull. Facial fractures. Fractures of the facial bones typically result from blunt impact. For example, the patient's head collides with a steering wheel or windshield in an automobile crash or is hit by a baseball bat or pipe in an assault. You should assume that any patient who has sustained a direct blow to the mouth or nose has a facial fracture. Other clues to the possibility of fracture include bleeding in the mouth, inability to swallow or talk, absent or loose teeth. and or loose or movable bone fragments patients may also report that it doesn't feel right when they close their jaw signaling an irregularity a bite facial fractures alone are not acute emergencies unless there is serious bleeding however they are an indication of significant blunt force trauma applied to that region of the body serious bleeding from a facial fracture can be life-threatening in addition to external hemorrhage. there is the danger of blood clots lodging in the upper airway and causing an obstruction fractures around the face and mouth can also produce deformity and loose bone fragments however plastic surgeons can repair the damage if the injuries are treated within seven to ten days of the injury be sure to remove and save loose teeth or bone fragments from the mouth it is often possible to reimplant them It is also important to remove them as well as any loose dentures or dental bridges to protect against airway obstruction. The removal of dentures will affect the apparent shape of the patient's jaw. Another source of potential airway obstruction is swelling, which can be extreme within the first 24 hours after injury. If you notice swelling during assessment or at any time while the patient is in your care, check for airway obstruction. Dental injuries. Dental injuries can be traumatic to a patient. Not only is the injury itself traumatic, but the patient's permanent teeth may also be lost, affecting everything from eating to smiling. keep this in mind when providing care bleeding will occur whenever a tooth is violently displaced out of its socket therefore apply direct pressure to stop the bleeding to keep the airway patent perform suctioning if needed also keep in mind that cracked or loose teeth can potentially obstruct the airway therefore suctioning may be necessary when dealing with an avulsed tooth handle it by its crown and not by the root when transporting the patient bring along the tooth placing it in a special tooth storage solution if available in your supplies or in cold milk or sterile saline there are also commercially available kits that may be used notify the receiving facility about the avals tooth because reimplantation is recommended within one hour after the trauma injuries of the cheek you may encounter an object that is impaled in the patient's cheek if you are unable to control the bleeding and it is compromising the patient's airway. Remove the impaled object if possible and provide direct pressure on the inside and outside of the cheek. The amount of bandaging should not be so overwhelming that it occludes the mouth and makes it difficult for the patient to breathe. Injuries of the neck The neck contains many structures that are vulnerable to injury by blunt trauma, such as from a steering wheel in a car crash, or by penetrating injury, such as a stab or gunshot wound. These structures include the upper airway, the esophagus, the carotid arteries, and jugular veins, the thyroid cartilage or Adam's apple, the cricoid cartilage, and the upper part of the trachea. Any injury to the neck is serious and should be considered life-threatening until proven otherwise in the emergency department. Blunt injuries. Any crushing injury of the upper part of the neck has the potential to involve the larynx or trachea. Examples include a collision with a steering wheel, an attempted suicide by hanging, and a clothesline injury sustained while riding a bicycle. Once the cartilages of the upper airway and larynx are fractured, they do not spring back to their normal position. This type of fracture 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. The presence of air in the soft tissues of the neck can cause a severe and severe airway obstruction. tissues produces a characteristic crackling sensation called subcutaneous emphysema. If you feel this sensation when you palpate the neck, you should maintain the airway as best you can and provide immediate transport. Be aware that complete airway obstruction can develop rapidly in these patients as a result of swelling or bleeding into the underlying tissues. It may be difficult to manage the airway in patients with these injuries, therefore, Advanced life support should be considered early if available. An incident involving an injury to the throat may also have caused a cervical spinal injury. Therefore, spinal motion restriction may be indicated. Penetrating injuries. Penetrating injuries to the neck can cause profuse bleeding from laceration of the great vessels in the neck, the carotid arteries or the jugular veins. Injuries to the carotid and jugular vessels in the neck can cause the body to bleed out. also known as exsanguination. Injuries to these large vessels may also allow air to enter the circulatory system. If a vein has been punctured, air may be sucked through it to the heart, a clinical situation called an air embolism. A large amount of air in the right atrium and right ventricle of the heart can lead to cardiac arrest. The airway, the esophagus, and even the spinal cord can be damaged by a penetrating injury. Direct pressure over the bleeding site will control most neck bleeding. Follow the steps in skill drill 28-3. 1. Apply direct pressure to the bleeding site using a gloved fingertip, if necessary, to control bleeding. Step 1. 2. Apply a sterile occlusive dressing to ensure that air does not enter a vein. Step 2. 3. dressing in place with roller gauze adding more dressings if needed. 4. Wrap the gauze around and under the patient's shoulder. To avoid possible airway and circulation problems, do not wrap the gauze around the neck. Skill Drill 28-3 Controlling Bleeding from a Neck Injury Step 1. Apply direct pressure to the bleeding site using a gloved fingertip, if necessary, to control bleeding. Step 2. Apply a sterile occlusive dressing to ensure that air does not enter a vein. Despite the use of these measures, the tissues within the neck may continue to bleed and compress the upper airway, so you should look for signs of airway obstruction. You might find it necessary to apply pressure both above and below the penetrating wound to control life-threatening bleeding from the carotid artery, above, and the jugular vein, below. You may also need to treat the patient for shock. If indicated, initiate spinal motion restriction precautions, and provide prompt transport. Ensure that the airway remains open en route, and apply high-flow oxygen. Laryngeal injuries. Blunt force trauma to the larynx can occur when an unrestrained driver strikes the steering wheel or when a snowmobile rider or off-road biker strikes a clothesline or a fixed wire strung across a property line. The larynx becomes crushed against the cervical spine, resulting in soft tissue injury, fractures, and or separation of the fascia that connects the thyroid and cricoid cartilages. These strangulation injuries can also be found in either intentional or unintentional hangings. anytime there is suspected injury to the larynx you should suspect possible cervical spine injury open injuries to the larynx can occur as a result of a stabbing or penetration by a similar object penetrating and impaled objects should not be removed unless they interfere with cardiopulmonary resuscitation stabilize all impaled objects if they're not obstructing the airway see chapter 27 soft tissue injuries Significant injuries to the larynx pose an immediate risk of airway compromise because of disruption of the normal passage of air, soft tissue swelling, or aspiration, entry of solids or fluids from the oropharynx or nasopharynx into the airway, of blood. The signs and symptoms of larynx injuries include respiratory distress, hoarseness, pain, difficulty swallowing, dysphagia, cyanosis, pale skin, sputum in the wound, sub- subcutaneous emphysema, bruising on the neck, hematoma, or bleeding. To manage a laryngeal injury, secure the patient's airway, and provide oxygenation and ventilation as needed. Follow local protocols regarding use of spinal precautions.

Penetrating trauma to the neck may cause severe bleeding. An open injury may allow an air embolism to enter the circulatory system. If a hematoma forms in this area, it may stop or slow blood flow to the brain, causing a stroke.

Appropriate pre-hospital and hospital care can sometimes allow a seemingly devastating injury to result in a surprisingly good outcome. As an emergency medical technician, your objectives when treating a patient with face and neck injuries include preventing further injury, particularly to the cervical spine. managing any acute airway problems and controlling bleeding this chapter first reviews the anatomy of the head and neck and then examines the factors that can produce upper airway obstruction a discussion follows that includes emergency medical care of soft tissue wounds of the face nose and ear facial fractures penetrating injuries of the neck and dental injuries anatomy and physiology the head is divided into two parts the cranium and the face.

The cranium, or skull, contains the brain, which connects to the spinal cord through the forearm and magnum, a large opening at the base of the skull. The most posterior portion of the cranium is called the occiput. On each side of the cranium, the lateral portions are called the temples or temporal regions. Between the temporal regions and the occiput lie the parietal regions. The forehead is called the frontal region.

just anterior to the ear in the temporal region you can feel the pulse of the superficial temporal artery the face is composed of the eyes ears nose mouth and cheeks six bones the nasal bone the two maxillae upper jaw bones the two zygomas cheekbones and the mandible jawbone are the major bones of the face the orbit of the eye is composed of the lower edge of the frontal bone of the skull The Zygoma the maxilla and the nasal bone the bony orbit protects the eye from injury by viewing the face from the side you can see the eyeball recessed in the orbit only the proximal third of the nose the bridge is formed by bone the remaining two-thirds are composed of cartilage the exposed portion of the ear is composed entirely of cartilage that is covered by skin the external visible part of the ear is called the pinna The ear lobes are the fleshy portions at the bottom of each ear. 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 inch, 2.5 centimeters, posterior to the external opening of the ear is a prominent bony mass at the base of the skull called the mastoid process. The mandible forms the jaw and chin. The jaw is the lower border of the mouth, where the tongue and 32 teeth are located.

Motion of the mandible occurs at the temporomandibular joint, which lies just in front of the ear on either side of the face. Below the ear, and anterior to the mastoid process, the angle of the mandible is easily palpated. The neck also contains many important structures. It is supported by the cervical spine, or the first seven vertebrae in the spinal column. C1 through C7.

The spinal cord exits from the foramen magnum, and lies within the spinal canal formed by the vertebrae. The upper part of the esophagus, and the trachea lie in the midline of the neck. The carotid arteries are found on either side of the trachea, along with the jugular veins, and several nerves.

Several useful landmarks can be palpated and seen in the neck. The most obvious is the firm prominence in the center of the anterior surface. commonly known as the Adam's apple. Specifically, this prominence is the upper part of the larynx, formed by the thyroid cartilage.

It is more prominent in men than in women. The other portion of the larynx is the cricoid cartilage, a firm ridge of cartilage, the only complete circular cartilage structure of the trachea, below the thyroid cartilage, which is somewhat more difficult to palpate. Between the thyroid cartilage, and the cricoid cartilage in the midline of the neck is a soft depression, the cricothyroid membrane.

This is a thin sheet of connective tissue, fascia, that joins the two cartilages. The cricothyroid membrane is covered at this point only by skin. Below the larynx, several additional firm ridges are palpable in the anterior midline.

These ridges are the cartilage rings of the trachea. The trachea connects the oropharynx and the larynx with the main air passages of the lungs, the bronchi. On either side of the lower larynx, and the upper trachea lies the thyroid gland.

Unless it is enlarged, this gland is usually not palpable. Pulsations of the carotid arteries are easily palpable in a groove approximately 0.5 inch, 13 millimeters, lateral to the larynx. Lying immediately adjacent to these arteries, but not palpable, are the internal jugular veins, and several important nerves. Lateral to these vessels and nerves lie the sternocleidomastoid muscles. These muscles 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 they allow movement of the head a series of bony prominences like posteriorly in the midline at the neck they are the spines of the cervical vertebrae the lower cervical spines are more prominent than the upper ones they are more easily palpable when the neck is inflection at the base of the neck posteriorly the most prominent spine is the seventh cervical vertebra The eye. The eye is globe shaped. approximately 1 inch 2.5 centimeters in diameter and located within a bony socket in the skull called the orbit figure 28-5 the orbit is composed of the adjacent bones of the face and skull the orbit forms the base of the floor of the cranial cavity and directly above it are the frontal lobes of the brain in the adult more than 80% of the eyeball is protected within this bony orbit between and below the orbits of the nasal bone. and the sinuses, respectively. Therefore, any severe injury to the face or head can potentially damage the eyeball or the muscles attached to the eyeball that cause the eye to move.

The eyeball, or globe, keeps its global shape as a result of the pressure of the fluid contained within its two chambers. The clear, jelly-like fluid near the back of the eye is called the vitreous humor. In front of the lens is a clear fluid called the aqueous humor, named for its watery appearance. In Latin, aqua means water.

In penetrating injuries of the eye, aqueous humor can leak out, but with time, and appropriate medical treatment, the body can make more. The inner surface of the eyelids, and the exposed surface of the eye itself, which are covered by a delicate membrane, the conjunctiva, are kept moist by fluid produced by the lacrimal glands, often called tear glands. Humans blink unconsciously many times per minute. This action sweeps fluid from the lacrimal glands over the surface of the eye, cleaning it.

The tears drain on the inner side of the eye through to lacrimal tear, ducts into the nasal cavity. This is why people sometimes need to blow their nose when they cry. The white of the eye, called the sclera, extends over the surface of the globe. This extremely tough, fibrous tissue helps maintain the eye's globular shape, and protects the more delicate inner structures.

On the front of the eye, the sclera is replaced by a clear, transparent membrane called the cornea, which allows light to enter the eye. A circular muscle lies behind the cornea with an opening in its center. Like the shutter in a camera, this muscle adjusts the size of the opening to regulate the amount of light that enters the eye.

This circular muscle, and surrounding tissue are called the iris. The iris is pigmented, giving the eye its characteristic brown, green. or blue color.

The opening in the center of the iris, which allows light to move to the back of the eye, is called the pupil. Normally, the pupil appears black. Like the opening in a camera, the pupil becomes smaller in bright light and larger in dim light.

The pupil also becomes smaller and larger when the person is looking at objects near at hand and farther away. These adjustments occur almost instantaneously. Normally, the pupils in both eyes are equal in size.

Some people are born with pupils that are not equal, an isochoria, however, particularly in unconscious patients, an equal pupil size may indicate serious injury or illness of the brain or eye. Behind the iris is the lens. Like the lens of a camera, this lens focuses images on the light-sensitive area at the back of the globe, called the retina.

Within the retina are numerous nerve endings that respond to light. by transmitting nerve impulses through the optic nerve to the brain. In the brain, the impulses are interpreted as vision. The retina is nourished by a layer of blood vessels between it and the sclera at the back of the globe. This layer is called the choroid.

If, as sometimes happens, the retina detaches from the underlying choroid and sclera, the nerve endings are not nourished, and the patient experiences blindness. This may be partial blindness, depending on how much of the retina is separated. This condition is called retinal detachment. Injuries of the face and neck. 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. Bleeding from facial injuries can be heavy, producing large blood clots in the upper airway. These clots can lead to complete obstruction, particularly in a patient who is not fully conscious. In particular, Direct injuries to the nose and mouth, the larynx, or the trachea are often the source of significant bleeding and or respiratory compromise.

You may need to suction the airway if you are unable to control the bleeding. In addition, the injuries may cause loosened teeth or dentures to become dislodged into the throat, where they may be swallowed or aspirated. The swelling that often accompanies direct and indirect injury to the soft tissues in these areas can also contribute to airway obstruction.

the airway may also be affected when the patient's head is turned to the side as often is done when the patient has an altered level of consciousness or is unconscious other factors that interfere with normal respirations include possible injuries to the brain and or cervical spine that may be associated with facial injuries if the great vessels in the neck are injured significant bleeding and pressure on the upper airway are common these can result in airway obstruction as well Depending on the mechanism of injury, there may be a cervical spine injury. If there is significant impact to the face, suspect accompanying cervical spine injury, and follow your agency's protocol for spinal motion restriction. Soft tissue injuries. Soft tissue injuries of the face and neck are common.

Because the face and neck are extremely vascular, swelling from soft tissue injuries in this area may be more severe than in other injured parts of the body. The skin and underlying tissues in these areas have a rich blood supply, so bleeding from penetrating injuries may be heavy. Even minor soft tissue wounds of the face and neck may bleed profusely. A blunt injury that does not break the skin may cause a break in a blood vessel wall, causing blood to collect under the skin.

This is called a hematoma. In some situations, a flap of skin is peeled back, or avulsed, from the underlying muscle and fascia. dental injuries mandible lower jaw fractures are relatively common because of the prominence of the mandible itself these fractures are second only to nasal fractures in frequency most of these fractures are the result of vehicle collisions and assaults if your patient has a mandibular fracture then consider the major force necessary to cause that fracture there is a strong probability your patient will have additional facial trauma and or cervical injuries Signs of a mandibular fracture include a misalignment of the teeth, numbness of the chin, and an inability to open the mouth.

The patient will most likely have swelling, bruising, and loosened or missing teeth. Maxillary fractures are predominantly found after blunt force, high energy impacts such as an unrestrained driver striking the steering wheel, a fall, or a direct blow from an object such as a pipe. The signs include massive facial swelling.

instability of the facial bones, and misalignment of the teeth. Fractured and avulsed teeth are common following facial trauma. Dental injuries may be associated with motor vehicle crashes or an assault. Always assess the patient's mouth following a facial injury, especially if your examination reveals fractured or avulsed teeth. Teeth fragments, or even whole teeth, can become an airway obstruction, and should be removed from the patient's mouth immediately.

Patient Assessment Scene Size Up As you arrive on the scene, observe for hazards and threats to the safety of the crew, bystanders, and the patient. Assess the effect of hazards on patient care, and address those hazards. Assess for the potential for violence, and for environmental hazards.

Patients who are conscious and supine and have oral or facial bleeding may protect their airway by coughing, projecting the blood at you. Therefore, Standard precautions require eye protection and a face mask. Also, put several pairs of gloves in your pocket for easy access in the event your gloves tear or there are multiple patients with bleeding. If your response is to a motor vehicle crash, you may be confronted with more than one patient in a vehicle.

Determine the number of patients, and consider whether you will need additional or specialized resources on the scene. As you observe the scene, look for indicators of the mechanism of injury. This assessment helps you develop an early index of suspicion for underlying injuries in the patient who has sustained a significant mechanism of injury.

As you put together information from dispatch and your observations of the scene, consider how the mechanism of injury produced the injuries expected. Common mechanism of injuries for face and neck injuries include motor vehicle collisions, sports participation, falls, penetrating trauma, and blunt trauma. In motor vehicle collisions, the probability of injury increases if the vehicle rolled over or came to an abrupt stop when striking an immovable object, such as a tree. During sports participation, injuries can occur in a player without a helmet who was struck by a baseball or two players who sustained a helmet-to-helmet collision in football.

Primary Assessment The primary assessment focuses on identifying and managing life-threatening concerns. Threats to Airway breathing or circulation must be treated immediately when there is obvious active life-threatening external hemorrhage it should be addressed before airway and breathing as you approach the patient look for important indicators to alert you to the seriousness of the patient's condition is the patient interacting with the environment or lying still making no sounds does the patient have any apparent life threats such as significant bleeding How is the patient's skin color? The general impression will help you develop an index of suspicion for serious injuries and determine your sense of urgency for medical intervention. Injuries to the face and throat, such as bleeding and significant swelling, may be obvious but may also be hidden under collars and hats.

Because of the likelihood of respiratory distress with these injuries, they should be recognized as early as possible. As with any injury with life-threatening bleeding, Control the blood loss with direct pressure. Always consider the need for manual spinal stabilization and check for responsiveness using the awake and alert verbal stimuli pain unresponsive scale.

Ensure that the patient has a clear and patent airway. If the patient is unresponsive or has a significantly altered level of consciousness, consider inserting a proper size oropharyngeal airway. The use of a nasopharyngeal airway is controversial.

many believe that inserting a nasopharyngeal airway into the nares of a patient with facial or head trauma carries the risk of introducing the device into the cranial vault and brain tissue however recent research suggests this risk is extremely small as always be aware of and follow your local protocols quickly assess the pulse rate and quality determine the skin condition color and temperature and check the capillary refill time Significant bleeding is an immediate life threat. If the patient has obvious life-threatening bleeding, you must control it quickly. If the patient you are treating has an airway or a breathing problem or significant bleeding, you must consider quickly transporting the patient to the hospital for treatment or requesting advanced life support if that will result in faster access to someone who will be able to intubate the patient. stabilization and maintenance of airway and breathing and controlling bleeding can be difficult in patients with facial or neck injuries avoid delays in transport and consider advanced life support backup if the transport time is long a patient with signs and symptoms of internal bleeding must be transported quickly to the appropriate hospital for treatment by a physician internal bleeding in face and throat injuries may compromise blood flow to the brain Bleeding from major vessels of the throat can have a serious effect on the patient's airway. The condition of a patient with visible significant bleeding or signs of significant internal bleeding may quickly become unstable.

Treatment is directed at quickly addressing life threats and providing rapid transport to the closest appropriate hospital. Signs such as tachycardia, tachypnea, low blood pressure, weak pulse, and cool, moist Pale skin are signs of hypoperfusion and imply the need for rapid transport. Note that because skin paleness can be difficult to detect in patients with dark skin, you may need to check for pale mucous membranes inside the inner lower eyelid or slow capillary refill. The patient who has a significant mechanism of injury but whose condition appears stable should also be transported promptly to the closest appropriate hospital.

Remember that any significant blow to the face or throat should increase your suspicion of spinal or brain injury. Be alert to these signs, and reconsider your priority, and transport decision if they develop, even if the patient has no signs of hypoperfusion or other life-threatening injuries. If the patient has an injury involving the eye it should be considered potentially serious.

Consider transporting a patient with serious, isolated eye injuries to an eye care specialty center depending on local protocol. Do not delay transport of a seriously injured patient, particularly one with significant bleeding, even if it is controlled, to take a patient's history or perform a secondary assessment. Further assessment can continue during transport. History taking. After the life threats have been managed during the primary assessment, investigate the chief complaint or history of present illness.

Obtain a medical history, and be alert for injury-specific signs and symptoms, as well as any pertinent negatives such as no pain or no loss of sensation. Next, obtain a sample history from your patient. If the patient is not responsive.

Attempt to obtain the sample history from friends or family members who may be present. In an unresponsive patient you will only be able to notice the signs of the patient's injuries. Any other information will need to be obtained by someone who is knowledgeable about the patient. Keep in mind that the information you obtain may or may not be accurate and may be incomplete. The person providing the information may not be able to give you the actual names of the patient's medications but might be able to provide some pertinent medical history and possibly known allergies.

Secondary Assessment The secondary assessment is a comprehensive examination of the patient that is used to uncover injuries that may have been missed during the primary assessment. In some instances, such as when a patient is critically injured or a short transport time, you may not have time to conduct a secondary assessment. If there is significant trauma that likely affects multiple systems, start with an assessment of the entire body looking for DCAP-BTLS to be sure that you have found all life threats and injuries. When this is completed, perform a detailed examination of specific areas. However, do not delay transport to complete a thorough physical examination.

In the responsive patient who has an isolated injury with a limited mechanism of injury, consider focusing your physical examination on the isolated injury, the patient's chief complaint, and the body region affected, which, in this case, is the face and throat. Ensure that control of bleeding is maintained and note the location of the injury. Inspect open wounds for any foreign matter, and stabilize impaled objects if they do not obstruct the airway. During the physical examination, use your eyes, and your hands.

Your eyes will be looking for swelling, deformities of the bones, contusions, and discoloration, whereas your hands will be gently palpating the face, looking and feeling for any abnormalities such as deformity or tenderness. Ask yourself the following questions. 1. Do the facial bones seem to be in alignment?

2. Does the nasal bone seem to deviate from the midline? 3. Note any variations from the normal facial examination. Is there any facial drooping? 4. Does one eye appear to be lower than the other?

If so, this is an indication of an orbital fracture. 5. Does the mandible appear to deviate toward one side or the other? If your patient is responsive, explain exactly what you are doing.

and what you are looking for. Your discovery of what you consider to be an abnormality may actually be an old injury that the patient can tell you more about. Assess all underlying systems. This should include the neurologic system, including the brain, and major nerves, sensory organs, including the eyes and nose, the respiratory system, including the mouth, nose, sinuses, and airway, and the circulatory system. particularly focusing on the carotid arteries and jugular veins.

When you are evaluating the eyes, start at the outer aspect of the eye and work your way in toward the pupils. Examine the eye for any obvious foreign matter. Your patient may relay this information to you, I have something in my eye. Visual acuity, or the clarity of the patient's vision in each eye, is considered the vital sign of the eye.

Quickly assess the patient's visual acuity by gently covering one eye, and holding fingers up at arm's length in front of the open eye. Test for the ability to see fingers in both the injured and uninjured eyes and document your findings. Note any discoloration of the eye, bleeding in the iris area, or redness. Look for eye symmetry because asymmetry is a possible indication of a brain injury.

Look at each pupil for equal size and reaction to light. If the pupils are not symmetric, ask the patient if he or she has undergone any previous eye surgeries or sustained any injuries. Previous surgery or injury, rather than brain injury, may be the root cause of the pupils not appearing the same.

Cataract surgery can cause unequal pupils, but when you have a patient with a suspected head injury or ocular injury, anisocoria, unequal pupils in dim light, may be present. Determine whether the unequal pupils are caused by physiologic or pathologic issues. Use of over-the-counter eye drops can change pupil size, and certain asthma inhalers can have the same effect if inadvertently sprayed into the eye.

Brain injury, nerve disease, glaucoma, and meningitis are all possible causes of unequal pupils. Does the patient have the ability to follow your finger from side to side as well as up and down? Can the patient read normal print? Does the patient report blurry vision in either eye?

Is there a new sensitivity to light? Assess vital signs to obtain a baseline so that you can observe any changes a patient may display during treatment. A systolic blood pressure reading of less than 100 millimeters of mercury with a weak, rapid pulse and cool, moist skin that is pale or gray should alert you to the presence of hypoperfusion in a patient who may have significant bleeding.

Remember, you must be concerned with visible bleeding, and unseen bleeding inside a body cavity. With facial and throat injuries, baseline information about the rate and quality of respirations and pulse is very important, as is monitoring throughout patient care. In addition to hands-on assessment, use monitoring devices to quantify your patient's oxygenation and circulatory status. Reassessment Repeat the primary assessment.

Reassess vital signs, and the chief complaint. Continually reassess the adequacy of the patient's airway, breathing, and circulation. Recheck patient interventions. Are the treatments you provided for problems with airway, breathing, and circulation still effective? This is particularly important in patients with facial or neck injuries because of the ease with which injuries can affect associated systems, such as the respiratory, airway and breathing.

circulatory and nervous systems the patient's condition should be reassessed at least every five minutes if you suspect possible spinal injury follow local protocols regarding spinal motion restriction precautions spinal injuries should be suspected any time there is significant trauma to the face or neck maintain an open airway be prepared to suction the patient and consider an or opharyngeal airway if the patient becomes unresponsive. Whenever you suspect significant bleeding, provide high-flow oxygen. Adequate oxygenation and airway maintenance are important for all patients with face and neck injuries. If needed, provide assisted ventilation using a bag-mask device with high-flow oxygen. Control any significant visible bleeding.

If the patient has signs of hypoperfusion, treat the patient aggressively for shock, and provide rapid transport to the appropriate hospital. Do not delay transport of a seriously injured trauma patient to complete non-life-saving treatments in the field, such as splinting extremity fractures. Instead, complete these treatments en route to the hospital. If there is no cervical spine injury suspected, the patient may be more comfortable in the sitting position during transport. In your documentation, describe the mechanism of injury and the position in which you found the patient when you arrived at the scene.

Document difficulties that occurred when removing the patient from the vehicle, for example, prolonged extrication. In patients with severe external bleeding, it is important to recognize, estimate, and report the amount of blood loss that has occurred, and how rapidly or how much time has passed since the bleeding started. This can be a challenge for you, especially if the patient is on a surface that is wet or absorbs fluids or if the environment is dark.

Inform the hospital personnel about all injuries involving the patient's head and neck. Emergency Medical Care The emergency care of soft tissue injuries to the face and neck is the same as treatment of soft tissue injuries elsewhere on the body. You should assess the X-airway, breathing, and circulations and care for any life threats first.

Remember also to follow standard precautions in all cases. In the absence of life-threatening bleeding, your first step is to open and clear the airway. Securing and maintaining a patent airway is paramount. Remember that blood draining into the throat can produce vomiting and airway obstruction, therefore, the patient may need frequent suctioning.

Avoid moving the neck if you suspect that the patient may have sustained a cervical spine injury. Use the jaw thrust maneuver to open the patient's airway, and then suction the mouth. Once spinal motion restriction is achieved, you can tilt the patient or backboard to one side to allow any blood or vomitus to drain out of the mouth rather than pool in the pharynx. and obstruct the airway control bleeding by applying direct manual pressure with a dry sterile dressing use roller gauze wrapped around the circumference of the head to hold a pressure dressing in place do not apply excessive pressure if there is a possibility of an underlying skull fracture when an injury exposes the brain I or other structures cover the exposed parts with a moist sterile dressing to protect them from further damage For injuries in which the skin is not broken, apply ice or a cold pack locally to help control the swelling of bruised tissues. For soft tissue injuries around the mouth, always check for bleeding inside the mouth.

Broken teeth and lacerations to the tongue may cause profuse bleeding and obstruction of the upper airway. Often, the patient will swallow the blood from lacerations inside the mouth, so the hemorrhage may not be apparent. You should also inspect the inside of the mouth for bleeding, and it and injuries in patients who have sustained facial trauma.

Remember that patients who swallow significant amounts of blood are prone to vomiting. Often, physicians will be able to graft a piece of a vulva's skin back into the appropriate position. For this reason, if you find portions of a vulva's skin that have become separated, wrap them in a sterile dressing, place them in a plastic bag, and keep them cool. Never place tissue directly on ice because freezing will cause further injury to the tissue and make it unusable.

Deliver the bag labeled with the patient's name to the emergency department along with the patient. In many avulsion injuries, the skin will still be attached in a loose flap. Place the flap in a position that is as close to normal as possible and hold it in place with a dry, sterile dressing.

These steps will help to increase the patient's chances of having his or her normal appearance restored. Emergency medical care for specific injuries. Injuries of the eyes. Eye injuries are common, particularly in sports. An eye injury can produce severe, lifelong complications, including blindness.

Proper emergency treatment will minimize pain, and may very well help to prevent a permanent loss of vision. In a normal, uninjured eye. the entire circle of the iris is visible the pupils are round usually equal in size and react equally when exposed to light both eyes move together in the same direction when following your moving finger after an injury pupil reaction or shape and eye movement are often disturbed any of these conditions should cause you to suspect an injury of the globe or its associated tissues Remember, though, In patients who are unconscious or who have a significantly altered mental status, abnormal pupil reactions sometimes are a sign of brain injury rather than eye injury. Treatment starts with a thorough examination to determine the extent and nature of any damage. Perform your examination using standard precautions, taking care to avoid aggravating any problems.

You are looking for specific abnormalities or conditions that may suggest the nature of the injury. For example, blunt or penetrating injuries can produce swollen or lacerated eyelids. Bleeding soon after irritation or injury can result in a bright red conjunctiva. A damaged cornea quickly loses its smooth, wet appearance. Foreign objects.

Large objects are prevented from penetrating the eye by the protective orbit that surrounds it. However, Moderately sized and smaller foreign objects of many different types can enter the eye and cause significant damage. Even a tiny foreign object, such as a grain of sand lying on the surface of the conjunctiva, may produce severe irritation.

The conjunctiva becomes inflamed and red, a condition known as conjunctivitis, almost immediately, and the eye begins to produce tears to flush out the object. Irritation of the cornea or conjunctiva causes intense pain. The patient may have difficulty keeping the eyelids open, because the irritation is further aggravated by bright light. If a small foreign object is lying on the surface of the patient's eye, you should use a normal saline solution to gently irrigate the eye irrigation with a sterile saline solution will frequently flush away loose small particles if a small bulb syringe is available you can use this or nasal airway or cannula to direct the saline into the affected eye always flush from the nose side of the eye toward the outside to avoid flushing material into the other eye After it has been flushed away. foreign body will often leave a small abrasion on the surface of the conjunctiva for this reason the patient will report irritation even when the particle itself is gone it is always a good idea to transport the patient to the hospital for further assessment to ensure appropriate medical care to the affected eye gentle irrigation usually will not wash out foreign bodies that are stuck to the cornea or lying under the upper eyelid to examine the undersurface of the upper eyelid.

pull the lid upward and forward if you spot a foreign object on the surface of the eyelid you may be able to remove it with a moist sterile cotton tipped applicator skill drill 28 dash one never attempt to remove a foreign body that is stuck to the cornea one tell the patient to look down while you grasp the lashes of the upper eyelid with your thumb and index finger gently pull the eyelid away from the eyeball step 1 2. Gently place a cotton tipped applicator horizontally along the center of the outer surface of the upper eyelid step 2 3 Pull the eyelid forward and up which causes it to roll or fold back over the applicator Exposing the under surface of the eyelid step 3 4 if you see a foreign object on the surface of the eyelid Gently remove it with a moistened sterile cotton tipped applicator step 4 Skill Drill 28-1 Removing a Foreign Object from Under the Upper Eyelid. Step 1. Have the patient look down, grasp the upper lashes, and gently pull the lid away from the eye. Step 2. Place a cotton-tipped applicator on the outer surface of the upper lid. Step 3. Pull the lid forward and up, folding it back over the applicator. Step 4. Gently remove the foreign object from the eyelid with a moistened, sterile cotton-tipped applicator.

Foreign bodies ranging in size from a pencil to a sliver of metal may be impaled in the eye. These objects must be removed by a physician. Your care involves stabilizing the object and preparing the patient for transport to definitive care.

The greater the length of the foreign object you can see sticking out of the eye, the more important stabilization becomes in avoiding further damage. Bandage the object in place to support it. Cover the eye with a moist, sterile dressing, and then surround the object with an eye shield or donut-shaped collar made from roller gauze or a small gauze pack. Follow the steps in skill drill 28-2. 1. Begin to prepare the donut ring by wrapping a 2-inch, 5-centimeter, gauze roll circumferentially around your fingers and thumb enough times to make a thick dressing layer.

You can adjust the inner diameter of what will become the ring by spreading your fingers or squeezing them together. Step 1. 2. Remove the gauze from your hand and wrap the remainder of the gauze roll radially around the ring that you have created. Step 2. 3. Work your way around the ring until you have wrapped all the way around it and finish the donut. Step 3. 4. Carefully place the ring over the eye and impaled object without bumping the object.

you can then stabilize the object with a cup or other protective barrier over the object and secure the object with the roller bandage surrounding their head bandage both the injured and uninjured eyes to minimize eye movement and prevent further damage to the globe because when one eye moves so does the other transport to an appropriate medical facility for treatment step 4 skill drill 28 dash to stabilizing a foreign object impaled in the I Step 1. To prepare a donut ring, wrap a 2 inch, 5 centimeter, gauze roll around your fingers and thumb 7 or 8 times. Adjust the diameter by spreading your fingers or squeezing them together. Step 2. Remove the gauze from your hand, and wrap the remainder of the gauze roll radially around the ring that you have created.

Step 3. Work around the entire ring to form a donut. Step 4. Place the dressing over the eye with a protective barrier to hold the impaled object in place, and then secure it with a roller bandage. Sometimes, a variety of types of large and small foreign bodies, particularly small metal fragments, become completely embedded within the eye itself.

The patient may not even be aware of the cause of the problem. Suspect such an injury when the history includes metal work, such as hammering, exposure to splinters, grinding, vigorous filing, and when there are other signs of ocular injury. When you see or suspect an impaled object in the eye, place an eye shield over the affected eye, and then bandage both eyes with soft bulky dressings to prevent further injury to the affected I your bandage should be loose enough to hold the eyelid closed but not cause pressure on the I itself using this technique prevents sympathetic motion the movement of one eye causing both eyes to move which may cause additional damage to the injured I this type of injury must be handled by an ophthalmologist on an urgent basis radiographs and special equipment may be required to find the foreign body Burns of the eye.

Chemicals, heat, and light rays all can burn the delicate tissues, such as the cornea, often causing permanent damage. Your role is to stop the burn and prevent further damage. Chemical burns. Chemical burns, usually caused by acid or alkaline solutions, require immediate emergency care.

This consists of flushing the eye with water or a sterile saline irrigation solution. If sterile saline is not available, you can use any clean water. The idea is to direct the greatest amount of irrigating solution or water into the eye as gently as possible. Because opening the eye spontaneously may cause the patient pain, you may have to force the lids open to irrigate the eye adequately. Ideally, you will use a bulb or irrigation syringe, a nasal cannula, or some other device that will allow you to control the flow.

In some circumstances, You may have to resort to pouring water into the eye by holding the patient's head under a gently running faucet. You can even have the patient immerse his or her face in a large pan or basin of water, and rapidly blink the affected eyelid. If only one eye is affected, care must be taken to avoid contaminated water from getting into the unaffected eye. Be sure to flush from the inner corner of the affected eye toward the outside corner. never flush from the outside corner as this may cause the substance to contaminate the unaffected I if the burn was caused by an alkali or a strong acid irrigate the I continuously for 20 minutes follow local protocols or consult with medical control as to whether to try to irrigate while transporting or to stay unseen until flushing is complete strong acids and all alkaline solutions can penetrate deeply requiring a prolonged flush Again.

Always take care to protect the uninjured eye and prevent irrigation fluid from running into it. After you have completed irrigation, apply a clean, dry dressing to cover the eye and transport the patient promptly to the hospital for further care. If the irrigation can be carried out satisfactorily in the ambulance, it should be done during transport to save time.

Thermal burns. When a patient is burned on the face during a fire, the eyes usually close rapidly because of the heat this reaction is a natural reflex to protect the eye from further injury however the eyelids remain exposed and are frequently burned burns of the eyelids require highly specialized care it is best to provide prompt transport for these patients without further examination first however you should cover both eyes with a sterile dressing moistened with sterile saline you may apply shields over the dressing consider transporting these patients to a designated burn center depending on local protocol or medical control recommendations light burns infrared rays the light from a solar eclipse if the patient has looked directly at the Sun and laser burns all can cause significant damage to the sensory cells of the eye when rays of light become focused on the retina Retinal injuries that are caused by exposure to extremely bright light are generally not painful but may result in permanent damage to vision. Superficial burns of the eye can result from ultraviolet rays from an arc welding unit, light from prolonged exposure to a sun lamp, or reflected light from a bright, snow-covered area, snow blindness.

this kind of burn often is not painful at first but may become so three to five hours later when the damage cornea responds to the injury severe conjunctivitis usually develops with redness swelling and excessive tear production you can ease the pain from these corneal burns by covering each eye with a sterile moist pad and an eye shield have the patient lie down during transport to the hospital and protect him or her from further exposure to bright light the patient should be examined by a physician as soon as possible lacerations lacerations of the eyelids require careful repair to restore appearance and function bleeding may be heavy but it usually can be controlled by gentle manual pressure if there is a laceration of the globe itself apply no pressure to the I compression can interfere with the blood supply to the back of the eye and result in loss of vision from damage to the retina Furthermore, pressure may squeeze the vitreous humor, iris, lens, or even the retina out of the eye and cause irreparable damage or blindness. Follow these three important guidelines in treating penetrating injuries of the eye. 1. Never exert pressure on or manipulate the injured eye, globe, in any way. 2. If part of the eyeball is exposed, gently apply a moist, sterile dressing to prevent drying.

3. Cover the injured eye with a protective metal eye shield, cup, or sterile dressing. Apply soft dressings to both eyes, and provide prompt transport to the hospital. On rare occasions following a serious injury, the eyeball may be displaced out of its socket. Do not attempt to reposition it.

Simply cover the eye, and stabilize it with a moist, sterile dressing. remember to cover both eyes to prevent further injury because of sympathetic movement have the patient lie in a supine position en route to the hospital to prevent further loss of fluid from the eye blunt trauma blunt trauma can cause many serious eye injuries these range from the ordinary black eye a result of bleeding into the tissue around the orbit to a severely damaged globe you may see an injury called hyphema or bleeding into the anterior chamber of the eye that obscures part or all of the iris. This injury is common in blunt trauma and may seriously impair vision. 25% of hyphemas are associated with underlying globe injuries, a serious injury to the eye.

Cover the eye to protect it from further injury, and provide transportation to the hospital for further medical evaluation. Blunt trauma can also cause a fracture of the orbit. specifically of the bones that form its floor and support the globe. When associated with displacement, this injury is sometimes referred to as a blowout fracture.

The fragments of fractured bone can entrap some of the muscles that control eye movement, causing double vision. Any patient who reports pain, double vision, or decreased vision following a blunt injury about the eye should be placed on a stretcher, and promptly transported to the emergency department. Protect the eye from further injury with a metal shield cover the other eye to minimize movement on the injured side Another possible result of blunt eye injury is retinal detachment This injury is often seen in sports especially boxing It is painless but produces flashing lights Specs or floaters in the field of vision and a cloud or shade over the patient's vision Because the retina is separated from the nourishing choroid This injury requires prompt medical attention to preserve vision in the eye.

Eye injuries following head injury. Abnormalities in the appearance or function of the eyes often occur following a brain injury. Any of the following eye findings should alert you to the possibility of a head injury. One pupil larger than the other in an unconscious patient.

The eyes not moving together or pointing in different directions. failure of the eyes to follow the movement of your finger as instructed bleeding under the conjunctiva which obscures the sclera white portion of the eye protrusion or bulging of one eye record any of these observations along with the time that you make them for an unconscious patient remember to keep the eyelids closed drying of the ocular tissue can cause permanent injury and may result in blindness cover the lids with moist gauze or hold them closed with clear tape normal tears will then keep the tissues moist blast injuries the signs and symptoms a blast injuries range from severe pain and loss of vision to foreign bodies within the globe Before responding to patients after the blast, first ensure that the scene is safe. Management of blast injuries to the eye depends on the severity of the injury.

If there is a foreign body within the globe, do not attempt to remove it. Use a clean cup or similar item to protect the area. If only one eye is injured, follow local protocols, which may include covering the other eye to eliminate sympathetic motion.

Patients with a sudden loss or decrease of vision will need to be verbally instructed on what actions are taking place around them. If the patient has severe swelling or a hematoma to the eyelid, do not attempt to force the eyelid open to examine the eye because this increases the pressure already present within the globe. Contact lenses and artificial eyes. Small, hard contact lenses usually are tinted, making them relatively easy to see.

Large Soft contact lenses are clear and can be very difficult to see. In general, you should not attempt to remove either type of lens from a patient's eye. You should never attempt to remove a lens from an eye that has been, or may have been, injured because manipulating the lens can aggravate the problem.

The only time that contact lenses should be removed immediately in the field is in the case of a chemical burn of the eye. In this situation, the lens can trap the chemical and make irrigation difficult. If it is necessary to remove a hard contact lens, use a small suction cup, moistening the end with saline.

To remove soft lenses, place one to two drops of saline in the eye. Gently pinch the lens between your gloved thumb and index finger, and lift it off the surface of the eye. Place the contact lens in a container filled with sterile saline solution to prevent damage to the contact lens.

Always advise the emergency department staff if a patient is wearing contact lenses. Occasionally, you may find yourself caring for a patient who is wearing an eye prosthesis, an artificial eye. Many people are surprised to find that it can be difficult to distinguish a prosthesis from a natural eye.

You should suspect that an eye is artificial when it does not respond to light, move in concert with the opposite eye, or appear quite the same as the opposite eye. If you think that a patient may have an artificial eye but you are not sure, go ahead and ask about it. Although no harm will be done if you care for an artificial eye as you would a normal one, you need to clearly understand the patient's eye function. Injuries of the nose, nosebleeds, epistaxis, are a common problem that can occur spontaneously or from trauma.

One of the most common causes of nosebleeds is digital trauma, picking the nose with a finger. Nosebleeds are further classified in anterior and posterior epistaxis. Anterior nosebleeds usually originate from the area of the septum and bleed slowly. They are usually self-limited and resolve quickly.

Posterior nosebleeds are usually more severe and often cause the patient to swallow blood, which can lead to nausea and vomiting. Trauma to the face and skull that results in a basilar skull fracture can cause the posterior wall of the nasal cavity to become unstable. Due to this risk, attempting to place a nasopharyngeal airway in a patient with significant facial trauma, or a suspected basilar skull fracture, is controversial. Follow local protocols regarding insertion of a nasopharyngeal airway in a patient with head or facial trauma. When you are assessing injuries involving the nose, it helps to picture the inside of the nose itself the nasal cavity is divided into two sections or chambers by the nasal septum which is made of cartilage within each nasal chamber there are layers of bone called the turbinates which are covered with a moist lining both chambers have a superior turbinate a middle turbinate and an inferior turbinate as a person breathes air moves through the nasal chambers and is humidified as it passes over the turbanets Directly above the nose are the frontal sinuses and, on either side, the orbit of the eye.

In patients with severe nasal injury, there may also be injury to the cervical spine. Keep in mind that cerebral spinal fluid may escape down through the nose, or ears, following a fracture at the base of the skull. If blood or drainage contains cerebral spinal fluid, a characteristic staining of the dressing will occur.

This can be seen by using a piece of gauze to absorb blood that is flowing from the nose or ears. If cerebrospinal fluid is present, the blood will be surrounded by a lighter ring of fluid. This is often called the halo test.

Do not delay care or transportation of a priority patient to perform the halo test. You can control bleeding from abrasions and lacerations to the nose by applying a sterile dressing. If the patient is bleeding heavily from the nose, this is most likely caused by significant trauma, and you must consider cervical spine injury. The patient should not be moved if the airway can be managed in the patient's current position. For a non-trauma patient who is bleeding from the nose, one effective way to control bleeding is to place the patient in a sitting position, leaning forward.

and pinch his or her nostrils together for 10 to 15 minutes. For a detailed discussion of the care for epistaxis, see Chapter 26, Bleeding. Injuries of the ear.

The ear is a complex organ that is associated with hearing and balance. The ear is divided into three parts. The external ear is composed of the pinna, or auricle, which is the part lying outside of the head, and the external auditory canal.

which leads in toward the tympanic membrane or air drum. The middle ear contains three small bones, the hammer, anvil, and stirrup, that move in response to sound waves hitting the tympanic membrane. This is the mechanism by which sounds are heard and differentiated. The middle ear is connected to the nasopharynx by the eustachian tube. This connection permits equalization of pressure in the middle ear when external atmospheric pressure changes.

The inner ear is composed of bony chambers filled with fluid. As the head moves, so does the fluid. In response, fine nerve endings within the fluid send impulses to the brain indicating the position of the head, and the rate of change of position. Ears are often injured, but they usually do not bleed very much.

If local pressure does not control the bleeding, you can apply a roller dressing. First, however, you should place a soft Pattern dressing between the back of the ear and the scalp because bandaging the ear against the tender underlying scalp can be extremely painful for the patient. In the case of an ear avulsion, you should wrap the avulsed part in a dry sterile dressing and put it in a plastic bag labeled with the patient's name. Keep the avulsed part cool and transported to the hospital with the patient. Often, avulsed tissue from the ear can be reattached.

Sudden changes in pressure created by a blast wave may rupture one or both tympanic membranes. Patients with a ruptured tympanic membrane will often report severe ear pain, difficulty hearing, or ringing in the affected ear. The tympanic membrane may also be perforated by insertion of objects, such as a cotton swab, too far into the ear.

Any patient with a suspected tympanic membrane injury should be transported to the hospital for a more detailed evaluation. The external auditory canal is a favorite place for children to place foreign bodies such as crayons or food. All such items should be removed by a physician in the emergency department.

Never try to manipulate the foreign body because you may press it further into the auditory canal and cause permanent damage to the tympanic membrane. Again, note any clear fluid coming from the ear of a severely injured patient because this may indicate a fracture at the base of the skull. Facial fractures.

Fractures of the facial bones typically result from blunt impact. For example, the patient's head collides with a steering wheel or windshield in an automobile crash or is hit by a baseball bat or pipe in an assault. You should assume that any patient who has sustained a direct blow to the mouth or nose has a facial fracture.

Other clues to the possibility of fracture include bleeding in the mouth, inability to swallow or talk, absent or loose teeth. and or loose or movable bone fragments patients may also report that it doesn't feel right when they close their jaw signaling an irregularity a bite facial fractures alone are not acute emergencies unless there is serious bleeding however they are an indication of significant blunt force trauma applied to that region of the body serious bleeding from a facial fracture can be life-threatening in addition to external hemorrhage. there is the danger of blood clots lodging in the upper airway and causing an obstruction fractures around the face and mouth can also produce deformity and loose bone fragments however plastic surgeons can repair the damage if the injuries are treated within seven to ten days of the injury be sure to remove and save loose teeth or bone fragments from the mouth it is often possible to reimplant them It is also important to remove them as well as any loose dentures or dental bridges to protect against airway obstruction. The removal of dentures will affect the apparent shape of the patient's jaw.

Another source of potential airway obstruction is swelling, which can be extreme within the first 24 hours after injury. If you notice swelling during assessment or at any time while the patient is in your care, check for airway obstruction. Dental injuries.

Dental injuries can be traumatic to a patient. Not only is the injury itself traumatic, but the patient's permanent teeth may also be lost, affecting everything from eating to smiling. keep this in mind when providing care bleeding will occur whenever a tooth is violently displaced out of its socket therefore apply direct pressure to stop the bleeding to keep the airway patent perform suctioning if needed also keep in mind that cracked or loose teeth can potentially obstruct the airway therefore suctioning may be necessary when dealing with an avulsed tooth handle it by its crown and not by the root when transporting the patient bring along the tooth placing it in a special tooth storage solution if available in your supplies or in cold milk or sterile saline there are also commercially available kits that may be used notify the receiving facility about the avals tooth because reimplantation is recommended within one hour after the trauma injuries of the cheek you may encounter an object that is impaled in the patient's cheek if you are unable to control the bleeding and it is compromising the patient's airway. Remove the impaled object if possible and provide direct pressure on the inside and outside of the cheek. The amount of bandaging should not be so overwhelming that it occludes the mouth and makes it difficult for the patient to breathe.

Injuries of the neck The neck contains many structures that are vulnerable to injury by blunt trauma, such as from a steering wheel in a car crash, or by penetrating injury, such as a stab or gunshot wound. These structures include the upper airway, the esophagus, the carotid arteries, and jugular veins, the thyroid cartilage or Adam's apple, the cricoid cartilage, and the upper part of the trachea. Any injury to the neck is serious and should be considered life-threatening until proven otherwise in the emergency department.

Blunt injuries. Any crushing injury of the upper part of the neck has the potential to involve the larynx or trachea. Examples include a collision with a steering wheel, an attempted suicide by hanging, and a clothesline injury sustained while riding a bicycle.

Once the cartilages of the upper airway and larynx are fractured, they do not spring back to their normal position. This type of fracture 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. The presence of air in the soft tissues of the neck can cause a severe and severe airway obstruction. tissues produces a characteristic crackling sensation called subcutaneous emphysema. If you feel this sensation when you palpate the neck, you should maintain the airway as best you can and provide immediate transport.

Be aware that complete airway obstruction can develop rapidly in these patients as a result of swelling or bleeding into the underlying tissues. It may be difficult to manage the airway in patients with these injuries, therefore, Advanced life support should be considered early if available. An incident involving an injury to the throat may also have caused a cervical spinal injury.

Therefore, spinal motion restriction may be indicated. Penetrating injuries. Penetrating injuries to the neck can cause profuse bleeding from laceration of the great vessels in the neck, the carotid arteries or the jugular veins.

Injuries to the carotid and jugular vessels in the neck can cause the body to bleed out. also known as exsanguination. Injuries to these large vessels may also allow air to enter the circulatory system.

If a vein has been punctured, air may be sucked through it to the heart, a clinical situation called an air embolism. A large amount of air in the right atrium and right ventricle of the heart can lead to cardiac arrest. The airway, the esophagus, and even the spinal cord can be damaged by a penetrating injury.

Direct pressure over the bleeding site will control most neck bleeding. Follow the steps in skill drill 28-3. 1. Apply direct pressure to the bleeding site using a gloved fingertip, if necessary, to control bleeding.

Step 1. 2. Apply a sterile occlusive dressing to ensure that air does not enter a vein. Step 2. 3. dressing in place with roller gauze adding more dressings if needed. 4. Wrap the gauze around and under the patient's shoulder.

To avoid possible airway and circulation problems, do not wrap the gauze around the neck. Skill Drill 28-3 Controlling Bleeding from a Neck Injury Step 1. Apply direct pressure to the bleeding site using a gloved fingertip, if necessary, to control bleeding. Step 2. Apply a sterile occlusive dressing to ensure that air does not enter a vein.

Despite the use of these measures, the tissues within the neck may continue to bleed and compress the upper airway, so you should look for signs of airway obstruction. You might find it necessary to apply pressure both above and below the penetrating wound to control life-threatening bleeding from the carotid artery, above, and the jugular vein, below. You may also need to treat the patient for shock.

If indicated, initiate spinal motion restriction precautions, and provide prompt transport. Ensure that the airway remains open en route, and apply high-flow oxygen. Laryngeal injuries. Blunt force trauma to the larynx can occur when an unrestrained driver strikes the steering wheel or when a snowmobile rider or off-road biker strikes a clothesline or a fixed wire strung across a property line. The larynx becomes crushed against the cervical spine, resulting in soft tissue injury, fractures, and or separation of the fascia that connects the thyroid and cricoid cartilages.

These strangulation injuries can also be found in either intentional or unintentional hangings. anytime there is suspected injury to the larynx you should suspect possible cervical spine injury open injuries to the larynx can occur as a result of a stabbing or penetration by a similar object penetrating and impaled objects should not be removed unless they interfere with cardiopulmonary resuscitation stabilize all impaled objects if they're not obstructing the airway see chapter 27 soft tissue injuries Significant injuries to the larynx pose an immediate risk of airway compromise because of disruption of the normal passage of air, soft tissue swelling, or aspiration, entry of solids or fluids from the oropharynx or nasopharynx into the airway, of blood. The signs and symptoms of larynx injuries include respiratory distress, hoarseness, pain, difficulty swallowing, dysphagia, cyanosis, pale skin, sputum in the wound, sub- subcutaneous emphysema, bruising on the neck, hematoma, or bleeding. To manage a laryngeal injury, secure the patient's airway, and provide oxygenation and ventilation as needed. Follow local protocols regarding use of spinal precautions.

Transcript for:Understanding Face and Neck Injuries

Transcript for:
Understanding Face and Neck Injuries